Abstract：
In an aging population, the prevalence and burden of diabetes mellitus, diabetic retinopathy, and vision-threatening diabetic macular edema (DME) are only expected to rise around the world. Similarly to other complications of diabetes mellitus, DME requires long-term management. This article aims to review the current challenges associated with the long-term management of DME, opportunities to improve outcomes for patients, and to develop a treat-to-target strategy based on macular morphology. At present, intravitreal anti-vascular endothelial growth factor (VEGF) therapy is the standard of care for the management of DME; however, best-achievable vision outcomes with treatment are reliant on frequent injections and close monitoring, which are difficult to maintain in current clinical practice because of the burden this imposes on patients. Achieving and maintaining good vision with treatment are the most important factors for patients with DME. Landmark trials have shown that vision gains with anti-VEGF therapy are typically accompanied by anatomical improvements (e.g., reductions in retinal thickness); therefore, multimodal imaging measures of macular morphology are often used in patients with DME to guide real-world treatment decisions. We would like to propose a hypothetical treat-to-target algorithm to guide physicians on treatment strategies for the long-term management of DME. Alternative measures of retinal fluid (e.g., persistence, stability, location) may be stronger predictors of visual acuity in DME, although further research is required to confirm whether alternate quantifiable biomarkers such as subretinal fluid and intraretinal fluid volumes can be used as a biomarker of clinical improvement. Identifying novel biomarkers and treatments that target neuroinflammation and neurodegeneration, improving patient-physician communication around treatment adherence, and using treat-to-target measures may help to ensure that the long-term benefits of treatment are realized.
摘要：
在人口老龄化的情况下,糖尿病的患病率和负担，糖尿病视网膜病变，威胁视力的糖尿病性黄斑水肿（DME）预计只会在世界各地上升。类似于糖尿病的其他并发症，DME需要长期管理。本文旨在回顾当前与DME长期管理相关的挑战，改善患者预后的机会，并制定基于黄斑形态的治疗目标策略。目前,玻璃体内抗血管内皮生长因子(VEGF)治疗是治疗DME的标准治疗方法;然而,治疗可实现的最佳视力结果依赖于频繁注射和密切监测，这在目前的临床实践中是难以维持的，因为这给患者带来了负担。对于DME患者而言，通过治疗实现和保持良好的视力是最重要的因素。具有里程碑意义的试验表明，抗VEGF治疗的视力增加通常伴随着解剖学上的改善（例如，视网膜厚度的减少)；因此，DME患者常使用黄斑形态的多模态成像测量来指导现实世界的治疗决策.我们想提出一种假设的治疗目标算法，以指导医生对DME的长期管理的治疗策略。视网膜液的替代措施(例如，持久性,稳定性,位置)可能是DME视力的更强预测因子，尽管需要进一步的研究来确认视网膜下液和视网膜内液体积等替代的可量化生物标志物是否可以用作临床改善的生物标志物。确定靶向神经炎症和神经变性的新型生物标志物和治疗方法，改善患者与医生围绕治疗依从性的沟通，使用治疗对目标的措施可能有助于确保实现治疗的长期益处。
