Department of Ophthalmology, Juntendo University Graduate School of Medicine, Tokyo, Japan.
Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.
Graefes Arch Clin Exp Ophthalmol. 2024 Dec;262(12):3749-3759. doi: 10.1007/s00417-024-06558-y. Epub 2024 Jul 12.
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.
在人口老龄化的背景下，糖尿病、糖尿病视网膜病变以及威胁视力的糖尿病黄斑水肿（DME）的患病率和负担预计将在全球范围内上升。与糖尿病的其他并发症一样，DME 需要长期管理。本文旨在回顾 DME 长期管理相关的当前挑战、改善患者结局的机会，并制定基于黄斑形态的治疗目标策略。目前，玻璃体内抗血管内皮生长因子（VEGF）治疗是 DME 管理的标准治疗方法；然而，治疗的最佳视力结局取决于频繁的注射和密切监测，由于这给患者带来的负担，在当前的临床实践中难以维持。实现和维持治疗后的良好视力是 DME 患者最重要的因素。标志性试验表明，抗 VEGF 治疗的视力获益通常伴随着解剖结构的改善（例如，视网膜厚度的降低）；因此，DME 患者常采用多模态成像测量黄斑形态，以指导实际治疗决策。我们希望提出一种假设性的治疗目标策略，为 DME 的长期管理提供治疗策略。视网膜液（如持续时间、稳定性、位置）的替代测量可能是 DME 中视力的更强预测指标，但需要进一步研究来确认替代可量化的生物标志物（如视网膜下液和视网膜内液体积）是否可作为临床改善的生物标志物。确定针对神经炎症和神经退行性变的新型生物标志物和治疗方法，改善治疗依从性方面的医患沟通，以及使用治疗目标策略，可能有助于确保实现治疗的长期获益。
