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Purpose: To evaluate real-life outcomes in treatment-naive patients with diabetic macular edema (DME) treated with anti-vascular endothelial growth factor (VEGF) agents using a treat-and-extend regimen without a fixed loading phase. Methods: Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) measured using optical coherence tomography at baseline and after 1 year of treatment, intervals and number of injections were analyzed. Subgroup analysis was performed to compare anatomical and functional outcomes between patients receiving ranibizumab or aflibercept. Results: Seventy-five eyes of 61 patients met the inclusion criteria and had follow-up for 1 year. Baseline BCVA and CRT were 68.1 ± 13.2 letters and 424 ± 135 µm, retrospectively. After 1 year, there was a significant mean gain in BCVA of +5.8 ± 7.4 letters (paired t test: p < 0.0001) and a significant decrease in mean CRT of –117 ± 134 µm (paired t test: p < 0.0001). The mean number of anti-VEGF injections was 10.0 ± 1.6 (range 6–12). The mean maximum interval between injections was 8.5 ± 2.9 weeks (range 4–14) and the mean interval 6.0 ± 1.2 weeks (range 4.1–8.9). 96% of eyes could be extended after a mean of 5.3 injections and 17% of patients could be extended before reaching a formal loading dose of 3 injections. Subgroup analysis did not reveal any differences in outcomes between patients treated with ranibizumab or aflibercept. Subretinal fluid at baseline was associated with better BCVA gain after 1 year (stepwise forward regression analysis, p = 0.003). Conclusion: Our results suggest that not all patients with DME require a fixed loading phase when initiating anti-VEGF treatment. Finding anatomical predictors to identify this subgroup of patients would help to reduce treatment burden and optimize clinical outcomes.

Objective: To investigate the influence of the stimulus parameters on perimetry at various distances and draw conclusions for the clinical exploration of nonorganic visual loss. Methods: Visual field testing using Goldmann kinetic perimetry was performed on 15 healthy volunteers. The I/1e isopter at 33 cm was compared to the I/1e, II/1e and I/2e isopters at 66 cm. The 0/1e isopter at 33 cm was compared to the 0/1e, I/1e and 0/2e isopters at 66 cm. Results: Doubling the examination distance without adjusting the stimulus parameters resulted in significant perimetric visual field constriction. Doubling the stimulus diameter resulted in perimetric visual field expansion by a factor of 2.26 and 3.32 for I/1e and 0/1e, respectively. Increasing stimulus luminance by a factor of 3.17 caused expansion by a factor of 2.15 and 2.32 for I/1e and 0/1e, respectively. Conclusions: To avoid falsely diagnosing visual field constriction, stimulus parameters need to be adjusted when visual field testing is performed at double distance. Increasing stimulus luminance was more appropriate than augmenting stimulus size.

Although diabetic retinopathy (DR) remains a leading cause of vision loss, the last decade has brought significant advances in the diagnosis and treatment of this common complication of diabetes mellitus. First, optical coherence tomography allows for noninvasive imaging of the retina, in particular, the macula, with very high resolution, thus facilitating the management of diabetic macular edema. In addition, recent advances in the understanding of the pathophysiology of DR, in particular, the key role of cytokines, such as vascular endothelial growth factor (VEGF), have led to the development of anti-VEGF antibodies for intraocular use. Anti-VEGF therapies have largely replaced laser photocoagulation for the treatment of diabetic macular edema. The benefit of intravitreal anti-VEGF in diabetic macular edema has been proven in numerous large randomized controlled trials. Moreover, a role of inflammation in DR has been recognized, and several mainly steroid-based, anti-inflammatory agents for intravitreal treatment have been shown to be effective. Despite these recent advances, strict systemic control of glycemia remains the cornerstone of the management of DR, significantly reducing ocular complications. This chapter will provide an overview of current and novel concepts of DR and will allude to promising novel therapeutic options for this sight-threatening disease.

is therefore difficult to quantify the response to therapy only from one of the many functional and various anatomical parameters. However, as Dr. Kaya points out, the fluctuation speed reflects on the degree of exudative activity and may therefore be used to guide retreatment decisions. To address the heterogeneity of treatment responses and increase the cost-effectiveness of anti-VEGF treatment, a number of flexible dosing strategies are increasingly being used in clinical practice. Of these flexible treatment strategies, the treat-and-extend regimen is based on time to recurrence, and therefore the optimal dosing intervals reflect the degree of fluctuation speed. Data from ongoing randomized controlled trials using a treat-and-extend apDear Editor We thank Dr. Kaya for his interest in our article and his observations regarding fluctuation speed in patients with exudative age-related macular degeneration under treatment with anti-VEGF agents [1] . The primary purpose of our study was to describe fluid fluctuations using a fixed, bimonthly regimen with intravitreal aflibercept injections. Despite significant overall best-corrected visual acuity gain, we observed marked fluctuations in intraretinal and subretinal fluid as well as serous pigment epithelial detachment in many patients using a bimonthly treatment interval [2] . From clinical experience and from data of the pivotal randomized controlled trials we know that patient responses to antiVEGF therapy are remarkably varied, and it Received: March 30, 2016 Accepted: March 30, 2016 Published online: April 21, 2016