A novel 4-point scleral fixation technique with a hydrophobic IOL: The LOTO technique.

PURPOSE: to describe a new surgical technique that combines 4-point, flanged polypropylene scleral fixation with a hydrophobic IOL. METHODS: Using the Envista MX60 and 6.0 polypropylene, scleral 4-point fixation was achieved using a flanged-suture technique 5 times in a model eye and in a case series of 8 patients, retrospectively reviewed. The polypropylene is passed through each eyelet in a novel configuration (LOTO: Loop to Optic and Trailing ends to Outside). Conjunctival peritomies, scleral flaps/pockets, glue, and suture knots are avoided. The load needed for haptic fracture and scanning electron microscopy (SEM) at fracture sites were studied. RESULTS: Haptic fracture occurred once following the first model eye implantation due to excessive suture tension. The fracture load was similar between the LOTO and the simple-pass technique (1.08 ± 0.52 N vs 1.09 ± 0.32 N), suggesting no safety compromise. SEM did not disclose cheese-wiring effect. Over a mean follow-up of 10.8 months (range: 3 to 19; median 11.5 months), all cases experienced visual improvement with best-achieved-postoperative uncorrected visual acuity (BAPUCVA) of 20/25-20/200, and the IOL was well-centered. Postoperative IOL tilt averaged 2.9 degrees (range: 0 to 9.6; median: 2.9 degrees). Two patients developed post-operative CME treated topically. The first case developed flange extrusion that was readily repaired in clinic. CONCLUSIONS: This novel technique adds 2 main advantages to previously described flanged-suture techniques: 1) 4-point fixation of a hydrophobic IOL and 2) immediate application at the time of initial complicated cataract surgery since it requires no additional supply, IOL, or instrumentation.

Switch to faricimab after initial treatment with aflibercept in eyes with diabetic macular edema.

PURPOSE: To assess the effectiveness of a switch to faricimab in individuals affected by DME and previously treated with aflibercept. METHODS: In this retrospective, single-center study, DME patients previously treated with at least 3 injections of aflibercept then switched to faricimab were enrolled. Best corrected visual acuity (BCVA) and central subfield thickness (CST) were recorded at baseline, at the time of the switch and at 6 months follow-up. At transition to faricimab, patients were categorized as "good visual responders" (≥ 5 letters from baseline) or "poor visual responders" (< 5 letters), and as "good anatomical responders" (any reduction in edema compared to baseline) or "poor anatomical responders" (no reduction or worsening of edema). Changes in BCVA and CST were recorded at 6 months after the switch to faricimab. RESULTS: 100 eyes of 100 patients (61 female, 61%) were switched to faricimab after a mean of 6.8 ± 3.3 aflibercept injections. At the 6 months follow-up, only "poor visual responders" (N = 62) demonstrated a meaningful increase in BCVA (Δswitch-6M = + 5 letters; P = 0.007), coupled with a reduction in CST (Δswitch-6M = - 67.9 µm; P = 0.004); participants with "poor anatomical response" upon transitioning exhibited a significant functional gain (Δswitch-6M = + 4.5 letters; p = 0.05) but limited CST enhancements (Δswitch-6M = - 95.1 µm; p = 0.05). CONCLUSIONS: Faricimab shows a positive impact on anatomical and functional metrics in DME cases refractory to aflibercept.

The distinct optic disk and peripapillary appearance in Donnai-Barrow syndrome.

INTRODUCTION: Biallelic mutations in low-density lipoprotein-related protein 2 (LRP2) cause the multi-system Donnai-Barrow syndrome (facio-oculo-acoustico-renal syndrome). Although Donnai-Barrow syndrome is recognized as a form of vitreo-retinopathy, the ocular phenotype has not been well defined. The purpose of this study is to document the disk and peripapillary appearance in Donnai-Barrow syndrome. METHODS: Retrospective cases series (five children with low vision from a consanguineous Emirati family known to harbor LRP2 mutation (NM_004525.2: c.7564T>C; p.Y42522H)). RESULTS: All five children had high myopia (spherical equivalent from -15 to -22). One had an ophthalmic phenotypic pathognomonic for Knobloch syndrome, and genetic testing confirmed a homozygous novel COL18A1 mutation (NM_130455.3: c.2978_2987del; p.Pro993Leufs*35) with heterozygosity for the LRP2 mutation. The other four children, confirmed to be homozygous for the LRP2 mutation, had hypertelorism and down-slanting palpebral fissures. Three had spontaneous retinal detachment (two bilateral and one unilateral) with complicated post-surgical courses following retinal detachment repair. The three eyes (two children) without retinal detachment had a consistent unique optic nerve head appearance, with thin emanating vessels and multiple rings of depigmentation that made it difficult to discern the edge of the apparently small and recessed neuroretinal rim. This distinct appearance was also present in the post-surgical eyes which were not phthisical and seemed present in the single published posterior pole image found during literature review. CONCLUSIONS: A distinctive optic nerve head dysgenesis is part of Donnai-Barrow syndrome and can help distinguish its ocular phenotype from other vitreo-retinopathies associated with high myopia.

Rhegmatogenous retinal detachments associated to Stickler syndrome in a tertiary eye care center in Saudi Arabia.

PURPOSE: To investigate the clinical findings and outcomes of rhegmatogenous retinal detachment (RRD) in Stickler syndrome on affected and fellow eyes that underwent prophylactic retinopexy. PATIENTS AND METHODS: Chart review of 70 eyes (62 patients). Incidence of RRD, postoperative visual acuity, and risk factors were evaluated. RESULTS: Twenty-two patients (35%) had RRD in the fellow eye, 37% of the eyes had cataract, 93% had macular detachment, 50% had proliferative vitreoretinopathy, and 41% had posterior vitreous detachment. Success rates were: 60% of patients after scleral buckling; 57.1% after pars plana vitrectomy; and 75% after combined scleral buckling and pars plana vitrectomy. Sixty-one (93.8%) of patients had successful surgery (including second surgery). Silicone oil tamponade was significantly associated with final anatomic outcome, with a protective odds ratio of 0.11 (P=0.027). Visual acuity improved in 54% of eyes and decreased in 5%. Statistically significant associations were present for eyes with final visual acuity ≥20/200, and total retinal detachment (P<0.001); preoperative cataract (P=0.023); and proliferative vitreoretinopathy (P<0.001). RRD developed in 16/44 eyes despite laser prophylaxis. CONCLUSION: Prophylactic retinopexy was not beneficial for Stickler syndrome patients. Success of primary surgery for RRD remains low. The primary surgery should be vitrectomy combined with scleral buckling and silicone oil tamponade.

Treatment of retinitis pigmentosa due to MERTK mutations by ocular subretinal injection of adeno-associated virus gene vector: results of a phase I trial.

MERTK is an essential component of the signaling network that controls phagocytosis in retinal pigment epithelium (RPE), the loss of which results in photoreceptor degeneration. Previous proof-of-concept studies have demonstrated the efficacy of gene therapy using human MERTK (hMERTK) packaged into adeno-associated virus (AAV2) in treating RCS rats and mice with MERTK deficiency. The purpose of this study was to assess the safety of gene transfer via subretinal administration of rAAV2-VMD2-hMERTK in subjects with MERTK-associated retinitis pigmentosa (RP). After a preclinical phase confirming the safety of the study vector in monkeys, six patients (aged 14 to 54, mean 33.3 years) with MERTK-related RP and baseline visual acuity (VA) ranging from 20/50 to <20/6400 were entered in a phase I open-label, dose-escalation trial. One eye of each patient (the worse-seeing eye in five subjects) received a submacular injection of the viral vector, first at a dose of 150 µl (5.96 × 10(10)vg; 2 patients) and then 450 µl (17.88 × 10(10)vg; 4 patients). Patients were followed daily for 10 days at 30, 60, 90, 180, 270, 365, 540, and 730 days post-injection. Collected data included (1) full ophthalmologic examination including best-corrected VA, intraocular pressure, color fundus photographs, macular spectral domain optical coherence tomography and full-field stimulus threshold test (FST) in both the study and fellow eyes; (2) systemic safety data including CBC, liver and kidney function tests, coagulation profiles, urine analysis, AAV antibody titers, peripheral blood PCR and ASR measurement; and (3) listing of ophthalmological or systemic adverse effects. All patients completed the 2-year follow-up. Subretinal injection of rAAV2-VMD2-hMERTK was associated with acceptable ocular and systemic safety profiles based on 2-year follow-up. None of the patients developed complications that could be attributed to the gene vector with certainty. Postoperatively, one patient developed filamentary keratitis, and two patients developed progressive cataract. Of these two patients, one also developed transient subfoveal fluid after the injection as well as monocular oscillopsia. Two patients developed a rise in AAV antibodies, but neither patient was positive for rAAV vector genomes via PCR. Three patients also displayed measurable improved visual acuity in the treated eye following surgery, although the improvement was lost by 2 years in two of these patients. Gene therapy for MERTK-related RP using careful subretinal injection of rAAV2-VMD2-hMERTK is not associated with major side effects and may result in clinical improvement in a subset of patients.

Combined Nonmydriatic Spectral-Domain Optical Coherence Tomography and Nonmydriatic Fundus Photography for the Detection of Age-Related Macular Degeneration Changes.

BACKGROUND AND OBJECTIVE: Nonmydriatic fundus photography (FP) has been a suboptimal tool for detecting age-related macular degeneration (AMD) changes. This study sought to enhance the detection of AMD changes by combining nonmydriatic FP with nonmydriatic spectral-domain optical coherence tomography (SD-OCT). PATIENTS AND METHODS: The study population included 249 patients aged 65 years and older who were assessed for AMD changes using standard mydriatic biomicroscopic fundus examination. Each eye then underwent nonmydriatic FP in one session followed 1 week later with nonmydriatic FP coupled with nonmydriatic SD-OCT. Images were interpreted for detection of AMD changes, and findings were compared to the original mydriatic biomicroscopic examination. RESULTS: Nonmydriatic FP had 64% sensitivity, 97% specificity, and a kappa value of 0.67 in detecting AMD changes compared with the traditional mydriatic biomicroscopic examination. Combined nonmydriatic FP and nonmydriatic SD-OCT increased sensitivity to 91.5%, specificity to 98.6%, and kappa to 0.91. CONCLUSION: The addition of nonmydriatic SD-OCT to nonmydriatic FP enhances the detection of AMD changes.

CLINICAL CHARACTERISTICS AND TREATMENT OUTCOMES OF COATS DISEASE IN A SAUDI ARABIAN POPULATION.

PURPOSE: To present the clinical aspects and treatment outcomes of Coats disease in Saudi Arabia. METHODS: A retrospective chart review was performed of 92 patients (97 eyes) diagnosed with Coats disease at King Khalid Eye Specialist Hospital from 1983 to 2010. RESULTS: The most common presenting complaint was decreased visual acuity followed by strabismus and then leukocoria. Snellen visual acuity was 20/20 to 20/50 in 9 eyes (9%), 20/50 to 20/160 in 11 eyes (11%), 20/200-counting fingers in 29 eyes (30%), and hand motion to no light perception in 24 eyes (25%). Telangiectasia was located in the preequatorial area in 71 eyes (73%) and most commonly involved the temporal retina in 67 eyes (69%). In eyes with clear view to the fundus, quadrant involvement by telangiectasia had the following distribution: 1) quadrant (n = 36, 37%); 2) quadrants (n = 26, 27%); 3) quadrants (n = 8, 8%); and 4 quadrants (n = 15, 15%). Total retinal detachment was present at presentation in 28 eyes (29%) and neovascular glaucoma in 8 (8%). Based on the Shields classification, the eyes were Stage 1 (n = 1, 1%), Stage 2A (n = 7, 7%), Stage 2B (n = 23, 24%), Stage 3A1 (n = 26, 27%), Stage 3A2 (n = 12, 12%), Stage 3B (n = 16, 17%), Stage 4 (n = 11, 11%), and Stage 5 (n = 5, 1%). Stage 3A was the most commonly presented stage (39%). Primary management included cryotherapy (19%), laser photocoagulation (64%), intravitreal agents (9%), and surgical drainage (4%). Combination treatment was performed in 29% of eyes. Thirteen eyes (13%) were enucleated because of clinical suspicion of retinoblastoma or the presence of glaucoma. Factors that were associated with a poor visual outcome of 20/200 or worse included age less than 10 years (relative risk: 1.27), Stages 3 and 4 disease (relative risk: 1.40), presence of subretinal fluid in all 4 quadrants including the fovea (relative risk: 14.25), and initial visual acuity of 20/200 (relative risk: 6.72) or worse (P < 0.005 for all factors). CONCLUSION: Although rare, Coats disease is usually advanced at presentation and has a poor visual prognosis in the Saudi population, like in other populations. The findings of this study give validity and applicability to the Shields staging scheme, which we recommend using in clinical practice.

Posterior microphthalmos and papillomacular fold-associated cystic changes misdiagnosed as cystoid macular edema following cataract extraction.

PURPOSE: Novel spectral-domain optical coherence tomography (SD-OCT) findings in posterior microphthalmos (PM) include cystoid changes in the papillomacular fold (PMF). These changes may be misdiagnosed as cystoid macular edema (CME) and may trigger unnecessary treatment including intravitreal injections. We report a case that underscores this scenario aiming to increase awareness of this entity among ophthalmologists. METHOD: A case report. RESULTS: A 25-year-old male presented with a history of clear lens extraction in both eyes as a refractive procedure. Postoperatively, he was diagnosed with CME and received five intravitreal bevacizumab injections in each eye as well as oral diamox for persistent cystic spaces noted on OCT. He was referred to our institution with the diagnosis of non-responding CME. A complete ophthalmic evaluation, including ultrasonography and SD-OCT, confirmed the diagnosis of PM and PMF with cystic cavities in the PMF. A fluorescein angiogram disclosed absence of macular leakage or optic nerve head staining indicating that the cystic cavities seen on SD-OCT are not due to postoperative CME but are rather the intrinsic cystic changes commonly seen in eyes with PM and a PMF. These cystic cavities were incorrectly thought to represent postoperative CME, which triggered the unnecessary treatment and lack of response. CONCLUSION: Cystic-like cavities are a component of the PMF in PM eyes and may be misdiagnosed as CME, especially in a postoperative setting. This case underscores the importance of understanding the intrinsic features of the PMF in eyes with PM and may help increase awareness among ophthalmologists of such a potentially confusing scenario.

Navigated laser (navilas) therapy for choroidal neovascular and hyperpermeability pathologies.

PURPOSE: To report the utility of navigated laser (NAVILAS) in the treatment of leaking areas in central serous chorioretinopathy and a feeder vessel in choroidal neovascular membrane. METHODS: Two patients with choroidal lesions were treated with NAVILAS. The first patient had central serous chorioretinopathy with visible leaking angiographic spots, and the second had choroidal neovascular membrane with a well-defined feeder vessel on angiography. Both patients underwent NAVILAS treatment. RESULTS: Both patients were successfully treated with resolution of clinical symptoms after a single session of NAVILAS. In addition, complete resolution of the subretinal fluid and leakage, and the subretinal blood and feeder vessel, were noted in the central serous chorioretinopathy and feeder vessel cases, respectively. CONCLUSION: NAVILAS may be of utility in targeting choroidal vascular pathologies with laser.

Intraocular pressure trends after intravitreal injections of anti-vascular endothelial growth factor agents for diabetic macular edema.

PURPOSE: To study intraocular pressure (IOP) trends and risk factors of IOP elevation after intravitreal anti-vascular endothelial growth factor injections in diabetic macular edema. METHODS: A retrospective review of 760 eyes treated with intravitreal anti-vascular endothelial growth factor injections for diabetic macular edema was performed. The rate and risk factors of IOP elevation were assessed. Intraocular pressure elevation was defined as an increase above baseline IOP by ≥ 6 mmHg, increase above baseline by > 20%, or IOP elevation to > 24 mmHg on 2 or more consecutive visits after treatment. When more than one pretreatment IOP reading was available, baseline IOP was calculated as the mean of the available pretreatment IOP readings (up to a maximum of three last IOP readings). Intraocular pressure elevation was considered transient unless it was maintained throughout the follow-up or required treatment (persistent elevation). RESULTS: Over a mean follow-up of 18 months, persistent and transient IOP elevation occurred in 44 (5.8%) and 53 (7%) eyes, respectively. The majority of eyes with persistent IOP elevation (70.4%) showed IOP elevation of > 20% from baseline. Only 13 eyes (1.71%) met the more strict criteria (> 6 mmHg from baseline or an IOP elevation > 24 mmHg). Final IOP was higher in the persistent IOP elevation group than the rest of the eyes (P < 0.001). Only the number of injections was associated with IOP elevation (P < 0.001). CONCLUSION: Persistent IOP elevation after intravitreal anti-vascular endothelial growth factor injections for diabetic macular edema is uncommon but may be associated with a higher number of injections.

Spectral-domain optical coherence tomography findings in polypoidal choroidal vasculopathy suggest a type 1 neovascular growth pattern.

PURPOSE: To report spectral-domain optical coherence tomography (SD-OCT) findings in polypoidal choroidal vasculopathy (PCV). PATIENTS AND METHODS: Seventeen eyes of 15 consecutive patients diagnosed with PCV based on typical clinical and angiographic findings were imaged with macular SD-OCT including line scans passing through the polyps. RESULTS: SD-OCT findings included typical and atypical retinal pigment epithelial (RPE) detachments and subretinal and intraretinal fluid in all eyes. In the areas corresponding to the polypoidal lesions, well-delineated round-oval, sub-RPE cavities were present and were adherent to the posterior surface of the detached RPE above Bruch membrane. No retinal or choroidal connections to the cavities were noted. CONCLUSION: These SD-OCT findings document that the vascular lesions in PCV are not located in the inner choroid, but in the sub-RPE space, suggesting that PCV is a variant of type 1 choroidal neovascularization rather than a distinct clinical entity as initially thought.

Role of Intravitreal Antivascular Endothelial Growth Factor Injections for Choroidal Neovascularization due to Choroidal Osteoma.

We treated 26 eyes of 25 young patients having a mean age of 30 years with intravitreal vascular endothelial growth factor (VEGF) inhibitor for choroidal new vessel (CNV) formation overlying choroidal osteoma over a mean follow-up of 26 months. Mean number of injections was 2.4 at 6 months, 3.2 at 12 months, and 5.5 at 24 months. CNV was subfoveal in 14 eyes, juxtafoveal in 5, extrafoveal in 5, and peripapillary in 2. By paired comparison, mean decrease from baseline was 119.7 microns at 6 months (n = 15; P = 0.001), 105.3 microns at 1 year (n = 10; P = 0.03), and 157.6 microns at 2 years (n = 7; P = 0.08). BCVA improved by 3.3 lines at 6 months after therapy (n = 26; P < 0.001), 2.8 lines (n = 20; P = 0.01) at 1 year, and 3.1 lines (n = 13; P = 0.049) at 2 years. We conclude that intravitreal anti-VEGF injections improve vision in majority of eyes with CNV from choroidal osteoma.

Spectral domain optical coherence tomography predictors of visual outcome in diabetic cystoid macular edema after bevacizumab injection.

PURPOSE: To study prognostic spectral domain optical coherence tomography parameters in diabetic cystoid macular edema after anti-vascular endothelial growth factor therapy. METHODS: Retrospective cohort study included 49 eyes with the new onset diabetic cystoid macular edema that had to have a macular spectral domain optical coherence tomography and fluorescein angiography at presentation. The baseline optical coherence tomography scans were analyzed for variables indicative of the extent of retinal involvement by the cystoid change and its location about the center. Univariate and multivariate analyses were performed comparing the optical coherence tomography findings between the two groups of eyes: the "No improvement" and the "Improvement" groups, based on at least two Snellen lines improvement after treatment. RESULTS: There were 30 and 19 eyes in the No improvement and Improvement groups, respectively. In the univariate analysis, the baseline optical coherence tomography parameters associated with visual improvement included the photoreceptor inner segments thickness centrally (P = 0.009) and within the central 1-mm subfield (P < 0.0001), and the presence of bridging retinal processes centrally (P = 0.004). Multivariate analysis showed both presence and central location of bridging retinal processes within the central 1-mm subfield to be significantly associated with visual improvement (P = 0.041 and 0.005, respectively), with an odds ratio of 13.4 (95% confidence interval, 1.336-636.18; P = 0.010) for their central location. CONCLUSION: In diabetic cystoid macular edema, visual improvement after anti-vascular endothelial growth factor therapy is more likely to occur in eyes with residual central retinal processes on baseline macular spectral domain optical coherence tomography. This finding may be helpful in patient counseling, case selection, and clinical trial planning.

High-power handheld blue laser-induced maculopathy: the results of the King Khaled Eye Specialist Hospital Collaborative Retina Study Group.

PURPOSE: To report various types of maculopathy caused by momentary exposure to a high-power handheld blue laser. DESIGN: Consecutive case series. PARTICIPANTS: Fourteen eyes of 14 patients. METHODS: Patients with a history of eye exposure to a blue laser device (450 nm and a power range of 150-1200 mW) to a single institution were included. Evaluation included a full ophthalmic examination, fundus photography, macular spectral-domain optical coherence tomography, and fundus fluorescein angiography. MAIN OUTCOME MEASURES: Analysis of the types of maculopathy and vitreoretinal pathologic features. RESULTS: All patients were young males. The most common setting for injury was accidental at play. The types of maculopathies encountered were: a full-thickness macular hole (FTMH) in 4 eyes, a premacular subhyaloid hemorrhage in 5 eyes, premacular sub-internal limiting membrane hemorrhage in 2 eyes, an outer retinal disruption at the fovea in 1 eye, an epimacular membrane in 1 eye, and a schisis-like cavity in 1 eye. Best-corrected Snellen visual acuity at presentation ranged from 20/40 to 4/200 (mean, 20/290). Only 4 eyes (29%) improved spontaneously with increase in vision, whereas 10 eyes (71%) required intervention. The latter consisted of neodymium:yttrium-aluminum-garnet hyaloidotomy in the 5 eyes with subhyaloid hemorrhage and pars plana vitrectomy (PPV) for the eyes with FTMH and epimacular membrane. All 4 FTMH were closed successfully after PPV. Final mean best-corrected visual acuity in all cases was 20/35 (range, 20/15-20/300). CONCLUSIONS: Exposure to high-power handheld laser devices can cause a variety of maculopathies that can reduce central vision permanently. Although vision may improve spontaneously, most cases require intervention. Unrestricted access to commercially available high-power handheld laser devices is dangerous and public awareness should be encouraged.

A modified ultrasound-guided surgical technique for the management of the uveal effusion syndrome in patients with normal axial length and scleral thickness.

PURPOSE: The purpose of this study was to describe a modified surgical technique for the management of the uveal effusion syndrome (UES). METHODS: A consecutive interventional case series of six eyes with UES is reported. The diagnosis of the UES was based on detailed ophthalmic examination, fluorescein angiography, B-scan ultrasonography, biometry, and magnetic resonance imaging. All eyes underwent an ultrasound-guided placement of the sclerostomies subjacent to the area of maximal choroidal swelling using a scleral punch without scleral flaps or vortex vein decompression. RESULTS: All patients were men with a mean age of 53 years. The mean postoperative follow-up was 16.25 months. Five eyes had normal axial lengths (22.54-23.05 mm) by ultrasound and normal sclera thickness on magnetic resonance imaging. One eye had a shorter axial length (21.65 mm) and mild scleral thickening on magnetic resonance imaging. All six eyes had anterior peripheral choroidal swelling. Three eyes had associated serous retinal detachment, and three eyes had acute appositional angles. After surgery, five eyes had total resolution of the peripheral choroidal swelling and retinal detachment or normalization of the angle. One eye had partial resolution of the retinal detachment. Of the three eyes with retinal detachment, two eyes experienced improvement in visual acuity after surgery. No complications were noted. CONCLUSION: This modified ultrasound-guided surgical technique for sclerostomy placement seems to be effective in the management of the UES, including eyes with normal axial length and scleral thickness, a subset of the UES that has been previously reported not to respond to surgery.

A case of cat-scratch disease with unusual ophthalmic manifestations.

We report a case of cat-scratch disease with unusual posterior segment manifestations. A 12-year-old healthy male presented with three weeks history of decreased visual acuity in the right eye. A significant history of cat exposure and elevated Bartonella titers were present. A large white-gray vascularized mass extending off the optic disk, an early stellate maculopathy, a plaque of choroiditis, an inferior serous retinal detachment involving the macula were present in the right eye. Sector papillitis and a focal area of chorioretinitis along the superotemporal arcade with associated retinal artery to vein anastomosis were present in the left eye. Bilateral optic nerve head involvement including peripapillary angiomatosis, retinal-retinal anastomosis and plaque choroiditis as ocular complications of cat-scratch disease have not been previously described to our knowledge and make this case noteworthy.

Diabetic macular edema: new trends in management.

The treatment of diabetic macular edema may be evolving from a laser ablative approach into a pharmacotherapeutic approach. The exponential growth that has occurred over the past decade in the retinal pharmacotherapy field has led to the development of several pharmacotherapies for retinal vascular diseases such as diabetic macular edema. Many of these agents, in the form of intravitreal injections or sustained delivery devices, have already undergone clinical trial testing for safety and efficacy and many others are currently being similarly evaluated. Some of these agents have proven to be more efficacious than traditional laser therapy, and it is possible that traditional laser therapy for diabetic macular edema may be abandoned altogether in the near future, especially with the introduction of the micropulse laser. However, more research and experience is still needed in order to determine the best treatment agent or combination of therapeutic modalities, as well as the best treatment regimen for a given patient. In this article, we briefly review the major new developments in the field of diabetic macular edema treatment. In addition, we touch on some of the promising forthcoming therapies.