In eyes with chronic DME despite frequent anti-VEGF, what is your threshold to add or switch to intravitreal steroid therapy?

I’m quick to add steroids to anti-VEGF treatment. If there is little to no response to 3 anti-VEGF injections, adding a dexamethasone implant (Ozurdex) can help a lot. I will usually do that before switching in class. I usually switch to a different anti-VEGF if there is good but incomplete response...

In a similar scenario, with radiation maculopathy, I add a steroid as polypharmacy when I have exhausted the use of anti-VEGF alternative drugs and the macular edema is either persistent or progressing.

I agree with the above strategies, and indeed, three injections of bevacizumab are required by insurance, often in any case. Having said that, there are plenty of cases that are obviously (to me) not going to respond to anti-VEGF of any variety, and my guesses are usually pretty accurate. I'm sure s...

I am thinking about switching after three injections if I don't see a substantial (i.e.,> 50%) reduction in edema. I may try to go to a 2nd generation agent (usually faricimab) if I don't see a 50% reduction after the 1st injection --- by getting to faricimab early, I am able to make the switch to s...

Very interesting discussion.

With persistent CSME despite Anti-VEGF treatment, with or without steroids, one must consider peripheral ischemia, which is a factor in persistent edema as well. One should consider traction in the vitreoretinal interface with an ERM.