A 45-year-old male with a 10-year history of type 1 diabetes mellitus presents for his annual dilated eye examination. He reports that his vision has been slightly blurry over the last few months. Funduscopic examination reveals multiple microaneurysms, several dot-and-blot hemorrhages, and hard exudates in all four quadrants. Neovascularization is not visualized. There is notable thickening of the macula with associated hard exudates.
Which of the following is the most appropriate next step in the management of this patient’s ocular condition?
The correct answer is:
A) Intravitreal vascular endothelial growth factor (VEGF) inhibitor
This patient has non-proliferative diabetic retinopathy (NPDR) complicated by clinically significant macular edema. The presence of macular thickening and hard exudates in the macular region is the primary cause of his decreased visual acuity. Intravitreal anti-VEGF agents, such as ranibizumab or aflibercept, are currently the first-line treatment for diabetic macular edema involving the center of the macula, as they effectively reduce vascular permeability and improve vision.
Answer choice B: Observation with follow-up in one year, is incorrect. While mild NPDR without macular edema can be observed annually, this patient has vision-threatening macular edema that requires active intervention to prevent permanent vision loss.
Answer choice C: Panretinal photocoagulation, is incorrect. Panretinal photocoagulation (PRP) is the gold standard treatment for proliferative diabetic retinopathy (PDR) to induce regression of neovascularization. It is generally not used for macular edema, as it can occasionally worsen macular swelling.
Answer choice D: Pars plana vitrectomy, is incorrect. Vitrectomy is indicated for complications of PDR, such as non-clearing vitreous hemorrhage or tractional retinal detachment. It is not an initial treatment for uncomplicated macular edema.
Answer choice E: Topical corticosteroid drops, is incorrect. Topical steroids do not reach the retina in therapeutic concentrations for macular edema. While intravitreal steroids can be used in some cases of refractory macular edema, they are not first-line due to side effects like cataracts and glaucoma.
Key Learning Point
In patients with diabetic retinopathy, the presence of macular edema, clinically characterized by macular thickening and hard exudates, is the most common cause of vision loss. First-line management for center-involving diabetic macular edema consists of intravitreal anti-VEGF inhibitors.
