The Role of Steroids in the Management of Diabetic Macular Edema

Inflammation is substantially contributing to the development and worsening of diabetic retinopathy in general and diabetic macular edema (DME) in particular, which provides the rationale to treat DME with corticosteroids. While anti-vascular endothelial growth factor (VEGF) agents are mostly chosen as a first-line treatment, there is an important role for steroids in the treatment algorithm for DME. A slow-release bioerodible dexamethasone implant and an extended-release nonbioerodible fluocinolone acetonide insert are both approved for the treatment of DME and provide the advantage of sustained drug delivery and reduced treatment burden. Steroids bare the complications of cataract progression and increase of intraocular pressure (IOP). However, with dexamethasone implant, IOP rise is well manageable with topical treatment in almost all cases. Dexamethasone implant has been shown to be effective in the treatment of naive DME as well as in eyes nonresponding to anti-VEGF agents. In these cases, early switching to steroids may be considered and has been shown to be beneficial. Fluocinolone acetonide is reserved for severe cases of chronic DME insufficiently responsive to other available therapies. Future randomized controlled trials are needed to realize the role of steroids in the current treatment algorithm of DME.