Therapeutic landscape for diabetic macular edema: durable strategies with a focus on aflibercept 8 mg

To evaluate current therapies for diabetic macular edema (DME), with emphasis on durability, safety, access, and the evidence supporting aflibercept 8 mg. An expert-selected narrative synthesis of primary clinical trials, pharmacologic studies, regulatory documents, and selected real-world evidence published from January 1, 2000, through August 8, 2026, was performed. Anti-vascular endothelial growth factor therapy remains first-line treatment for most center-involved DME with visual impairment, but observation or focal/grid laser is reasonable for selected eyes with good visual acuity. In PHOTON, aflibercept 8 mg every 12 or 16 weeks after three monthly doses was noninferior to aflibercept 2 mg every 8 weeks for visual acuity at week 48; durability and similar safety were maintained through week 96 with fewer injections. Faricimab, brolucizumab, dexamethasone and fluocinolone implants, and the ranibizumab Port Delivery System offer alternative durability profiles with distinct evidence and risks. Aflibercept 8 mg provides an effective option for extending treatment intervals while maintaining visual and anatomical outcomes; however, no single therapeutic strategy is optimal for all patients. Treatment should therefore be individualized according to visual and anatomical response, ocular and systemic characteristics, patient preference, treatment burden, access, and local health-system constraints.