How do you determine whether to switch to a different anti-VEGF agent or to Ozurdex after a patient with diabetic macular edema fails a series of Avastin?

For my practice, macular oedema (CSME) is based on three factors. Ischemia, inflammation, and traction: the three factors which lead to persistent oedema. IVFA will show the level of non-perfusion in the far periphery, which is a major producer of VEGF, and laser (PRP) is the treatment. IV anti-VEGF can temporarily treat the central oedema, but the definitive treatment is laser ablation. I often will use topical steroids early in the course of treatment to see if the patient is a steroid respond...

The decision to switch to Ozurdex for treatment of diabetic macular edema depends largely on the OCT characteristics of the edema. If large cystic/cystoid-like edema is present centrally, then the more likely the patient will have a better or more dramatic anatomic response to intravitreal steroids, like Ozurdex. In these cases, switching early to Ozurdex often leads to better visual and anatomic outcomes. After ozurdex injection, patients typically require continued anti-VEGF for disease (retin...