Medication Summary
Several medications are indicated for treatment of diabetic retinopathy. At present, these medications are administered into the eye by intravitreal injection. [50, 51]
Intravitreal triamcinolone, a steroid, is being used in the treatment of diabetic retinopathy and diabetic macular edema. A Diabetic Retinopathy Clinical Research Network (DRCR.net) clinical trial demonstrated that although some reduction in macular edema occurred after intravitreal triamcinolone, this effect was not as robust as that achieved with focal laser treatment at the primary endpoint of 2 years. [16] In addition, intravitreal triamcinolone can have some adverse effects, including steroid response with intraocular pressure increase and cataracts.
Other steroids used against diabetic macular edema include dexamethasone and fluocinolone acetonide. A retrospective study by Nikolopoulou et al reported that in patients with center-involving macular edema complicating diabetic retinopathy, treatment with an intravitreal dexamethasone implant had by 2 months post injection significantly improved best corrected visual acuity and central macular thickness. The improvement occurred in both treatment-naïve and previously treated patients. No significant changes were found in the foveal avascular zone area and retinal vascular density. [52]
Other medications used in clinical practice and in clinical trials include intravitreal aflibercept (Eylea, Eylea HD), ranibizumab (Lucentis), brolucizumab (Beovu), or faricimab (Vabysmo). These medications are VEGF antibodies and antibody fragments, respectively. They can help to reduce diabetic macular edema and neovascularization of the disc or retina. Combinations of some of these medications with focal laser treatment have been investigated in the DRCR.net clinical trials and have proven efficacious, as previously described.
Corticosteroids
Class Summary
Corticosteroids inhibit inflammatory responses. They inhibit processes associated with inflammation such as edema, fibrin deposition, capillary dilation, deposition of collagen, leukocyte migration, and fibroblast and capillary proliferation.
Triamcinolone acetonide (Triesence)
Triamcinolone is a synthetic corticosteroid with anti-inflammatory effects. It is indicated for several ophthalmic diseases such as ocular inflammatory conditions and visualization during vitrectomy. Intravitreal triamcinolone is also being used in the treatment of diabetic macular edema.
Ophthalmics, VEGF Inhibitors
Class Summary
These agents can help reduce diabetic macular edema and neovascularization of the disc or retina.
Ranibizumab intravitreal injection (Lucentis, Byooviz, Cimerli)
Ranibizumab is a recombinant humanized monoclonal antibody indicated for all forms of diabetic retinopathy (ie, with or without diabetic macular edema). It is also indicated for neovascular (wet) age-related macular degeneration (AMD), macular edema following retinal vein occlusion, myopic choroidal neovascularization, and diabetic macular edema. It prevents the interaction of VEGF-A with its receptors (VEGFR1 and VEGFR2), thereby suppressing neovascularization, endothelial cell proliferation, and vascular leakage.
Aflibercept intravitreal (Eylea, Eylea HD)
Aflibercept is a recombinant decoy VEGF receptor that competes for ligand binding with the endogenous VEGFR 1 and 2 receptors to prevent angiogenesis. It is indicated for all stages of diabetic retinopathy. It is also indicated for neovascular (wet) AMD, macular edema following retinal vein occlusion, and diabetic macular edema. Following the administration of three once-monthly loading doses, the patient receives maintenance doses, the frequency of which depends on which product is being administered (ie, original formulation or high-dose).
Brolucizumab intravitreal (Beovu)
Indicated for neovascular (wet) AMD, macular edema following retinal vein occlusion, and diabetic macular edema.
Faricimab (Vabysmo)
Indicated for treatment of diabetic macular edema. It is also indicated for neovascular (wet) AMD.
-
Fundus photograph of early background diabetic retinopathy showing multiple microaneurysms.
-
Retinal findings in background diabetic retinopathy, including blot hemorrhages (long arrow), microaneurysms (short arrow), and hard exudates (arrowhead).
-
Fluorescein angiogram demonstrating an area of capillary nonperfusion (arrow).
-
Fluorescein angiogram demonstrating foveal dye leakage caused by macular edema.
-
Fundus photograph of clinically significant macular edema demonstrating retinal exudates within the fovea.
-
New vessel formation on the surface of the retina (neovascularization elsewhere)
-
An area of neovascularization that leaks fluorescein on angiography.
-
Boat-shaped preretinal hemorrhage associated with neovascularization elsewhere.
-
Fibrovascular proliferations within the vitreous cavity
-
Extensive fibrovascular proliferations within and around the optic disc
