Challenges in Diabetic Macular Edema Management: An Expert Consensus Report

Abstract

Purpose: This paper aimed to present daily-practice recommendations for the management of diabetic macular edema (DME) patients based on available scientific evidence and the clinical experience of the consensus panel. Methods: A group of Spanish retina experts agreed to discuss different aspects related with the clinical management of DME patients. Results: Panel was mainly focused on therapeutic objectives in DME management; definition terms; and role of biomarkers as prognostic and predictive factors to intravitreal treatment response. The panel recommends to start DME treatment as soon as possible in those eyes with a visual acuity less than 20/25 (always according to the retina unit capacity). Naïve patient was defined, in a strict manner, as a patient who, up to that moment, had never received any treatment. A refractory DME patient may be defined as the one who did not achieve a complete resolution of the disease, regardless of the treatment administered. Different optical coherence tomography biomarkers, such as disorganization of the retinal inner layers, hyperreflective dots, and cysts, have been identified as prognostic factors. Conclusion:This document has sought to lay down a set of recommendations and to identify key issues that may be useful for the daily management of DME patients.

Contribution of Müller Cells in the Diabetic Retinopathy Development: Focus on Oxidative Stress and Inflammation

“…Further, diabetes also leads to a reduction in and displacement of the Kir4.1 channel and to an increase in aquaporin-4 in MGC, which can be associated with edematous alterations and retinal hyperexcitation [75,82]. Intercellular fluid accumulation in MGC provokes the cyst formation observed in DME, even though it is still in debate whether this is intracellular or extracellular [185]. In DR progression, regulation of neurotransmitters is also impaired.…”

“…According to the idea that MGC play a crucial role in the outer retina [45,[51][52][53], a disruption in OLM and in the distance between OLM and RPE, known as outer retinal layer, observed in OCT, has been correlated with poorer visual acuity [50,185] and to poor responses to anti-VEGF therapy in DME [186,187]. Chronic DME can also lead to structural disorganization of retinal inner layers (DRIL) due to glial and neuronal cell death.…”

The Role of Intravitreal Corticosteroids in the Treatment of DME: Predictive OCT Biomarkers

“…It further identifies vitreoretinal interface abnormalities, including macular traction and vitreoretinal changes, intraretinal cysts, disorganization of inner retinal layers (DRIL), and hyperreflective foci, subfoveal fluid, and the integrity of the inner and outer retina and the photoreceptor layers. OCT is also used to localize edema to specific layers of the retina [ 55 , 56 ]. This imaging modality is widely used to monitor treatment response in DME in both clinical and research settings and is a highly valuable tool to identify and assess potential morphologic biomarkers.…”

Impact of Different Clinical Baseline Characteristics on Intravitreal Dexamethasone Implant Ozurdex® Outcomes

“…As aforementioned in the introduction section, different OCT biomarkers have been identified as predictive factors of DEX outcomes. [17][18][19][20] Additionally, integrity of external limiting membrane and ellipsoid zone was associated with the final BCVA improvement in patients with DME. 26 Nevertheless, while recognizing the importance of OCT for the clinical management of patients with DME, our study focus on identifying predictive factors beyond OCT.…”

“…Different optical coherence tomography (OCT) biomarkers, including presence of submacular fluid, absence/number of hyperreflective foci, integrity of the inner segment-outer segment, outer nuclear layer, disorganization of the retinal inner layers, outer retinal layer, and presence of cysts have been identified as prognostic and predictive factors in patients with DME. [17][18][19][20] The purpose of this study was to determine the impact of different baseline clinical characteristics on the improvement in best corrected visual acuity (BCVA) in patients with DME who underwent the DEX Ozurdex ® .…”