Inherent Challenges in Managing Long Standing Refractory Diabetic Macular Edema

Introduction: Diabetic macular edema (DME) poses a significant management dilemma for visual impairment. We present a challenging case with terrible centre-involved maculopathy, unsuitable for ranibizumab and heading toward steroid implant relatively soon. To date, no similar reports have been published. Case Presentation: A 54-year-old man presented with poor visual acuity (VA) [right count fingers, left 20/100], bilateral proliferative diabetic retinopathy (PDR) and DME. He was hypertensive, anaemic, had poor renal function and diabetic control. Optical coherence tomography (OCT) and fundus fluorescein angiography (FFA) confirmed mixed maculopathy, worse in right. Management and Outcome: Diabetic parameters were examined and optimized. In the 20 months following urgent laser treatment, he was followed up every three months with serial VA, stereoscopic biomicroscopy and OCT. Despite further laser therapy, his DME persisted, and VA remained poor. A recent stroke precluded ranibizumab use. A flucinolone implant was considered to save his vision. Discussion: Flucinolone implant has recently been approved in Scotland for pseudophakic chronic DME cases unresponsive to other options; effects last 3 years, with promising visual recovery. We plan to perform cataract surgery at the time of flucinolone implantation and monitor intraocular pressure (IOP) and other potential side effects post-operatively. In the manuscript, we provide an integrated treatment approach to help physicians treating chronic DME. Conclusion: Flucinolone has a place as an implantable drug delivery device that offers benefits in chronic DME therapy, adding to a new range of treatment options to suit specific lines and to recover vision in patients previously unresponsive to treatment.