Meta-Analysis Provides Reevaluation of Intravitreal Steroids for DME Management

Rajeev H. Muni, MD, MSc

Credit: EurekAlert!

A meta-analysis revealed intravitreal steroid treatment for diabetic macular edema (DME) was associated with a significantly lower retinal thickness, but no significant differences in visual acuity and a higher risk of intraocular pressure (IOP)-related events compared to anti-VEGF agents.¹

The investigative team, led by Rajeev H. Muni, MD, MSc, Department of Ophthalmology and Vision Sciences, University of Toronto indicated the certainty of evidence ranged from low to moderate, while additionally noting the analysis was limited by heterogeneity.

“Our results reinforce the importance of a continual reevaluation of the role of intravitreal steroids in DME management,” wrote the investigative team.

As the prevalence of diabetes increases worldwide, so does its possible visual impairing sequelae, with DME remaining a major cause of visual impairment. Recent literature has described the pathogenesis of the disease as consisting of a vascular component, an inflammatory process, and a neurodegenerative process.² While anti-VEGF therapies remain the first line of treatment for DME, recent studies have cited the role of steroids in its management, particularly for those who may not respond to anti-VEGF therapy or are non-compliant to a treatment regimen.

Thus, patients with DME can either be treated with intravitreal anti-VEGF injections or intravitreal corticosteroid injections. To provide an updated meta-analysis of the comparative efficacy and safety of intravitreal steroids and anti-VEGF agents for DME treatment, Muni and colleagues performed a systematic search of databases.

Between January 2005 - November 2021, the team searched Ovid MEDLINE, Embase, and Cochrane Controlled Register of Trials and included published randomized clinical trial data comparing their endpoint. However, nonrandomized, noncomparative, and non-English studies were excluded from the analysis.

The investigative team included a total of 14 randomized clinical trials reporting on 827 eyes. When comparing intravitreal steroid and anti-VEGF treatments, the analysis indicated a lack of significant differences in best-corrected visual acuity (BCVA) outcomes at 3 months (P = .11), 6 months (P = .21), 12 months (P = .24), and final follow-up (P = .91).

Additionally, the analysis revealed the retinal thickness was significantly lower with steroid treatment at 3 months (P = .04), 6 months (P <.00001), and final follow-up (weighted mean difference, 39.99 µm; 95% CI, 14.58 - 65.41; P = .002). However, investigators found no significant difference at 12 months (P = .18).

The analysis showed intravitreal anti-VEGF agents were associated with lower incidence of IOP-related adverse events, with a risk ratio of 0.13 (95% CI, 0.05 - 0.34; P <.00001). Meanwhile, investigators observed no significant difference between comparators for other adverse events, particularly cataract-related adverse events (P = .22).

“Overall, intravitreal steroid treatment for DME was associated with no significant differences in BCVA, a significantly lower retinal thickness, and a higher risk of intraocular pressure-related events,” investigators wrote.

References

1. Patil NS, Mihalache A, Hatamnejad A, Popovic MM, Kertes PJ, Muni RH. Intravitreal steroids compared with Anti-VEGF treatment for diabetic macular edema. Ophthalmology Retina. 2023;7(4):289-299. doi:10.1016/j.oret.2022.10.008
2. Weinberg, T., Loewenstein, A. The role of steroids in treating diabetic macular oedema in the era of anti-VEGF. Eye 34, 1003–1005 (2020). https://doi.org/10.1038/s41433-019-0739-x