Macular edema explained

Synonyms:Macular oedema,[1] familial macular edema
Macular edema

Macular edema occurs when fluid and protein deposits collect on or under the macula of the eye (a yellow central area of the retina) and causes it to thicken and swell (edema). The swelling may distort a person's central vision, because the macula holds tightly packed cones that provide sharp, clear, central vision to enable a person to see detail, form, and color that is directly in the centre of the field of view.

Cause

The causes of macular edema are numerous and different causes may be inter-related.

Diagnosis

Classification

Cystoid macular edema (CME) involves fluid accumulation in the outer plexiform layer secondary to abnormal perifoveal retinal capillary permeability. The edema is termed "cystoid" as it appears cystic; however, lacking an epithelial coating, it is not truly cystic. The cause for CME can be remembered with the mnemonic "DEPRIVEN" (diabetes, epinepherine, pars planitis, retinitis pigmentosa, Irvine-Gass syndrome, venous occlusion, E2-prostaglandin analogues, nicotinic acid/niacin).

Diabetic macular edema (DME) is similarly caused by leaking macular capillaries. DME is the most common cause of visual loss in both proliferative, and non-proliferative diabetic retinopathy.[9]

Treatment

Macular edema sometimes occurs for a few days or weeks (sometimes even much longer) after cataract surgery, but most such cases can be successfully treated with NSAID or cortisone eye drops. Prophylactic use of Nonsteroidal anti-inflammatory drugs has been reported to reduce the risk of macular edema to some extent.[10] Higher frequency use of topical steroids provides benefit in difficult to treat cases.[11]

Diabetic macular edema may be treated with laser photocoagulation, reducing the chance of vision loss.[12]

In 2010, the US FDA approved the use of Lucentis intravitreal injections for macular edema.[13]

Iluvien, a sustained release intravitreal implant developed by Alimera Sciences, has been approved in Austria, Portugal and the U.K. for the treatment of vision impairment associated with chronic diabetic macular edema (DME) considered insufficiently responsive to available therapies. Additional EU country approvals are anticipated.[14]

In 2013 Lucentis by intravitreal injection was approved by the National Institute for Health and Care Excellence in the UK for the treatment of macular edema caused by diabetes[15] and/or retinal vein occlusion.[16]

On July 29, 2014, Eylea (aflibercept), an intravitreal injection produced by Regeneron Pharmaceuticals Inc., was approved to treat DME in the United States.[17]

Research

In 2005, steroids were investigated for the treatment of macular edema due to retinal blood vessel blockage such as CRVO and BRVO.[18]

A 2014 Cochrane Systematic Review studied the effectiveness of two anti-VEGF treatments, ranibizumab and pegaptanib, on patients with macular edema caused by CRVO.[19] Participants on both treatment groups showed a reduction in macular edema symptoms over six months.[19]

Another Cochrane Review examined the effectiveness and safety of two intravitreal steroid treatments, triamcinolone acetonide and dexamethasone, for patients with from CRVO-ME.[20] The results from one trial showed that patients treated with triamcinolone acetonide were significantly more likely to show improvements in visual acuity than those in the control group, though outcome data was missing for a large proportion of the control group. The second trial showed that patients treated with dexamethasone implants did not show improvements in visual acuity, compared to patients in the control group.

Intravitreal injections and implantation of steroids inside the eye may result in a small improvement of vision for people with chronic or refractory diabetic macular edema.[21] There is low certainty evidence that there does not appear to be any additional benefit of combining anti-VEGF and intravitreal steroids when compared to either treatment alone.[22]

Anti‐tumour necrosis factor agents have been proposed as a treatment for macular oedema due to uveitis but a Cochrane Review published in 2018 found no relevant randomised controlled trials.[23]

See also

Notes and References

  1. 'Oedema' is the standard form defined in the Concise Oxford English Dictionary (2011), with the precision that the spelling in the United States is 'edema'.
  2. Web site: What Causes Macular Edema . American Academy of Ophthalmology . 30 January 2016 .
  3. Web site: What is Age-Related Macular Degeneration? . American Academy of Ophthalmology . 30 January 2016 .
  4. Web site: Pseudophakic Cystoid Macular Edema . Laly . David R . vanc . 5 March 2014 . Review of Ophthalmology . 30 January 2016 .
  5. Web site: Complications of Uveitis . 27 January 2015 . Her Majesty's Government, UK . 30 January 2016 .
  6. Web site: Retinal Vein Occlusion . Lusby . Franklin W . vanc . 8 May 2014 . Medline Plus . US Library of Medicine . 30 January 2016 .
  7. Web site: Common Medications That May Be Toxic To The Retina . Abaasi . Omar . vanc . 11 June 2009 . Review of Ophthalmology . 30 January 2016 .
  8. Web site: Medication Cautions in Macular Degeneration . American Macular Degeneration Foundation . 30 January 2016 .
  9. Varma R, Bressler NM, Doan QV, Gleeson M, Danese M, Bower JK, Selvin E, Dolan C, Fine J, Colman S, Turpcu A . 6 . Prevalence of and risk factors for diabetic macular edema in the United States . JAMA Ophthalmology . 132 . 11 . 1334–40 . November 2014 . 25125075 . 4576994 . 10.1001/jamaophthalmol.2014.2854 .
  10. Lim BX, Lim CH, Lim DK, Evans JR, Bunce C, Wormald R . Prophylactic non-steroidal anti-inflammatory drugs for the prevention of macular oedema after cataract surgery . The Cochrane Database of Systematic Reviews . 11 . CD006683 . November 2016 . 11 . 27801522 . 6464900 . 10.1002/14651858.CD006683.pub3 .
  11. Campochiaro PA, Han YS, Mir TA, Kherani S, Hafiz G, Krispel C, Liu TY, Wang J, Scott AW, Zimmer-Galler. Increased Frequency of Topical Steroids Provides Benefit in Patients With Recalcitrant Postsurgical Macular Edema . Am. J. Ophthalmol. . 178 . 163–175 . June 2017 . 28392176 . 10.1016/j.ajo.2017.03.033 .
  12. Jorge. Eliane C. Jorge. Edson N. Botelho. Mayra. Farat. Joyce G. Virgili. Gianni. El Dib. Regina. 2018-10-15. Cochrane Eyes and Vision Group. Monotherapy laser photocoagulation for diabetic macular oedema. Cochrane Database of Systematic Reviews. 2018. 10. CD010859. en. 10.1002/14651858.CD010859.pub2. 6516994. 30320466.
  13. Web site: GEN | News Highlights: FDA Green-Lights Genentech's Lucentis for Macular Edema following Retinal Vein Occlusion . Genengnews.com . 2012-12-15.
  14. Web site: Iluvien gains marketing authorization in Portugal for chronic DME. OSN SuperSite, June 7, 2012. Retrieved June 20, 2012
  15. Web site: Ranibizumab for treating diabetic macular oedema . February 2013 . NICE Guidance . .
  16. Web site: Ranibizumab for treating visual impairment caused by macular oedema secondary to retinal vein occlusion . May 2013 . NICE Guidance . NICE . 30 January 2016 .
  17. Web site: Archived copy . 2014-07-30 . https://web.archive.org/web/20140808052115/http://files.shareholder.com/downloads/REGN/3361382769x0x772028/698a12f7-a8dc-4f89-b9e2-f8134ae6f3de/REGN_News_2014_7_29_General_Releases.pdf . 2014-08-08 . dead .
  18. Web site: Steroid Injections vs. Standard Treatment for Macular Edema Due to Retinal Blood Vessel Blockage - Full Text View . 3 March 2008 . ClinicalTrials.gov . 2012-12-15.
  19. Braithwaite T, Nanji AA, Lindsley K, Greenberg PB . Anti-vascular endothelial growth factor for macular oedema secondary to central retinal vein occlusion . The Cochrane Database of Systematic Reviews . 5 . CD007325 . May 2014 . 5 . 24788977 . 4292843 . 10.1002/14651858.CD007325.pub3 .
  20. Gewaily D, Muthuswamy K, Greenberg PB . Intravitreal steroids versus observation for macular edema secondary to central retinal vein occlusion . The Cochrane Database of Systematic Reviews . 2021 . 9 . CD007324 . September 2015 . 26352007 . 4733851 . 10.1002/14651858.CD007324.pub3 .
  21. Rittiphairoj. Thanitsara. Mir. Tahreem A.. Li. Tianjing. Virgili. Gianni. November 17, 2020. Intravitreal steroids for macular edema in diabetes. The Cochrane Database of Systematic Reviews. 2020. 11 . CD005656. 10.1002/14651858.CD005656.pub3. 1469-493X. 33206392. 8095060.
  22. Mehta. Hemal. Hennings. Charles. Gillies. Mark C. Nguyen. Vuong. Campain. Anna. Fraser-Bell. Samantha. 2018-04-18. Anti-vascular endothelial growth factor combined with intravitreal steroids for diabetic macular oedema. Cochrane Database of Systematic Reviews. 2018. 4. CD011599. 10.1002/14651858.cd011599.pub2. 1465-1858. 6494419. 29669176.
  23. Barry RJ, Tallouzi MO, Bucknall N, Mathers JM, Murray PI, Calvert MJ, Moore DJ, Denniston AK . 6 . Anti-tumour necrosis factor biological therapies for the treatment of uveitic macular oedema (UMO) for non-infectious uveitis . The Cochrane Database of Systematic Reviews . 2018 . CD012577 . December 2018 . 12 . 30562409 . 6516996 . 10.1002/14651858.CD012577.pub2 . Cochrane Eyes and Vision Group .

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