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PE firms supposedly create efficiencies through economies of scale, negotiate better contracts with payers, and standardize our practices with the end goal of helping us to provide more efficient patient care High-net-worth investors that think the stock market is overvalued or that are looking for alternative investments are investing their capital with PE firms 3 With interest rates being at all-time lows, these firms are also able to tap into the debt markets The PE firm's goal is to increase value by adding revenue, cutting costs, adding debt, and doing so in the shortest timeline possible 3 The average PE holding period for an investment like this is 5 6 years before they sell the practice and exit their investment 11 Although the younger physician may have had input on the initial sale and the PE firm that they would be working with, there is very little likelihood that they will have any input on who their next owner will be, which can have a negative impact on the practice culture and day-to-day experience for the physicians and their patients In the mid-1990s we saw physician practice management companies raise billions of dollars, purchase numerous physician practices, then go bankrupt 12 We could see a repeat scenario like this if PE shareholders see lower-than-expected returns (ie, from lower reimbursements) or a lack of secondary buyers for the groups the firms have collected (especially in context of the amount of debt taken on during these transactions)

In the United States, diabetic macular edema (DME) is the leading cause of vision loss among people with diabetic retinopathy. Despite the availability of different therapies for DME, up to half of patients with DME show some persistent edema after anti-vascular endothelial growth factor (VEGF) treatment alone, leaving these patients at high risk for vision loss. However, dosing in a similar fashion to that of pivotal anti-VEGF trials is difficult because of real-life challenges faced in clinical practice. This is particularly true for DME, in that the frequency and burden of anti-VEGF injections are a major challenge to patient care. Research evaluating anti-VEGF therapies has shaped the treatment paradigms for patients with DME, and similar benefits have also been noted in clinical trials evaluating the use of intravitreal steroids. Treatment with a long-term intravitreal corticosteroid, which requires fewer injections than treatment with most short-acting therapies, has been found to reduce inflammation and improve vision in a percentage of patients. This roundtable discussion, which took place during the 2018 annual meeting of the Vit-Buckle Society, reviews the current treatment paradigms for DME and evaluates how to customize and optimize treatment strategies geared toward individualized patient care. [ Ophthalmic Surg Lasers Imaging Retina . 2018;49:S5–S15.]

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