Anti-VEGF vs Steroids for DME

For intravitreal Anti-VEGF round:

Anti-VEGF therapy is an effective and safe for naive, denovo, and refractory DME. It is cost-effective using Bevacizumab, and you may gain better visual acuity outcomes by using Ranibizumab or Aflibercept in cases presented with worse visual acuity at baseline. In addition, intravitreal Anti-VEGF may improve DR status. Finally, there are promising results in newly approved Anti-VEGF agents in terms of the durability of the treatment.

For intravitreal steroids round:

In DME, beneficial gain of steroids is achieved by appropriate patient selection. The timing of injecting and switching from anti-VEGF agent to steroids may add durability and cost benefits but with an increased risk of IOP spikes and cataract.

For expert opinion round:

Whether to use anti-VEGF or steroids in a case of DME is an important question. An equally important question is when to shift from one agent to the other.

For verdict round (Rational Use):

• First-Line: Intravitreal Anti-VEGF as a first-line therapy for cases of central DME with BCVA 20/32.
• Loading Dose: Start with a loading dose of intravitreal Anti-VEGF for three to five injections four weeks apart (except for every six weeks).
• Follow-up: T&E (Treat and Extend) for Anti-VEGF.
• Second-Line: Intravitreal steroids are used as a second-line therapy for cases that are not responsive or/and contraindicated for intravitreal Anti-VEGF.
• Steroid Follow-up: PRN basis.
• Caveat: Keep in mind that intravitreal steroids may increase IOP and cataract formation.