Intravitreal Faricimab Prior to Direct Photocoagulation Improves Anatomical Outcomes in Focal Diabetic Macular Edema

Purpose: To determine the optimal treatment sequence for combination therapy using intravitreal faricimab (IVF) and direct photocoagulation (PC) in eyes with non-center-involved diabetic macular edema (DME). Methods: This retrospective study included 35 eyes with focal DME treated with IVF and PC targeting microaneurysms (MAs). Treatment success was defined as resolution of focal edema, indicated by disappearance of the white area (WA) on optical coherence tomography. Eyes were assigned to a PC-IVF group (initial PC followed by IVF if edema persisted after 2 months; n = 20) or an IVF-PC group (initial IVF followed by PC for residual edema; n = 15). Additional PC was performed every 2 months as needed. Results: Cumulative success rates at 2, 4, and 6 months were 35.0%, 70.0%, and 90.0% in the PC-IVF group and 60.0%, 93.3%, and 100% in the IVF-PC group, respectively. Macular volume significantly decreased at all time points in the IVF-PC group (all p < 0.01), whereas a significant reduction was observed only after 6 months in the PC-IVF group (p < 0.01). The number of MAs and the extent of edema were significantly reduced after 2 months in both groups, with greater reductions in the IVF-PC group (p < 0.05). The number of laser shots required for initial PC was significantly lower in the IVF-PC group (p < 0.0001), and the mean number of PC sessions was also reduced (0.6 vs. 1.8). In the PC-IVF group, baseline edema size was significantly smaller in successfully treated eyes (p < 0.001). Conclusions: Initiating treatment with IVF prior to PC may be advantageous in focal DME, particularly in eyes with larger edema, enabling faster anatomical improvement and reducing the need for laser treatment. Direct PC alone may be sufficient for small focal lesions with limited edema, supporting an individualized treatment strategy.