International consensuses and controversies on causes, diagnosis and management of diabetic macular edema (DME)

Diabetic macular edema (DME) is the most common cause of vision-threatening diabetic retinopathy (VTDR) with an increasing prevalence tied to the global epidemic in diabetes. Despite significant advances, the management of DME remains a dynamic field with many unresolved controversies. Optical coherence tomography (OCT) allows objective assessment, however, correlation between vision and morphological changes can be inconsistent, causing disagreements on treatment strategies. DME is a complex disease with multifactorial pathophysiological pathways, leading to heterogenous treatment responses. There is a lack of standardized definition of treatment "non-response" and protocol for switching to second-line or adjuvant treatments. New anti-vascular endothelial growth factor (anti-VEGF) drugs and multi-targeted therapies seem to demonstrate improved durability, but long-term data is not yet available. Research in artificial intelligence (AI) is developing rapidly, however, rigorous appraisal of its reliability and generalizability are necessary before its implementation. Significant vision loss from DME in pregnant women, young children and elderly patients with systemic comorbidities are challenging conundrums. An international panel of experts (IPE) comprising 36 experts from 16 countries formulated and voted on the consensus statements in 5 key areas: 1) Diagnostic controversies around classification and imaging; 2) Treatment controversies; 3) Management paradigm between protocol-based and individualized approaches; 4) Emerging controversies in novel therapeutics and AI application, and 5) Special considerations for specific patient populations. There is an imminent need for mutual agreement on the best-possible approach to DME management in order to promote the optimal patient outcomes and to identify specific issues that require prioritization of resources and research.