Table 3 Tips for effective service delivery during treatment with aflibercept

• Develop separate pathways for anti-VEGF, laser and steroid treatments

• Ideally, manage patients in a dedicated DMO clinic, or alternatively in a dedicated anti-VEGF clinic, with clinicians who have appropriate expertise in managing DMO

• As an institution, consider each aflibercept regimen and agree on which pathway is best to follow, and if there are any exceptions to a particular pathway

• Make use of two-stop services and virtual clinics, where appropriate, to help to overcome capacity issues

   ◦ In a one-stop service, OCT/VA and injection are performed on the same day

   ◦ In a two-stop service, OCT/VA and injection performed on different days, and OCT assessments are made remotely in a ‘virtual’ clinic

   ◦ A one-stop service can work well in clinics where the assessment and injection teams are optimised and where capacity is not a concern

   ◦ The success of a two-stop approach may depend on region and the distance that the patient has to travel to the clinic. Furthermore, additional appointments, particularly during the loading phase, may not be prudent, given that patients with DMO are more likely than those with neovascular AMD to miss appointments

   ◦ Upscaling virtual reviews for non-anti-VEGF patients may help to improve capacity for anti-VEGF patients

   ◦ Clinicians should be flexible and provide different pathways for patients who are at different stages of treatment; a one-stop service may be suitable for those who require frequent injections initially, while a two-stop service and virtual clinics may be preferred for those unlikely to require ongoing injections e.g. patients who have been stable for some time

• Before initiating aflibercept treatment, set treatment expectations for the patient

   ◦ Together with the patient, decide which regimen is best for them (bearing in mind local agreed pathways)

   ◦ Remind the patient that intensive dosing in Year 1 is likely to yield benefits in Year 2 and beyond

   ◦ Show the OCT map (Appendices Figure 2) to patients to help them visualise current fluid status and treatment goals

   ◦ Adequate patient counselling should help to ensure good attendance

• Schedule a limited number of aflibercept injections in advance

   ◦ Patients with DMO have a tendency to miss appointments and this can make scheduling difficult

   ◦ Compared with patients with neovascular AMD, patients with DMO are usually younger, working, and often have many other clinic appointments to attend. Furthermore, their vision does not deteriorate as quickly, meaning that they may feel less urgency to managing their disease

   ◦ If an appointment is missed, either offer an additional appointment (and reschedule subsequent planned appointments) or continue with the planned scheduled appointments and do not reschedule

• Remind patients to bring their distance glasses to their appointment

• Measure CFT consistently; Appendix Fig. 2 shows where the CFT measurement should be taken from

• Liaise regularly with diabetes physicians in order to ensure optimal glycaemic and blood pressure control