Daniel F Kiernan, MD, FACS, describes a case of a 62-year-old-man with diabetic macular edema (DME) and nonproliferative diabetic retinopathy (NPDR).
Daniel F. Kiernan MD, FACS: Hello, I’m Dr Daniel Kiernan, a retina specialist at The Eye Associates in Sarasota, Bradenton and Venice, Florida. I’m excited to share 2 DME [diabetic macular edema] cases we discussed at a recent Ophthalmology Times®Roundtable. Patient case 1 is a 62-year-old gentleman referred by an outside optometrist for diabetic eye exam as the patient complains of decreased vision, wavy lines, and occasional floaters in both eyes. He does have a past medical history of type 1 diabetes for many years, although his A1C level is currently 6.4, so it is controlled. Medications are typical for a diabetic. On the first day of presentation, 9/27/21, visual acuity in the right eye is 20/80, 20/40 in the left. Normal intraocular pressures and the patient is phakic with a 2-plus nuclear sclerotic cataract, both eyes with dilated fundus exam showing hemorrhage, microaneurysms, and diabetic macular edema. Both eyes consistent with moderate NPDR [nonproliferative diabetic retinopathy] with DME-OU [oculus uterque]. On that same day of presentation, the OCT [optical coherence tomography] of the patient showed a fair amount of diabetic macular edema, left eye greater than the right eye. Because of the patient’s insurance plan, which was a commercial plan requiring step therapy, he was started on bevacizumab injections in both eyes with the plan to follow up for shot number 2 in 1 month. Here on Nov. 1, 2021, visual acuity is 20/70 in the right eye and 20/40 in the left. You can see a reduction, although persistent, diabetic macular edema in both eyes. This was Nov. 1, 2021, and then a month later, Nov. 29, 2021, visual acuity was 20/70 in the right eye and 20/30 in the left. Because of persistent edema and the visual acuity being what it was, aflibercept was requested initially, and approval was finally given because of the vision being worse than 20/40, and because the right eye qualified, the left eye also was approved for aflibercept, which was given on this date because of persistent disease activity and macular edema. A month later, on Dec. 27, 2021, visual acuity was 20/80 in the right and 20/50 in the left. You can see that there’s decreased but persistent fluid still, so aflibercept was given again in both eyes. Then a month later, on Jan. 31, 2022, visual acuity was 20/100 in the right, 20/50 in the left. There was decreased but still a little bit of persistent edema, especially in the right eye, so aflibercept once again given in both eyes. A month later, visual acuity was stable, 20/80 in the right, 20/30 in the left. The relatively dry appearing OCTs, just a little bit of intraretinal edema in the left eye. Aflibercept once again applied in both eyes. Then in April, the following month, April 18, 2022, visual acuity was 20/70 in the right, 20/40 in the left, and vision was improving in both eyes. The right vision is likely limited by cataract, and the cataract surgery discussion was had, but the patient defers any cataract evaluation. OCT was stable, so we decided to extend to every 12 week treatment intervals in both eyes. 12 weeks later, visual acuity is stable, 20/60 in the right, 20/30 in the left. And there was increased fluid but stable vision in the left eye, so we continued q12 week, or 3 month intervals. Ergo, 3 months later, vision was 20/60 in the right, 20/50 in the left. Intraretinal fluid was present, and the visual acuity had dropped in the left eye, so I decided to reduce the treatment interval and see the patient back about 4 to 5 weeks later. Vision stabilized and the edema improved, so we proceeded with the aflibercept shot just in the left. And we at this point felt that the patient had had maximum improvement and was stable, so we could continue the right eye being treated q12 weeks and the left eye q6 weeks.
Transcript edited for clarity