86 years old diabetic patient presented for diabetic eye exa | Figure 1

Patient Case

86 years old diabetic patient presented for diabetic eye examination. Only complaint was blurry vision in both eyes. Best corrected vision was 20/60 OD and OS. Cataracts were fairly consistent for degree of visual acuity. There was very mild retinal background diabetic retinopathy. Photos and an OCT (optical coherence tomography) were obtained. What stood out was vitreo-macular traction (VMT), leading to pseudomacular cyst formation in one eye. Should this just be monitored waiting on the vitreous to fully detach or should this be sent to retina for possible intervention and separate the two so a macular hole doesn’t form?

Benefits and Risks of Steroid Injections for Diabetic Macular Edema

Why this question is important
Diabetes causes high levels of sugar in the blood. This can damage the small blood vessels at the back of the eye (the retina). If they leak, the central part of the retina (the macula) swells. This is called diabetic macular edema, and it can cause blurred vision and potentially lead to permanent vision loss. One treatment method is steroid injections (anti-inflammatory medicines) into the eye.

How we identified and assessed the evidence
We reviewed relevant studies in medical literature, assessed study quality, sizes, and consistency of findings, categorizing evidence as very low, low, moderate, or high certainty.

What we found
10 studies were identified involving 4348 participants with diabetic macular edema, followed for 9 to 36 months. The studies examined three steroids: dexamethasone, fluocinolone, and triamcinolone.

Benefits (measured 12 or 24 months after treatment)

• Compared to a sham treatment:
  • Dexamethasone and fluocinolone probably improve visual sharpness and reduce retinal thickness; triamcinolone may also do this.
  • More patients’ vision improved by three lines or more on a vision chart with fluocinolone.
• Compared to antiangiogenics:
  • Dexamethasone likely improves visual sharpness similarly or slightly less, but may reduce retinal thickness slightly more.
  • Inconsistency in evidence for dexamethasone and triamcinolone.
• Compared to laser therapy:
  • Little or no difference for triamcinolone regarding improvement in vision by three lines or more.

Risks (measured 9 to 36 months after treatment)

• Compared to a sham treatment:
  • Higher probability of cataract progression with dexamethasone or fluocinolone; potential with triamcinolone too.
  • Possible increased need for eye pressure-lowering drops.
  • Fluocinolone may increase the risk of glaucoma surgery.
• Compared to antiangiogenics:
  • Likely increased cataract progression and pressure-lowering eye drops requirement with dexamethasone.
• Compared to laser therapy:
  • Similarly increased likelihood for triamcinolone regarding cataract progression.

What this means
Evidence suggests that:

• Steroids may be more effective than sham treatments.
• Steroids may be less effective in improving visual sharpness than antiangiogenics.
• Steroids may increase the risk of cataract progression and elevated eye pressure.

Review currency
The evidence in this Cochrane Review is current to 15 May 2019.