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Medically reviewed and verified by Kate Burke, MD, MHA
When it comes to treating diabetic macular edema (DME), there are a few options out there to consider. The first line treatment for DME primarily involves intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) agents. According to the American Diabetes Association, intravitreal injections of anti-VEGF are indicated as the first-line treatment for most eyes with DME that involves the foveal center and impairs visual acuity. For patients with persistent DME despite anti-VEGF therapy or not candidates for anti-VEGF alternative treatments include intravitreal corticosteroid injections as well as focal-grid laser therapy. Corticosteroids are synthetic drugs that work in the body by mimicking cortisol, a natural hormone produced by the adrenal glands. They help regulate immune responses, control inflammation, and give you relief from pain. They are commonly used to treat autoimmune diseases and conditions with inflammation. But what exactly do they do in the body? Why would you take a corticosteroid over another treatment option, and what risks are there? Here is a guide from PatientsLikeMe..
How Do Corticosteroids Work?
Corticosteroids are primarily used to reduce inflammation. When your immune system is trying to fight an infection or repair an injury, it releases cells called cytokines. Cytokines help your body respond to damage by directing both immune and blood cell growth. Activity around an injury or infection can increase up to 1,000 times in response! Inflammation is a byproduct of this process however, and if left unchecked can cause discomfort and pain. What a corticosteroid does is slow down the production of these inflammatory cells. This helps with swelling and pain. They usually start working quickly too, which makes them a great treatment option to consider.
Why Are Corticosteroids Used for DME?
DME comes about as a result of fluid building up in the macula, which is a part of the retina. The fluid causes swelling, which in turn can lead to vision loss if untreated. The primary treatment for DME is anti-VEGF (vascular endothelial growth factor) injections. These target a protein that causes blood vessels in the eye to grow. This protein is called VEGF, hence the name anti-VEGF therapy. However, not all cases of DME are driven by this protein. Sometimes inflammation is the cause, meaning doctors will turn to a powerful anti-inflammatory as a treatment instead. This is when they will consider corticosteroids.
Corticosteroids help by:
- Reducing inflammation that contributes to macular swelling.
- Stabilizing the blood-retina barrier to prevent more fluid from leaking.
- Suppressing immune responses that make DME worse.
- Regulating VEGF levels, reducing abnormal blood vessel growth.
Benefits and Risks of Corticosteroids
Corticosteroids certainly have a number of benefits as a treatment. To start, they are longer-lasting than anti-VEGF treatments! That means patients can go longer between doses. They are also more effective at treating chronic cases of DME, particularly when cases are unresponsive to anti-VEGF therapy. Doctors typically recommend corticosteroids for patients who did not respond well to anti-VEGF therapy or have had a hard time with the regular administration of anti-VEGF treatments.
The main reason doctors prefer to use anti-VEGF therapy is that it is safer. Corticosteroids increase your risk of developing a cataract, especially when used over a long period of time. They also can increase the pressure in your eye, which has been shown to increase your chances of getting glaucoma. There is also an increased risk of infection or inflammation in the eye from the use of corticosteroids.
Corticosteroids Used for DME
Triamcinolone Acetonide (TA)
Triamcinolone acetonide is an injectable steroid used to treat DME in cases where other treatments have failed. TA reduces inflammation, stabilizes blood vessels, and stops more fluid from leaking out. It usually last between 2 and 4 months, but does require repeated injections. This treatment is fast-acting. It can cause the pressure in your eye to increase, as well as cataracts and eye infections.
Dexamethasone (DEX) Intravitreal Implant
This treatment option is a biodegradable implant that slowly releases the corticosteroid dexamethasone over time! It lasts longer than TA, usually between 4 and 6 months. A DEX implant also gives you anti-inflammatory effects and lowers macular swelling. Like TA, it also comes with the risk of cataracts and an increase in eye pressure. Because it is an implant, there is also a small chance it will migrate over time. Intravitreal implant means that doctors inject this into the vitreous humor. The vitreous humor is the jelly-like tissue that fills the eyeball behind the lens. It is mostly made of water and helps your eyeball keep its shape. If the implant migrates, it can move from the vitreous humor to the front chamber of the eye. This can lead to a complication called corneal edema, which is when the cornea swells up, making your vision blurry.
Fluocinolone Acetonide (FA) Intravitreal Implant
Another implant, this option is not biodegradable but releases corticosteroids over a longer time period. FA implants can last up to 3 years, which greatly lowers the burden to go in for treatments. You will need to get regular checkups with your doctor to monitor your progress, however. FA implants help with redness, pain and swelling in the eye. There are some risks, like temporary blurred vision after injection, developing cataracts and implant migration. Other side effects like bleeding, dry or itchy eyes, difficulty seeing at night, pain, and floating spots can happen! Be in close contact with your doctor or ophthalmologist to catch these early.
Corticosteroids are an effective second-line treatment option for diabetic macular edema! This is particularly true for people with chronic or treatment-resistant cases. These are long-lasting options that have to be administered less often. However, corticosteroids do come with risks. You should always go over your options carefully with your doctor to figure out the best treatment approach for you.
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