Anti-VEGF therapy for the long-term management of diabetic macular edema: a treat-to-target strategy based on macular morphology

In an aging population, the prevalence and burden of diabetes mellitus, diabetic retinopathy, and vision-threatening diabetic macular edema (DME) are only expected to rise around the world. Similarly to other complications of diabetes mellitus, DME requires long-term management. This article aims to review the current challenges associated with the long-term management of DME, opportunities to improve outcomes for patients, and to develop a treat-to-target strategy based on macular morphology. At present, intravitreal anti-vascular endothelial growth factor (VEGF) therapy is the standard of care for the management of DME; however, best-achievable vision outcomes with treatment are reliant on frequent injections and close monitoring, which are difficult to maintain in current clinical practice because of the burden this imposes on patients. Achieving and maintaining good vision with treatment are the most important factors for patients with DME. Landmark trials have shown that vision gains with anti-VEGF therapy are typically accompanied by anatomical improvements (e.g., reductions in retinal thickness); therefore, multimodal imaging measures of macular morphology are often used in patients with DME to guide real-world treatment decisions. We would like to propose a hypothetical treat-to-target algorithm to guide physicians on treatment strategies for the long-term management of DME. Alternative measures of retinal fluid (e.g., persistence, stability, location) may be stronger predictors of visual acuity in DME, although further research is required to confirm whether alternate quantifiable biomarkers such as subretinal fluid and intraretinal fluid volumes can be used as a biomarker of clinical improvement. Identifying novel biomarkers and treatments that target neuroinflammation and neurodegeneration, improving patient-physician communication around treatment adherence, and using treat-to-target measures may help to ensure that the long-term benefits of treatment are realized. What is known:center dot Intravitreal anti-vascular endothelial growth factor (VEGF) therapy is the standard of care for patients with diabetic macular edema (DME); however, the burden of frequent injections is a key reason why real-world vision outcomes are often inferior to those reported in clinical trials.center dot There is increasing evidence that the persistence, stability, and location of retinal fluid may be stronger predictors of visual acuity in DME; and that achieving rapid, stable, and sustained fluid control with anti-VEGF treatment could be an important treatment goal with the aim of improving longer-term outcomes.What is new:center dot A hypothetical treat-to-target algorithm to guide physicians on treatment paths for the long-term management of DME was proposed.center dot Introducing a treat-to-target strategy, which sets treatment targets based on factors such as intraretinal fluid volume, and involves selecting customized treatment regimens and conducting regular assessments, could improve the future management of DME.