I recently listened to a video post by David M Brown, M.D.  (available on MedScape) in which he summarizes an article regarding intravitreal steroids versus focal laser for control of diabetic retinopathy (Diabetic Retinopathy Clinical Research Network). A randomized trial comparing intravitreal triamcinolone acetonide and focal/grid photocoagulation for diabetic macular edema. Ophthalmology. 2008 Sep;115(9):1447-9, 1449.e1-10. Epub 2008 Jul 26).  Dr. Brown made several points; 1) the study showed that while intraocular steroids were better than focal laser in the short-run, focal laser was better after one year, 2) evidenced based medicine should be used to keep us more “grounded” in our choice for therapies, and 3) standard randomized trials really give us the truth about our treatments.

Simply stated, the trial concluded that focal laser is better than steroids for the diabetic patient.  While I do not disagree, I feel there is still a use for intravitreal steroids in diabetic patients.  There are many patients that have clinically significant macular edema that is not treatable with focal photocoagulation.  Either there are centrally located microaneurysms (i.e. treating these would cause scotoma), or there is persistent macular edema despite careful laser treatment up to the foveal edge (i.e. no room for additional treatment).  These patients often benefit from intravitreal steroids.

It is my usual practice to attempt laser followed by intravitreal steroids, if needed.

Just my thoughts,

Randall V. Wong, M.D.
Retinal Specialist
www.TotalRetina.com