In Diabetic Macular Edema, Steroids, Anti-VEGF Drugs Lead to Similar Outcomes

Compared with anti-vascular endothelial growth factor (VEGF) treatments, intravitreal steroid treatment does not significantly alter best-corrected visual acuity (BCVA) for patients with diabetic macular edema (DME). However, steroids do significantly decrease retinal thickness and increase risk for intraocular pressure (IOP)-related events compared with anti-VEGF injections, according to research published in Ophthalmology Retina.

Investigators from McMaster University and the University of Toronto in Canada included 14 studies of 827 eyes in the analysis.

The studies reported outcomes after treatment with bevacizumab (n=10), ranibizumab (n=2), ranibizumab or aflibercept (n=1), and bevacizumab or ranibizumab (n=1) compared with intravitreal triamcinolone acetonide (n=9) or intravitreal dexamethasone implant (n=5).

At the final follow-up (3-24 months), BCVA did not differ significantly between eyes that received intravitreal steroids compared with anti-VEGF agents (weighted mean difference [WMD], 0.00; 95% CI, -0.05 to 0.04; I², 54%; P =.91).

The final retinal thickness was significantly decreased in eyes that received intravitreal steroids compared with anti-VEGF agents (WMD, 39.99; 95% CI, 14.58-65.41 μm; I², 56%; P =.002). Similar observations were made in studies with 3- (P =.04) and 6- (P <.00001) month follow-ups, but no difference was observed for studies with a 12-month follow-up (P =.18).

The adverse event rate of IOP-related events was higher among patients who received intravitreal steroid injections compared with anti-VEGF agents (risk ratio [RR], 0.13; 95% CI, 0.05-0.34; I², 39%; P <.00001).

In contrast to the main results, in the subgroup analyses, BCVA at 3 months was greater in eyes that received triamcinolone acetonide compared with eyes that received anti-VEGF agents (WMD, 0.09; 95% CI, 0.05-0.13; I², 14%; P <.00001), eyes that received intravitreal steroids had better BCVA at 3 months compared with bevacizumab (WMD, 0.10; 95% CI, 0.07-0.13; I², 0%; P <.00001), BCVA at the final follow-up was poorer in eyes that received intravitreal steroids compared with ranibizumab (WMD, -0.11; 95% CI, -0.19 to -0.03; I², 0%; P =.009), and retinal thickness did not differ at 3 months between eyes that received dexamethasone implant or anti-VEGF agents (WMD, 10.90; 95% CI, -82.29 to 104.09; I², 59%; P =.82).

“Typically, first-line treatment for patients with DME is anti-VEGF treatment. However, in circumstances in which there is a poor response to anti-VEGF therapy or in pseudophakia, steroid treatments can be considered,” the researchers explain. “Previous recommendations have been made, suggesting that patients with DME undergoing cataract surgery may also be better suited for first line treatment with intravitreal steroids. Our analysis of published RCT data found no significant difference in the development and progression of cataracts between steroid and anti-VEGF treatment, despite the increased risk of cataract development as a result of intravitreal steroids that has been previously described.”

Disclosure: Multiple authors declared affiliations with the biotech, pharmaceutical, and/or device companies.. Please refer to the original article for a full list of disclosures.