Introduction

 

Eye care is the NHS’s highest-volume outpatient specialty, and treatments for retinal vascular conditions represent some of the costliest and most frequently used in secondary care. The NHSE commissioning priorities for DMO aim to reduce variation in care and improve cost-effectiveness while maintaining clinician choice and ensuring timely intervention to prevent vision loss.

 

Purpose

 

The treatment landscape for centre-involved diabetic macular oedema (CI-DMO) is evolving rapidly, with longer-acting anti-VEGF agents, biosimilars, and updated NICE recommendations supporting the use of corticosteroids in phakic patients. NHSE commissioning prioritises high-quality, cost-effective care that ensures patients receive the most appropriate therapy at the right time. Against this backdrop, establishing a validated consensus to define the optimal use of anti-VEGFs and corticosteroids in CI-DMO. Updating current care pathways accordingly aims to provide clear, evidence-based direction for clinicians and supports implementation of NHSE treatment guidance, align with national and ICB priorities, and promotes consistent, patient-centred care.

 

Methods

A modified Delphi process was undertaken with 10 medical retina specialists across NHS England.  Individual and anonymous opinions were collected by completing an 82-item questionnaire across seven topics (approach to care and patient outcomes, baseline assessments and monitoring, key definitions, anti-VEGF switching and stopping criteria, corticosteroids as first-line treatment, corticosteroid stopping and switching criteria, and corticosteroid benefits, risks, and mitigation strategies). Two iterative online survey rounds were conducted. Statements were rated using a 4-point Likert scale with a predefined consensus threshold of ≥ 75% agreement. Statements not reaching this threshold were revised and retested in a second round.

 

Results

Consensus was achieved in 64/82 statements (78%). Key outcomes included: consensus on the value of personalised treatment strategies, consensus to validate a definition of non-response to intravitreal treatment for DMO as a reduction in Central Retinal Thickness (CRT) by ≤10%, and a suboptimal response as a reduction in CRT by 10-20%. Early evaluation of anti-VEGF treatment response was recommended at 3-6 months and after trying two different anti-VEGF agents. Switching early (after 9-12 months) to corticosteroids if response remains sub-optimal. Patients who achieved a positive response after 1-2 injections of short-acting corticosteroid should then be switched early to a sustained-release, long-acting corticosteroid.

 

Conclusions

This validated Delphi consensus provides clear guidance on optimising anti-VEGF and corticosteroid use in CI-DMO, supporting timely treatment switching and improved clinical outcomes. The recommendations align with NHSE commissioning priorities by promoting high-quality, cost-effective, patient-centred pathways that enable consistent, nationally aligned care for people with DMO.