Table 2

Potential adaptations to the guidelines for DMO in the COVID-19 era

Treatment stageSuggested action
At any point on the anti-VEGF pathwayFor the elderly or for pseudophakic eyes, consider corticosteroid treatment regardless of apparent anti-VEGF response.
For other patients, if anti-VEGF injections cannot be given as frequently as wished (perhaps because the clinic has capacity issues or the patient is unable or unwilling to attend), discuss locally if it may be appropriate to consider a change from anti-VEGF to corticosteroid treatment as, although outside the evidence base, adequate dosing with a corticosteroid may offer superior outcomes to inadequate dosing with anti-VEGF treatment. In order to achieve the greatest reduction in the number of injections as rapidly as possible, while at the same time also minimising injection risks and helping to ease clinic capacity, consider using a longer acting corticosteroid instead of a shorter acting corticosteroid. If it might be difficult for the patient to have an intraocular pressure check after 8 weeks, consider prescribing a pressure-lowering drop for them to start using after 4 weeks as preventive therapy. However, it should be emphasised that such prophylaxis is not an evidence-based practice and there is a risk that such an intervention could be inadequate and/or inappropriate and might create a false sense of security. Thus, it does not reflect the personal opinion and practice of all members of the consensus group.
Resuming treatment that was interrupted during the loading dose phase:
Give another three anti-VEGF injections and review response. Preinjection OCT values and patient feedback about any visual improvement experienced may suggest whether the initial course of anti-VEGF had any impact. Before continuing anti-VEGF, carefully counsel about the likely burden of injections in the first year of anti-VEGF therapy (potentially up to 13),41 especially in light of current and future challenges posed by the pandemic. If anti-VEGF injections cannot be given as frequently as wished, consider locally if it may be better for eyes to receive adequate dosing of a corticosteroid than inadequate dosing with an anti-VEGF.
After the loading dose phase on the anti-VEGF pathwayIf, after 24 months of anti-VEGF injections, anti-VEGF has been given more often than every 8 weeks* in the 12 months preceding interruption by the COVID-19 pandemic, consider changing to a corticosteroid treatment to reduce the treatment burden.
Resuming treatment that was interrupted after the loading dose phase:
Repeat OCT and assess disease activity. Treatment resumption depends on the extent of DMO recurrence relative to the last visit before treatment interruption. If OCT has increased by ≥20% relative to preinterruption level or visual acuity has lost ≥5 letters (with associated residual cystoid macular oedema), initiate another loading dose phase with anti-VEGF or consider suitability for corticosteroid treatment. Otherwise, restart anti-VEGF using the last injection frequency that was successful in maintaining a dry/stable macula (however, in the second 12 months, if anti-VEGF injections are being required more frequently than every 8 weeks, discuss treatment decision with the responsible retina specialist to explore the suitability of corticosteroid therapy to reduce treatment burden).
After dexamethasone treatment with prior good effectConsider changing from the shorter acting corticosteroid to a longer acting corticosteroid as soon as possible in order to achieve the greatest reduction in the number of injections, while at the same time also minimising injection risks and helping to ease clinic capacity. The longer acting corticosteroid has the major advantage over the shorter acting corticosteroid of being more likely to ensure continuity of efficacy in the event of further lockdowns. Intraocular pressure checks can be conducted using non-contact tonometers in virtual clinics or by optometrists in the community.
After dexamethasone treatment with prior effect unknownIf the patient felt there was an improvement in visual acuity that lasted for more than 8 weeks, and there was no evidence of significantly raised intraocular pressure, consider this a successful response and offer them the choice of a dexamethasone or fluocinolone acetonide implant.
If it is unclear whether the dexamethasone implant achieved clinical benefits, consider injecting another dexamethasone implant, and then if this achieves a successful response without significant intraocular pressure problems, offer patients the choice of a dexamethasone or fluocinolone acetonide implant.
  • The guideline refers only to DMO and not to other potential complications of diabetic retinopathy such as proliferative retinopathy.

  • *Equivalent to ‘≥6 anti-VEGF injections in the preceding 12 months’ as stated in figure 2.

  • DMO, diabetic macular oedema; OCT, optical coherence tomography; VEGF, vascular endothelial growth factor.