Managing Diabetic Macular Edema in Clinical Practice: Systematic Review and Meta-Analysis of Current Strategies and Treatment Options

Abstract

Purpose This meta-analysis aims to summarize 12-month best-corrected visual acuity (BCVA) outcomes in response to anti-vascular endothelial growth factor (VEGF) therapy and dexamethasone implant for the treatment of diabetic macular edema (DME) and to identify factors affecting treatment response using evidence generated from meta-regression. Methods A systematic review of electronic databases was conducted to identify randomized controlled trials (RCTs) and real-life/observational studies that reported 12-month changes in BCVA in patients with DME on anti-VEGF or dexamethasone implant treatment in monotherapy. Study factors that were analyzed are baseline patient characteristics, study type, drug employed, number of injections and 12-month change in BCVA. Data were pooled in a random-effects meta-analysis with BCVA change as the main outcome. Meta-regression was conducted to assess the impact of multiple covariates. Results One-hundred-five heterogeneous study populations (45,032 eyes) were identified and included in the analysis. The use of anti-VEGFs and dexamethasone implant induced an overall increase of +8.13 ETDRS letters in BCVA at 12 months of follow-up. Meta-regression provided evidence that mean BCVA change using anti-VEGFs was not statistically higher for RCTs (p=0.35) compared to observational studies. Dexamethasone implant showed a trend for better results in observational studies over RCTs. Populations following a fixed aflibercept regimen performed better than those following a reactive treatment regimen. Mean BCVA gain was higher in younger populations (p<0.001), with lower baseline BCVA (p<0.0001) and longer diabetes duration (p<0.0001), receiving a higher number of injections (p<0.0001). Conclusion Intravitreal therapy with anti-VEGFs or dexamethasone implant produces a significant improvement in BCVA at 12 months in patients with DME. Meta-regression identified the modifiable covariates that can be targeted in order to maximize functional results.

Efficacy and safety profile of intravitreal dexamethasone implant versus antivascular endothelial growth factor treatment in diabetic macular edema: a systematic review and meta-analysis

“…However, their study included a limited number of trials. Recently, Veritti et al 67 published a meta-analysis discussing the strategies and treatment options for DME. They included 45,032 eyes from RCTs and observational studies.…”

Economic Aspects in the Management of Diabetic Macular Edema in Italy

“…DME is the main cause of vision loss among patients with diabetes worldwide (9) and, with progressive population aging, a greater burden of this disease is expected in the coming years (8). In the last few years, the treatment of this eye disease has been revolutionized by the introduction into clinical practice of intravitreal therapy with anti-VEGF agents and corticosteroid implants (11). Anti-VEGFs, such as ranibizumab, aflibercept and bevacizumab-the latter used as an off-label treatment-have proved much more efficacious than the previous standard of care (laser photocoagulation), achieving clinically relevant improvements in visual acuity (9).…”

“…However, according to the European Society of Retina Specialists (EURETINA) guidelines, focal/grid laser therapy is now reserved mostly for non-center-involving DME (10). In recent years, the introduction into clinical practice of intravitreal therapy with vascular endothelial growth factor inhibitors (anti-VEGFs) and corticosteroid implants has revolutionized the medical management of DME (11). Indeed, these treatments result in a significant improvement in the bestcorrected visual acuity (BCVA) at 12 months in patients with DME (11).…”

Foveal Microvascular Integrity Association With Anti-VEGF Treatment Response for Diabetic Macular Edema

“…4 PRN regimen is commonly adopted. 15,17,18 However, frequent clinical visits for monitoring recurrence is needed. Recent treat-and-extend studies have showed that approximately 41% to 67% of patients were able to extend their injection interval to ≥16 weeks at two years, while other patients still required frequent injections in four to 12week intervals.…”