Differences in the characteristics of subjects achieving complete, partial, or no resolution of macular edema in the READ-3 study

Predictive impact of serous retinal detachment in refractory diabetic macular edema

BACKGROUND

Anti-vascular endothelial growth factor (VEGF) drugs are the first-line treatment option for DME management. However, part of DME was refractory to anti-VEGF medicine. With promotion of imaging technology, various retinal morphological characteristics are considered to be related to the prognosis of DME treatment. This study aimed to identify reliable predictive baseline morphological characteristics for refractory diabetic macular edema.

METHODS

This retrospective study was to investigate refractory diabetic macular edema and were followed up for 6 months post-treatment. According to the treatment results, the cohort was divided into refractory or improved group. Baseline morphological characteristics were evaluated and analyzed using optical coherence tomography.

RESULTS

Serous retinal detachment (63% vs. 25%, P < 0.05) and foveal eversion (77.8% vs. 41.7%, P < 0.05) are more common morphological characteristics in refractory DME than improved group. Binary logistic regression analysis showed average thickness of serous retinal detachment can predict the risk of refractory DME (OR = 1.052, 95% CI 1.005-1.102, P = 0.030). The area under the receiver operating characteristic curves for serous retinal detachment thickness was 0.922 (95% confidence interval 0.713-0.992).

CONCLUSION

Patients with refractory diabetic macular edema exhibited an increased incidence of baseline morphological characteristics, including serous retinal detachment and foveal eversion. The thickness of serous retinal detachment can serve as reliable quantitative biomarker, with diabetic macular edema displaying a serous retinal detachment thickness > 162 μm having a potential to become refractory in this study. This finding may promote early detection of refractory diabetic macular edema.

Hispanic Ethnicity and OCT-based Biomarkers as Predictive Factors of DME Refractory to Bevacizumab

BACKGROUND AND OBJECTIVE

While anti-vascular endothelial growth factor (anti-VEGF) therapy has revolutionized treatment for diabetic macular edema, many patients still manifest refractory disease. This study evaluated rates of diabetic macular edema (DME) refractory to intravitreal bevacizumab in a diverse real-world setting, with the aim of studying demographic and optical coherence tomography (OCT)-based morphological factors associated with refractory disease.

PATIENTS AND METHODS

This was a retrospective cohort study of patients receiving treatment. Refractory DME was defined as a gain in visual acuity of < 5 letters after three consecutive injections of bevacizumab or less than 20% reduction in central retinal thickness (CRT) after three consecutive injections of bevacizumab. OCT images from preand post-injection visits were reviewed by two independent image readers. Multivariate logistic regression analysis evaluated for statistical significance between responders and those refractory to bevacizumab, and between Hispanic and non-Hispanic groups.

RESULTS

Ninety-nine patients were included. Of the participants, 42% were Hispanic, 10% were reported as white, 11% were Asian, 11% were Black, and 26% were defined as "not reported." Fifty-four (54.5%) patients were refractory to bevacizumab and 45 were responders. Between responders and refractory patients, race was statistically significant (P = 0.04) with more refractory subjects found to be Hispanic (28/54, 51.9%). OCT morphologic characteristics (CRT, number of hyperreflective foci, disorganization of inner retinal layers, ellipsoid zone discontinuity, and sub-retinal fluid) were not statistically significant between responders and refractory subjects. Multivariate logistic regression demonstrated an odds ratio of 5.7 for refractory disease for Hispanics (CI 1.687 to 19.445, P = 0.01). When comparing Hispanics to non-Hispanics, Hispanics had an average lower baseline visual acuity, lower CSTs, and higher HbA1C.

CONCLUSIONS

Our study showed that Hispanics have a nearly 6 times relatively higher likelihood of refractory disease. There is a notable under-representation of these patients in completed clinical trials for diabetic retinopathy and DME. [Ophthalmic Surg Lasers Imaging Retina 2025;56:XX-XX.].

Exploring the role of retinal fluid as a biomarker for the management of diabetic macular oedema

Anti-VEGF therapies are associated with significant gains in visual acuity and fluid resolution in the treatment of diabetic macular oedema (DMO) and have become the standard of care. However, despite their efficacy, outcomes can be unpredictable, vary widely between individual eyes, and a large proportion of patients have persistent fluid following initial treatment, with a negative impact on visual outcomes. Anatomical parameters measured by optical coherence tomography (OCT), in addition to visual acuity, are key to monitoring treatment effectiveness and guiding retreatment decisions; however, existing guidelines on the management of DMO lack clear recommendations for interpretation of OCT parameters, or proposed thresholds of various markers to guide retreatment decisions. Although central subfield thickness (CSFT) has been widely used as a marker for retreatment decisions in clinical trials in DMO, and a reduction in CSFT has generally been shown to accompany improvements in best-corrected visual acuity with treatment, analyses of the relationship between these parameters show that the correlation is small to moderate. A more direct relationship can be seen between an increased magnitude of CSFT fluctuations over time and poorer visual acuity, suggesting that control of CSFT could be important in maximising visual outcomes. The relationship between visual outcomes and qualitatively assessed intraretinal fluid and subretinal fluid is also unclear, although quantitative assessments of fluid parameters suggest that untreated intraretinal fluid and subretinal fluid negatively impact visual outcomes. These findings highlight a need for clearer guidelines on the management of retinal fluid to improve visual outcomes for patients with DMO.

Multi-ancestry GWAS analysis identifies two novel loci associated with diabetic eye disease and highlights APOL1 as a high risk locus in patients with diabetic macular edema

Diabetic retinopathy (DR) is a common complication of diabetes. Approximately 20% of DR patients have diabetic macular edema (DME) characterized by fluid leakage into the retina. There is a genetic component to DR and DME risk, but few replicable loci. Because not all DR cases have DME, we focused on DME to increase power, and conducted a multi-ancestry GWAS to assess DME risk in a total of 1,502 DME patients and 5,603 non-DME controls in discovery and replication datasets. Two loci reached GWAS significance (p<5x10-8). The strongest association was rs2239785, (K150E) in APOL1. The second finding was rs10402468, which co-localized to PLVAP and ANKLE1 in vascular / endothelium tissues. We conducted multiple sensitivity analyses to establish that the associations were specific to DME status and did not reflect diabetes status or other diabetic complications. Here we report two novel loci for risk of DME which replicated in multiple clinical trial and biobank derived datasets. One of these loci, containing the gene APOL1, is a risk factor in African American DME and DKD patients, indicating that this locus plays a broader role in diabetic complications for multiple ancestries. Trial Registration: NCT00473330, NCT00473382, NCT03622580, NCT03622593, NCT04108156.

Persistent diabetic macular edema: Definition, incidence, biomarkers, and treatment methods

Intravitreal antivascular endothelial growth factor (anti-VEGF) treatment has drastically improved the visual and anatomical outcomes in patients with diabetic macular edema (DME); however, success is not always guaranteed, and a proportion of these eyes demonstrate persistent DME (pDME) despite intensive treatment. While standardized criteria to define these treatment-resistant eyes have not yet been established, many studies refer to eyes with no clinical response or an unsatisfactory partial response as having pDME. A patient is considered to have pDME if the retinal thickness improves less than 10-25% after 6 months of treatment. A range of treatment options have been recommended for eyes with pDME, including switching anti-VEGF agents, using corticosteroids and/or antioxidant drugs in adjunct with anti-VEGF therapy, and vitrectomy. In addition, multimodal imaging of DME eyes may be advantageous in predicting the responsiveness to treatment; this is beneficial when initiating alternative therapies. We explore the literature on persistent DME regarding its defining criteria, incidence, the baseline biological markers that may be useful in anticipating the response to treatment, and the available treatment options.

The Impact of Residual Retinal Fluid Following Intravitreal Anti-Vascular Endothelial Growth Factor Therapy for Diabetic Macular Edema and Macular Edema Secondary to Retinal Vein Occlusion: A Systematic Review

The association between residual retinal fluid and visual acuity for diabetic macular edema (DME) and macular edema (ME) secondary to retinal vein occlusion (RVO) is not well established. We conducted a systematic literature search for peer-reviewed articles reporting on visual acuity stratified by subretinal fluid (SRF), intraretinal fluid (IRF), or any retinal fluid at final follow-up after intravitreal anti-vascular endothelial growth factor therapy injection for treatment of DME or ME secondary to RVO. Two observational studies on ME secondary to RVO and one study for DME found no significant differences between eyes with and without residual retinal fluid for final BCVA. One randomized controlled trial (RCT) found that eyes with residual retinal fluid had significantly worse final best-corrected visual acuity in ME secondary to RVO, whereas another RCT found no significant difference for DME. There is a paucity of evidence examining the impact of residual retinal fluid on visual acuity in DME and ME secondary to RVO. The limited evidence suggests that aggressive fluid resolution is worthwhile. [Ophthalmic Surg Lasers Imaging Retina 2023;54:50-58.].

The Impact of Laboratory Findings and Optical Coherence Tomography Biomarkers on Response to Intravitreal Anti-VEGF Treatment in Patients with Diabetic Macular Edema

PURPOSE

To investigate potential laboratory and imaging biomarkers as treatment response predictors to intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents in patients with diabetic macular edema (DME).

METHODS

The study included 36 treatment naïve patients with DME, treated with intravitreal anti-VEGF agents and followed-up for 12 months. At baseline, all participants underwent best-corrected visual acuity (BCVA) measurement, dilated fundoscopy, optical coherence tomography, color fundus photography and fluorescein angiography, while full blood count and biochemical analysis of various parameters was also performed. At month 12, treatment response was examined and classified as "favorable" or "non-response". Potential associations between laboratory/imaging biomarkers and treatment response were assessed.

RESULTS

Univariate analysis showed that favorable response at month 12 after initiation of anti-VEGF treatment was correlated with baseline central subfield thickness (CST)≤405 μm (p < .001), absence of subretinal fluid (p = .034), absence of exudates (p = .041), absence of disorganization of the inner retinal layers (p = .037), intact ellipsoid zone (EZ) and external limiting membrane (ELM) (p < .001 and p = .002, respectively), absence of epiretinal membrane (ERM) (p = .040) and absence of macular ischemia (p = .042), while increased lipoprotein(a) was associated with no treatment response (p = .025). At the multivariate analysis, CST was found to be independent predictor of treatment response, while EZ, ELM and ERM were found to predict treatment response perfectly and they could not be entered in the model.

CONCLUSION

Intact EZ and ELM, absence of ERM and CST≤405 μm at baseline can predict favorable treatment response in patients with treatment naïve DME, while no correlation with baseline laboratory parameters was found.