Treatment of Diabetic Macular Edema (DME)

Diabetic macular edema is a common complication of diabetic retinopathy where fluid accumulates in the macula and blurs the vision.

Diabetic macular edema (DME) is a condition characterized by the accumulation of fluid in the macula, the central part of the retina responsible for sharp, detailed vision. It is a common complication of diabetic retinopathy, a disease affecting the blood vessels of the retina. The management of diabetic macular edema (DME) involves various treatment approaches aimed at reducing macular edema and preserving vision.

Anti-VEGF Injections – Treatment of Diabetic Macular Edema

One of the primary treatment options for DME is intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) medications. Drugs like ranibizumab, bevacizumab, and aflibercept are commonly used to inhibit the abnormal growth of blood vessels and reduce leakage, thus decreasing macular edema. These injections are typically administered on a monthly or as-needed basis, with the aim of improving visual acuity and reducing central retinal thickness.

Steroids for Diabetic Macular Edema

Another treatment modality for DME is the use of corticosteroids. Intravitreal injections of triamcinolone acetonide or dexamethasone implants can help suppress inflammation and reduce fluid accumulation in the macula. These steroid injections are usually performed at longer intervals compared to anti-VEGF agents due to their sustained-release properties.

In some cases, laser photocoagulation may be employed to treat DME. Focal laser treatment can be used to seal leaking blood vessels and reduce fluid accumulation. However, this approach is typically reserved for cases where the edema is away from the central macula to avoid damaging central vision.

New Treatments

Recently, a new class of medications called integrin receptor antagonists has shown promise in the treatment of DME. These drugs, such as pegpleranib and abicipar, target specific proteins involved in the pathogenesis of macular edema and are administered via intravitreal injections.

In addition to these specific treatments, managing the underlying diabetes is crucial in preventing and managing DME. Maintaining optimal blood sugar control, blood pressure, and cholesterol levels can help reduce the risk and progression of DME.

Regular eye examinations and early detection of DME are essential for timely intervention and optimal outcomes. Treatment options should be individualized based on the severity of the edema, visual impairment, and patient characteristics. By employing a combination of these treatment modalities and a comprehensive approach to diabetes management, healthcare professionals can improve visual outcomes and enhance the quality of life for individuals living with DME.

If you would like to schedule an appointment, please call us (877) 245.2020.

Nader Moinfar, M.D., M.P.H.
Retina Specialist
Orlando, FL

Face Mask May Increase Eye Infections

Here’s another reason to be careful about wearing a mask.

Wearing a face mask is important for patients from the moment they walk into a clinic to protect themselves and others from SARS-CoV-2 infection. But additional safety measures should be used when the patient is wearing a face mask and receiving intravitreal injections to prevent contamination that could occur when exhaled breath is blown toward their eyes.

A study to investigate the air that escapes from the top of face masks used a thermal camera and found that air jets originating from the top edges of face masks and radiating toward the eye were detected in 81% of cases.

3 Face Masks

Three face masks were tested. A regular face mask with four tying strips, one with elastic ear loops, and the 220 N95 tuberculosis particulate face mask.

Exhaled breath that is normally blown forward is blocked by face masks and that air is redirected toward the eye. People who wear glasses and face masks are aware of this issue. It causes their glasses to fog up.

Anti-VEGF injections have a very low risk of endophthalmitis. Several large studies have estimated the risk at approximately 0.05% or 5 in 10,000 for any individual patient receiving monthly injections. Having face masks blowing air into the eye could increase that risk slightly and for that reason extra precautions are recommended.  

Study Recommendations

The additional precaution can be done in one of two ways—a surgical drape can be used to isolate the eye or medical adhesive tape can be applied on the upper border of the face mask to block air passage. The study also recommends using an eyelid speculum to keep the eye open and prevent the eyelid from coming into contact with the needle.

The study’s author, Amir Hadayer, MD, says, “Protocols for preparing patients for intravitreal injections vary and not all specialists use draping and a speculum in normal times, but under the current circumstances, these extra precautions are recommended.”

What is Endophthalmitis?

Endophthalmitis is an infection that causes severe inflammation of the tissues inside the eye. The infection is typically caused by bacteria for fungi.

Symptoms of Endophthalmitis

  • Decreased vision
  • Pain
  • Redness or swelling of the eye

These symptoms don’t always mean you have endophthalmitis, but if you experience one or more of these symptoms, contact your ophthalmologist.

If you would like to schedule an appointment, please call us (877) 245.2020.

Nader Moinfar, M.D., M.P.H.
Retina Specialist
Orlando, FL

Drug Delivery for Eye Disease

Eye drops are great for only certain eye diseases. There are other routes used to treat your retina.

There are different routes of drug delivery to treat your eye disease.

Not all parts of the eye can be reached by the same route. Eye drops and ointments applied by patients directly to the eye is the route to get to the cornea, conjunctiva, and sclera, but getting to the retina in the back of the eye requires a different route—an injection.

Intravitreal Injections

Only an intravitreal injection will reach the retina because the retina is part of the brain and is protected by the blood-brain barrier.

Intravitreal means that the injection is into the vitreous of the eye. The vitreous is a clear, colorless, jelly-like substance that fills the space between the lens and the retina. Intravitreal injections of anti-VEGF are placed in the vitreous near the retina to treat wet macular degeneration and diabetic retinopathy.

The injections are done in a doctor’s office and the eye is numbed before the injection. They are a safe and effective way to prevent further vision loss.

Eye Drops

Eye drops are the preferred route of drug delivery to treat eye diseases in the front part of the eye. They are commonly used to treat eye infections, allergies, inflammation, glaucoma, and to provide lubrication for dry eyes.

Eye drops come in solutions and suspensions. In a solution the particle sizes are very small and they completely dissolve in the solvent mixture making a solution clear. Suspensions consist of larger particles that are suspended in a solvent. The larger particles will settle to the bottom so suspensions must be shaken before use to re-suspend the therapeutic particles.

If you are applying more than one drop to an eye, allow the first drop to absorb completely before applying a second drop so the medication doesn’t end up running down your cheek.

Medicated Contact Lenses

For some corneal infections a special type of contact lens or a collagen shield is soaked in antibiotics and placed on the eye.


Although ointments are greasy and somewhat difficult to apply they are the preferred eye medication for use on infants and very small children because they stay in the eye longer than eye drops. Ointments are also used for nighttime applications of eye medication so the ointment can cover the eye while you sleep.

Sustained Release Drug Systems

These are biodegradable, implanted devices that supply a slow, steady release of a drug over an extended time to maintain the therapeutic level of the drug to the target area. It is new technology and is available for the treatment of glaucoma, vascular occlusions and diabetic retinopathy.

If you would like to schedule an appointment, please call us (877) 245.2020.

Nader Moinfar, M.D., M.P.H.
Retina Specialist
Orlando, FL

Warnings Issued About Beovu

Beovu is FDA approved for the treatment of wet ARMD. An unusual complication may be associated with the drug…

Beovu was recently cleared by the FDA for the treatment of wet macular degeneration. Warnings about its use were recently issued by the American Society of Retina Specialists (ASRS).

Beovu is yet another anti-VEGF medication and, like the others, is delivered directly into the eye by injection. The drugs usually need to be repeated every 4-6 weeks and for an undetermined period.

At the recent meeting of the American Society of Retina Specialists (ASRS), a warning letter was issued to its retina specialist members that a very unusual side effect has been reported.

14 patients with retinal vasculitis have been reported. 11 of the 14 cases were reported to have occlusive retinal vasculitis resulting in severe vision loss. Retinal vasculitis is an unusual complication of any of the anti-VEGF medications.

Anti-VEGF Medications

Other medications used for the treatment of wet macular degeneration include:

  • Macugen (pegaptanib)
  • Avastin (bevacizumab)
  • Lucentis (ranibizumab)
  • Eylea (aflibercept)

Anti-VEGF medications temporarily halt the abnormal growth of neovascularization (abnormal blood vessels) within the layers of the retina. Because the vessels tend to grow back, injections need to be repeated.

Until Beovu was FDA approved, most anti-VEGF injections are repeated every 4-6 weeks. Beovu is unique in that it was approved for a possible 3 month dosing schedule (i.e. an interval of 3 months vs. 4-6 week).

Visual results were comparable to the visual results obtained by Eylea. The drug was not tested against the other anti-VEGF injections in the data submitted for FDA approval.

Novartis Response

Novartis Pharmaceuticals is the manufacturer of Beovu and in two public statements stands by the safety and efficacy of the drug as reported to the FDA.

The company states that the 14 cases of vasculitis fall well within the reported incidence of severe vision loss although it is not clear that vasculitis, specifically, was ever reported as a side effect.

The company is moving forward with its own investigation of these “post-marketing” events and is engaging the help of an external Safety Review Committee (SRC).

If you would like to schedule an appointment, please call us (877) 245.2020.

Nader Moinfar, M.D., M.P.H.
Retina Specialist
Orlando, FL

Beovu | New Treatment ARMD

This new FDA approved drug for wet macular degeneration requires fewer injections.

The FDA recently approved another intravitreal injection for the treatment of wet-ARMD. Beovu (brolucizumab) is an anti-VEGF medication which may be useful for extending the frequency of injections in patients requiring multiple treatments.

The FDA found that Beovu may be useful in the treatment wet macular degeneration and offers an extended 3 month dosing schedule.

Anti-VEGF Medications

Other anti-VEGF medications for the treatment of wet macular degeneration include:

  • Avastin
  • Lucentis
  • Eylea
  • Macugen

Wet macular Degneration

There are two forms of macular degeneration: wet and dry. The dry form accounts for about 90% of patients with macular degeneration. Symtoms of distortion, blind spots and blurry vision are less so than the “wet” counterpart.

Wet macular degeneration accounts for the other 10% of ARMD patients. Wet macular degeneration is more aggressive and causes more pronounced and quicker loss of vision.

Wet macular degeneration occurs with the development of abnormal blood vessels growing within the layers of the retina. The abnormal blood vessels, aka neovascularization, are stimulated by a protein called Vascular Endothelial Growth Factor (VEGF).

anti-VEGF medications, like Beovu, work by neutralizing the VEGF protein making it ineffective. As a result, the neovascularization regresses and can not be stimulated to grow.

Timing of Injections

All the anti-VEGF medications work in similar fashion and share similar results. In addition, the dosing schedule of all the anti-VEGF injections usually ranges between every 4-6 week dosing (a shot every 4-6 weeks).

Beovu was compared to Eylea to gain FDA approval. Beovu may have the advantage of achieving similar results (non-inferior) to Eylea, but may be given once every 3 months compared to monthly injections.

FDA approval usually only gives the retina specialist guidance or suggestions on a drug’s use. Though dosing is approved for every 3 months, it does not necessarily mean that a retina specialist will find this necessarily true in practice.

Most retina specialists will slowly try the new drug and determine for ourselves which type of patients will derive the most benefit in terms of treatment efficacy and dosing.

If you would like to schedule an appointment, please call us (877) 245.2020.

Nader Moinfar, M.D., M.P.H.
Retina Specialist
Orlando, FL

Retinal Vascular Occlusions (RVO)

Retinal vascular occlusions cause painless loss of vision. Here’s a short review of the 4 different types.

There are four types of retinal vascular occlusions (RVO).  All have similar symptoms of acute (sudden) and painless loss of vision.  

In general, vein obstructions occur when the vessel is compressed from the outside of the blood vessel whereas artery obstructions occur when cholesterol plaque (or other substances) travel through the blood stream and become lodged in a blood vessel.

Vein and artery occlusions have characteristic appearances and can be easily diagnosed by a retina specialist.

Artery occlusions are more likely to be associated with coronary artery disease and stroke.

The four types of retinal vascular occlusions include:

  • Branch retinal vein occlusion (BRVO)
  • Central retinal vein occlusion (CRVO)
  • Branch retinal artery occlusion (BRAO)
  • Central retinal artery occlusion (CRAO)

Branch Retinal Vein Occlusion

Compared to a central vein occlusion, this is a “partial” occlusion of the retinal vein.  Usually branch occlusions involve about 50% or less of the retina. If the macula becomes involved, there is usually moderate vision loss.  On occasion, the macula is not involved and vision remains normal. 

Treatment of BRVO includes laser surgery, injections of anti-VEGF and/or intraocular steroids including Ozurdex, a sustained release device which allows continuous treatment for up to 4-6 months.

Central Retinal Vein Occlusion

The entire retinal vein is occluded.  Severe vision loss is normally experienced.  Unlike the branch vein occlusion, the macula is always involved.

Treatment of CRVO may include laser, anti-VEGF injections or sustained release steroids.  Vision usually does not improve as well as the branch retinal vein occlusion.

Branch Retinal Artery Occlusions

Branch artery occlusions do not involve the entire retina and, similar to venous occlusions, less than 50% of the retina is involved.  If the macular area is involved, central vision is decreased. 

Branch artery occlusions do cause retinal edema, but the vision loss is usually more permanent though there is resolution of the retinal swelling.

Both branch and central artery occlusions are caused by an embolus:  usually a cholesterol plaque carried through the bloodstream and becomes lodged in a retinal artery. 

Central Retinal Artery Occlusion

As with the branch artery occlusion, an embolus lodges in the central artery thus cutting off blood flow to the entire retina.  Vision loss is severe and usually does not respond well to treatment.

Historically, many different methods have been described to dislodge the embolus, but none with resounding success.

Patients with artery occlusions should be assessed for the risk of cardiovascular disease and stroke.  It’s important that your retina specialist or eye doctor coordinate care with your primary care physician. 

If you would like to schedule an appointment, please call us (877) 245.2020.

Nader Moinfar, M.D., M.P.H.
Retina Specialist
Orlando, FL

Jon Doe