A 62-year-old diabetic has center-involving macular edema with best corrected visual acuity of 6/36. OCT shows a taut posterior hyaloid adherent at the fovea with vitreomacular traction and an epiretinal membrane. Three monthly anti-VEGF injections have produced no anatomical or visual improvement. What is the most appropriate next step?

• A Continue anti-VEGF injections indefinitely at monthly intervals
• B Intravitreal dexamethasone implant every month
• C Grid pattern macular laser photocoagulation
• D Pars plana vitrectomy with removal of the posterior hyaloid and epiretinal membrane ✓

Explanation

Tractional DME driven by a taut posterior hyaloid or epiretinal membrane responds poorly to anti-VEGF therapy because the mechanical traction component persists regardless of VEGF levels. Vitrectomy with posterior hyaloid separation and membrane peeling directly removes the traction and improves both anatomy and vision in such eyes. Grid laser also fails here since it addresses diffuse leakage, not traction, and steroids would again leave the mechanical cause untouched.

Reference: Kanski's Clinical Ophthalmology, 9th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.