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Shall we stay, or shall we switch? Continued anti-VEGF therapy versus early switch to dexamethasone implant in refractory diabetic macular edema

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Abstract

Aims

To compare functional and anatomical outcomes of continued anti-vascular endothelial growth factor (VEGF) therapy versus dexamethasone (DEX) implant in eyes with refractory diabetic macular edema (DME) after three initial anti-VEGF injections in a real-world setting.

Methods

To be included in this retrospective multicenter, case–control study, eyes were required: (1) to present with early refractory DME, as defined by visual acuity (VA) gain ≤ 5 letters or reduction in central subfield thickness (CST) ≤ 20%, after a loading phase of anti-VEGF therapy (three monthly injections) and (2) to treat further with (a) anti-VEGF therapy or (b) DEX implant. Main outcome measures were change in visual acuity (VA) and central subfield thickness (CST) at 12 months. Due to imbalanced baseline characteristics, a matched anti-VEGF group was formed by only keeping eyes with similar baseline characteristics as those in the DEX group.

Results

A total of 110 eyes from 105 patients were included (anti-VEGF group: 72 eyes, DEX group: 38 eyes). Mean change in VA at 12 months was − 0.4 ± 10.8 letters (anti-VEGF group), and + 6.1 ± 10.6 letters (DEX group) (P = 0.004). Over the same period, mean change in CST was + 18.3 ± 145.9 µm (anti-VEGF group) and − 92.8 ± 173.6 µm (DEX group) (P < 0.001). Eyes in the DEX group were more likely to gain ≥ 10 letters (OR 3.71, 95% CI 1.19–11.61, P = 0.024) at month 12.

Conclusions

In a real-world setting, eyes with DME considered refractory to anti-VEGF therapy after three monthly injections which were switched to DEX implant and had better visual and anatomical outcomes at 12 months than those that continued treatment with anti-VEGF therapy.

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Author notes

  1. Matias Iglicki and Matus Rehak contributed equally.

Authors and Affiliations

  1. Department of Ophthalmology, University Hospital Leipzig, Liebigstr. 10-14, 04103, Leipzig, Germany

    Catharina Busch & Matus Rehak

  2. Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

    Dinah Zur, Isaac Hindi & Anat Loewenstein

  3. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

    Dinah Zur, Isaac Hindi & Anat Loewenstein

  4. Department of Ophthalmology, Sydney University, Sydney, Australia

    Samantha Fraser-Bell

  5. Faculty of Medicine, University of Coimbra, Coimbra, Portugal

    Inês Laíns

  6. Association for Innovation and Biomedical Research on Light, Coimbra, Portugal

    Inês Laíns & Ana Rita Santos

  7. Massachusetts Eye and Ear, Harvard Medical School, Boston, USA

    Inês Laíns

  8. School of Allied Health Technologies, Polytechnic Institute of Porto, Porto, Portugal

    Ana Rita Santos

  9. Section of Ophthalmology, Department of Biomedical and Surgical Sciences, University of Perugia, Perugia, Italy

    Marco Lupidi & Carlo Cagini

  10. Ophthalmology Department, Dijon University Hospital, Dijon, France

    Pierre-Henry Gabrielle

  11. Center for Taste and Feeding Behaviour, INRA, UMR1324, Dijon, France

    Pierre-Henry Gabrielle

  12. Department of Ophthalmology, Hôpital Lariboisière, AP-HP, Université Paris 7, Sorbonne Paris Cité, Paris, France

    Aude Couturier & Valérie Mané-Tauty

  13. Department of Surgical, Microsurgical and Medical Sciences, Eye Clinic, University of Sassari, Sassari, Italy

    Ermete Giancipoli & Giuseppe D’Amico Ricci

  14. Department of Biomedical Sciences, University of Sassari, Sassari, Italy

    Ermete Giancipoli & Giuseppe D’Amico Ricci

  15. Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey

    Zafer Cebeci

  16. Instituto de Oftalmología y Ciencias Visuales, Escuela de Medicina, Tecnológico de Monterrey, Monterrey, Mexico

    Patricio J. Rodríguez-Valdés

  17. Retina Division, Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

    Voraporn Chaikitmongkol

  18. Department of Ophthalmology, Faculty of Medicine, Rajavithi Hospital, Rangsit University, Bangkok, Thailand

    Atchara Amphornphruet

  19. L.V. Prasad Eye Institute, Banjara Hills, Hyderabad, India

    Kushal Agrawal & Jay Chhablani

  20. Incumbent, Sydney A. Fox Chair in Ophthalmology, Tel Aviv University, Tel Aviv, Israel

    Anat Loewenstein

  21. Private Retina Service, University of Buenos Aires, Buenos Aires, Argentina

    Matias Iglicki

Authors
  1. Catharina Busch
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  2. Dinah Zur
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Consortia

For the International Retina Group

Contributions

AL: consultant for Allergan. CB, DZ, SF-B, IL, ML, P-HG, AC, EG, ZC, PJR-V, VC, AA, JC, MI, and MR receive travel support by Allergan.

Corresponding author

Correspondence to Catharina Busch.

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Conflict of interest

The authors declare that they have no competing interests.

Ethical approval

Institutional review board (IRB) approval was obtained through the individual IRBs at the participating institutes for a retro-spectiveconsecutive chart review. The research adhered to the tenets the Declaration of Helsinki.

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The Statement of human and animal rights in this article is not correct, because it does contain studies with human subjects performed by the authors.

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Busch, C., Zur, D., Fraser-Bell, S. et al. Shall we stay, or shall we switch? Continued anti-VEGF therapy versus early switch to dexamethasone implant in refractory diabetic macular edema. Acta Diabetol 55, 789–796 (2018). https://doi.org/10.1007/s00592-018-1151-x

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  • DOI: https://doi.org/10.1007/s00592-018-1151-x

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