Injecting both Avastin and a steroid injection can be a useful way to treat stubborn macular edema from diabetic retinopathy. While both can be used alone to treat macular swelling in diabetic patients, the combination is sometimes considered as an alternative.
The gold standard has been to treat diabetic macular edema with laser treatment. This has been a very effective means of achieving visual stability, that is, preventing further loss of vision. About 20-25% of patients do improve.
Many patients do not improve with laser. Their vision doesn’t improve and the macular edema does not resolve. Usually additional laser won’t help as the persistent swelling is due to leaky “microaneurysms” located in the center of the macula. Treating these centrally located areas with laser treatment would create permanent blind spots in the central vision.
Alternatives to the laser treatment include intraocular injections of steroid (e.g. Kenalog/triamcinolone acetonide) or anti-VEGF medications (e.g. Avastin, Lucentis). Many times a single injection of either can improve both the vision and the macular edema.
Once in a while, I have patient that doesn’t respond to either a single injection of steroid or anti-VEGF. The next alternative is to alternate treatments with the other drug. For instance, if I start with the steroid and get minimal or no response, I’ll usually recommend that the next injection be Avastin, or something similar.
Occasionally we have to alternate treatments several times before getting a satisfactory response.
What Does This Mean? The use of anti-VEGF and steroids is not new. These drugs have been used “off-label” for the treatment of diabetic macular edema for several years. Remember, though “off-label,” it is standard of care.
The recent report of success using a combination of Lucentis and laser treatment for diabetic macular edema underscores the need for an adequate treatment for this common complication of diabetic retinopathy.
In a few years, I predict that laser will be used only sparingly for the treatment of diabetic retinopathy and that the mainstay of treatment for diabetic macular edema will be more drug based.
We have come a long way in successfully treating diabetic retinopathy and preserving vision.