A 68-year-old pseudophakic patient with center-involving diabetic macular edema has received six monthly intravitreal aflibercept injections with incomplete response; best corrected vision remains 6/24 and central macular thickness is 480 micrometers. What is the most appropriate next step?
- A Sub-Tenon triamcinolone every 3 years
- B Macular grid laser photocoagulation as monotherapy
- C Oral acetazolamide with topical carbonic anhydrase inhibitor drops
- D Switch to intravitreal dexamethasone implant ✓
Explanation
Persistent center-involving diabetic macular edema despite an adequate course of anti-VEGF therapy is a recognized indication for a corticosteroid implant such as dexamethasone, providing roughly 3 to 6 months of drug delivery. Being pseudophakic removes the main barrier to steroids, namely cataract progression, though pressure monitoring remains mandatory. Grid laser alone yields limited gains in thickened center-involved disease, and systemic acetazolamide has no established role in diabetic macular edema.
Reference: American Academy of Ophthalmology Basic and Clinical Science Course, Section 12, Retina/Vitreous, recent edition ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.