Characterization of poor visual outcomes of DME treated with intravitreal injections


Patients treated early and aggressively with more intravitreal injections for diabetic macular edema (DME) are more likely to have better visual outcomes.

Study design

This is an observational study that included patients from Australia, France, Italy, New Zealand, Spain, Switzerland, and the United Kingdom. The goal was to ascertain the incidence, characteristics, and baseline predictors of poor visual outcomes in eyes with DME receiving intravitreal injections in routine clinical practice. Poor visual outcomes were defined as either (1) sustained vision loss of greater than 10 letters from baseline without recovery of visual acuity (VA), or (2) VA of less than 55 letters at 2 years. The control group was any eye that did not experience a poor outcome.


At 2 years, 14% of patients sustained a greater than 10 letter VA loss, and 16% of eyes had a VA of less than 55 letters at 2 years after starting intravitreal injections, demonstrating the persistent nonresponders to our current standard of care treatments. This study shows that eyes with a sustained loss of VA were less intensely treated compared with eyes without this significant VA loss. Other predictors of poor visual outcomes included initial treatment with intravitreal corticosteroids, no improvement in vision at 3 months after treatment initiation, older age, and poor baseline visual acuity.


A major limitation of this study is its observational design. In addition, pivotal parameters such as hemoglobin A1c and blood pressure were not recorded in this registry, and systemic control can affect DME response. Loss to follow-up may also have affected outcomes.

Clinical significance

This study demonstrates what we have seen in prior studies where eyes treated with fewer injections lose more vision. This reaffirms the need to continue to treat patients with DME more aggressively. In addition, the current study and prior studies suggest that eyes that do not improve after 3 months of treatment are more likely to have poor visual outcomes. There was also a subset of patients who were found to be slow responders. It is unclear whether the patients who were initially treated with intravitreal steroids had poor visual outcomes because of worse baseline disease. Identifying factors that predict a poor visual outcome can help guide treatment as well as patient expectations.

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