clinical science use of corticosteroids in the treatment ... · treatment decision when patient has...

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April 2017 · Vol. 48, No. 4 291

Use of Corticosteroids in the Treatment of Patients With Diabetic Macular Edema Who Have a Suboptimal Response to Anti-VEGF: Recommendations of an Expert Panel

Carl D. Regillo, MD; David G. Callanan, MD; Diana V. Do, MD; Howard F. Fine, MD, MHSc; Nancy M. Holekamp, MD; Baruch D. Kuppermann, MD, PhD; Michael A. Singer, MD; Rishi P. Singh, MD

BACKGROUND AND OBJECTIVE: Guidance on the use of corticosteroids in the treatment of diabetic macular edema (DME) is lacking. This study aimed to develop a clinically recommended treatment paradigm for DME with emphasis on the role of corticosteroids.

PATIENTS AND METHODS: An expert panel of nine reti-nal specialists in the United States developed consensus recommendations for DME treatment through a modi-fied Delphi process.

RESULTS: The panelists typically use intravitreal injec-tions of vascular endothelial growth factor (VEGF) antag-onists as first-line treatment of DME and switch patients with an inadequate response to anti-VEGF therapy (fail-ure of best-corrected visual acuity to improve to 20/40 or better because of edema after three to six monthly in-jections, or a less-than-50% reduction in excess macular thickness after three to four monthly injections) to intra-vitreal corticosteroid treatment.

CONCLUSION: Intravitreal corticosteroids have a poten-tially useful role in the treatment of patients with DME who have an inadequate response to intravitreal anti-VEGF therapy.

[Ophthalmic Surg Lasers Imaging Retina. 2017;48:291-301.]

From the Retina Service of Wills Eye Hospital, Mid Atlantic Retina, Philadelphia (CDR); Texas Retina Associates, Arlington, Texas (DGC); Byers Eye Institute, Stanford Uni-versity School of Medicine, Palo Alto, CA (DVD); NJ Retina, New Brunswick, NJ (HFF); Rutgers UMDNJ Department of Ophthalmology, New Brunswick, NJ (HFF); Pepose Vision Institute, Chesterfield, MO (NMH); Gavin Herbert Eye Institute, University of California, Irvine, CA (BDK); Medical Center Ophthalmology Associates, San Antonio, TX (MAS); Cole Eye Institute, Cleveland (RPS).© 2017 Regillo, Callanan, Do, et al.; licensee SLACK Incorporated. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 Interna-tional (https://creativecommons.org/licenses/by/4.0). This license allows users to copy and distribute, to remix, transform, and build upon the article, for any purpose, even commercially, provided the author is attributed and is not represented as endorsing the use made of the work.Originally submitted February 7, 2017. Revision received March 15, 2017. Accepted for publication March 20, 2017.

This study was sponsored by Allergan plc, Dublin, and conducted by Endpoint Outcomes, Boston, MA. The study sponsor had the opportunity to review the manuscript but could not make changes in the manuscript; the content of the manuscript was fully controlled by and approved by the authors.The authors report no proprietary interests in the products described in the article. Dr. Regillo is a consultant for Alcon, Allergan, Bayer, Genentech, Iconic, and Novartis and has received research grant support from Accucela, Alcon, Alimera, Allergan, Bayer, Genentech, GSK, Iconic, Novartis, Ophthotech, and Regeneron. Dr. Callanan is a consultant for AbbVie, Alcon, Allergan, Allgenesis, Forsight, Graybug, Regeneron, pSivida, and Santen. Dr. Do is a consultant for Allergan, Genentech, and Santen and has received research funding from Allergan, Genentech, Regeneron, and Santen. Dr. Fine is a consultant for Alimera, Allergan, Genentech, and Regeneron and has received research grant support from Alcon, Alimera, Allergan, Genentech, GSK, and Regeneron. Dr. Holekamp is a consultant for Alimera Sciences, Allergan, Genentech, Katalyst, Novartis, and Regeneron and has received research grant support from Alimera Sciences, Allergan, Genentech, and Opthotech. Dr. Kuppermann is a consultant for Acucela, Aerpio, Alcon, Alimera, Allegro, Allergan, Ampio, Catalyst, Dose, Eleven Biotherapeutics, Genentech, Glaukos, Lumenis, Novartis, Ophthotech, Regeneron, and ThromboGenics and has received research grant support from Alcon, Alimera, Allegro, Allergan, Apellis, Genentech, GSK, J-Cyte, Neurotech, Ohr, Ophthotech, Regeneron, and ThromboGenics. Dr. Singer is a consultant for Aerpio, Alimera, Allergan, Ampio, Genentech, and Santen and has received research grant support from Acucela, Aerpio, Alcon, Alimera, Allergan, Ampio, Genentech, Ophthotech, and Regeneron. Dr. Singh is a consultant for Alcon, Genentech, Optos, Regeneron, Shire, and Zeiss and has received research grant support from Alcon, Apellis, Ophthotech, Regeneron, and Roche.The authors thank Chris Evans, Nate Johnson, and Nicole Lyn of Endpoint Outcomes for their contributions to the study. Writing and editorial assistance was provided to the authors by Kate Ivins, PhD, of Evidence Scientific Solutions, Philadelphia, and funded by Allergan plc. All authors met the ICMJE authorship criteria. Neither honoraria nor pay-ments were made for authorship.Address correspondence to Carl D. Regillo, MD, Wills Eye Hospital, 840 Walnut Street, Suite 1020, Philadelphia, PA 19107; email: [email protected].

doi: 10.3928/23258160-20170329-03

EXPEDITED REVIEW

INTRODUCTION

Diabetic macular edema (DME) is character-ized by accumulation of fluid and retinal thicken-ing within the macula. The pathogenesis of DME is multifactorial. Vascular endothelial growth factor (VEGF) has a central role in the breakdown of the blood-retinal barrier that leads to DME,1 but other pro-inflammatory factors and processes also appear to be involved.2,3 DME is the most common cause of vision loss in patients with diabetes.4 It is estimated to affect approximately one in 25 individuals with diabetes older than age 40 in the United States,5 and the number of cases of DME can be expected to increase because of the growing prevalence of dia-betes and its complications.6

The American Academy of Ophthalmology Pre-ferred Practice Patterns-recommended first-line treatment for center-involved DME is intravitreal anti-VEGF therapy, with or without adjunct focal laser treatment.7 Ranibizumab 0.3 mg (Lucentis; Ge-nentech, South San Francisco, CA) and aflibercept 2 mg (Eylea; Regeneron, Tarrytown, NY) are U.S. Food and Drug Administration (FDA)-approved anti-VEGF treatments for DME. Bevacizumab 1.25 mg (Avastin; Genentech, South San Francisco, CA)

292 Ophthalmic Surgery, Lasers & Imaging Retina | Healio.com/OSLIRetina

is commonly used via an intravitreal injection in an off-label fashion for treatment of DME; a for-mulation approved for systemic cancer therapy is repackaged in syringes by a compounding pharmacy for off-label intravitreal ophthalmic use. Many studies have demonstrated that intravitreal anti-VEGF treat-ment has a favorable tolerability profile and is effective in reducing central retinal thickness and improving best-corrected visual acuity (BCVA) in patients with DME.8 Even with monthly administration of anti-VEGF, however, the response to anti-VEGF therapy is subop-timal in a substantial proportion of patients.9-11 After 2 years of monthly ranibizumab 0.3 mg injections for the treatment of DME in the RISE/RIDE registration trials, central foveal thickness remained greater than 250 µm on time-domain optical coherence tomography (OCT) in 24.8% of patients, and BCVA was worse than 20/40 in 42.8% of patients.9

Corticosteroids are also available for the treatment of DME. Although intraocular corticosteroid treatment is commonly associated with adverse effects of cataract and increases in intraocular pressure (IOP), intravitreal corticosteroids have demonstrated efficacy in improv-ing central retinal thickness and BCVA in DME and, therefore, are viable treatment options.7,12,13 In the Unit-ed States, dexamethasone intravitreal implant 0.7 mg (DEX implant) (Ozurdex; Allergan plc, Dublin, Ireland) is FDA-approved for treatment of DME, and intravitreal fluocinolone acetonide insert (FAc) (Iluvien; Alimera Sciences, Alpharetta, GA) is approved for treatment of DME in patients who have been previously treated with a course of corticosteroids and did not have a clini-cally significant rise in IOP. In addition, intravitreal tri-amcinolone acetonide (TA) has been used off-label for many years and has demonstrated beneficial effects in patients with DME.14

Figure. Recommended treatment paradigm for center-involved DME. BCVA = best-corrected visual acuity; DME = diabetic macular edema; VEGF = vascular endothelial growth factor.

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TABLE 1

Delphi Panel Consensus on Issues in the Treatment of DMEIssue Consensus Opinion/Recommendation

Classification of DME Center-involved or non-center-involved

First-line treatment for center-involved DME Intravitreal anti-VEGF injections

Ideal response to anti-VEGF treatment 1. Resolution of edema (primary)

2. Improvement in visual acuity (secondary)

Most important factor contributing to different levels of patient response to anti-VEGF

The balance of VEGF versus other inflammatory cytokines

Second most important factor contributing to different levels of patient response to anti-VEGF

The chronicity of the DME

Long-term DME Results in poorer outcomes

Treatment decision when early response to anti-VEGF (after three or more injections) is suboptimal

Switch to a different anti-VEGF agent if initial anti-VEGF agent was not the most efficacious available

Definition of inadequate response to anti-VEGF therapy

BCVA worse than 20/40 after three to six monthly anti-VEGF injections because of edema, or less-than-50% reduction in excess macular thickness after three to four monthly anti-VEGF injections

How long to tolerate persistent edema 4 to 6 months

Reasons to incorporate additional treatment modali-ties beyond anti-VEGF

1. Fluid still present on the retina

2. Lack of anatomical improvement (eg, CRT)

3. Lack of improvement in BCVA

4. Monthly injections are too burdensome (ie, poor compli-ance)

Reasons to potentially consider switching or stopping anti-VEGF treatment

1. Fluid still present on the retina

2. Lack of anatomical improvement (eg, CRT)

3. Lack of improvement in BCVA

4. Monthly injections are too burdensome (ie, poor compli-ance)

5. Recent stroke or cardiovascular event

Importance of treating the inflammatory versus the VEGF component of DME

More important to treat the inflammatory component after a suboptimal response to anti-VEGF therapy

Treatment decision when patient has an inadequate response to anti-VEGF therapy

Switch to a corticosteroid (consensus choice is DEX implant)

Choice of corticosteroid FDA-approved corticosteroid is preferred

Use of macular laser in center-involved DME Laser used as adjunct (not rescue) treatment

Frequency of monitoring 1. Monthly for patients on anti-VEGF

2. Every 1 to 2 months for patients on corticosteroid

3. Every 1 to 2 months for patients newly on combination of anti-VEGF and corticosteroid

4. Every 2 months for patients established on combination of anti-VEGF and corticosteroid

Management of IOP increases during corticosteroid treatment

1. Treat elevated IOP of 30 mm Hg or less with topical IOP-low-ering medication (single medication or fixed combination)

2. For patients with IOP higher than 30 mm Hg, treat with fixed-combination IOP-lowering eye drop and/or refer the patient to a glaucoma specialist

BCVA = best-corrected visual acuity; CRT = central retinal thickness; DEX implant = dexamethasone intravitreal implant; DME = diabetic macular edema; FDA = U.S. Food and Drug Administration; IOP = intraocular pressure; VEGF = vascular endothelial growth factor


There is a need for guidelines on how DME should be treated to provide patients with the best possible outcomes when the response to anti-VEGF therapy is inadequate. To address this need, a panel of clin-ical experts in retinal ophthalmology was brought together to develop consensus recommendations for DME treatment through a modified Delphi pro-cess. The objective was to develop a clinically rec-ommended treatment paradigm for DME, with par-ticular focus on how corticosteroids fit within the treatment paradigm.

PATIENTS AND METHODS

The Delphi technique is a widely used and ac-cepted method for building consensus from experts in a field through iterations of a survey and anony-mous feedback; in each round of the survey, the par-ticipants review and assess the results and feedback from the previous round, then respond to the survey again, and the process is repeated until consensus is reached.15 A modified Delphi approach incorporat-ing a face-to-face meeting led by a moderator has been used in previous studies to develop recom-

mendations for the assessment and management of ophthalmic diseases16-21 and was used in this study to develop a recommended treatment paradigm for DME. A panel of nine retina specialists with expertise in the treatment of diabetic retinopathy and DME were invited and agreed to participate in the development of the treatment guidelines. After a literature review was conducted to identify cur-rent treatment patterns in DME, a survey includ-ing 22 multipart, multiple-choice, and open-ended questions regarding treatment scenarios and clini-cal decision-making was developed by Endpoint Outcomes and Allergan (Appendix A available at www.Healio.com/OSLIRetina). The questions were designed to elucidate key elements of the treatment paradigm including assessment of the response to anti-VEGF therapy, the role of corticosteroids in the treatment paradigm, differentiation of available corticosteroid treatment options, and corticosteroid use and side effects.

The panel responded to the survey in two for-mal rounds of feedback. The first round of the sur-vey was conducted on the SurveyMonkey online

TABLE 2

Delphi Panel Consensus on Candidates for Corticosteroid Treatment of DMEPatient Scenario Definite or Likely

Candidate for Corticosteroid Treatment

Unlikely Candidate for Corticosteroid Treatment

Inadequate responder to anti-VEGF after three to six injections

Inadequate responder to anti-VEGF who is pseudophakic

Inadequate responder to anti-VEGF who is phakic and older than 60 years old

Inadequate responder to anti-VEGF who is phakic and younger than 60 years old

Patient in need of rescue

Patient who is scheduled to undergo cataract surgery

Patient with a history of vitrectomy

Patient with persistent DME

Patient with severe edema

Suboptimal response to anti-VEGF treatment after three injections

Patient who is resistant to laser photocoagulation

Patient who had successful filtration surgery to control IOP

Patient with POAG well controlled on one glaucoma drop

Patient with POAG well controlled on two glaucoma drops (status of optic nerve not specified)

Patient with POAG well controlled on two glaucoma drops and a healthy optic nerve

DME = diabetic macular edema; IOP = intraocular pressure; POAG = primary open-angle glaucoma; VEGF = vascular endothelial growth factor

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survey platform (www.surveymonkey.com). Nine panelists participated in the survey and provided anonymous feedback. Following the first round, the results were summarized and provided to the panelists. Eight of the panelists then participat-ed in the second round of the survey at a “real-time” Delphi panel meeting on June 4, 2016, in Philadelphia, Pa. At the meeting, the anonymous summary results of the first round were presented to the panelists. Answers to open-ended questions in the first round were used to frame multiple-choice answers to survey questions for the second round (Appendix B available at www.Healio.com/OSLI-Retina). For each survey question, if consensus was not reached in the first round, the results were dis-cussed and debated by the panelists. The panelists then voted for their chosen response. An electronic audience response system (ResponseCards; Turn-ing Technologies, Youngstown, OH) was used to capture anonymous votes during the Delphi panel discussion, and all panelists were required to vote before results were displayed. Discussion was con-tinued and voting was repeated until consensus was reached, or it was clear that it was impossible to achieve consensus. During this process, modifi-cation of survey questions and possible responses, based on opinions expressed during the discus-sion, was allowed to facilitate the achievement of consensus. Consensus was defined as agreement by at least six of the nine panelists in the first round (66.7%), or by at least six of eight panelists at the Delphi panel meeting (75%).

RESULTS

The panelists reached consensus on many issues in the treatment of DME (Table 1) and developed a recommended treatment paradigm for center- involved DME in patients who have an incomplete response to anti-VEGF treatment (Figure).

The key aspects of the treatment paradigm are as follows.

Disease ClassificationThe majority of panelists (75%; six of eight)

agreed that clinical decision-making on whether and how to treat DME begins with the classifica-tion of the DME as center-involved or non-center-involved.

First-line Treatment for Center-Involved DME: Anti-VEGF Therapy

Members of the expert panel typically use intra-vitreal bevacizumab, ranibizumab, and aflibercept as first-line treatment for center-involved DME. In

the first round (online) survey, there was consen-sus agreement (77.8%; seven of nine) that if there was a suboptimal response to anti-VEGF injections early in treatment (after three or fewer injections), the patient is typically switched to another anti-VEGF agent. In the discussion at the Delphi meet-ing, panelists clarified that insurance coverage and reimbursement can affect the choice of anti-VEGF agent initially used. When the early response to anti-VEGF is poor, they may switch to a different anti-VEGF agent that is believed to be more effi-cacious, but they generally limit the total time on anti-VEGF-only therapy to 6 months for patients who have an inadequate response.

The response to anti-VEGF treatment is vari-able among patients. All panelists agreed that the relative roles of VEGF and other inflammatory cy-tokines in the edema is the most important factor contributing to different levels of patient response to anti-VEGF. The panelists also all agreed that the chronicity of the edema is a second key factor con-tributing to different levels of patient response to anti-VEGF.

There was unanimous agreement that long-term DME results in poorer outcomes. Panelists stated that chronic DME may be less responsive to anti-VEGF therapy and is likely to involve inflamma-tory pathways and cytokines other than VEGF that can cause tissue damage. Photoreceptor damage and permanent loss of visual acuity can occur in chronic DME. Prompt treatment of center-involved DME with anti-VEGF is recommended for optimal outcomes.

Evaluating the Response to Anti-VEGF TherapyAll panelists agreed that the most important de-

terminant of an ideal response to anti-VEGF therapy is the resolution of edema. Most of the panelists (87.5%; seven of eight) further agreed that improve-ment in visual acuity is the second most important determinant of an ideal response to anti-VEGF ther-apy. Improvement in visual acuity is important, but it is a secondary factor in evaluation of the treatment response because other factors beyond DME can af-fect vision.

A patient can be determined to be an inadequate responder to anti-VEGF therapy based on anatomic criteria, or a combination of BCVA and anatomic cri-teria. Almost all (87.5%; seven of eight) of the pan-elists agreed that a DME patient who after three to four monthly anti-VEGF injections has a less than 50% reduction from baseline in the excess macular thickness (defined as thickness over the upper limit of normal) is an inadequate responder to anti-VEGF


therapy. In addition, the majority of panelists (75%; six of eight) agreed that a DME patient whose BCVA after three to six monthly anti-VEGF injections has failed to improve to 20/40 or better because of edema is an inadequate responder to anti-VEGF therapy.

The panel was unable to agree on a value for the central subfield thickness on OCT that indicates an inadequate response to anti-VEGF therapy. Although the central subfield thickness measurement is valu-able for evaluation of changes in retinal thickness over time and after treatment, qualitative assessment of the persistence of edema, which is associated with visual acuity loss, may drive treatment decisions.

Almost all panelists (87.5%; seven of eight) agreed that they are prepared to tolerate persistent edema for 4 to 6 months in patients who are receiving monthly anti-VEGF injections. Panelists agreed that waiting longer than 6 months to move on to other modalities of treatment is potentially detrimental. It was noted that DME may be present for months before patients are seen by a clinician and initiate treatment, so the persistence of edema through 6 months of treat-ment may indicate the development of chronic DME, which involves inflammatory pathways and cyto-kines other than VEGF and potentially has reduced responsiveness to anti-VEGF therapy. Panelists cited clinical data (the EARLY Study) showing that the BCVA outcomes of patients in the DRCR.net Protocol I study after 3 years of ranibizumab 0.5 mg treatment could be predicted by results at week 12.11 These re-sults support a change in therapy when edema per-sists and BCVA does not improve after 3 months of ranibizumab treatment, because most patients who had less-than-five-letter BCVA gain from baseline af-ter 3 months continued to have less-than-five-letter BCVA gain from baseline after 3 years of ranibizumab administration.

Reasons to Change TherapyIn the first round of the survey, all panelists re-

ported that they were somewhat or very likely to use treatment options in addition to anti-VEGF if month-ly injections were too burdensome for the patient (ie, there was poor compliance with frequent injections). After discussion at the Delphi panel meeting, the ma-jority of panelists (62.5%; five of eight) agreed that they typically would be likely to consider switching anti-VEGF treatment to other therapy if monthly in-jections are too burdensome. Panelists emphasized that to facilitate compliance, it is important to discuss with patients the importance of frequent injections to preserve vision.

The panelists agreed that persistent edema and lack of improvement in BCVA are important factors

driving decisions to change therapy. In the first round of the survey, all panelists reported that they would be somewhat or very likely to incorporate additional treatment modalities beyond anti-VEGF if fluid was still present on the retina, and all but one of the pan-elists responded that they would be somewhat or very likely to consider switching or stopping anti-VEGF treatment in this scenario. Similarly, all panelists re-ported that they would be somewhat or very likely to incorporate additional treatment modalities beyond anti-VEGF if there was lack of anatomical improve-ment (eg, in retinal thickness). In the second round, consensus was reached regarding switching treat-ment, and 75% (six of eight) of panelists agreed that they typically would be likely to consider switching from anti-VEGF to another treatment modality if there was a lack of anatomical improvement. Consensus was reached in the first round of the survey with re-spect to the effect of lack of improvement in BCVA on treatment decisions. Most panelists (77.8%; seven of nine) reported that they would be very likely to in-corporate additional treatment modalities in patients who had no improvement in BCVA with anti-VEGF therapy, and almost all panelists (88.9%; eight of nine) reported that they would be somewhat or very likely to switch or stop anti-VEGF treatment.

Most panelists (87.5%; seven of eight) also agreed that they typically would be likely to consider switch-ing from anti-VEGF to another treatment modality in patients who have had a recent stroke or cardiovas-cular event.

The panelists were unable to reach consensus on the relative importance of treating the VEGF compo-nent of DME compared with the inflammatory com-ponent of DME. However, all panelists agreed that it is more important to treat the inflammatory compo-nent of DME than the VEGF component of DME after it has been established that the response to anti-VEGF therapy is suboptimal.

Treatment When the Response to Anti-VEGF Is Inadequate

The panelists agreed unanimously that they would be most likely to switch a patient who is an inadequate responder after three to six monthly injec-tions of anti-VEGF agents to corticosteroid treatment. All panelists reported they are most likely to switch an anti-VEGF inadequate responder to DEX implant treatment, and their second most likely choice for corticosteroid therapy is intravitreal TA (Triesence; Alcon, Fort Worth, TX).

All panelists further agreed that laser photoco-agulation should be used as an adjunct treatment in patients with center-involved DME, but should not

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be considered a rescue treatment. Panelists agreed that the rescue treatment for patients with subopti-mal anti-VEGF response is a corticosteroid.

Role of Corticosteroids in the Treatment ParadigmConsensus was reached that intravitreal cortico-

steroid treatment is appropriate in multiple scenarios of DME (Table 2). Phakic as well as pseudophakic pa-tients who have an inadequate response to anti-VEGF therapy can be candidates for corticosteroid treatment, and corticosteroid treatment can be used in patients with severe edema and those who have undergone vitrectomy. Corticosteroid treatment can also be con-sidered in DME patients with co-existing glaucoma as long as IOP is controlled on one or two medications and the optic nerve is healthy. Several panelists indi-cated that patients who have had successful filtering surgery can be candidates for corticosteroid therapy as long as the cup-to-disc ratio does not exceed 0.8.

Patient MonitoringMost panelists (77.8%; seven of nine) reported that

their patients who are on anti-VEGF therapy are moni-tored monthly. There was no consensus regarding the frequency of monitoring for patients on corticosteroid-only therapy. Two panelists reported that they moni-tor patients monthly, four monitor patients at intervals of 6 to 8 weeks, and two monitor 1 month after the corticosteroid injection and 2 to 3 months afterward, depending on the IOP. During subsequent discussion, it was pointed out that these results indicate that the panelists typically monitor patients on corticosteroid-only therapy every 1 to 2 months. Patients who receive a sustained-release implant may be monitored at 4 to 6 weeks after their first corticosteroid injection, then subsequently at extended intervals not exceeding 3 months.

For patients receiving a combination of anti-VEGF and corticosteroid treatment, the frequency of moni-toring is dependent on whether patients are new to or established on the combination treatment. Most panelists (75%; six of eight) agreed that patients who are new to combination therapy should be monitored every 1 to 2 months, and almost all panelists (87.5%; seven of eight) agreed that patients who are established on combination therapy should be monitored every 2 months.

Choosing Among Corticosteroid OptionsAll panelists agreed that they would prefer to use

a corticosteroid approved by the FDA for DME treat-ment (DEX implant or FAc) when considering efficacy, safety, and duration of effect, and all panelists reported that they use an FDA-approved corticosteroid in most

cases. In their comments on the first-round survey, panelists indicated that they usually treat patients with DEX implant and sometimes use the FAc implant after DEX implant treatment in patients who are not steroid responders, who have shown a good response to multiple DEX implants, and who need long-term treatment.

Some panelists reported that they occasionally use a nonapproved corticosteroid (TA) when lack of insur-ance coverage or cost is an issue.

Management of the Side Effects of Corticosteroid Treatment

All panelists agreed that side effects of corticoste-roid treatment are monitored in conjunction with ef-ficacy, and no additional office visits are scheduled to monitor for side effects, unless a problem is detected and requires follow-up. Panelists commented that side effects of cataract are manageable and side effects of in-creases in IOP are generally manageable. The panelists reached consensus on how they treat increased IOP in patients on corticosteroid therapy. For patients who have elevated IOP of 25 mm Hg or less, six panelists (75%) agreed that they would prescribe a single topical IOP-lowering medication, and for patients with IOP between 26 mm Hg and 30 mm Hg, almost all panel-ists (87.5%; seven of eight) agreed that they would pre-scribe a fixed-combination IOP-lowering eye drop. For patients with IOP higher than 30 mm Hg, all panelists agreed that they would prescribe a fixed-combination IOP-lowering eye drop or refer the patient to a glau-coma specialist, and most agreed that they would both prescribe the fixed combination and make the referral.

DISCUSSION

The introduction of anti-VEGF treatment has great-ly improved visual outcomes in patients with DME, but a significant proportion of patients have an in-complete response to anti-VEGF treatment.9-11 Corti-costeroids are a rational approach to the treatment of DME because inflammatory mediators and pathways in addition to VEGF appear to be involved in the de-velopment of DME. However, there has been limited practical guidance on when and how to use corticoste-roids in the treatment regimen. The consensus recom-mendation of this panel is that corticosteroids be used in patients with an inadequate response to anti-VEGF treatment, and guidance is provided on how to iden-tify patients who are inadequate responders to anti-VEGF, and when to progress to corticosteroid therapy.

The recommendation of the panel is that center-involved DME with some degree of decreased visual acuity should be treated promptly with anti-VEGF therapy. Most patients with DME respond well to


anti-VEGF treatment. Currently bevacizumab is used more frequently than ranibizumab or afliber-cept for treatment of ophthalmic disease in clinical practice22 because of its lower cost. In the DRCR.net Protocol T study comparing these anti-VEGF agents in patients with DME, after 1 year of treatment, aflibercept was more effective than ranibizumab or bevacizumab in improving BCVA in patients with baseline BCVA worse than 20/40, whereas the anti-VEGF agents showed comparable efficacy in patients with baseline BCVA of 20/32 to 20/40.23 After 2 years of treatment, aflibercept and ranibi-zumab provided similar improvement in BCVA, and aflibercept continued to be more effective than bevacizumab in improving BCVA in patients with baseline BCVA worse than 20/40.24 Although the efficacy of switching among anti-VEGF therapies has not been well studied,25 favorable outcomes have been reported after patients with suboptimal response switched from bevacizumab to ranibi-zumab,26 or from bevacizumab or ranibizumab to aflibercept.27 Therefore, if a patient has a poor early response to anti-VEGF, and the initial anti-VEGF agent used was not aflibercept because of consid-erations such as cost and reimbursement, the clini-cian may consider switching the patient to afliber-cept. The consensus of the panel, however, is that whether or not there is a switch among anti-VEGF therapies, continued edema should be tolerated for no longer than 6 months.

There are three fundamental reasons why a pa-tient with an inadequate response to anti-VEGF therapy typically should remain on anti-VEGF treatment for no longer than 6 months before pro-ceeding to a corticosteroid. First, there is evidence that anti-VEGF treatment is most effective in early disease.28-30 In the RISE/RIDE registration studies of ranibizumab, patients in the initial sham group who crossed over to ranibizumab treatment at year 2 had less favorable outcomes after 12 months of ranibi-zumab treatment than patients in the initial ranibi-zumab groups,28 and patients with a longer duration of DME at baseline required more as-needed ranibi-zumab injections during the open-label study ex-tension after year 3,29 suggesting that prompt treat-ment of shorter-term DME with ranibizumab results in better outcomes. Similarly, in the VIVID/VISTA registration studies of aflibercept, patients in the initial laser treatment group achieved a smaller gain in BCVA after receiving rescue aflibercept treatment compared with patients in the initial aflibercept treatment groups, suggesting that delaying afliber-cept treatment results in poorer outcomes and that aflibercept treatment is more effective in shorter-

term DME.30 Second, continuing anti-VEGF treat-ment when the early response to treatment is poor usually does not result in favorable outcomes. The EARLY study analysis of results from the DRCR.net Protocol I study showed that the majority of pa-tients who had a less-than-five-letter gain in BCVA from baseline at week 12 (after three monthly ra-nibizumab injections) continued to have less-than-five-letter gains in BCVA from baseline at week 156 (after 3 years of monthly ranibizumab injections).11 Third, delaying effective treatment increases the risk of permanent vision loss, because chronicity of DME is associated with foveal atrophy and photore-ceptor damage.31

Members of the panel agreed that the balance of VEGF versus other inflammatory cytokines ap-pears to be an important factor contributing to the different levels of anti-VEGF response observed in patients with DME. The importance of this bal-ance goes hand-in-hand with the importance of the chronicity of DME in the variability observed in pa-tient response to anti-VEGF treatment, because it is generally believed that DME is primarily mediated by VEGF in its early phase, whereas the involve-ment of other cytokines and inflammatory mecha-nisms becomes more important in chronic disease.2 Low-grade inflammation has been postulated to be responsible for the retinal damage that occurs in chronic DME.2

It may be important to treat the inflammatory component of DME in patients who do not respond adequately to anti-VEGF treatment. Studies have demonstrated the effectiveness of corticosteroid treatment in long-standing and refractory DME. In the MEAD registration studies for DEX implant, the treatment effects of DEX implant relative to sham were similar in subgroups defined by the duration of DME at baseline: DEX implant had beneficial ef-fects in longer-term (duration of more than 3 years) as well as short-term (less than 1 year in duration) DME.12,32 Furthermore, in the FAME registration studies for FAc, the percentage of patients with 15-letter or greater gains in BCVA from baseline was superior with FAc relative to sham only in the subgroup of patients with long-standing DME (dura-tion of 3 years or longer),33 consistent with an im-portant role of inflammatory pathways amenable to corticosteroid treatment in the pathophysiology of persistent DME.

The panel recommends that a patient who has a less than 50% reduction from baseline in the ex-cess macular thickness after three to four monthly anti-VEGF injections, or whose BCVA has not im-proved to 20/40 after three to six monthly injections

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because of edema, be switched to corticosteroid treatment. The definitions of inadequate response include a range in the number of anti-VEGF injec-tions, because the decision of whether to change treatment should take into account the trajectory of the response. A patient with continual improve-ment in edema after three or four sequential injec-tions typically would be re-treated with anti-VEGF, whereas a patient with no improvement in edema after three or four anti-VEGF injections typically would be switched to a corticosteroid.

The panelists recommend that patients on anti-VEGF therapy receive frequent (monthly) injections and have monthly assessments to evaluate the tra-jectory of the response to treatment and identify inadequate responders. However, they recognize that some practitioners may see patients monthly for anti-VEGF injections but wait until after three to four injections before doing a full examination and OCT, rather than doing full exams at every vis-it. With this approach, the decision of whether to continue anti-VEGF treatment or switch to a corti-costeroid is still made 3 to 4 months after the initial anti-VEGF injection, consistent with the suggestion from the EARLY study that this is an appropriate timeframe for deciding whether to switch therapy, since BCVA outcomes at week 12 in the Protocol I study were predictive of long-term outcomes.11 Al-though this approach does not consider the trajec-tory of the treatment response, there are cost savings associated with fewer examinations, and there is little risk of overtreatment, since edema is unlikely to resolve after one to three anti-VEGF injections. The panelists also recognize that the frequency of anti-VEGF injections required can be burdensome for patients,34,35 but in the experience of the panel-ists, patients are likely to adhere to frequent injec-tions if they are educated on the alternative of risk of permanent loss of vision. The consensus opin-ion of the panel is that frequent monitoring is also needed for patients who have switched to cortico-steroid implant treatment, but the recommended in-terval between visits for these patients is longer (1 to 2 months) than that recommended for patients on anti-VEGF therapy.

The panel’s consensus choice of corticosteroid for treatment of DME in inadequate responders to anti-VEGF is DEX implant, primarily because DEX implant has a more favorable safety profile compared with FAc and intravitreal TA. The increases in IOP associated with intraocular corticosteroid use are less frequent, less severe, and more easily managed with DEX implant than with FAc or intravitreal TA.12,13,36-38 Accordingly, the FDA-approved indica-

tion for FAc in DME is limited to patients who have been demonstrated to have no clinically significant IOP response to a corticosteroid. Disadvantages of use of intravitreal TA include its lack of FDA ap-proval for treatment of DME and the possible need for more frequent injections. DEX implant has been demonstrated to be effective in patients with previ-ous vitrectomy,39 patients with previously treated DME,40 and patients with DME that has been dem-onstrated to be resistant to anti-VEGF treatment.41-45

The primary role of corticosteroids in the treat-ment paradigm for DME is as alternative treatment after a suboptimal anti-VEGF response, but cortico-steroids may also be considered for treatment in pa-tients who discontinue anti-VEGF therapy because of systemic safety concerns. Although intravitreal anti-VEGF treatment is generally believed to be systemically safe, it has been difficult to determine whether anti-VEGF might increase the risk of stroke, arteriothrombotic events, or cardiovascular events because studies have been underpowered and pa-tients with DME may be at increased risk of these events regardless of treatment.46 However, the ma-jority of panelists agreed that they typically would likely consider a change in therapy if a patient be-ing treated with anti-VEGF had a recent stroke or cardiovascular event. In a recent meta-analysis that pooled systemic safety data from patients treated with ranibizumab 0.5 mg or aflibercept in clinical studies, the risk of cerebrovascular accidents and vascular deaths was significantly higher in patients treated monthly for 2 years with anti-VEGF injec-tions than in patients treated with sham,47 suggest-ing that frequent anti-VEGF injections over the long term may increase the risk of serious systemic ad-verse events.

There is a lack of evidence from clinical studies concerning some aspects of care in DME, such as the benefits of using combination therapy with an anti-VEGF agent and a corticosteroid. In their dis-cussion at the Delphi meeting, panelists indicated that they generally use combination anti-VEGF and corticosteroid therapy only for patients with severe and persistent DME. Furthermore, based on their clinical experience, the panelists believe that a pa-tient with a suboptimal response to anti-VEGF has better improvement in retinal drying if the patient is switched to a corticosteroid than if the patient is switched to a different anti-VEGF agent, but sup-porting data from clinical trials are lacking.

The clinically recommended treatment paradigm for DME presented here includes recommendations for the medical treatment of DME, and it was devel-oped with the understanding that the recommen-


dations should be general and applicable in 80% of cases. The authors recognize that there are ex-ceptions and that there is a need for individualized patient care, as well as a need for surgery in cases of epiretinal membrane or vitreomacular traction. Some patients will lose vision irretrievably even if the recommendations are followed. The recom-mendations are based on evidence from reported studies and the clinical experience of the panel-ists, and they may be modified when more data be-come available. It is anticipated that results of the ongoing DRCR.net Protocol U study (clinicaltrials.gov identifier: NCT01945866), comparing ranibi-zumab monotherapy to combination therapy with ranibizumab and DEX implant in patients with an incomplete response to three monthly injections of ranibizumab, may further help guide corticosteroid use in the treatment of DME.

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21. Rodrigues IA, Sprinkhuizen SM, Barthelmes D, et al. Defining a minimum set of standardized patient-centered outcome measures for macular degeneration. Am J Ophthalmol. 2016;168:1-12.

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25. Do DV, Nguyen QD, Vitti R, et al. Intravitreal aflibercept injection in diabetic macular edema patients with and without prior anti-vascular endothelial growth factor treatment: Outcomes from the phase 3 program. Ophthalmology. 2016;123(4):850-857.

26. Fechter C, Frazier H, Marcus WB, Farooq A, Singh H, Marcus DM. Ranibizumab 0.3 mg for persistent diabetic macular edema after recent, frequent, and chronic bevacizumab: The ROTATE trial. Ophthalmic Surg Lasers Imaging Retina. 2016;47(11):1-18.

27. Lim LS, Ng WY, Mathur R, et al. Conversion to aflibercept for dia-betic macular edema unresponsive to ranibizumab or bevacizumab. Clin Ophthalmol. 2015;9:1715-1718.

28. Brown DM, Nguyen QD, Marcus DM, et al. Long-term outcomes of ranibizumab therapy for diabetic macular edema: The 36-month results from two phase III trials: RISE and RIDE. Ophthalmology. 2013; 120(10):2013-2022.

29. Wykoff CC, Elman MJ, Regillo CD, Ding B, Lu N, Stoilov I. Predictors of diabetic macular edema treatment frequency with ra-nibizumab during the open-label extension of the RIDE and RISE Trials. Ophthalmology. 2016;123(8):1716-1721.

30. Heier JS, Korobelnik JF, Brown DM, et al. Intravitreal aflibercept for diabetic macular edema: 148-week results from the VISTA and VIVID studies. Ophthalmology. 2016;123(11):2376-2385.

31. Channa R, Sophie R, Khwaja AA, et al. Factors affecting visual out-comes in patients with diabetic macular edema treated with ranibi-zumab. Eye (Lond). 2014;28(3):269-278.

32. Loewenstein A, MEAD Study Group. MEAD: Diabetic macular edema trial subanalysis. Paper presented at: American Academy of Ophthalmology Annual Meeting; October 18-21, 2014; Chicago, IL.

33. Cunha-Vaz J, Ashton P, Iezzi R, et al. Sustained delivery fluo-cinolone acetonide vitreous implants: Long-term benefit in pa-tients with chronic diabetic macular edema. Ophthalmology. 2014;121(10):1892-1903.

34. Shea AM, Curtis LH, Hammill BG, et al. Resource use and costs

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associated with diabetic macular edema in elderly persons. Arch Ophthalmol. 2008;126(12):1748-1754.

35. Wallick CJ, Hansen RN, Campbell J, Kiss S, Kowalski JW, Sul-livan SD. Comorbidity and health care resource use among com-mercially insured non-elderly patients with diabetic macular ede-ma. Ophthalmic Surg Lasers Imaging Retina. 2015;46(7):744-751.

36. Diabetic Retinopathy Clinical Research Network. A randomized trial comparing intravitreal triamcinolone acetonide and focal/grid photocoagulation for diabetic macular edema. Ophthalmol-ogy. 2008;115(9):1447-1459.e10.

37. 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;118(4):609-614.

38. Kiddee W, Trope GE, Sheng L, et al. Intraocular pressure monitoring post intravitreal steroids: A systematic review. Surv Ophthalmol. 2013;58(4):291-310.

39. Boyer DS, Faber D, Gupta S, et al. Dexamethasone intravitreal im-plant for treatment of diabetic macular edema in vitrectomized patients. Retina. 2011;31(5):915-923.

40. Augustin AJ, Kuppermann BD, Lanzetta P, et al. Dexamethasone intravitreal implant in previously treated patients with diabetic macular edema: Subgroup analysis of the MEAD study. BMC Oph-thalmol. 2015;15:150.

41. Alshahrani ST, Dolz-Marco R, Gallego-Pinazo R, Diaz-Llopis M, Arevalo JF, KKESH International Collaborative Retina Study Group. Intravitreal dexamethasone implant for the treatment of refractory macular edema in retinal vascular diseases: Results of the KKESH International Collaborative Retina Study Group. Retina. 2016;36(1):131-136.

42. Zhioua I, Semoun O, Lalloum F, Souied EH. Intravitreal dexameth-asone implant in patients with ranibizumab persistent diabetic macular edema. Retina. 2015;35(7):1429-1435.

43. Totan Y, Güler E, Guraǧaç FB. Dexamethasone intravitreal im-plant for chronic diabetic macular edema resistant to intravitreal bevacizumab treatment. Curr Eye Res. 2016;41(1):107-113.

44. Gutiérrez-Benítez L, Millan E, Arias L, Garcia P, Cobos E, Cami-nal M. Dexamethasone intravitreal implants for diabetic macular edema refractory to ranibizumab monotherapy or combination therapy. Arch Soc Esp Oftalmol. 2015;90(10):475-480.

45. Lazic R, Lukic M, Boras I, et al. Treatment of anti-vascular endo-thelial growth factor-resistant diabetic macular edema with dexa-methasone intravitreal implant. Retina. 2014;34(4):719-724.

46. Avery RL. What is the evidence for systemic effects of intravitreal anti-VEGF agents, and should we be concerned? Br J Ophthalmol. 2014;98 Suppl 1:i7-10.

47. Avery RL, Gordon GM. Systemic safety of prolonged monthly anti-vascular endothelial growth factor therapy for diabetic macular edema: A systematic review and meta-analysis. JAMA Ophthalmol. 2016;134(1):21-29.

Ophthalmic Surgery, Lasers & Imaging Retina | Healio.com/OSLIRetina

APPENDIX A

Draft Questions for DME Round 1 Delphi Survey [via SurveyMonkey]

Instructions: Thank you for your participation in the diabetic macular edema (DME) Delphi panel. In this survey, we will be asking

you open and closed-ended questions about your experience with DME treatment scenarios. Your answers will remain anonymous,

however the results of this survey will be summarized along with other panelists’ answers in order to inform our discussion during the

Delphi meeting on [June 4th].

Section 1: Defining Treatment Response to Anti-VEGF Therapy

1. Do you classify DME patients into types before deciding on treatment options?

a. Response options: Yes/No

b. If Yes, how do you classify DME patients?

i. [Open-ended]

2. What would you consider to be an adequate response to anti-VEGF therapy? Please describe in a few brief sentences.

a. [Open-ended]

3. When would you consider someone an inadequate responder to anti-VEGF treatment?

a. [Open-ended]

b. Please fill in the blanks:

i. After X injections failed to improve best-corrected visual acuity to 20/XX

ii. After X injections failed to improve best-corrected visual acuity by X lines

iii. After X injections, OCT-measured retinal thickness of is equal to or above X µm

iv. After X injections, OCT-measured retinal thickness has not improved by X% from baseline

4. How long are you prepared to tolerate persistent edema despite treatment with multiple anti-VEGF injections? Please explain.

a. [Open ended]

5. What are the reason(s) for different levels of response to anti-VEGF therapy?

a. [Open ended]

6. What do you consider an optimal response when treating DME with an anti-VEGF?

a. [Open ended]

7. Does long-term presence of DME result in poorer outcomes? Please explain why.

a. [Open ended]

8. Listed below are various scenarios for DME patients that are being considered for, or are on, anti-VEGF treatment. How likely are you to consider incorporating additional treatment modalities (eg, introducing steroid) based on each scenario?

a. Monthly injection is too burdensome for patients (poor compliance by patients):

i. Response options for a-f:

1. Very likely to discontinue anti-VEGF treatment

a. [please explain open-ended question after each response option]

2. Somewhat likely to discontinue anti-VEGF treatment

3. Somewhat unlikely to discontinue anti-VEGF treatment

4. Very unlikely to discontinue anti-VEGF treatment

b. Systemic considerations (patients with increased risk of stroke/cardiovascular events)

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c. Lack of improvement in best corrected visual acuity

d. Lack of anatomical improvement (central retinal thickness)

e. Fluid still present on the retina

f. Other (please specify):

9. Listed below are various scenarios for DME patients that are being considered for or are on anti-VEGF treatment. How likely are you to consider switching or stopping treatment based on each scenario?

a. Monthly injection is too burdensome for patients (poor compliance by patients):

i. Response options for a-f:

1. Very likely to discontinue anti-VEGF treatment

a. [please explain open-ended question after each response option]

2. Somewhat likely to discontinue anti-VEGF treatment

3. Somewhat unlikely to discontinue anti-VEGF treatment

4. Very unlikely to discontinue anti-VEGF treatment

b. Systemic considerations (patients with increased risk of stroke/cardiovascular events)

c. Lack of improvement in best corrected visual acuity

d. Lack of anatomical improvement (central retinal thickness)

e. Fluid still present on the retina


10. How important is it to treat the inflammatory component of DME compared to the VEGF component? Please select one answer below:

a. Response options:

i. Inflammation most important to treat

1. Please explain [open-ended] after each response option

ii. Inflammation somewhat more important to treat

iii. Inflammation and VEGF equally important to treat

iv. VEGF somewhat more important to treat

v. VEGF most important to treat

11. What would you typically do for a patient that does not respond optimally to anti-VEGF early in their treatment? Please choose all that apply:

a. Continue anti-VEGF therapy with the same agent

i. For how many injections? [1, 2, 3, etc.]

b. Switch anti-VEGF therapy to a different agent within the anti-VEGF class

i. Which anti-VEGF treatment would you typically start with?

1. Intravitreal bevacizumab

2. Intravitreal ranibizumab

3. Intravitreal aflibercept

ii. Which anti-VEGF treatment would you typically switch to?

1. Intravitreal bevacizumab

2. Intravitreal ranibizumab

3. Intravitreal aflibercept


iii. For how many injections? [1, 2, 3, etc.]

c. Introduce a steroid

i. How would you introduce the steroid? Please choose one:

1. Monotherapy

2. In combination with anti-VEGF agent

ii. Which steroid would you typically introduce? Please rank in the order of steroid you would most likely use, to steroid you would least likely use [ranking exercise 1-4]

1. Dexamethasone intravitreal implant (DEX)

2. Fluocinolone acetonide implant (FA)

3. Intravitreal triamcinolone acetonide

4. Other:

d. Incorporate laser treatment

i. How would you incorporate laser treatment? Please choose one.

1. In combination with anti-VEGF agent

2. In combination with steroid

3. In isolation

Section 2: Steroid Treatment Options

12. Listed below are various DME patient scenarios. Please indicate how likely you would be to recommend steroid treat-ment for each type of patient listed:

a. Persistent diabetic macular edema

i. Response options for a-k:

1. Definite candidate for steroid treatment

2. Likely candidate for steroid treatment

3. Unlikely candidate for steroid treatment

4. Not a candidate for steroid treatment

a. If 3 or 4 are chosen, please explain why [open ended]:

b. Cases with severe edema

c. Patients who do not respond optimally to anti-VEGF treatment after 3 injections

d. Patients who do not respond optimally to anti-VEGF treatment after 6 injections

e. Anti-VEGF suboptimal responders who are pseudophakic

f. Anti-VEGF suboptimal responders who are phakic and older than 60 years of age

g. Anti-VEGF suboptimal responders who are phakic and younger than 60 years of age

h. Patients scheduled to undergo cataract surgery

i. Patients resistant to laser photocoagulation

j. Patients with a history of vitrectomy

k. Patients with POAG well controlled on 1 glaucoma drop

l. Patients with POAG well controlled on 2 glaucoma drops

m. Patients who have had successful filtration surgery to control IOP

n. Patients that cannot afford branded anti-VEGF treatment?

o. Other (please specify):

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13. How frequently do you monitor subjects who are on anti-VEGF treatment?

a. Monthly

b. Every 2 months

c. Every 3 months

d. Other (please specify):

14. How frequently do you monitor subjects who are on combination anti-VEGF treatment and steroids?

a. Monthly

b. Every 2 months

c. Every 3 months


15. How frequently do you monitor subjects who are on steroid only treatment?

a. Monthly

b. Every 2 months

c. Every 3 months


16. What clinical observations occur after a DME patient has either switched treatments from anti-VEGF therapy to steroid therapy, or steroid therapy has been incorporated in addition to anti-VEGF therapy?

a. [Open ended]

17. Considering your choice of steroids in the management of patients with DME:

a. When would you use a FDA approved steroid? [Open ended]

b. When would you use a non-approved steroid? [Open ended]

c. Which would you prefer when thinking about each of the following items:

i. Efficacy. Please choose from below:

1. Prefer FDA-approved steroid

2. Prefer non-approved steroid

ii. Safety. Please choose from below:



iii. Duration of effect. Please choose from below:



iv. Cost/cost effectiveness. Please choose from below:



18. Which type of implant do you prefer to use, and why? If you use both, please select both options and describe the scenarios for using each type of implant:

a. Short acting implant [please explain]

b. Long acting implant [please explain]


Section 3: Steroid Use and Side Effects

19. Approximately how frequently do you monitor patients for possible side effects of steroid use?

a. At first follow-up only

b. Once every month

c. Every 2 to 3 months after the first month from an injection

d. Once every 6 months

e. Once a year


20. To what extent are the side effects of steroid use manageable?

a. [open ended]

21. How do you treat an increase in intraocular pressure following steroid use?

a. [open ended]

b. Is the treatment for increased IOP effective?

i. [open ended]

22. How do you treat glaucoma following steroid use?

a. [open ended]

b. Is the treatment for glaucoma following steroid use effective?

i. [open ended]

DME = diabetic macular edema; VEGF = vascular endothelial growth factor; IOP = intraocular pressure; POAG = primary open-angle glaucoma; FDA = U.S. Food and Drug Administration

April 2017 · Vol. 48, No. 4

APPENDIX B

Final Questions

1. How do you classify DME patients?

a. Center-involved or non-center-involved

b. Focal areas of leakage, peripheral non-perfusion, or diffuse leakage

c. Focal versus diffuse (level of diabetic retinopathy matters)

d. Do not classify DME patients

e. Other

2. Out of the following, which do you consider to be the most important factor determining an ideal response when treating DME with an anti-VEGF?

a. Resolution of edema

b. Improvement in VA

c. Improvement in OCT thickness

d. Other

3. Out of the following, which do you consider to be the second most important factor determining an ideal response when treating DME with an anti-VEGF?

a. Resolution of edema

b. Improvement in VA

c. Improvement in OCT thickness

d. Other

4. An inadequate responder to anti-VEGF treatment is determined when after monthly three to four injections, OCT-measured retinal thickness has not improved by what percent of excess thickness from baseline?

a. 50%

b. 33%

5. An inadequate responder to anti-VEGF treatment is determined after what number of injections failed to improve BCVA to 20/x attributable to edema? (Value of “x” be defined in the next question.)

a. One to three

b. Three to six

c. Six to 10

d. Other

6. An inadequate responder to anti-VEGF treatment is determined after three to six monthly injections failed to improve BCVA to 20/x attributable to edema, with “x” = what value?

a. 40

b. 20

c. 30

7. Do you use the number of lines of BCVA improvement in determining inadequate responders to anti-VEGF treatment?

a. Yes

b. No

8. How long are you prepared to tolerate persistent edema despite treatment with monthly anti-VEGF injections (includ-ing any type of anti-VEGF used)?

a. 3 months


b. 4 to 6 months

c. As long as vision is stable or improving

d. Other

9. Out of the following, what are two key factors that contribute to the different levels of anti-VEGF response? Choose two answers from below:

a. Level of diabetic retinopathy

b. Balance of VEGF versus other inflammatory cytokines

c. Glycemic control (in diabetes)

d. Previous laser treatments

e. Chronicity of DME

f. Other

10. Out of the following, what is the most important factor that contributes to the different levels of anti-VEGF response?

a. Level of diabetic retinopathy

b. Balance of VEGF versus other inflammatory cytokines

c. Glycemic control (in diabetes)

d. Previous laser treatments

e. Chronicity of DME

f. Other

11. If monthly injection is too burdensome for patients (eg, poor compliance by patients), how would you typically pro-ceed?

a. Likely to consider incorporating additional treatment modalities

b. Likely to consider switching treatment modalities

c. Likely to stop current treatment

d. Likely to continue current treatment

e. Provide better education to improve compliance

f. Other

12. Due to systemic considerations (eg, patients with recent stroke/cardiovascular events), how would you typically pro-ceed?


b. Likely to consider switching treatment



e. Other

13. If there is lack of improvement in best-corrected visual acuity, how would you typically proceed?





e. Other

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14. If there is a lack of anatomical improvement (eg, central retinal thickness), how would you typically proceed?





e. Other

15. When is it important to treat the inflammation component of DME compared to the VEGF component?

a. From the beginning

b. After a suboptimal response to anti-VEGF therapy

c. Never

d. Always

16. What would you most likely do for a patient that does not respond optimally to anti-VEGF agents early (three to six monthly injections) in their treatment?

a. Continue anti-VEGF therapy

b. Switch anti-VEGF therapy to a different agent within the anti-VEGF class

c. Switch to a steroid

d. Add a steroid

e. Incorporate laser treatment

17. Which steroid would you most typically introduce?

a. Dexamethasone intravitreal implant

b. Fluocinolone acetonide implant

c. Intravitreal triamcinolone acetonide

d. Kenalog

e. Triescence

18. Which steroid would be your second most likely choice for initial steroid therapy?

a. Dexamethasone intravitreal implant

b. Fluocinolone acetonide implant

c. PFTA compounding therapy

d. Kenalog

e. Triescence

19. In a patient being treated for DME, do you use a steroid to help to protect against edema from cataract surgery?

a. Highly likely

b. Somewhat likely

c. Somewhat unlikely

d. Highly unlikely

20. Do you agree that steroid is the most preferred rescue modality?

a. Strongly agree

b. Somewhat agree

c. Somewhat disagree


d. Strongly disagree

21. How do you incorporate macular laser in center-involving DME treatment?

a. Adjunct

b. Rescue

c. First line

d. Never

22. Would you recommend steroid treatment for a patient with POAG and healthy nerve that is well controlled on two glaucoma drops?

a. Potential candidate

b. Not potential candidate

23. How frequently do you monitor subjects after their first steroid injection?

a. Monthly

b. 6 to 8 weeks

c. Every 2 months

d. Every 3 months

e. 1 month after steroid and 2 to 3 months afterwards depending on IOP

f. Other

24. How frequently should you monitor subjects who are new to combination anti-VEGF treatment and steroids?

a. Monthly

b. 1 to 2 months

c. 2 to 3 months depending on IOP

d. Other

25. How frequently should you typically monitor subjects who are established on combination anti-VEGF treatment and steroids?

a. Monthly

b. Every 2 months

c. Every 3 months

d. Other

26. After the first steroid injection, approximately how frequently do you monitor patients for possible side effects?

a. Every 2 two 3 months after the first month from an injection

b. Every 6 to 8 weeks

c. Every month for the first one to three injections, then just every 3 months

d. Other

27. Do you do any additional screening for side effects after steroid use beyond efficacy monitoring?

a. Yes

b. No

28. After a problem is detected, do you do any additional monitoring?

a. Yes

b. No

April 2017 · Vol. 48, No. 4

29. How do you typically treat an increase in intraocular pressure (25 mm Hg or below)?

a. Single agent

b. Fixed combination

c. Refer to glaucoma specialist

d. Observe

30. How do you typically treat an increase in intraocular pressure (26 mm Hg to 30 mm Hg)?

a. Single agent



d. Observe

31. How do you typically treat an increase in intraocular pressure (above 30 mm Hg)?

a. Single agent



d. Fixed combination and refer to a glaucoma specialist

DME = diabetic macular edema; IOP = intraocular pressure; OCT = optical coherence tomography; PFTA = preservative-free triamcinolone acetonide; POAG = primary open-angle glaucoma; VA = visual acuity; VEGF = vascular endothelial growth factor

clinical science use of corticosteroids in the treatment ... · treatment decision when patient has...

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