Intraocular Pressure Monitoring Post Intravitreal Steroids: A Systematic Review

Comparative analysis of intravitreal triamcinolone acetonide-moxifloxacin versus standard perioperative eyedrops in cataract surgery

PURPOSE

To compare the effectiveness of intravitreal injection of triamcinolone acetonide-moxifloxacin (Tri-Moxi) to a standard eyedrop regimen in controlling postoperative inflammation, corneal edema, and the rate of high intraocular pressure (IOP) among cataract patients.

SETTING

Loma Linda University Eye Institute, California, USA.

DESIGN

Retrospective longitudinal comparative study.

METHODS

The electronic medical records of patients who underwent cataract surgery using triamcinolone acetonide-moxifloxacin injection along with a postoperative nonsteroidal antiinflammatory drug drop were reviewed (Group 1). Group 1 was compared with patients who received a standard eyedrop (Group 2) in terms of intraocular inflammation and corneal edema severity, and the rate of high IOP, postoperatively.

RESULTS

A total of 1195 consecutive eyes (Group 1 [681 eyes], Group 2 [514 eyes]) of 919 patients were included in the study. The anterior chamber cell reaction severity decreased by 34.0% and 35.7% at 1 week and 1 month, respectively, after surgery following triamcinolone acetonide-moxifloxacin injection compared with standard eyedrop therapy (P = .001 and P = .02, respectively). Group 1 was associated with increased severity of corneal edema (odds ratio, 1.48; P = .001) on postoperative day 1, with no statistically significant difference at 1 week and 1 month postoperatively (P = .25 and P = .48, respectively). There was no statistically significant difference in the rate of high IOP between the two groups at different timepoints postoperatively.

CONCLUSIONS

Triamcinolone acetonide-moxifloxacin injection is an effective method to control intraocular inflammation after cataract surgery. It is a promising substitute for standard eyedrop therapy, especially for patients who have poor compliance with eyedrop usage.

Factors Influencing Intravitreal Bevacizumab and Triamcinolone Treatment in Patients with Diabetic Macular Edema

PURPOSE

To evaluate factors associated with response to intravitreal bevacizumab (IVB) and intravitreal triamcinolone acetonide (IVTA) in diabetic macular edema (DME).

METHODS

Ninety-one eyes of 88 patients diagnosed with DME were enrolled in this retrospective chart review. Group 1 included eyes that showed good response to IVB. Group 2 included eyes that did not respond to IVB but responded to IVTA. Group 3 included eyes that responded to neither. Clinical factors, HbA1c, and optical coherence tomography (OCT) findings including patterns of macular edema were compared among the 3 groups.

RESULTS

A total of 44, 27, and 20 eyes were included in groups 1, 2, and 3, respectively. HbA1c was higher in group 3 than in the other groups. Proportion of full (combination of all patterns) type edema was higher in group 3 than in the other 2 groups. In group 1, the proportion of sponge-like diffuse retinal thickening type was higher and cystoid macular edema type was lower than in the other groups.

CONCLUSIONS

The degree of diabetic control and morphologic subtypes with OCT should be considered to better predict the prognosis after treatment in DME.

Phaco-non-penetrating deep sclerectomy in ocular hypertension secondary to dexamethasone intravitreal implant

PURPOSE

To evaluate the characteristics and progression of patients treated with a 0.7mg dexamethasone intravitreal implant (Ozurdex^®) and required glaucoma filtering surgery (phaco-non-penetrating deep sclerectomy) to control ocular hypertension (OHT).

METHODS

A retrospective observational study including patients treated with Ozurdex^® in a tertiary-care university hospital from May 2011 to April 2016.

RESULTS

In five years of follow-up, 1.10% (4/363) of patients treated with 0.7mg dexamethasone intravitreal implant required phaco-non-penetrating deep sclerectomy (PNPDS) to control OHT refractory to topical treatment. All four patients started or increased previous antihypertensive topical treatment since the first dexamethasone intravitreal implant. Three or more dexamethasone intravitreal implants were injected in the four cases before intraocular pressure (IOP) became uncontrolled and PNPDS was performed. All four patients have a successfully controlled IOP without treatment after PNPDS. Two patients required additional treatment with dexamethasone intravitreal implants after PNPDS, maintaining IOP under control without treatment.

CONCLUSIONS

To the best of our knowledge, this is the first study describing the successful results of PNPDS in OHT secondary to dexamethasone intravitreal implant. All four patients have achieved controlled IOP without treatment. Re-treatment with dexamethasone intravitreal implant in those patients who underwent PNPDS is also possible, and IOP remains controlled.

Retina and glaucoma: surgical complications

Background

The close structural and microcirculatory co-relation between anterior and posterior segments of eye make them very vulnerable to complications when one of them is affected surgically. With the advent of anti-fibrotic agents in the management of glaucoma, the rates of vitreoretinal complications have become more frequent.

Main body

Common retinal complications after glaucoma surgeries include choroidal detachment; ocular decompression retinopathy; haemorrhagic choroidal detachment; hypotony maculopathy; malignant glaucoma; vitreous haemorrhage; bleb endophthalmitis; retinal detachment. Similarly, intraocular pressure rise is often noted after scleral buckle; pars plana vitrectomy; intravitreal gas injection; silicone oil injection; intravitreal steroid injection.

Conclusion

The article provides some insight into some of the complications after glaucoma and retina surgeries, including the pathogenetic mechanisms behind each complication and available management options.

Intravitreal therapeutic agents in noninfectious uveitic macular edema

The management of uveitis is challenging for most treating ophthalmologists. The treatment of uveitis often requires the use of high dose of systemic corticosteroid and immunosuppressive agents, which are almost always associated with potential side effects. Intravitreal medications have become a popular mode of drug administration in uveitis patients as they provide high volume of drug to the target tissues, eliminating the risk of systemic toxicity. There has been tremendous development in the intravitreal therapeutics over the last few years. With the advent of sustained-release technique, increasing patient compliance, biodegradable nature of the implant, and introduction of newer agents with better safety profile, the intravitreal medications have become more popular in recent years. This review presents evidence in the scientific literature supporting the use of intravitreal medications for the management of uveitis and its complications.

Pigment dispersion syndrome and pigmentary glaucoma: a review and update

INTRODUCTION

Pigment dispersion syndrome (PDS) is a condition where anomalous iridozonular contact leads to pigment dispersion throughout the anterior segment and the released pigment is abnormally deposited on various ocular structures.

CLINICAL PRESENTATION

The clinical presentation of PDS is defined by the presence of pigmented cells on the corneal endothelium, an increase of pigmentation of the trabecular meshwork, and mid-periphery transillumination defects of the iris. This syndrome, more common in myopes, is usually bilateral and can be associated with ocular hypertension or glaucoma. Secondary open-angle pigmentary glaucoma (PG) can develop due to reduction of the outflow of aqueous humour and consequent increase in intraocular pressure leading to glaucomatous optic neuropathy. Diagnosis of PG is commonly between 40 and 50 years of age, occurring more frequently in men. The advent of ultrasound biomicroscopy and anterior segment optical coherence tomography has contributed to enhancing our knowledge on the condition. Typical alterations of the anterior segment are the posterior insertion of the iris and iris concavity. Treatment of PG should be initiated early to hinder disease progression, glaucomatous damage, and vision loss. Management is based on medical therapy, laser iridotomy, selective laser trabeculoplasty, and filtration procedures.

CONCLUSIONS

The differential diagnosis of PDS with other disorders can be challenging and awareness of the condition together with meticulous ophthalmologic examination allows early diagnosis followed by appropriate management strategies. The present review is a comprehensive report on the clinical characteristics, pathogenesis, current management, and status quo of PDS and PG.

Short-Term Results of Intravitreal Triamcinolone Acetonide Combined with Cataract Surgery for Diabetic Macular Edema in Japan: In the Era of Anti-Vascular Endothelial Growth Factor Therapy

PURPOSE

To evaluate the effectiveness of an intravitreal triamcinolone acetonide injection (IVTA) combined with cataract surgery for diabetic macular edema (DME) resistant to anti-vascular endothelial growth factor (anti-VEGF) therapy.

PROCEDURE

IVTA combined with cataract surgery was performed on 29 eyes of patients with DME (aged 70.5 ± 6.2 years) who were refractive to anti-VEGF treatments. The visual acuity, central retinal thickness (CRT), and the central retinal sensitivity were assessed at 1, 4, 12, and 24 weeks after the treatment.

RESULTS

The visual acuity improved significantly from 0.49 ± 0.30 logMAR units to 0.35 ± 0.33 logMAR units at 24 weeks after the treatment (p < 0.05; repeated ANOVA). The CRT decreased significantly from 435.1 ± 112.3 μm to 350.8 ± 123.3 μm at 12 weeks after the treatment (p < 0.05). The retinal sensitivity threshold also improved significantly from 18.2 ± 4.3 dB to 20.4 ± 3.8 dB at 4 weeks after the treatment (p < 0.05).

CONCLUSIONS

IVTA combined with cataract surgery is effective for successful treatment of eyes with DME refractive to anti-VEGF therapy.

Clinical Decision-Making when Treating Diabetic Macular Edema Patients with Dexamethasone Intravitreal Implants

Diabetes mellitus (DM) is a metabolic disease frequently associated with comorbidities that include diabetic macular edema (DME). The current medical approach to treating DME involves intravitreal injections with either anti-vascular endothelial growth factors or steroids. However, the burden associated with intravitreal injections and DM-derived complications is high, underlining the need to find optimal treatment regimens. In this article we describe the considerations we apply when treating DME patients with dexamethasone intravitreal implants (Ozurdex®), particularly those that influence the clinical decision-making process during the follow-up period. These considerations are based both on the available medical literature and on our clinical experience following the use of these implants in this type of patient, the goal being to optimize the number of injections and the clinical outcome of this therapy. We also provide a general overview of the pathophysiology of DME, highlighting the inflammatory component as a rationale to use steroids in these patients.

[Therapeutic strategy for the treatment of non-infectious uveitis proposed by an expert panel]

Conventional immunosuppressive drugs, anti-TNF alpha and other biotherapies used in clinical practice are capable of controlling non-infectious anterior uveitis, posterior uveitis and panuveitis. The present work has been led by a multidisciplinary panel of experts, internists, rheumatologists and ophthalmologists and is based on a review of the literature. In case of corticodependency or sight-threatening disease, conventional immunosuppressive drugs (methotrexate, azathioprine and mycophenolate mofetil) and/or anti-TNF alpha (adalimumab, infliximab) are used to achieve and maintain remission. Interferon is an efficient immunomodulatory treatment, as a second-line therapy, for some therapeutic indications (refractory macular edema, Behçet's vascularitis). Other biologics, especially tocilizumab, are showing promising results. Local treatments (corticosteroids, sirolimus etc.) are adjuvant therapies in case of unilateral inflammatory relapse. Therapeutic response must be evaluated precisely by clinical examination and repeated complementary investigations (laser flare photometry, multimodal imaging, perimetry, electroretinography measures).

Dexamethasone Inserts in Noninfectious Uveitis: A Single-Center Experience

PURPOSE

To report the effectiveness of repeated intravitreal dexamethasone (DEX) inserts in noninfectious uveitis patients.

DESIGN

Prospective, single-center, interventional clinical trial between February 2010 and March 2015.

PARTICIPANTS

Patients with noninfectious uveitis with cystoid macular edema and/or vitreitis.

METHODS

Patients were treated with a 700-μg intravitreal DEX insert (Ozurdex; Allergan, Inc., Irvine, CA). Follow-up visits were scheduled 1, 3, and 6 months after injection. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), vitreous haze (VH) score, intraocular pressure (IOP), and adverse events were recorded.

MAIN OUTCOME MEASURES

Primary outcome was the reduction of CRT. Secondary outcome was the improvement in BCVA and reduction of VH.

RESULTS

In total, 109 eyes of 76 patients received 298 DEX inserts. Fifty-two patients were women (68%). The mean age of all participants was 57 years (range, 24-88 years). More than 3 DEX inserts were injected into 44% of eyes. Mean number of injections were 1.54±0.5 (standard deviation [SD]), 1.98±0.84, and 2.46±1.1 over 12, 18, and 24 months, respectively. Central retinal thickness decreased significantly (P < 0.001) from 465 μm at baseline to 318, 342, and 388 μm after 1, 3, and 6 months, respectively. Similar trends were seen in eyes receiving a second, third, and fourth DEX insert. Patients with idiopathic uveitis and sarcoidosis benefited well from DEX inserts. The greatest overall benefit was achieved in patients with no systemic treatment and patients receiving antimetabolites and cyclosporin A. A significant VH score reduction was documented in 44% of eyes after 1 month. A gain of more than 3 lines in BCVA was recorded in 31% to 37%, 26% to 39%, and 8% to 32% of eyes after 1, 3, and 6 months, respectively. A transient rise in mean IOP after 1 month (P < 0.001) and after 3 months (P = 0.001) was seen.

CONCLUSIONS

The repeated longer-term administration of DEX inserts in noninfectious uveitis patients, either alone or in combination with other therapies, led to improved CRT, BCVA, and VH. Underlying diseases and concomitant systemic therapy seem to have an impact on overall treatment benefit. Ocular complications were reversible and were managed by local treatment, with exception of cataract formation.

Canaloplasty in Corticosteroid-Induced Glaucoma. Preliminary Results

Purpose: to present the mid-term results of canaloplasty in a small cohort of corticosteroid glaucoma patients. Material and Methods: Nine eyes from seven patients with various types of corticosteroid glaucoma in maximum medical therapy underwent canaloplasty. Patients underwent complete ophthalmic examination every six months. Success was defined as: post-operative intraocular pressure (IOP) ≤ 21 mmHg and ≤ 16 mmHg without (“complete success”), and with/without medical treatment (“qualified success”). The IOP reduction had to be ≥ 20. The number of medications before and after surgery was considered. The follow-up mean period was 32.7 ± 20.8 months (range 14–72 months). Results: The pre-operative mean IOP was 30.7 ± 7.2 mmHg (range: 24–45). The mean IOP at 6 and 12-month follow-up was 13.1 ± 2.6 mmHg, and 13.7 ± 1.9 mmHg, respectively. Qualified and complete success at 6 and 12 months was 100% for both of the two definitions. The number of medications used preoperatively and at the 12-month follow-up was 4.3 ± 0.7, and 0.2 ± 1.0, respectively. No serious complication was observed. Conclusions: The mid-term results of canaloplasty in patients with corticosteroid-induced glaucoma appear to be very promising. Canaloplasty should be considered as a possible alternative to filtering surgery in this form of glaucoma, when medical therapy is not sufficient to maintain the IOP within reasonable limits.

OCULAR HYPERTENSION AFTER INTRAVITREAL DEXAMETHASONE (OZURDEX) SUSTAINED-RELEASE IMPLANT

PURPOSE

To evaluate ocular hypertension (OHT) after Ozurdex injection to determine the incidence of OHT, therapy for OHT, and any associative factors such as diagnosis, underlying glaucoma and therapy, or sequential Ozurdex injection(s).

METHODS

Retrospective consecutive case series with patients receiving one or more intravitreal Ozurdex implantations at a tertiary care academic center. Ocular hypertension was defined as a single measurement of ≥30 mmHg or an increase of ≥10 mmHg from baseline.

RESULTS

Ninety-four injections in 52 patients (59 eyes) were reviewed. Forty eyes received a single injection, and 19 eyes received multiple injections. Ocular hypertension developed in 14 patients (26.9%). Thirteen patients (25%) had preexisting glaucoma or suspicion of glaucoma, and 6 of these developed OHT. Glaucoma eye drops were initiated after 13 injections (13.8%). Invasive surgery for glaucoma was required in 3 patients (3.2%): all had glaucoma or suspicion of glaucoma (one case was related to neovascular glaucoma and unlikely related to steroid response after Ozurdex). There was no difference in relative intraocular pressure increase (i.e., difference between final follow-up or subsequent intravitreal injection vs. baseline) between single versus multiple Ozurdex injections (P = 0.883).

CONCLUSION

Patients (26.9%) who received Ozurdex developed OHT. Glaucoma or glaucoma-suspicion factors were present in all patients who required invasive surgery for glaucoma. A greater proportion of patients who received multiple injections had an intraocular pressure elevation, but the relative intraocular pressure increase was not significant.

SAFETY OF INTRAVITREAL DEXAMETHASONE IMPLANT (OZURDEX): The SAFODEX study. Incidence and Risk Factors of Ocular Hypertension

PURPOSE

To analyze the incidence, risk factors, and time course of intraocular pressure elevation after intravitreal dexamethasone implant (Ozurdex).

METHODS

The medical charts of 421 consecutive eyes (361 patients) receiving one or more Ozurdex implant between October 2010 and February 2015 were reviewed retrospectively. Ocular hypertension was defined as intraocular pressure of at least 25 mmHg or an increase of at least 10 mmHg from baseline. The main indications for treatment were retinal vein occlusion (34%), diabetic macular edema (30%), postsurgical macular edema (17%), uveitis (14%), and other etiologies (5%).

RESULTS

Among 1,000 intravitreal injections, ocular hypertension was recorded for 28.5% of injected eyes over a mean follow-up period of 16.8 months (3-55). Intraocular pressure-lowering medication was required for 31% of eyes. Only three eyes with preexisting glaucoma required filtering surgery to manage postinjection intraocular pressure elevation. Early retreatment between the third and fourth month does not increase the risk of intraocular pressure elevation. Younger age, male sex, Type 1 diabetes, preexisting glaucoma treated with dual or triple therapy, and a history of retinal vein occlusion or uveitis were significant risk factors for ocular hypertension after dexamethasone implant injection (P < 0.05 for all the above).

CONCLUSION

Episodes of ocular hypertension after Ozurdex implant were generally transient and successfully managed with topical treatment. An analysis of the risk factors may help to determine the risk-benefit ratio for individual patients treated with dexamethasone implants.

Paracentesis following intravitreal drug injections in maintaining physiologic ocular perfusion pressure

A retrospective analysis was performed of patients who received a paracentesis immediately following an intravitreal injection of bevacizumab or triamcinolone acetonide. These patients were previously diagnosed as having glaucoma, ocular hypertension, or had responded previously with sustained elevated intraocular pressure. Of 1661 procedures were performed. Totally 219 (13%) of the injections were on phakic patients. A median (SD) of 210 µL (40 µL) of aqueous was removed during each paracentesis. There were no reported incidences of any complications. We propose performing a paracentesis immediately following intravitreal injections for patients at risk for ocular hypertension, glaucoma, and retinal vein or artery occlusion.

Dexamethasone implants in paediatric patients with noninfectious intermediate or posterior uveitis: first prospective exploratory case series

BACKGROUND

To evaluate the efficacy and safety of dexamethasone (DEX) implants in paediatric patients with noninfectious intermediate or posterior uveitis.

METHODS

Prospective single center exploratory case series. Children and adolescents, 6 to 17 years old, with a vitreous haze score of ≥1.5+ or cystoid macular edema (CME) of >300 μm were enrolled. Vitreous haze score at month 2 was chosen as primary endpoint. Best corrected visual acuity (BCVA), central retinal thickness (CRT) and concomitant medication at month 6 were defined as secondary endpoints. Intraocular pressure (IOP) and cataract formation were determined as safety endpoints.

RESULTS

Three out of 6 eligible patients participated in the case series. At month 2, vitreous haze was reduced from a score of 1.5+ to 0.5+ and 0 and BCVA improved by ≥3 lines, ≥4 lines and ≥2 lines of Early Treatment of Diabetic Retinopathy (ETDRS)-letters, respectively. Visual acuity gain was accompanied by a CRT reduction of -186 μm and -83 μm in the first and third patient, in whom CME was the indication for DEX implantation. A reduction of concomitant medication was achieved in 1 patient. IOP increase was seen in all 3 patients, but could be treated sufficiently with primarily IOP lowering medications and without need for glaucoma surgery. Cataract progression did not occur.

CONCLUSIONS

DEX implants led to an improvement in all endpoints, especially BCVA. This study confirms that IOP rises may also occur in the paediatric population and should be monitored and treated appropriately.

TRIAL REGISTRATION

European Union Drug Regulating Authorities Clinical Trials (EudraCT)- nr: 2013-000541-39.

The acute and chronic effects of intravitreal anti-vascular endothelial growth factor injections on intraocular pressure: A review

The acute and chronic effects of repeated intravitreal antivascular endothelial growth factor (VEGF) injections on intraocular pressure have not been fully characterized, and the development of sustained ocular hypertension could adversely affect patients who are at risk of glaucomatous optic neuropathy. As expected, volume-driven, acute ocular hypertension immediately follows intravitreal injection, but this pressure elevation is generally transient and well tolerated. Several medications have been investigated to limit acute ocular hypertension following anti-VEGF therapy, but the benefits of pretreatment are not conclusive. Chronic, sustained ocular hypertension, distinct from the short-term acute ocular hypertension after each injection, has also been associated with repeated intravitreal anti-VEGF injections. Risk factors for chronic ocular hypertension include the total number of injections, a greater frequency of injection, and preexisting glaucoma. Proposed mechanisms for chronic ocular hypertension include microparticle obstruction, toxic or inflammatory effects on trabecular meshwork, as well as alterations in outflow facility by anti-VEGF agents. Although limiting anti-VEGF therapy could minimize the risk of both acute and chronic ocular hypertension, foregoing anti-VEGF therapy risks progression of various macular diseases with resulting permanent central vision loss. While definitive evidence of damage to the retinal nerve fiber layer is lacking, patients receiving repeated injections should be monitored for ocular hypertension and patients in whom sustained ocular hypertension subsequently developed should be periodically monitored for glaucomatous changes with optic nerve optical coherence tomography and static visual fields.

Combined Intravitreal Dexamethasone Implant And Micropulse Yellow Laser For Treatment Of Anti-VEGF Resistant Diabetic Macular Edema

Purpose:

To report the efficacy and safety of combined intravitreal dexamethasone implant and micropulse laser for anti-VEGF resistant diabetic macular edema.

Patients and Methods:

Prospective, non-controlled study that was conducted for twenty eyes with center-involved diabetic macular edema not responding to anti-VEGF therapy. Ozurdex intravitreal implant was injected to all eyes with subsequent micropulse yellow laser one month after the injection. All eyes were followed up after one, three, four, six, nine and twelve months. The primary outcome measure is the change in best corrected visual acuity (BCVA) after one year and secondary outcome measures are central macular thickness (CMT) change and safety of both dexamethasone implant and micropulse laser. Reinjection was done for those eyes with recurrent edema.

Results:

The mean age was 58.8 ±7.94 years. The mean BCVA was 0.6± 0.14, 0.57 ±0.12, 0.51±0.15, 0.59±0.12, 0.6± 0.12 and 0.59±0.14 after one, three, four, six, nine and twelve months in comparison to 0.45± 0.14 as initial BCVA [SS,P<0.05]. The CMT was 302.5±30.01, 330.6±20.24, 357.6±32.15, 285.4±19.95, 292.9±25.07 and 285.2±14.99 after one ,three, four ,six , nine and twelve months µm in comparison to initial CMT of 420.7 ±38.74µm [HS, P<0.01]. Cataract occurred in 6 eyes from 14 phakic eyes (42.8%). Transient ocular hypertension occurred in 6 eyes (30%). Reinjection was done for eight eyes (40%).

Conclusion:

Intravitreal dexamethasone implant and micropulse laser are both effective and safe treatment options for anti-VEGF resistant diabetic macular edema.

Outcomes of Ahmed glaucoma valve implantation for steroid-induced elevated intraocular pressure in patients with retinitis pigmentosa

PURPOSE

To evaluate the outcomes of Ahmed glaucoma valve (AGV) in the management of elevated intraocular pressure (IOP) secondary to steroid use for macular edema in patients with retinitis pigmentosa (RP).

METHODS

A total of nine eyes of five patients were evaluated retrospectively. Complete success was defined as IOP ≤ 21 mmHg without glaucoma medications, while qualified success was defined as IOP ≤ 21 mmHg with glaucoma medications.

RESULTS

Mean age at surgery was 25.0 ± 8.3 years, and mean follow-up time was 38.4 ± 13.2 months. Mean IOP was 41.0 ± 8.3 mmHg preoperatively, 9.4 ± 3.5 mmHg at first week (p = 0.008), 13.1 ± 3.6 mmHg at first month (p = 0.008), 14.8 ± 4.1 mmHg at 6th month (p = 0.008), 11.7 ± 2.6 mmHg at 12th month (p = 0.008), 12.4 ± 2.9 mmHg at 24th month (p = 0.008), 12.6 ± 3.6 mmHg at 36th month (p = 0.043) and 12.8 ± 4.2 mmHg at 48th month (p = 0.068) postoperatively. The mean number of topical anti-glaucomatous medications decreased from 2.8 ± 0.4 preoperatively to 0.4 ± 0.9 postoperatively (p = 0.007). Complete success was obtained in 7 (77%) eyes, and qualified success in 2 (23%) eyes. No failure was detected.

CONCLUSIONS

AGV implantation can be considered as an alternative and safe option in the management of resistant, elevated IOP secondary to steroid treatment for macular edema in patients with RP.

Antiangiogenic activity of PLGA-Lupeol implants for potential intravitreal applications

Uncontrolled angiogenesis is directly associated with ocular diseases such as macular degeneration and diabetic retinopathy. Implantable polymeric drug delivery systems have been proposed for intravitreal applications and in the present work, we evaluated the antiangiogenic potential of PLGA ocular implants loaded with the triterpene lupeol using in vitro and in vivo models. The drug/polymer physiochemical properties of the lupeol-loaded PLGA were validated as functionally similar using differential scanning calorimetry, Fourier transform infrared spectroscopy, and scanning electron microscopy. Interestingly, in an in vitro culture system, lupeol (100μg/mL and 250μg/mL) was capable to inhibited the proliferation as well as the migration of Human Umbilical Vein Endothelial Cells (HUVEC), without interfering in cell viability, promoting a significant reduction in the percentage of vessels (39.41% and 44.12%, respectively), compared with the control group. In vivo test, by using the chorioallantoic membrane (CAM) model, lupeol-loaded PLGA ocular implants showed antiangiogenic activity comparable to the FDA-approved anti-VEGF antibody Bevacizumab. Overall, our results suggest lupeol-loaded PLGA ocular implants were able to inhibit the angiogenic process by impairing both proliferation and migration of endothelial cells.

Use of Corticosteroids in the Treatment of Patients With Diabetic Macular Edema Who Have a Suboptimal Response to Anti-VEGF: Recommendations of an Expert Panel

BACKGROUND AND OBJECTIVE

Guidance on the use of corticosteroids in the treatment of diabetic macular edema (DME) is lacking. This study aimed to develop a clinically recommended treatment paradigm for DME with emphasis on the role of corticosteroids.

PATIENTS AND METHODS

An expert panel of nine retinal specialists in the United States developed consensus recommendations for DME treatment through a modified Delphi process.

RESULTS

The panelists typically use intravitreal injections of vascular endothelial growth factor (VEGF) antagonists as first-line treatment of DME and switch patients with an inadequate response to anti-VEGF therapy (failure of best-corrected visual acuity to improve to 20/40 or better because of edema after three to six monthly injections, or a less-than-50% reduction in excess macular thickness after three to four monthly injections) to intravitreal corticosteroid treatment.

CONCLUSION

Intravitreal corticosteroids have a potentially useful role in the treatment of patients with DME who have an inadequate response to intravitreal anti-VEGF therapy. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:291-301.].

Interferon-alpha2a and Systemic Corticosteroid in Monotherapy in Chronic Uveitis: Results of the Randomized Controlled BIRDFERON Study

PURPOSE

Macular edema is the leading cause of vision loss in bilateral chronic noninfectious posterior uveitis, and is currently being treated using corticosteroids, immunosuppressive agents, and biotherapies. The aim of this trial was to assess and compare the efficacy and safety of corticosteroids and interferon-α (IFN-α) in adults with such conditions.

DESIGN

Randomized controlled trial.

METHODS

Subjects: Adult patients with bilateral posterior autoimmune noninfectious and nontumoral uveitis complicated by macular edema in at least 1 eye.

INTERVENTION

Patients received either subcutaneous IFN-α2a, systemic corticosteroids, or no treatment for 4 months. The efficacy and safety were assessed for up to 4 months.

MAIN OUTCOME MEASURES

The main endpoint was the change of the central foveal thickness (CFT) obtained by optical coherence tomography.

RESULTS

Forty-eight patients were included. In intention-to-treat analysis, the median CFT change showed no significant difference. However, the per-protocol analysis showed a significant difference between groups for both eyes (OD and OS), and for the worse and better eyes. Statistically significant difference was found between the control and corticosteroid groups for the OD (P = .0285), and between the control and IFN-α groups for the OD (P = .0424) and worse eye (P = .0354). Serious adverse events occurred in 2 patients in the IFN group, in 1 patient in the corticosteroid group, and in 2 patients in the control group and were completely resolved after switch.

CONCLUSIONS

IFN-α and systemic corticosteroids, compared with no treatment, were associated with significant anatomic and visual improvement shown in the per-protocol study.

TOLERANCE OF INTRAVITREAL DEXAMETHASONE IMPLANTS IN PATIENTS WITH OCULAR HYPERTENSION OR OPEN-ANGLE GLAUCOMA

PURPOSE

Evaluate the pressure tolerance of dexamethasone implants in open-angle glaucoma (OAG+) patients and ocular hypertension (OHT+) patients compared with nonglaucomatous and nonhypertensive patients.

METHODS

Retrospective observational 2-center, controlled study including 100 patients treated with intravitreal injections of dexamethasone, divided into 2 groups: Group 1, OAG+/OHT+ (n = 50), and Group 2, OAG-/OHT- (n = 50), matched for age and disease. Intraocular pressure (IOP) and hypotensive treatment were evaluated initially, at 8 days, and every month for 6 months after intravitreal treatment. The primary endpoint was IOP increase greater than 10 mmHg.

RESULTS

Thirty-four percent of glaucomatous patients experienced a transient IOP increase greater than 10 mmHg versus 16% in the OAG-/OHT- group (P = 0.06). Intraocular pressure greater than 25 mmHg was recorded early on Day 8 in 6% of the OAG+ patients versus 2% of the OAG- patients. Fifty-four percent of the glaucoma patients increased their treatment, and hypotensive treatment was initiated in 38% of the OAG- patients (P = 0.1). Filtering surgery was only required in the OAG+/OHT+ group (6% versus 0%), particularly in dual-therapy and triple-therapy patients, who had a higher risk of filtering surgery (P = 0.008).

CONCLUSION

Half of the OAG+ and OHT+ patients needed an add-on treatment, with early onset beginning on Day 8 in 6%. This emphasizes the need for IOP monitoring during treatment, especially for OAG+/OHT+ patients.

COMBINED VITRECTOMY AND INTRAVITREAL DEXAMETHASONE (OZURDEX) SUSTAINED-RELEASE IMPLANT

PURPOSE

To evaluate the safety and efficacy of combining intravitreal dexamethasone implantation (Ozurdex) with pars plana vitrectomy (PPV).

METHODS

A retrospective review was conducted on cases where Ozurdex injection was performed in the operating room in conjunction with pars plana vitrectomy. Our primary outcome measure was the presence of surgical complications in the perioperative and 3-month postoperative window. We also measured visual acuity, intraocular pressure (IOP), and macular edema at baseline, one, and 3 months after surgery.

RESULTS

Fifteen eyes in 14 cases were reviewed. There were no complications intraoperatively or at 1-month postoperatively. Two patients (2 eyes) with prior retinal detachment developed proliferative vitreoretinopathy and redetachment at 3 months. Visual acuity improved in 7 of 15 eyes, and an average improvement of 2 lines was achieved for the entire cohort. There was no overall change in intraocular pressure although 1 patient developed an increase in intraocular pressure >5 mmHg. Five of 9 patients with baseline macular edema experienced improvement or resolution at 3 months.

CONCLUSION

Intraoperative Ozurdex in combination with PPV may be safe and effective in treating macular edema caused by many different underlying diseases.

SAFETY AND EFFICACY OF INTRAVITREAL DEXAMETHASONE IMPLANTS IN THE MANAGEMENT OF MACULAR EDEMA SECONDARY TO INFECTIOUS UVEITIS

PURPOSE

To assess the safety and efficacy of intravitreal dexamethasone implants in the treatment of macular edema secondary to infectious uveitis.

METHODS

We retrospectively reviewed clinical records from three uveitis referral units in Spain. The main outcome measures were rate of reactivation of infection, improvements in visual acuity and resolution of macular edema, as measured by optical coherence tomography.

RESULTS

We included eight eyes from seven patients with a median age of 64 years (30-75). Etiologies of the infections were Herpes simplex virus-type 1, Varicela-Zoster virus, Treponema pallidum, Brucella mellitensis, Borrelia burgdorferi, Toxoplasma gondii, and cytomegalovirus. Median visual acuity was 20/160 (20/30-20/400) at baseline and 20/70 (20/25-20/200) at the last follow-up visit. Mean macular thickness was 516 μm (115) at baseline and 266.3 μm (40) at the last follow-up visit. Visual acuity improved in 100% of the eyes and none of the eyes showed macular edema at the last follow-up visit. Five patients required reinjections of the implant. Only one patient required antiglaucoma drops for a temporary increase in ocular pressure. There were no cases of reactivation of the infectious ocular disease. Median follow-up time was 18 months.

CONCLUSION

In this small case series of eyes with macular edema secondary to infectious uveitis, treatment with dexamethasone intravitreal implants was not associated with reactivation of the infectious ocular disease. Furthermore, significant improvements in visual acuity and macular thickness were observed in our patients.

Clinical Outcomes of Intravitreal Preservative-Free Triamcinolone Preparation (Triesence®) for Cystoid Macular Oedema and Inflammation in Patients with Uveitis

PURPOSE

To assess the outcomes of intravitreal benzyl alcohol-free triamcinolone acetonide suspension in uveitis-related macular oedema.

METHODS

Single-center retrospective cohort study of 66 injections to 44 eyes of 40 patients. Uveitis diagnosis, systemic and local therapy, intraocular pressure (IOP), central retinal thickness (CRT), number of injections, time to re-injection and side-effects were noted during 6-months minimum follow-up.

RESULTS

Sixty eight percent of eyes received a single injection. 18% required 2 injections, and 13% received ≥3 injections with mean time to second and third injections of 25.5 and 52.7 weeks, respectively. 90% of injections were unilateral. Mean CRT reduced, and by 12-weeks visual acuity improvement >0.3logMar was achieved in 46%. Cataract progression (47%) and IOP>21 mmHg (45%) were the commonest adverse events.

CONCLUSION

Preservative-free triamcinolone is an additional option for uveitis-related macular oedema, particularly in unilateral cases, with favorable CRT and visual outcomes. Repeat injections may be necessary, and the period of efficacy varies between eyes.

New Developments in the Classification, Pathogenesis, Risk Factors, Natural History, and Treatment of Branch Retinal Vein Occlusion

For years, branch retinal vein occlusion is still a controversial disease in many aspects. An increasing amount of data is available regarding classification, pathogenesis, risk factors, natural history, and therapy of branch retinal vein occlusion. Some of the conclusions may even change our impression of branch retinal vein occlusion. It will be beneficial for our doctors to get a deeper understanding of this disease and improve the treatment skills. The aims of this review is to collect the information above and report new ideas especially from the past a few years.

INTRAOCULAR PRESSURE IN PATIENTS WITH DIABETIC MACULAR EDEMA TREATED WITH DEXAMETHASONE INTRAVITREAL IMPLANT IN THE 3-YEAR MEAD STUDY

PURPOSE

To evaluate the occurrence, management, and clinical significance of increases in intraocular pressure (IOP) in patients with diabetic macular edema treated with dexamethasone intravitreal implant (DEX implant).

METHODS

Randomized, multicenter, 3-year, Phase III study. Patients (N = 1,048) with diabetic macular edema were randomized to DEX implant 0.7-mg, DEX implant 0.35-mg, or sham procedure with retreatment allowed at ≥6-month intervals (seven injections maximum).

RESULTS

In the DEX implant 0.7-mg, DEX implant 0.35-mg, and sham groups, respectively, ≥10-mmHg IOP increases from baseline occurred in 27.7%, 24.8%, and 3.7% of patients, and their frequency did not increase with repeat injections. IOP-lowering medication was used by 41.5%, 37.6%, and 9.1% of patients. Only one patient (0.3%) in each DEX implant group had filtering surgery to manage a steroid-induced IOP increase. Among DEX implant 0.7-mg-treated patients with and without a ≥10-mmHg IOP increase, 21.9% (21 of 96) and 22.4% (57 of 255), respectively, achieved ≥15-letter best-corrected visual acuity gain at the end of the study, and mean average change in central retinal thickness from baseline was -127 μm and -106 μm, respectively.

CONCLUSION

DEX implant demonstrated clear benefit of treatment despite increases in IOP. Sequential implants had no cumulative effect on IOP.

Severe Corticosteroid-Induced Ocular Hypertension Requiring Bilateral Trabeculectomies in a Patient with Takayasu's Arteritis

We present a rare case of severe corticosteroid-induced ocular hypertension (OHT) after prolonged systemic corticosteroid use in a young woman with Takayasu's arteritis. As she did not sufficiently respond to ocular antihypertensive therapies, bilateral enhanced trabeculectomies were required to normalize her intraocular pressures. The systemic side effects of corticosteroids are well known, yet steroid-induced OHT and glaucoma remain silent causes of ocular morbidity. This case highlights the importance of IOP-monitoring in visually asymptomatic patients on systemic corticosteroids. It further emphasizes the need to raise awareness of the potential ocular side effects of steroids amongst physicians, in particular those looking after patients with autoimmune and inflammatory diseases.

Intraocular Pressure after Intravitreal Triesence Injection

PURPOSE

Elevated intraocular pressure (IOP) is a frequent adverse event associated with intravitreal triamcinolone acetate injection. The incidence of elevated IOP with preserved forms of triamcinolone has been studied but the effect of preservative-free formulations has not been clinically evaluated.

DESIGN

A retrospective, observational clinical study.

METHODS

For patients undergoing intravitreal injections over the study period, age, sex, history of glaucoma or ocular hypertension were recorded. For each injection, preinjection IOP, maximum IOP (IOP_max), dose, and indication for injection were noted for both eyes.

RESULTS

Fourteen patients received 72 injections in 18 eyes. The mean baseline IOP was 15.4 mm Hg; the mean IOP_max was 19.8 mm Hg (P<0.001), occurring 63 days after injection. Outcomes were not significantly different between patients receiving 2 or 4 mg doses. History of glaucoma did not significantly affect IOP_max.

CONCLUSIONS

Eyes should be monitored for IOP rises after preservative-free triamcinolone acetonide injections.

Glucocorticoid therapy and ocular hypertension

The projected number of people who will develop age-related macular degeneration in estimated at 2020 is 196 million and is expected to reach 288 million in 2040. Also, the number of people with Diabetic retinopathy will grow from 126.6 million in 2010 to 191.0 million by 2030. In addition, it is estimated that there are 2.3 million people suffering from uveitis worldwide. Because of the anti-inflammatory properties of glucocorticoids (GCs), they are often used topically and/or intravitreally to treat ocular inflammation conditions or edema associated with macular degeneration and diabetic retinopathy. Unfortunately, ocular GC therapy can lead to severe side effects. Serious and sometimes irreversible eye damage can occur as a result of the development of GC-induced ocular hypertension causing secondary open-angle glaucoma. According to the world health organization, glaucoma is the second leading cause of blindness in the world and it is estimated that 80 million will suffer from glaucoma by 2020. In the current review, mechanisms of GC-induced damage in ocular tissue, GC-resistance, and enhancing GC therapy will be discussed.

Model systems for the study of steroid-induced IOP elevation

Steroid-induced IOP elevation affects a significant number of patients. It results from a decrease in outflow facility of the aqueous humor. To understand the pathophysiology of this condition a number of model systems have been created. These include ex-vivo cell and organ cultures as well as in-vivo animal models in organisms ranging from rodents to primates. These model systems can be used to investigate specific aspects of steroid-induced IOP elevation. This brief review summarizes the strengths and limitations of the various model systems and provides examples of where these systems have been successfully used to advance our understanding of steroid-induced IOP elevation.

Uveitic macular edema

Macular edema (ME) may complicate anterior, intermediate, and posterior uveitis, which may be because of various infectious, neoplastic or autoimmune etiologies. BRB breakdown is involved in the pathogenesis of Uveitic ME (UME). Optical coherence tomography has become a standard tool to confirm the diagnosis of macular thickening, due to its non-invasive, reproducible, and sensitive features. Retinal fluorescein and indocyanine green angiography is helpful to study the macula and screen for associated vasculitis, detect ischemic areas and preretinal, prepapillary or choroidal neovascular complications, and it may provide information about the etiology and be needed to assess the therapeutic response. UME due to an infection or neoplastic infiltration may require a specific treatment. If it remains persistent or occurs in other etiologies, immunomodulatory treatments may be needed. Intravitreal, subconjunctival, or subtenon corticosteroids are widely used. Their local use is contraindicated in glaucoma patients and limited by their short-lasting action. In case of bilateral sight-threatening chronic posterior uveitis, systemic treatments are usually needed, and corticosteroids are used as the standard first-line therapy. In order to reduce the daily steroid dose, immunosuppressive or immunomodulatory agents may be added, some of them being now available intravitreally. Ongoing prospective studies are assessing biotherapies and immunomodulators to determine their safety and efficacy in this indication.

Elevated Intraocular Pressure After Intravitreal Steroid Injection in Diabetic Macular Edema: Monitoring and Management

INTRODUCTION

With the increasing use of intravitreal administration of corticosteroids in macular edema, steroid-induced intraocular pressure (IOP) rise is becoming an emergent issue. However, for patients in whom intravitreal steroids are indicated, there are no specific recommendations for IOP monitoring and management after intravitreal administration of corticosteroids.

METHOD

An expert panel of European ophthalmologists reviewed evidence on corticosteroid-induced IOP elevation. The objective of the panel was to propose an algorithm based on available literature and their own experience for the monitoring and management of corticosteroid-induced IOP elevation, with a focus on diabetic patients.

RESULTS

Data from trials including diabetic patients with a rise of IOP after intravitreal steroid administration indicate that IOP-lowering medical treatment is sufficient for a large majority of patients; only a small percentage underwent laser trabeculoplasty or filtering filtration surgery. A 2-step algorithm is proposed that is based on the basal value of IOP and evidence for glaucoma. The first step is a risk stratification before treatment. Patients normotensive at baseline (IOP ≤ 21 mmHg), do not require additional baseline diagnostic tests. However, patients with baseline ocular hypertension (OHT) (IOP > 21 mmHg) should undergo baseline imaging and visual field testing. The second step describes monitoring and treatment after steroid administration. During follow-up, patients developing OHT should have baseline and periodical imaging and visual field testing; IOP-lowering treatment is proposed only if IOP is >25 mmHg or if diagnostic tests suggest developing glaucoma.

CONCLUSION

The management and follow-up of OHT following intravitreal corticosteroid injection is similar to that of primary OHT. If OHT develops, IOP is controlled in a large proportion of patients with standard IOP treatments. The present algorithm was developed to assist ophthalmologists with guiding principles in the management of corticosteroid-induced IOP elevation.

FUNDING

Alimera Sciences Limited.

Inducible scAAV2.GRE.MMP1 lowers IOP long-term in a large animal model for steroid-induced glaucoma gene therapy

Current treatment of glaucoma relies on administration of daily drops or eye surgery. A gene therapy approach to treat steroid-induced glaucoma would bring a resolution to millions of people worldwide that depend on glucocorticoid therapy for a myriad of inflammatory disorders. Previously, we had characterized a short-term Adh.GRE.MMP1 gene vector for the production of steroid-induced MMP1 in the trabecular meshwork and tested reduction of elevated intraocular pressure (IOP) in a sheep model. Here we conducted a trial transferring the same transgene cassette to a clinically safe vector (scAAV2), and extended the therapeutic outcome to longer periods of times. No evidence of ocular and/or systemic toxicity was observed. Viral genome distributions showed potential re-inducible vector DNAs in the trabecular meshwork (0.4 vg/cell) and negligible copies in six major internal organs (0.00002-0.005 vg/cell). Histological sections confirmed successful transduction of scAAV2.GFP to the trabecular meshwork. Optimization of the sheep steroid–induced hypertensive model revealed that topical ophthalmic drug difluprednate 0.05% (durezol) induced the highest IOP elevation in the shortest time. This is the first efficacy/toxicity study of a feasible gene therapy treatment of steroid-induced hypertension using clinically accepted scAAV vectors in a large animal model.

A 12-MONTH, SINGLE-MASKED, RANDOMIZED CONTROLLED STUDY OF EYES WITH PERSISTENT DIABETIC MACULAR EDEMA AFTER MULTIPLE ANTI-VEGF INJECTIONS TO ASSESS THE EFFICACY OF THE DEXAMETHASONE-DELAYED DELIVERY SYSTEM AS AN ADJUNCT TO BEVACIZUMAB COMPARED WITH CONTINUED BEVACIZUMAB MONOTHERAPY

PURPOSE

To determine whether a dexamethasone intravitreal implant 0.7 mg (dexamethasone delivery system [DDS], Ozurdex) combined with bevacizumab 1.25 mg (Avastin) provides greater benefit than bevacizumab monotherapy in eyes with diabetic macular edema with incomplete response to multiple antivascular endothelial growth factor injections.

METHODS

Eyes with diabetic macular edema were randomly assigned to receive combination therapy (bevacizumab plus DDS) or bevacizumab monotherapy. Combination therapy eyes received intravitreal bevacizumab at baseline, DDS at Month 1, and subsequent DDS (at Months 5 and 9), whereas monotherapy eyes received bevacizumab (monthly) if indicated. Eyes were eligible for retreatment if the central subfield thickness measured >250 μm, and Early Treatment of Diabetic Retinopathy Study visual acuity was <80 letters (20/25).

RESULTS

Forty eyes of 30 patients were enrolled. The mean visual acuity changes from baseline to 12 months were similar in the 2 groups (combined: +5.4 letters; bevacizumab: +4.9 letters; difference = 0.2 letters, 95% confidence interval = -5.9 to 6.3; P = 0.75). The mean reduction in central subfield thickness was greater in the combination group (-45 μm vs. -30 μm, difference = 69 μm, 95% confidence interval = 9-129; P = 0.03) and more patients in the combination group had central subfield thickness <250 μm. The combined treatment group received three fewer supplemental injections of bevacizumab, but this was counterbalanced by the need for an average of 2.1 DDS injections.

CONCLUSIONS

The dexamethasone implant combined with bevacizumab significantly improves visual acuity and significantly improves macular morphology in eyes with refractory diabetic macular edema, although visual acuity changes are not superior to continued bevacizumab monotherapy.

Intraocular pressure elevation after intravitreal triamcinolone acetonide injection: a Meta-analysis

AIM

To report on intraocular pressure (IOP) after intravitreal injections of triamcinolone acetonide.

METHODS

Systematic literature review of studies that investigated the effects of an injection of triamcinolone intravitreal triamcinolone acetonide on IOP was conducted according to the Cochrane Collaboration methodology and the reported effects have been analyzed with Meta-analysis.

RESULTS

We found that the IOP follows an inverted-U shape pattern over time starting with an average value of 14.81±1.22 mm Hg before the injection, rising to a maximum of 19.48±2.15 mm Hg after one month of injection and falling down to 16.16±1.92 mm Hg after 6mo. Moreover, country of study, age, previous history of glaucoma and gender compositions matter for cross-study were different in reported IOP changes.

CONCLUSION

Our findings may be helpful in determining pressure elevation risk of intravitreal triamcinolone acetonide therapy as well as comparing it with those of more recent therapies such as the anti-vascular endothelial growth factor agents.

Outcome of Treating Pediatric Uveitis With Dexamethasone Implants

PURPOSE

To describe the outcome in children of eyes with uveitis following repeated treatment with dexamethasone (Ozurdex) implants.

DESIGN

Retrospective, interventional study.

METHODS

Twenty-two eyes of 16 pediatric patients with uveitis were treated with 35 dexamethasone implants at a tertiary referral center. Following implantations, anatomic and functional outcomes, as well as ocular complications, were noted. Main outcome measures included best-corrected visual acuity, central retinal thickness, number and dosage of systemic immunosuppression drugs, vitreous haze score, and presence of raised intraocular pressure or cataract.

RESULTS

Following the first implantation, average best-corrected visual acuity improved significantly from 0.55 ± 0.08 logMAR to 0.37 ± 0.08 logMAR (P = .024), central retinal thickness decreased by 219 ± 55 μm (P = .01), and the percentage of eyes achieving a vitreous haze score of 0 increased from 41% to 88% (P = .006). The median time to relapse following the first injection was 9 months, with a similar response achieved after each repeat implantation. Children previously requiring systemic immunosuppression at the time of the first implantation were able to stop or significantly reduce the dose and number of drugs. In total there were 4 instances of cataract progression that were not visually significant and did not require surgical treatment and 6 cases of raised IOP, 5 of which were treated pharmacologically with no surgical intervention required and 1 that required revision of a previous filtration surgery. There were no cases of implant migration into the anterior chamber, endophthalmitis, or retinal detachment.

CONCLUSIONS

The use of dexamethasone implants in children results in improved retinal thickness and reduction in ocular inflammation, which can improve vision for several months. Repeat implantations result in continued control of the inflammation, allowing for reduction of systemic immunosuppression with few ocular complications.