In your experience, what factors prompt you to switch a patient with diabetic macular edema to Eylea HD?

In my practice, it isn’t switching to longer acting anti-VEGF, it is the treatment of the peripheral retinal ischemia. I often initially treat CSME with Avastin, but I use an IVFA to evaluate and treat the non-perfused retina with laser. It is the PRP that treats the VEGF production driving the diabetic oedema of the macula.

Ultimately, persistent macular edema must be evaluated for the causation. Ischemia with VEGF production, inflammation in the posterior pole, and tractional forces must be considered and treated. This triad is one way to consider the causes.

Many have advocated anti-VEGF injections as the “modern” treatment for CSME and PDR, but I lived through the post-COVID era and spent months doing extensive vitrectomies for traction...

There is a limited window of added benefit. Mostly, patients stuck between 7 and 10 weeks of Eylea 2 mg are the best candidates. In my experience, most patients will get 1-2 added weeks of control with 8 mg over 2 mg. So 7 weeks is the minimum to stay within labeling and insurance coverage after the loading dose. On the other hand, if a patient is at q12 week with 2 mg, and they can stretch to q14 week with 8 mg, how much benefit have they actually gained? That is the difference of about half an injection a year, and the cost of higher post-injection IOP, greater likelihood of needing an AC tap, and added cost and financial risk of denial or authorization expiration.

Another cohort that I consider is on Vabysmo 7 or more weeks interval, but...