Approach Considerations

Diagnosis of diabetic macular edema (DME) is made by funduscopic examination. However, other studies can provide valuable information for guiding treatment and for long-term follow-up.

Optical coherence tomography (OCT) captures reflected light from retinal structures to create a cross-sectional image of the retina, which is comparable to histologic sections as seen with a light microscope. OCT demonstrates a moderate correlation between retinal thickness and best-corrected visual acuity, and it has been able to demonstrate three basic structural changes of the retina from diabetic macular edema: retinal swelling, cystoid edema, and serous retinal detachment.

OCT is not required to establish a diagnosis, and it is not prescribed by current practice guidelines; however, OCT has gained widespread acceptance as an additional modality to help identify and evaluate macular pathology.^[5]Quantitative measurement of macular thickness and subjective analysis of the foveal architecture allow a precise and reproducible way to monitor macular edema.

Fluorescein angiography does not aid in the diagnosis of clinically significant macular edema (CSME), but it should be performed if treatment of CSME is being considered. Fluorescein angiography distinguishes and localizes areas of focal versus diffuse leakage, thereby guiding the placement of laser photocoagulation. Note the proximity of the leakage to the foveal avascular zone.

Color stereo fundus photographs provide an opportunity to evaluate long-term changes in the retina.

Treatment & Management

Albert DM, Jakobiec FA. Principles and Practice of Ophthalmology. 2nd ed. Philadelphia: WB Saunders Co; 2000.
Aiello LP, Avery RL, Arrigg PG, Keyt BA, Jampel HD, Shah ST, et al. Vascular endothelial growth factor in ocular fluid of patients with diabetic retinopathy and other retinal disorders. N Engl J Med. 1994 Dec 1. 331(22):1480-7. [QxMD MEDLINE Link].
Sohn HJ, Han DH, Kim IT, et al. Changes in aqueous concentrations of various cytokines after intravitreal triamcinolone versus bevacizumab for diabetic macular edema. Am J Ophthalmol. 2011 Oct. 152(4):686-94. [QxMD MEDLINE Link].
National Diabetes Information Clearinghouse. National Diabetes Statistics, 2007. [Full Text].
Otani T, Kishi S, Maruyama Y. Patterns of diabetic macular edema with optical coherence tomography. Am J Ophthalmol. 1999 Jun. 127(6):688-93. [QxMD MEDLINE Link].
Early Treatment Diabetic Retinopathy Study Research Group. Treatment techniques and clinical guidelines for photocoagulation of diabetic macular edema. Early Treatment Diabetic Retinopathy Study Report Number 2. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. 1987 Jul. 94(7):761-74. [QxMD MEDLINE Link].
Chew EY, Klein ML, Ferris FL 3rd, Remaley NA, Murphy RP, Chantry K, et al. Association of elevated serum lipid levels with retinal hard exudate in diabetic retinopathy. Early Treatment Diabetic Retinopathy Study (ETDRS) Report 22. Arch Ophthalmol. 1996 Sep. 114(9):1079-84. [QxMD MEDLINE Link].
Bonini-Filho MA, Jorge R, Barbosa JC, Calucci D, Cardillo JA, Costa RA. Intravitreal injection versus sub-Tenon's infusion of triamcinolone acetonide for refractory diabetic macular edema: a randomized clinical trial. Invest Ophthalmol Vis Sci. 2005 Oct. 46(10):3845-9. [QxMD MEDLINE Link].
Jonas JB, Martus P, Degenring RF, Kreissig I, Akkoyun I. Predictive factors for visual acuity after intravitreal triamcinolone treatment for diabetic macular edema. Arch Ophthalmol. 2005 Oct. 123(10):1338-43. [QxMD MEDLINE Link].
Patelli F, Fasolino G, Radice P, Russo S, Zumbo G, DI Tizio FM, et al. Time course of changes in retinal thickness and visual acuity after intravitreal triamcinolone acetonide for diffuse diabetic macular edema with and without previous macular laser treatment. Retina. 2005 Oct-Nov. 25(7):840-5. [QxMD MEDLINE Link].
Avitabile T, Longo A, Reibaldi A. Intravitreal triamcinolone compared with macular laser grid photocoagulation for the treatment of cystoid macular edema. Am J Ophthalmol. 2005 Oct. 140(4):695-702. [QxMD MEDLINE Link].
Tucker M. FDA OKs Implant (Ozurdex) for Some With Diabetic Macular Edema. Medscape Medical News. Available at http://www.medscape.com/viewarticle/827594. Accessed: July 5, 2014.
Ozurdex (dexamethasone intravitreal implant) [package insert]. Irvine, CA: Allergan, Inc. September, 2014. Available at [Full Text].
Boyer DS, Yoon YH, Belfort R Jr, Bandello F, Maturi RK, Augustin AJ, et al. Three-year, randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with diabetic macular edema. Ophthalmology. 2014 Oct. 121(10):1904-14. [QxMD MEDLINE Link].
Reuters. Eye Implant Iluvien for Diabetic Macular Edema Clears FDA. Medscape Medical News. Available at http://www.medscape.com/viewarticle/832439. Accessed: October 6, 2014.
Campochiaro PA, Brown DM, Pearson A, Chen S, Boyer D, Ruiz-Moreno J, et al. Sustained delivery fluocinolone acetonide vitreous inserts provide benefit for at least 3 years in patients with diabetic macular edema. Ophthalmology. 2012 Oct. 119(10):2125-32. [QxMD MEDLINE Link].
Wykoff CC, Abreu F, Adamis AP, and the, YOSEMITE and RHINE Investigators. Efficacy, durability, and safety of intravitreal faricimab with extended dosing up to every 16 weeks in patients with diabetic macular oedema (YOSEMITE and RHINE): two randomised, double-masked, phase 3 trials. Lancet. 2022 Jan 21. [QxMD MEDLINE Link].
Massin P, Bandello F, Garweg JG, et al. Safety and efficacy of ranibizumab in diabetic macular edema (RESOLVE Study): a 12-month, randomized, controlled, double-masked, multicenter phase II study. Diabetes Care. 2010 Nov. 33(11):2399-405. [QxMD MEDLINE Link]. [Full Text].
Nguyen QD, Shah SM, Heier JS, et al. Primary End Point (Six Months) Results of the Ranibizumab for Edema of the mAcula in diabetes (READ-2) study. Ophthalmology. 2009 Nov. 116(11):2175-81.e1. [QxMD MEDLINE Link].
Lang G, RESTORE study group. Safety and efficacy of ranibizumab as monotherapy or adjunctive to laser photocoagulation in diabetic macular edema: 12-month results of the RESTORE study. Late-breaker presentation at EASDec Meeting. May 22, 2010.
Elman MJ, Aiello LP, Beck RW, et al. Randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. Ophthalmology. 2010 Jun. 117(6):1064-1077.e35. [QxMD MEDLINE Link]. [Full Text].
Elman MJ, Bressler NM, Qin H, et al. Expanded 2-Year Follow-up of Ranibizumab Plus Prompt or Deferred Laser or Triamcinolone Plus Prompt Laser for Diabetic Macular Edema. Ophthalmology. 2011 Apr. 118(4):609-14. [QxMD MEDLINE Link].
Elman MJ, Qin H, Aiello LP, Beck RW, Bressler NM, Ferris FL 3rd, et al. Intravitreal Ranibizumab for Diabetic Macular Edema with Prompt versus Deferred Laser Treatment: Three-Year Randomized Trial Results. Ophthalmology. 2012 Sep 19. [QxMD MEDLINE Link].
Nguyen QD, Brown DM, Marcus DM, Boyer DS, Patel S, Feiner L, et al. Ranibizumab for diabetic macular edema: results from 2 phase III randomized trials: RISE and RIDE. Ophthalmology. 2012 Apr. 119(4):789-801. [QxMD MEDLINE Link].
Maturi RK, Glassman AR, Liu D, and the, Diabetic Retinopathy Clinical Research Network. Effect of Adding Dexamethasone to Continued Ranibizumab Treatment in Patients With Persistent Diabetic Macular Edema: A DRCR Network Phase 2 Randomized Clinical Trial. JAMA Ophthalmol. 2018 Jan 1. 136 (1):29-38. [QxMD MEDLINE Link]. [Full Text].
Korobelnik JF, Do DV, Schmidt-Erfurth U, Boyer DS, Holz FG, Heier JS, et al. Intravitreal Aflibercept for Diabetic Macular Edema. Ophthalmology. 2014 Jul 8. [QxMD MEDLINE Link].
Ghorayeb G. Intravitreal aflibercept 8 mg for diabetic macular edema: Week 48 efficacy outcomes by baseline demographics in the phase 2/3 PHOTON trial (abstract). Presented at the 2023 ARVO Annual Meeting. New Orleans, LA. Investigative Ophthalmology & Visual Science. June 2023. 64(2727):[Full Text].
Cunningham ET Jr, Adamis AP, Altaweel M, Aiello LP, Bressler NM, D'Amico DJ, et al. A phase II randomized double-masked trial of pegaptanib, an anti-vascular endothelial growth factor aptamer, for diabetic macular edema. Ophthalmology. 2005 Oct. 112(10):1747-57. [QxMD MEDLINE Link].
Michaelides M, Kaines A, Hamilton RD, et al. A prospective randomized trial of intravitreal bevacizumab or laser therapy in the management of diabetic macular edema (BOLT study) 12-month data: report 2. Ophthalmology. 2010 Jun. 117(6):1078-1086.e2. [QxMD MEDLINE Link].
Rajendram R, Fraser-Bell S, Kaines A, Michaelides M, Hamilton RD, Esposti SD, et al. A 2-Year Prospective Randomized Controlled Trial of Intravitreal Bevacizumab or Laser Therapy (BOLT) in the Management of Diabetic Macular Edema: 24-Month Data: Report 3. Arch Ophthalmol. 2012 Apr 9. [QxMD MEDLINE Link].
Diabetic Retinopathy Clinical Research Network, Wells JA, Glassman AR, Ayala AR, Jampol LM, Aiello LP, et al. Aflibercept, bevacizumab, or ranibizumab for diabetic macular edema. N Engl J Med. 2015 Mar 26. 372 (13):1193-203. [QxMD MEDLINE Link].
Wells JA, Glassman AR, Ayala AR, et al. Aflibercept, bevacizumab or ranibizumab for diabetic macular edema: two-year results from comparative effectiveness randomized clinical trial. Ophthalmology. June 2016. 123(6):1351-1359. [QxMD MEDLINE Link]. [Full Text].
Baker CW, Glassman AR, Beaulieu WT, Antoszyk AN, Browning DJ, Chalam KV, et al. Effect of Initial Management With Aflibercept vs Laser Photocoagulation vs Observation on Vision Loss Among Patients With Diabetic Macular Edema Involving the Center of the Macula and Good Visual Acuity: A Randomized Clinical Trial. JAMA. 2019 May 21. 321 (19):1880-1894. [QxMD MEDLINE Link].
Diabetic Retinopathy Clinical Research Network. A randomized trial comparing intravitreal triamcinolone acetonide and focal/grid photocoagulation for diabetic macular edema. Ophthalmology. 2008 Sep. 115(9):1447-9, 1449.e1-10. [QxMD MEDLINE Link]. [Full Text].
O'Day R, Barthelmes D, Zhu M, Wong TY, McAllister IL, Arnold JJ, et al. Baseline central macular thickness predicts the need for retreatment with intravitreal triamcinolone plus laser photocoagulation for diabetic macular edema. Clin Ophthalmol. 2013. 7:1565-70. [QxMD MEDLINE Link]. [Full Text].
Hsu J. Drug delivery methods for posterior segment disease. Curr Opin Ophthalmol. 2007 May. 18(3):235-9. [QxMD MEDLINE Link].
Lewis H, Abrams GW, Blumenkranz MS, Campo RV. Vitrectomy for diabetic macular traction and edema associated with posterior hyaloidal traction. Ophthalmology. 1992 May. 99(5):753-9. [QxMD MEDLINE Link].
Tachi N, Ogino N. Vitrectomy for diffuse macular edema in cases of diabetic retinopathy. Am J Ophthalmol. 1996 Aug. 122(2):258-60. [QxMD MEDLINE Link].
Fong DS, Segal PP, Myers F, Ferris FL, Hubbard LD, Davis MD. Subretinal fibrosis in diabetic macular edema. ETDRS report 23. Early Treatment Diabetic Retinopathy Study Research Group. Arch Ophthalmol. 1997 Jul. 115(7):873-7. [QxMD MEDLINE Link].
Takagi H, Otani A, Kiryu J, Ogura Y. New surgical approach for removing massive foveal hard exudates in diabetic macular edema. Ophthalmology. 1999 Feb. 106(2):249-56; discussion 256-7. [QxMD MEDLINE Link].

Media Gallery

of 0

Author

Emmanouil Mavrikakis, MD, PhD Ophthalmologist-in-Chief, Consultant Vitreoretinal Surgeon, Ophthalmology Department, G Gennimatas Athens General Hospital, Greece

Emmanouil Mavrikakis, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, European Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Baseer U Khan, MD Associate Professor of Ophthalmology, University of Toronto Faculty of Medicine; Ophthalmologist, Clarity Eye Institute, Canada

Baseer U Khan, MD is a member of the following medical societies: Canadian Ophthalmological Society

Disclosure: Nothing to disclose.

Wai-Ching Lam, MD, FRCSC Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine, Canada

Wai-Ching Lam, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, Canadian Ophthalmological Society, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Novartis for speaking and teaching; Received honoraria from Allergan for review panel membership; Received honoraria from Alcon for review panel membership; Received honoraria from Bayer for consulting; Received honoraria from Alcon for review panel membership; Received honoraria from Novartis for review panel membership.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steve Charles, MD Founder and CEO of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine

Disclosure: Received royalty and consulting fees for: Alcon Laboratories.

Chief Editor

Andrew A Dahl, MD, FACS Assistant Professor of Surgery (Ophthalmology), New York College of Medicine (NYCOM); Director of Residency Ophthalmology Training, The Institute for Family Health and Mid-Hudson Family Practice Residency Program; Staff Ophthalmologist, Telluride Medical Center

Andrew A Dahl, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Intraocular Lens Society, American Medical Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Medical Society of the State of New York, New York State Ophthalmological Society, Outpatient Ophthalmic Surgery Society

Disclosure: Nothing to disclose.

Macular Edema in Diabetes Workup

Approach Considerations

References

Tables

Contributor Information and Disclosures

What would you like to print?