Daniel F Kiernan, MD, FACS, reviews a case of a 49-year-old man with DME with extensive edema and high-risk proliferative diabetic retinopathy (PDR).
Daniel F. Kiernan MD, FACS:The second case of a 49-year-old gentleman referred by an outside optometrist for diabetic macular edema, complaining of blurred vision in both eyes for the last 6 months, much worse in the last 3 months, leading to a disability claim as a matter of fact. Past medical history of type 2 diabetes for 10 years. And this gentleman’s hemoglobin A1C is not under control at 10.5. Visual acuity without correction in both eyes was 20/200 with pinhole improvement to 20/60, though he claims that glasses don’t help. Normal pressures. There’s a history of hypertension that’s not quite under control and is on commercial insurance. This image on the slide is representative of both eyes. You can see a ton of intraretinal and subretinal edema on the OCT [optical coherence tomography] and multiple microaneurysms with light paramacular leakage in the left eye. This person was diagnosed with extensive macular edema OU, and active high risk proliferative diabetic retinopathy in both eyes. Treatment commenced July through September 2021. You can see on July 12, he was given bevacizumab in both eyes. Then he underwent PRP [panretinal photocoagulation] in both eyes in subsequent weeks. On Aug. 9, he was also given a second shot of bevacizumab. There, shown on these images, Aug. 23, his vision was 20/80 in the right, 20/150 in the left. Still had a lot of fluid, unresponsive to the initial 2 shots of bevacizumab. Nevertheless, because of the mandates of step therapy, was given a third shot, with very little effect, as seen on the below image. On Sept. 27, vision was still 20/80 in the right, 20/200 in the left, so he was switched to a different product, ranibizumab, 0.3 mg given in both eyes. The following slide shows, November 2021, that he still had persistent edema in spite of the injection of ranibizumab. There may have been a slight delay in that treatment for one reason or another. And at this point in time, I opted to treat him with a dexamethasone intravitreal implant in both eyes. And 2 months later, as you can see, he returned with near-resolution of the macular edema and a vast improvement of vision in both eyes. In order to continue with the combination therapy, since he obviously did well with the initial dexamethasone implant, I proceeded with ranibizumab in both eyes, asked him to follow up in about a month’s time. Unfortunately, he did not. He was a bit noncompliant and did not follow up until April 4, where he had a major recurrence of the macular edema in both eyes, and a drop in the vision to 20/60 in the right eye and 20/200 in the left eye. We switched to aflibercept in both eyes and saw him back about 2 months later, on June 13, 2022. We could see the edema improved greatly, and the vision also stabilized to 20/50 in the right eye and 20/80 in the left eye. We continued him on maintenance doses of aflibercept in both eyes, and the patient continues that every 8 weeks to maintain a fluid-free macula.
Transcript edited for clarity