Objective Perform a cost-effectiveness analysis of the treatment of Diabetic macular edema (DME) with ranibizumab plus prompt or deferred laser versus triamcinolone plus prompt laser. Data for the analysis was drawn from reports of the Diabetic Retinopathy Clinical Research Network (DRCRnet) Protocol I. Design Computer simulation based on Protocol I data. Analyses were conducted from the payor perspective. Participants Simulated participants assigned characteristics reflecting those seen in Protocol I. Methods Markov models were constructed to replicate Protocol I’s 104 week outcomes using a microsimulation approach to estimation. Baseline characteristics, visual acuity (VA), treatments, and complications were based on Protocol I data. Costs were identified by literature search. One-way sensitivity analysis was performed and the results were validated against Protocol I data. Main Outcome Measures Direct cost of care for two years, change in VA from baseline, and incremental cost-effectiveness ratio (ICER) measured as cost per additional letter gained from baseline (ETDRS). Results For sham plus laser (S+L), ranibizumab plus prompt laser (R+pL), ranibizumab plus deferred laser (R+dL), and triamcinolone plus laser (T+L), effectiveness through 104 weeks was predicted to be 3.46, 7.07, 8.63, and 2.40 letters correct, respectively. ICER values in terms of dollars per VA letter were $393 (S+L vs. T+L), $5,943 (R+pL vs. S+L), and $20 (R+dL vs. R+pL). For pseudophakics, the ICER value for comparison triamcinolone with laser versus ranibizumab with deferred laser was $14,690 per letter gained. No clinically relevant changes in model variables altered outcomes. Internal validation demonstrated good similarity to Protocol I treatment patterns. Conclusions In treatment of phakic patients with DME, ranibizumab with deferred laser provided an additional 6 letters correct compared to triamcinolone with laser at an additional cost of $19,216 over two years. That would indicate that if the gain in visual acuity seen at two years is maintained in subsequent years, then the treatment of phakic patients with DME using ranibizumab may meet accepted standards of cost-effectiveness. For pseudophakic patients, first line treatment with triamcinolone appears to be the most cost-effective option.

Greater awareness on the part of treating physicians, systematic study of at-risk populations, and advances in imaging technology will allow further insight into this phenomenon.

This case of bilateral cystoid macular edema and subfoveal neurosensory retinal detachments is remarkable for both its presentation and response to therapy. The macular edema and macular detachments along with nonspecific complaints of confusion, muscle stiffness, joint pain, and weight loss were the presenting signs and symptoms; signs typically used as guides to initiate treatment for multiple myeloma were not present. Macular edema in the context of paraproteinemia is usually associated with Waldenstrom's macroglobulinemia and has classically been reported as "silent" with respect to fluorescein angiography. Our patient has multiple myeloma and demonstrated leakage on fluorescein angiography. The case is also notable in that there was improvement in visual acuity and restoration of normal macular anatomy after receiving eight cycles of bortezomib and dexamethasone. Bortezomib, a chemotherapeutic agent used to treat refractory or rapidly advancing multiple myeloma, had been used previously to treat similar maculopathy in Waldenstrom disease along with plasmapheresis with resolution of macular edema and improvement in visual acuity. Our patient with multiple myeloma did not require plasmapheresis for significant clinical improvement. Treatment with bortezomib and dexamethasone alone was sufficient to clear the bilateral cystoid macular edema and subretinal fluid.