Vascular Endothelial Growth Factor and Diabetic Macular Edema

• Published in: Survey of ophthalmology 2016-11, Vol.61 (6), p.759-768
• Main Authors: Lally, David R., MD, Shah, Chirag P., MPH, MD, Heier, Jeffrey S., MD
• Format: Article
• Language: English
• Subjects: aflibercept; Angiogenesis Inhibitors - administration & dosage; bevacizumab; diabetes; diabetic macular edema; diabetic retinopathy; Diabetic Retinopathy - complications; Diabetic Retinopathy - epidemiology; Diabetic Retinopathy - metabolism; Fluorescein Angiography; Fundus Oculi; Global Health; Humans; Incidence; intravitreal anti-VEGF; Intravitreal Injections; Laser Coagulation; laser photocoagulation; Macular Edema - epidemiology; Macular Edema - etiology; Macular Edema - therapy; Ophthalmology; ranibizumab; retina; Retina - pathology; Tomography, Optical Coherence; vascular endothelial growth factor; Vascular Endothelial Growth Factor A - antagonists & inhibitors; Vascular Endothelial Growth Factor A - metabolism; VEGF; Visual Acuity
• ISSN: 0039-6257; 1879-3304
• DOI: 10.1016/j.survophthal.2016.03.010

Abstract Diabetes mellitus is a major global health epidemic, and diabetic macular edema (DME) is the leading cause of vision loss in this population. Macular focal and/or grid laser photocoagulation applied to microaneurysms and thickened retina had long been primary therapy for DME. Chronically elevated serum glucose is known to cause breakdown in the inner and outer retinal blood barrier resulting in up-regulation of vascular endothelial growth factor (VEGF). Intravitreal anti-VEGF agents, including ranibizumab, bevacizumab, and aflibercept, have been shown in randomized clinical trials to be superior to macular laser for the treatment of clinically relevant DME. The READ-2, RISE/RIDE, and RESTORE trials established ranibizumab’s superiority to macular laser, while the BOLT trial demonstrated bevacizumab’s superiority to laser. The DRCR.net Protocol T results showed that intravitreal aflibercept, bevacizumab and ranibizumab were all effective in reducing retinal thickness secondary to diabetic edema and in improving vision due to this cause. When the presenting vision was 20/40 or better, visual improvement was equivalent. With eyes presenting with 20/50 or worse vision, aflibercept was superior with respect to visual improvement. Intravitreal anti-VEGF therapy can be burdensome for the patient and healthcare system, often requiring monthly treatment visits. In order to reduce burdens, anti-VEGF strategies are in development to lengthen the treatment interval.