A comparison between the fluocinolone acetonide (Retisert) and dexamethasone (Ozurdex) intravitreal implants in uveitis

Rheumatologists and Ophthalmologists Differ in Treatment Decisions for Ocular Behçet Disease

BACKGROUND

Ocular involvement in patients with Behçet disease represents a significant clinical morbidity in this disease, and the prevention of visual impairment is an important treatment goal. There are no randomized controlled trials for the treatment of ocular Behçet disease; however, clinicians must still make treatment decisions.

OBJECTIVES

The goals of this study were to describe the treatment preferences of rheumatologists and ophthalmologists for the treatment of ocular Behçet disease and to identify factors that influence these decisions.

METHODS

Eight hundred fifty-two rheumatologists and 934 ophthalmologists were surveyed via e-mail regarding their choice of therapy for a hypothetical patient with ocular Behçet disease. Respondents were asked to select first- and second-choice therapies and then reselect first and second choices assuming there would be no issues with cost or insurance prior authorization.

RESULTS

One hundred thirty two physicians (7.4%) who were willing to recommend treatment completed the survey: 68 rheumatologists and 64 ophthalmologists. The most common first-choice therapy for both specialties was a biologic agent. Significantly more rheumatologists than ophthalmologists chose methotrexate (P < 0.025) and azathioprine (P < 0.005) as their first-choice therapy. After assuming there were no concerns with cost or prior authorization, rheumatologists were still more likely to choose azathioprine compared with ophthalmologists (P < 0.02), and ophthalmologists were more likely to choose local steroid implants (P < 0.02). Both rheumatologists and ophthalmologists increased their choice of an anti-tumor necrosis factor agent when cost and prior authorization issues were removed (P < 0.0001 and 0.008, respectively).

CONCLUSIONS

Physician decision making is influenced by medical specialty and concerns regarding cost and prior authorization.

INTRAVITREAL DEXAMETHASONE IMPLANTATION FOR BIRDSHOT CHORIORETINOPATHY

PURPOSE

Birdshot chorioretinopathy is a rare form of posterior uveitis. This article reports a case series of patients with HLA-A29+ birdshot chorioretinopathy managed with intravitreal dexamethasone implants.

METHODS

Retrospective case report.

RESULTS

Three patients with birdshot chorioretinopathy (6 eyes) were seen from 2013 to 2015 and managed with dexamethasone intravitreal implant; there was an average of 6 months between implants. All 3 experienced control of ocular inflammation and macular edema with intravitreal dexamethasone and achieved best-corrected visual acuity of at least 20/25 during the course of treatment. Two patients tolerated serial dexamethasone implants for over a year without glaucoma or cataract surgery. Dexamethasone implantation was not repeated in one patient with preexisting uveitic glaucoma because of persistently elevated intraocular pressure. In this series, all patients had improvement in visual acuity, macular edema, intraocular inflammation, and quality of life, and no patients developed visually significant cataracts. Only one eye with preexisting uveitic glaucoma exhibited an increased intraocular pressure requiring discontinuation of therapy.

CONCLUSION

Intravitreal dexamethasone implant can be an effective alternative in the management of birdshot chorioretinopathy.

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.

Management of noninfectious posterior uveitis with intravitreal drug therapy

Uveitis is an important cause of vision loss worldwide due to its sight-threatening complications, especially cystoid macular edema, as well as choroidal neovascularization, macular ischemia, cataract, and glaucoma. Systemic corticosteroids are the mainstay of therapy for noninfectious posterior uveitis; however, various systemic side effects can occur. Intravitreal medication achieves a therapeutic level in the vitreous while minimizing systemic complications and is thus used as an exciting alternative. Corticosteroids, antivascular endothelial growth factors, immunomodulators such as methotrexate and sirolimus, and nonsteroidal anti-inflammatory drugs are currently available for intravitreal therapy. This article reviews the existing literature for efficacy and safety of these various options for intravitreal drug therapy for the management of noninfectious uveitis (mainly intermediate, posterior, and panuveitis).

Moving Past Anti-VEGF: Novel Therapies for Treating Diabetic Retinopathy

Diabetic retinopathy is the leading cause of blindness in working age adults, and is projected to be a significant future health concern due to the rising incidence of diabetes. The recent advent of anti-vascular endothelial growth factor (VEGF) antibodies has revolutionized the treatment of diabetic retinopathy but a significant subset of patients fail to respond to treatment. Accumulating evidence indicates that inflammatory cytokines and chemokines other than VEGF may contribute to the disease process. The current review examines the presence of non-VEGF cytokines in the eyes of patients with diabetic retinopathy and highlights mechanistic pathways in relevant animal models. Finally, novel drug targets including components of the kinin-kallikrein system and emerging treatments such as anti-HPTP (human protein tyrosine phosphatase) β antibodies are discussed. Recognition of non-VEGF contributions to disease pathogenesis may lead to novel therapeutics to enhance existing treatments for patients who do not respond to anti-VEGF therapies.

Comparison of Surgical Outcome After Ahmed Valve Implantation for Patients With and Without Fluocinolone Intravitreal Implant (Retisert)

PURPOSE

To determine whether long-term, slow-release exposure to corticosteroids with Retisert promotes better surgical outcomes after Ahmed valve implantation.

PATIENTS

This comparative retrospective cohort study included 17 study eyes (10 patients) with uncontrolled uveitis requiring Retisert and Ahmed implantation, and 55 control eyes (51 patients) with other types of medically uncontrolled glaucoma that only received Ahmed.

MATERIALS AND METHODS

Main outcome measures were intraocular pressure (IOP), glaucoma eye drops per day, best-corrected visual acuity, early complications, and late complications at 1, 3, 6, and 12 months. Linear mixed effects models were used to model IOP, glaucoma drops per day, and visual acuity at 1 year after surgery.

RESULTS

At 1 year, the study eyes had a mean IOP of 12.24, which was lower than that for control eyes at 15.17 (P=0.04). At 1 year, the average number of glaucoma eye drops used per day for study eyes was 1.4, which was lower than that for control eyes at 2.3 (P=0.03). At 1 year, there were no statistically significant differences in change in visual acuity, early complications, and late complications between study and control eyes.

CONCLUSIONS

Patients who received a Retisert implantation had lower IOP and used fewer glaucoma eye drops compared with control eyes at 1-year post-Ahmed valve surgery. This study suggests that long-term, slow-release corticosteroid medication from Retisert (fluocinolone acetonide) may improve the surgical outcome for patients with an Ahmed valve implantation and/or Retisert helps control uveitis in patients with uveitic glaucoma receiving Ahmed valves.

Sustained-release dexamethasone for the treatment of ocular inflammation and pain after cataract surgery

PURPOSE

To evaluate the safety and efficacy of dexamethasone as a sustained-release drug depot when placed in the canaliculus for the treatment of ocular inflammation and pain in cataract surgery patients.

SETTING

Four private practice sites in the United States.

DESIGN

Multicenter randomized double-masked clinical trial.

METHODS

Patients were randomized (1:1) to receive either the sustained-release dexamethasone or a placebo vehicle punctum plug inserted into the inferior distal canaliculus of the operated eye intraoperatively during cataract surgery. The primary endpoints were the proportions of patients with absence of cells or pain in the anterior chamber at 8 days. Secondary endpoints included cells, flare, pain, and the presence of the device at various timepoints through 30 days.

RESULTS

Approximately one fifth (20.7%) of patients in the sustained-release dexamethasone group had an absence of anterior chamber cells at 8 days compared with 10.0% in the placebo group (P = .1495). A higher proportion of patients in the sustained-release dexamethasone group (79.3%) than in the placebo group (30.0%) had an absence of ocular pain at 8 days (P < .0001) and at all other timepoints (P < .0002). There were significantly higher proportions of patients in the sustained-release dexamethasone group than in the placebo group with an absence of anterior chamber cells, anterior chamber flare, and pain at several timepoints through 30 days (P ≤ .0251).

CONCLUSION

Sustained-release dexamethasone provided elution of drug for up to 1 month after cataract surgery, providing clinically significant reductions in inflammation and pain.

FINANCIAL DISCLOSURE

Dr. Masket is a consultant to and shareholder in Ocular Therapeutix, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

Clinical Considerations for Vascularized Composite Allotransplantation of the Eye

Vascularized composite allotransplantation represents a potential shift in approaches to reconstruction of complex defects resulting from congenital differences as well as trauma and other acquired pathology. Given the highly specialized function of the eye and its unique anatomical components, vascularized composite allotransplantation of the eye is an appealing method for restoration, replacement, and reconstruction of the nonfunctioning eye. Herein, we describe conventional treatments for eye restoration and their shortcomings as well as recent research and events that have brought eye transplantation closer to a potential clinical reality. In this article, we outline some potential considerations in patient selection, donor facial tissue procurement, eye tissue implantation, surgical procedure, and potential for functional outcomes.

Injectable Fluocinolone Acetonide Long-Acting Implant for Noninfectious Intermediate Uveitis, Posterior Uveitis, and Panuveitis: Two-Year Results

PURPOSE

To determine the effect of an injectable fluocinolone acetonide implant (FAi) in eyes with noninfectious intermediate uveitis, posterior uveitis, or panuveitis.

DESIGN

Noncomparative, interventional, dose-randomized, dose-masked, prospective, individual, investigator-sponsored investigational new drug study.

PARTICIPANTS

Eleven eyes of 11 participants with a history of recurrent noninfectious intermediate uveitis, posterior, or panuveitis.

METHODS

Participants were randomized to receive either a low- or a high-dose FAi. Eyes were observed on day 0 (day the implant was injected) and then at regular intervals through 2 years.

MAIN OUTCOME MEASURES

Ocular inflammation, visual acuity, anti-inflammatory medication use, and safety parameters before and after FAi implantation.

RESULTS

All participants were followed up for 2 years. At baseline, mean study eye visual acuity was 0.56 logarithm of the minimum angle of resolution (logMAR; standard deviation [SD], 0.43 logMAR). These values improved significantly to +0.25 logMAR (SD, 0.14 logMAR) and +0.17 logMAR (SD, 0.14 logMAR) at 12 and 24 months after implantation, respectively (P = 0.041 and P = 0.016, respectively). The average number of inflammation recurrences in the 12 months before implantation was 1.54 episodes per eye. None of the study eyes experienced a recurrence during the follow-up period. Of the 6 participants who continued receiving systemic medication after implantation, the dosage was reduced in 4 participants. Five of 11 eyes received an average of 1.6 posterior sub-Tenon triamcinolone acetonide (PSTA) injections in the 12 months preceding implantation. None required a PSTA injection after FAi implantation. The most common adverse event was intraocular pressure (IOP) rise. At baseline, 1 study eye (9%) required pressure-lowering drops; 2 additional study eyes (18%) required them during the follow-up period. Filtering procedures were performed in 2 of these eyes (18.1%). No FAi explantations were required, nor were any participants lost to follow-up during the investigation.

CONCLUSIONS

It is feasible to place a long-acting FAi in an outpatient setting, without prolonged adverse events attributed to the implant injection procedure. The FAi effectively controlled intraocular inflammation in all eyes in the study, and at the last follow-up, all implanted eyes demonstrated an improvement in visual acuity. Elevated IOP that occurred in 18% of FAi-implanted eyes was managed by standard means. The FAi implant is a promising approach for patients with noninfectious intermediate uveitis, posterior uveitis, or panuveitis who do not respond to, or are intolerant to, conventional therapy.

Controlled Release of Dexamethasone From an Intravitreal Delivery System Using Porous Silicon Dioxide

PURPOSE

The current study aims to evaluate a porous silicon-based drug delivery system meant for sustained delivery of dexamethasone (Dex) to the vitreous and retina.

METHODS

Dexamethasone was grafted covalently into the pore walls of fully oxidized porous silicon particles (pSiO2-COO-Dex), which then was evaluated for the pharmacological effect of the payload on cultured ARPE19 cells before intravitreal injection. The Dex release profile was investigated in a custom designed dynamic dissolution chamber to mimic the turnover of vitreous fluid in rabbit eyes. Ocular safety, in vivo release, and pharmacodynamics were evaluated in rabbit eyes, and the human VEGF-induced rabbit retinal vascular permeability model.

RESULTS

Loading efficiency of Dex was 69 ± 9 μg per 1 mg of the pSiO2-COO-Dex particles. Dynamic in vitro release demonstrated a sustained mode when compared to free Dex, with the drug half-life extended by 5 times. The released Dex was unaltered and biologically active. In vivo drug release in rabbit eyes revealed a mode similar to the release seen in vitro, with a vitreous half-life of 11 days. At 2 and 4 weeks after a single intravitreal injection of pSiO2-COO-Dex particles (mean 2.71 ± 0.47 mg), intravitreal 500 ng of VEGF did not induce significant retinal vessel dilation or fluorescein leakage, while these events were observed in the eyes injected with empty pSiO2 particles or with free Dex. The retinal vessel score from fluorescein angiography for the control eyes was double the score for the eyes injected with pSiO2-COO-Dex. No adverse reaction was observed for the eyes injected with drug-loaded pSi particles during the course of the study.

CONCLUSIONS

The porous silicon-based Dex delivery system (pSiO2-COO-Dex) can be administered safely into vitreous without toxicity. Dex release from the porous silicon particles was sustained for 2 months and was effective against VEGF-induced retinal vessel reaction.

Episcleral drug film for better-targeted ocular drug delivery and controlled release using multilayered poly-ε-caprolactone (PCL)

Triamcinolone acetonide (TA) and poly-ε-caprolactone (PCL) were engineered into a micro drug film for episcleral application to better manage chronic vitreoretinal diseases such as proliferative vitreoretinopathy (PVR). Compared to an intravitreal drug injection, this drug film is much safer without breaking into ocular barriers. Compared to a traditional subtenon injection, this drug film demonstrated superior therapeutic duration, better drug bioavailability in the choroid and retina, and better-targeted drug delivery ability. The rabbit eye study demonstrated that using the PCL-TA film led to 5.6 and 3.4 times higher drug AUC in the choroid and the retina respectively than in eyes following a subtenon drug injection. The mean drug residence time in the rabbit choroid was also doubled by using the episcleral TA film (86days versus 43days). Remaining TA in the drug film was consistently higher than that in the subtenon space, indicating controlled release of TA by the PCL-TA film. The pharmacokinetics of triamcinolone in the choroid and retina were optimized from typical first-order kinetics to a more sustained release by use of this film. This episcleral film system worked better on rabbit eyes than on guinea pig eyes, indicating that scleral thickness and eye size may be crucial aspects to consider when choosing an animal model or when designing a transscleral delivery device for human use. This engineered drug film may be very useful in preventing and managing PVR associated with open globe trauma or surgical repair for retinal detachment.

STATEMENT OF SIGNIFICANCE

This study demonstrated a novel micro episcleral drug film that is made from the engineering of triamcinolone acetonide (TA) into poly-ε-caprolactone (PCL). The film can be conveniently placed at the injury or disease site during primary surgery and provide controlled release of TA for four months that covers the high-risk time window for developing proliferative vitreoretinopathy (PVR). This engineered drug film may be very useful in preventing and managing PVR associated with open globe trauma or intraocular surgery.

Therapeutic effect of dexamethasone implant in retinal vein occlusions resistant to anti-VEGF therapy

Purpose

To test the efficacy of the intravitreal dexamethasone (DEX) implant in patients with retinal vein occlusions (RVOs) who have failed multiple anti-vascular endothelial growth factor (anti-VEGF) treatments.

Methods

A randomized exploratory study of ten patients with branch RVO or central RVO who received at least two previous anti-VEGF treatments and had persistent or unresponsive cystoid macular edema. Treatment with the DEX implant was either every 4 months or pro re nata (PRN) depending on their group assignment for 1 year. Multifocal electroretinography and microperimetry were the primary end points, with high-resolution optical coherence tomography and best-corrected visual acuity as the secondary end points.

Results

All patients in both the every 4 month and PRN cohorts who completed the study received the three maximal injections of DEX; therefore, the data from both cohorts were combined and reported as a case series. On average, the multifocal electroretinography amplitude increased significantly from 5.11±0.66 to 24.19±5.30 nV/deg2 at 12 months (P<0.005), mean macular sensitivity increased from 7.67±2.10 to 8.01±1.98 dB at 4 months (P=0.32), best-corrected visual acuity increased significantly from 51.0±5.1 to 55.4±5.1 early treatment of diabetic retinopathy study letters at 2 months (P<0.05), and central retinal thickness decreased from 427.6±39.5 to 367.1±37.8 μm at 4 months (P<0.05). Intraocular pressure increased significantly in one patient, with that patient requiring an additional glaucoma medication for management. Additionally, cataract progression increased significantly (P<0.05) in this patient population and partially limited analysis of other end points.

Conclusion

DEX should be considered as a treatment option in patients with RVOs who have failed anti-VEGF therapy, as the results of this study demonstrated an improvement in retinal morphology and macular function. Cataract progression did occur following multiple consecutive injections; however, steroid-induced glaucoma was not a limiting factor.

Treatment of Non-infectious Uveitic Macular Edema with the Intravitreal Dexamethasone Implant

PURPOSE

To describe the clinical outcome of phakic eyes with macular edema (ME) due to non-infectious uveitis treated with a dexamethasone intravitreal implant.

METHODS

A retrospective analysis of 41 eyes treated with a total of 58 dexamethasone intravitreal implants was conducted. Best corrected visual acuity (BCVA), central retinal thickness (CRT) and complications data were collected.

RESULTS

One month after the first implant, even as CRT improved significantly in most eyes (p<0.001), 31.7% showed no improvement in BCVA. At 6 months post-implantation, CRT and BCVA had deteriorated in up to 70% of patients. Thirteen eyes were re-implanted, with a similar effect to that of the first implant. Ocular hypertension developed in 36.2% of eyes, and three eyes had cataract surgery, all in eyes with repeated implants.

CONCLUSIONS

The dexamethasone intravitreal implant can be safely used to treat ME due to non-infectious uveitis, but with a limited and short effect on BCVA.

Uveitic Macular Edema: Treatment Update

The aim of this review is to summarize recent developments in the treatment of uveitic macular edema (ME). ME represent a major cause of visual loss in uveitis and adequate management is crucial for the maintenance of useful vision in patients with chronic uveitis.

Corticosteroid implants for chronic non-infectious uveitis

BACKGROUND

Uveitis is a term used to describe a heterogeneous group of intraocular inflammatory diseases of the anterior, intermediate, and posterior uveal tract (iris, ciliary body, choroid). Uveitis is the fifth most common cause of vision loss in high-income countries, accounting for 5% to 20% of legal blindness, with the highest incidence of disease in the working-age population.Corticosteroids are the mainstay of acute treatment for all anatomical subtypes of non-infectious uveitis and can be administered orally, topically with drops or ointments, by periocular (around the eye) or intravitreal (inside the eye) injection, or by surgical implantation.

OBJECTIVES

To determine the efficacy and safety of steroid implants in people with chronic non-infectious posterior uveitis, intermediate uveitis, and panuveitis.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (Issue 10, 2015), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to November 2015), EMBASE (January 1980 to November 2015), PubMed (1948 to November 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to November 2015), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) (last searched 15 April 2013), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic search for studies. We last searched the electronic databases on 6 November 2015.We also searched reference lists of included study reports, citation databases, and abstracts and clinical study presentations from professional meetings.

SELECTION CRITERIA

We included randomized controlled trials comparing either fluocinolone acetonide (FA) or dexamethasone intravitreal implants with standard-of-care therapy with at least six months of follow-up after treatment. We included studies that enrolled participants of all ages who had chronic non-infectious posterior uveitis, intermediate uveitis, or panuveitis with vision that was better than hand-motion.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed studies for inclusion. Two review authors independently extracted data and assessed the risk of bias for each study.

MAIN RESULTS

We included data from two studies (619 eyes of 401 participants) that compared FA implants with standard-of-care therapy. Both studies used similar standard-of-care therapy that included administration of prednisolone and, if needed, immunosuppressive agents. The studies included participants from Australia, France, Germany, Israel, Italy, Portugal, Saudi Arabia, Spain, Switzerland, Turkey, the United Kingdom, and the United States. We assessed both studies at high risk of performance and detection bias.Only one study reported our primary outcome, recurrence of uveitis at any point during the study through 24 months. The evidence, judged as moderate-quality, showed that a FA implant probably prevents recurrence of uveitis compared with standard-of-care therapy (risk ratio (RR) 0.29, 95% confidence interval (CI) 0.14 to 0.59; 132 eyes). Both studies reported safety outcomes, and moderate-quality evidence showed increased risks of needing cataract surgery (RR 2.98, 95% CI 2.33 to 3.79; 371 eyes) and surgery to lower intraocular pressure (RR 7.48, 95% CI 3.94 to 14.19; 599 eyes) in the implant group compared with standard-of-care therapy through two years of follow-up. No studies compared dexamethasone implants with standard-of-care therapy.

AUTHORS' CONCLUSIONS

After considering both benefits and harms reported from two studies in which corticosteroids implants were compared with standard-of-care therapy, we are unable to conclude that the implants are superior to traditional systemic therapy for the treatment of non-infectious uveitis. These studies exhibited heterogeneity in design and outcomes that measured efficacy. Pooled findings regarding safety outcomes suggest increased risks of post-implant surgery for cataract and high intraocular pressure compared with standard-of-care therapy.

Ocular Complications of Diabetes and Therapeutic Approaches

Diabetes mellitus (DM) is a metabolic disease defined by elevated blood glucose (BG). DM is a global epidemic and the prevalence is anticipated to continue to increase. The ocular complications of DM negatively impact the quality of life and carry an extremely high economic burden. While systemic control of BG can slow the ocular complications they cannot stop them, especially if clinical symptoms are already present. With the advances in biodegradable polymers, implantable ocular devices can slowly release medication to stop, and in some cases reverse, diabetic complications in the eye. In this review we discuss the ocular complications associated with DM, the treatments available with a focus on localized treatments, and what promising treatments are on the horizon.

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.

Nonbiological pharmacotherapies for the treatment of diabetic macular edema

INTRODUCTION

During the past decade, there have been significant advances in the pharmacotherapies for the treatment of diabetic macular edema (DME). Among the presently available treatment options, anti-vascular endothelial growth factors (anti-VEGF) agents are the most favored agents due to their efficacy and safety. The index review focuses on nonbiological therapies that have entered in phase 3 clinical trials for DME.

AREAS COVERED

An extensive review of the literature was performed to identify various nonbiological immunotherapies i.e., drugs other than '-mAbs' (monoclonal antibodies including anti-VEGF agents), '-mibs' (proteasome inhibitors), '-NAbs' (nanoparticle albumin-bound), and '-nibs' (small molecule inhibitor/tyrosine kinase inhibitors), among others. Extended-release low-dose corticosteroid devices have been recently approved for the treatment of DME. Other compounds such as non-steroidal anti-inflammatory drugs, antibody mimetic proteins, nonbiological growth factor inhibitors, and inhibitors of protein kinase C have been described.

EXPERT OPINION

A number of therapies are under development for the pharmacological management of DME. Due to the rising healthcare costs associated with anti-VEGF agents, a number of alternate treatment options have been explored recently. Some of these agents have reached phase 3 in clinical trials and appear to have a promising role in the management of DME. As further research is conducted, the role of each individual agent will become more defined, alone or in combination therapy.

Intravitreal Dexamethasone Implant for Treatment of Refractory Behçet Posterior Uveitis: One-year Follow-up Results

PURPOSE

To investigate the results of dexamethasone (DEX) implant in the treatment of eyes with refractory Behçet posterior uveitis.

METHODS

A total of 17 eyes of 12 patients with active Behçet posterior uveitis were enrolled in the study. A single intravitreal injection of DEX implant was applied to each eye. Best corrected visual acuity (BCVA), central macular thickness (CMT), vitreous haze score, and intraocular pressure (IOP) were determined, at baseline and control visits of months 1, 3, 6, and 12.

RESULTS

The mean BCVA was significantly increased from baseline at each control visit (all p < 0.05). The mean CMT and vitreous haze score were significantly decreased from baseline at each control visit (all p < 0.05). Three eyes showed IOP spikes requiring topical anti-glaucomatous treatment.

CONCLUSIONS

A single injection of DEX implant was safe and effective, as an additional treatment to systemic immunomodulatory drugs, in the treatment of refractory Behçet posterior uveitis, for a 6-month period.

Delivery strategies for treatment of age-related ocular diseases: From a biological understanding to biomaterial solutions

Age-related ocular diseases, such as age-related macular degeneration (AMD), diabetic retinopathy, and glaucoma, result in life-long functional deficits and enormous global health care costs. As the worldwide population ages, vision loss has become a major concern for both economic and human health reasons. Due to recent research into biomaterials and nanotechnology major advances have been gained in the field of ocular delivery. This review provides a summary and discussion of the most recent strategies employed for the delivery of both drugs and cells to the eye to treat a variety of age-related diseases. It emphasizes the current challenges and limitations to ocular delivery and how the use of innovative materials can overcome these issues and ultimately provide treatment for age-related degeneration and regeneration of lost tissues. This review also provides critical considerations and an outlook for future studies in the field of ophthalmic delivery.

Uveitis and glaucoma: new insights in the pathogenesis and treatment

Glaucoma is a potentially blinding complication of uveitis, where intraocular inflammation, secondary corticosteroid response, and varying types and degrees of angle abnormalities contribute to its pathogenesis. Management of uveitic glaucoma remains challenging. Treatment is targeted at reducing the inflammation and lowering the intraocular pressure. Recent studies have highlighted the role of viruses, such as cytomegalovirus, herpes simplex virus, and more recently Ebola virus, in the pathogenesis of uveitic glaucoma. Antiviral therapy may be beneficial in eyes with detectable viral DNA. The success of glaucoma surgery is decreased in eyes with uveitic glaucoma, and surgical interventions are associated with a higher incidence of postoperative complications. Novel glaucoma surgical and laser treatments may improve the predictability of surgery for uveitic glaucoma, but these require further evaluation.

Intravitreal drug administration for treatment of noninfectious uveitis

Intravitreal treatment became popular with the discovery of the blood ocular barriers, which significantly limit drug penetration in systemic or topical administration. As the mainstay of treatment in noninfectious uveitis (NOIU) is still corticosteroids, triamcinolone acetonide (TA) was the first intravitreally used agent in this subset of patients. Although it was very effective in controlling inflammation and improving the inflammation related complications, TA was found to have a high rate of intraocular complications and a relatively short half-life necessitating frequent reinjections. Other systemically used therapeutic options such as methotrexate and anti-tumor necrosis factor-α agents were also tried intravitreally. Additionally anti-vascular endothelial growth factor agents that are widely used intravitreally in the management of diabetic retinopathy and age related macular degeneration have become an option to control the uveitis related complications like macular edema, retinal and choroidal neovascularizations. Advances in biotechnology led to the slow release biodegradable implant era. These implants have a longer duration of action, which may help in decreasing the number of reinjections. Today two forms of implants have been approved for use in NOIU, Retisert (0.59 mg flucinolone acetonide, surgical intervention) and Ozurdex (0.7 mg dexamethasone, office based intervention). Studies dealing with newer agents (cyclosporine, LFG31, sirolimus) in the management of chronic NOIU are on the way. The search for ideal effective, safe and biocompatible intravitreal agents in the management of NOIU has not ended yet.

Intraocular Implants for the Treatment of Autoimmune Uveitis

Uveitis is the third leading cause of blindness in developed countries. Currently, the most widely used treatment of non-infectious uveitis is corticosteroids. Posterior uveitis and macular edema can be treated with intraocular injection of corticosteroids, however, this is problematic in chronic cases because of the need for repeat injections. Another option is systemic immunosuppressive therapies that have their own undesirable side effects. These systemic therapies result in a widespread suppression of the entire immune system, leaving the patient susceptible to infection. Therefore, an effective localized treatment option is preferred. With the recent advances in bioengineering, biodegradable polymers that allow for a slow sustained-release of a medication. These advances have culminated in drug delivery implants that are food and drug administration (FDA) approved for the treatment of non-infectious uveitis. In this review, we discuss the types of ocular implants available and some of the polymers used, implants used for the treatment of non-infectious uveitis, and bioengineered alternatives that are on the horizon.

Dexamethasone intravitreal implant (Ozurdex®) for pediatric uveitis

PURPOSE

The purpose of this study was to investigate the safety and effectiveness of an intravitreally injected dexamethasone-containing implant (Ozurdex(®)) in the treatment of uveitis in children.

METHODS

The study group included ten patients (14 eyes) aged 6.5-15 years (mean age 12 years) with intermediate or posterior uveitis who were treated with the Ozurdex implant at two tertiary medical centers between 2009 and 2014, following an insufficient response to standard uveitis therapy. All were followed for at least 6 months (mean 12.2 ± 4.9 months). Clinical data before and after treatment were collected retrospectively from the medical files. Outcome measures were best corrected visual acuity, vitreous haze, and macular thickness. Ocular complications were documented.

RESULTS

Visual acuity improved in 12 eyes (86 %) and intraocular inflammation decreased in 13 eyes (93 %) from 1 week to 3 months after the first injection. Macular edema decreased in all eyes from 1 month to 3 months after the first injection. Five patients underwent repeated injections because of an increase in macular thickness at 3-6 month follow-up. Complications included cataract progression in one patient after one injection and cataract formation in two patients after two injections, and an elevation in intraocular pressure in two patients who responded well to topical treatment.

CONCLUSIONS

Both single and repeated injections of a dexamethasone-containing implant are safe and effective for the treatment of noninfectious intermediate and posterior uveitis in children. The duration of the beneficial effect may be limited. More data are required to establish the safety profile of the implant in the pediatric age group.

Uveitis

Multidisciplinary management in the diagnosis and management of patients with ocular inflammatory disease is often critical. The workup of uveitis or scleritis may reveal an underlying systemic disease. Recognition of inflammation by the primary care physician can facilitate prompt referral to a uveitis specialist and improve patient outcomes. The primary care physician can assist the ophthalmologist in monitoring for potential side effects of corticosteroids and immunosuppressive drugs, including the newer biologic agents. The ophthalmologist in turn can assist the primary care physician in recognizing that active uveitis may suggest incomplete control of preexisting conditions.

Impact on intraocular pressure after 20-mg decanted triamcinolone acetonide (kenalog) injection when using prophylactic antiglaucoma therapy

PURPOSE

To analyze intraocular pressure (IOP) response after 20-mg decanted intravitreal triamcinolone acetonide followed by early prophylactic IOP-lowering therapy.

METHODS

Overall, IOP results of 120 high-dose decanted intravitreal triamcinolone acetonide injections from 58 nonglaucomatous patients with macular edema, with antiglaucoma therapy prescribed from Week 1 regardless of baseline IOP were retrospectively reviewed.

RESULTS

In cases of consistent compliance with IOP-lowering drugs (79.2%), IOP increased by 2 mmHg at 4 months (P = 0.300) and returned to baseline at 6 months. In cases of noncompliance (20.8%), IOP increased by 7 mmHg at 1 month (P < 0.001) and returned to baseline after starting treatment. Multivariate regression analysis showed that nonvitrectomized eyes and noncompliance with IOP-lowering drugs were independent predictors of increase in IOP greater than 21 mmHg (P = 0.0098 and P = 0.0019, respectively). Nonvitrectomized eyes had a 46% greater chance to experience increase in IOP compared with vitrectomized ones. Poor compliance with IOP-lowering drugs lead to a 45% greater likelihood of experiencing increase in IOP compared with compliant patients. Multiple injections were not associated with the increased risk for increase in IOP greater than 21 mmHg (P = 0.273). Of 120 cases, 2 eyes (1.7%) developed uncontrolled IOP and required glaucoma surgery by 4 months, with good final IOP outcome.

CONCLUSION

Twenty milligram decanted intravitreal triamcinolone acetonide can be safely used to treat macular edema in nonglaucomatous patients; IOP elevation can be adequately controlled with prophylactic antiglaucoma drugs. Noncompliance with prophylactic therapy creates an early spike in IOP, and vitreous status can significantly impact increase in IOP. Compliance with IOP-lowering drugs should be stressed to patients receiving high-dose intravitreal triamcinolone acetonide especially in cases of nonvitrectomized eyes.

Sustained-release fluocinolone acetonide intravitreal insert for macular edema: clinical pharmacology and safety evaluation

INTRODUCTION

Inflammation plays a key role in the pathological processes leading to macular edema. Sustained release, low-dose intraocular corticosteroid delivery devices provide long-term anti-inflammatory therapy. Recently, a novel fluocinolone acetonide intravitreal insert (FAi, Iluvien), has been introduced with promising long-term results in the treatment of macular edema.

AREAS COVERED

An extensive review of the literature in the English language was performed to provide comprehensive information on the pharmacological properties of FAi and its safety and efficacy data from various multi-center randomized clinical trials.

EXPERT OPINION

The FAc, Retisert is a sustained-release device that is surgically implanted in the vitreous and has been approved by the US FDA for the treatment of non-infectious intermediate, posterior or panuveitis. FAi was developed after FAc and is an intravitreal corticosteroid delivery system that allows controlled release of therapeutic levels of fluocinolone acetonide (FA). Initial efficacy and safety data suggest that this delivery system maintains clinical effectiveness for up to 3 years after a single delivery of the device. This second-generation fluocinolone delivery device has shown superior safety results in clinical trials compared to the previous version of the higher dose FAc (0.59 mg). Sustained delivery preparations may help to reduce the treatment burden and its associated risks by decreasing the frequency of intravitreal injections. However, much needs to be learnt from additional clinical trials, post-marketing surveillance and results of extension studies. Concerns of intravitreal corticosteroids, such as cataract and increase in intraocular pressure, remain major challenges for this therapeutic strategy.

Development and evaluation of dexamethasone nanomicelles with potential for treating posterior uveitis after topical application

PURPOSE

This study aims at the development and preliminary evaluation of dexamethasone nanomicelles for treating posterior uveitis. Nanomicelles were formulated using polyoxyl 40 stearate (P40S) and polysorbate 80 (P80), which are approved by the FDA for ocular use.

METHODS

Dexamethasone nanomicelles were prepared and characterized for critical micellar concentration, solubility of dexamethasone, particle size, surface charge, morphology, in vitro drug release, clarity, stability, filtration efficiency, and sterility. Ocular tolerance and the tissue drug distribution of dexamethasone were assessed in rabbits after single and multiple topical administration.

RESULTS

Dexamethasone nanomicelles (0.1% w/v) were successfully developed and characterized with an optimized composition of P40S/P80=7/3 by weight. The mean diameter of blank and drug-loaded nanomicelles was 13.3±0.4 and 14.5±0.4 nm, respectively. Transmission electron microscopy images revealed the spherical structure of nanomicelles. Nanomicelles were found to be stable with respect to clarity, size and drug content at 4°C and 25°C for up to 6 months. No irritation or redness was observed in the treated eyes as compared with the untreated control rabbit eyes. Therapeutic concentrations of dexamethasone were observed in the retina and choroid after single and multiple topical application in rabbits.

CONCLUSION

In conclusion, the nanomicelles of P40S and P80 could efficiently solubilize 0.1% dexamethasone in their cores. The results also indicate that mixed nanomicelles could be utilized as a potential delivery system for delivering dexamethasone to treat the back of the eye diseases such as posterior uveitis after topical application.

Factors affecting therapeutic decisions in intermediate and posterior uveitis

PURPOSE

To evaluate whether cost, insurance prior authorization, pregnancy considerations, and subspecialty practice lead to changes in therapeutic decisions among uveitis and retina specialists in the treatment of intermediate and posterior uveitis.

DESIGN

Prospective cross-sectional study.

METHODS

A total of 934 uveitis and retina specialists across the United States were surveyed via e-mail regarding their choice in long-term therapy for 3 hypothetical patients with uveitic conditions (Behçet disease, birdshot retinochoroiditis, and intermediate uveitis). Respondents were asked to select first- and second-choice therapies and then reselect first and second choices assuming cost of all options was equal to the patient and there would be no issues with insurance prior authorization. In 1 case, they were additionally asked for their treatment preferences if the patient desired a pregnancy. Outcomes of interest were differences in therapy choice based on cost/prior authorization, pregnancy, and subspecialty practice.

RESULTS

One hundred and six respondents (11.3%) completed the survey; 44 were uveitis specialists and 62 retina specialists. Cost and prior authorization affected the therapy choices of uveitis specialists treating ocular Behçet disease (P = .008). Uveitis specialists and retina specialists differed in their first choice in therapy for each vignette when cost and prior authorization were equalized (P = .0018, P = .0049, and P = .0156). Both uveitis specialists and retina specialists changed their therapeutic choices for intermediate uveitis when pregnancy was a consideration (P = .00001 for uveitis specialists, P = .0044 for retina specialists).

CONCLUSIONS

Physician decision making in intermediate and posterior uveitis is affected by cost and prior authorization concerns, pregnancy considerations, and subspecialty practice.

Multicenter study of intravitreal dexamethasone implant in noninfectious uveitis: indications, outcomes, and reinjection frequency

PURPOSE

To identify clinical outcomes and treatment patterns of intravitreal dexamethasone implant (Ozurdex; Allergan, Inc) in noninfectious uveitis in the clinical setting.

DESIGN

Multicenter retrospective cohort study.

METHODS

Eighty-two eyes (63 patients) receiving 142 implant injections over 35 months were included. Treatment indication, uveitis diagnosis, visual acuity, intraocular pressure, vitreous haze score, central retinal thickness by optical coherence tomography, phakic status, number of injections, time to reinjection, systemic treatments, and complications data were collected. Time to visual acuity and vitreous haze score improvement as per the Standardization of Uveitis Nomenclature guidelines were also determined.

RESULTS

The probability of visual acuity improvement (≥0.3 logarithm of the minimal angle of resolution units improvement) was 39% at 1 month, 49% at 3 months, 52% at 6 months, and 58% at 12 months. Eyes with baseline vitritis (vitreous haze score ≥+0.5, n = 45) had a probability of vitreous haze score improvement (2-step decrease or change from +0.5 to 0) at 2 weeks of 41%, at 1 month 63%, at 3 months 73%, at 6 months 79%, and at 12 months 88%. In eyes that completed 12-month follow-up (n = 54), 40.7% underwent 2 injections (mean time to second injection of 6.6 ± 1.9 months) and 11.2% required ≥3 injections (mean time to third injection of 11 ± 1.5 months).

CONCLUSIONS

Dexamethasone implant use in uveitis provides favorable visual acuity and vitreous haze score outcomes but requires repeated injections, an important consideration when choosing intraocular treatment as a route to controlling uveitis.

Fast and Successful Management of Intraocular Inflammation with a Single Intravitreal Dexamethasone Implant

Purpose: To investigate the efficacy and safety of a single dexamethasone intravitreal implant (Ozurdex®, 700 µg). Methods: In this prospective noncomparative case series, 84 patients (54 females) received a dexamethasone intravitreal implant. At weeks 4, 12 and 24 after the injection, vitreous haze, macular thickness and best corrected visual acuity (BCVA) were assessed and adverse events reported. Results: Clearance of vitreous haze could be achieved after 4 weeks in 61% of all eyes (p < 0.001) and remained significant until week 24 (p < 0.001). This was paralleled by a reduction of central retinal thickness after 4 (p < 0.001), 12 (p < 0.001) and 24 weeks (p < 0.006). Significant and fast improvement of BCVA was already achieved after 4 weeks (p < 0.001) but vanished by week 24. Intraocular pressure reached ≥35 mm Hg in 3 eyes and was significantly more frequent in intermediate uveitis compared to posterior uveitis (p < 0.016). Conclusions: The dexamethasone implant is effective in controlling intraocular posterior segment inflammation and reduces central retinal thickness fast and effectively. © 2014 S. Karger AG, Basel.

A comprehensive review and update on the non-biologic treatment of adult noninfectious uveitis: part I

INTRODUCTION

Treatment of adult, noninfectious uveitis remains a challenge for ophthalmologists around the world. The disease accounts for almost 10% of preventable blindness in the US and can be idiopathic or associated with infectious and systemic disorders. Strong evidence is still emerging to indicate that pharmacologic strategies presently used in rheumatologic or autoimmune disease may be translated to the treatment of intraocular inflammation. Corticosteroid monotherapy is widely regarded as wholly inappropriate, due to the unfavorable risk/benefit profile and poor long-term outcomes. Treatment plans have shifted away from low-dose, chronic corticosteroid therapy for maintenance, towards medium- to high-dose therapy for acute inflammation, followed immediately by initiation of immunomodulatory therapy. These therapies follow the 'stepladder approach', whereby least to more aggressive therapies are trialed to induce remission of inflammation, eventually without corticosteroids of any form (topical, local and systemic).

AREAS COVERED

This two-part review gives a comprehensive overview of the existing medical treatment options for patients with adult, noninfectious uveitis, as well as important advances for the treatment of ocular inflammation. Part I covers classic immunomodulation and latest information on corticosteroid therapy.

EXPERT OPINION

The hazard of chronic corticosteroid use for the treatment of adult, noninfectious uveitis is well-documented. Corticosteroid-sparing therapies, which offer a very favorable risk-benefit profile when administered properly, should be substituted.

Intravitreal dexamethasone implant in patients with persistent macular edema of variable etiologies

PURPOSE

To examine the effect of an intravitreal dexamethasone drug delivery system (DEX-DDS) in the treatment of persistent cystoid macular edema (CME) of different etiologies.

METHODS

Thirty-seven eyes with persistent CME were treated with DEX-DDS and analyzed for changes in best-corrected visual acuity (BCVA) and optical coherence tomography. Eyes were categorized into three groups: diabetic macular edema (DME, n = 14), vein occlusion (n = 15) and uveitis (n = 7).

RESULTS

The mean follow-up was 22 ± 6.9 weeks. BCVA improved from 0.62 ± 0.38 to 0.35 ± 0.29 logMAR (p < 0.0001). Central macular thickness decreased by 184 ± 246 µm from baseline (p < 0.0001). In eyes where CME resolved and recurred, the average CME-free period was 11 weeks. The uveitis group showed faster CME resolution (2 weeks) and a longer CME-free period (20 weeks). Similar efficacy was shown for repeat DEX-DDS injections. The safety profile was good.

CONCLUSION

DEX-DDS is beneficial in the treatment of persistent CME. In cases of uveitis, CME resolution is rapid, resulting in the longest effect duration, when compared with other CME etiologies.

Treatment of diabetic macular edema with sustained-release glucocorticoids: intravitreal triamcinolone acetonide, dexamethasone implant, and fluocinolone acetonide implant

INTRODUCTION

Diabetic macular edema (DME) can be treated with intravitreal glucocorticoids, particularly triamcinolone acetonide, dexamethasone (DEX), and fluocinolone acetonide (FA).

AREAS COVERED

The pathophysiology of DME includes multiple growth factors such as VEGF and also inflammatory mediators. Glucocorticoids act on DME through multiple pathways, and current research into their efficacy, safety, and therapeutic potential when administered intravitreally is discussed.

CONCLUSION

The intravitreal route of administration minimizes systemic side effects of glucocorticoids. Furthermore, sustained-release low-dose delivery via the DEX implant or the FA implant will limit frequent intravitreal injection and possibly some cost associated with intravitreal anti-VEGF therapy. In addition, the durable action of these treatments facilitates combination therapy. Patients can receive these implants as foundational therapy, and then receive additional treatment with laser or intravitreal anti-VEGF agents as combination therapy, which may conceivably provide some synergistic benefit. While the FA implant lasts much longer than the DEX implant, potentially decreasing the visit and treatment burden on patients and their families, the FA implant appears to have a greater risk of inducing ocular hypertension and cataract. However, these modalities have not been directly compared in a clinical trial and there is insufficient evidence to draw more elaborate conclusions.

Review of Systemic Immunosuppression for Autoimmune Uveitis

The purpose of this review is to comprehensively examine the various therapeutic agents available to treat autoimmune eye disease, their indications, clinical safety and recent developments. The stepladder approach is reviewed, including corticosteroid administration of various forms, classic immunomodulators, and newer biologic response modifiers. The authors present that corticosteroid monotherapy is almost never curative and carries significant side effects, while immunomodulatory therapy, when used appropriately as way to induce steroid-free remission, carries far less risk of causing long-term complications and provides greater potential of altering the immune system to induce a durable remission.

Treatment with repeat dexamethasone implants results in long-term disease control in eyes with noninfectious uveitis

PURPOSE

To describe the long-term outcome of eyes with uveitis after repeated treatment with dexamethasone implants (Ozurdex; Allergan, Inc., Irvine, CA).

DESIGN

Retrospective, observational case series.

PARTICIPANTS

Thirty-eight eyes of 27 patients with uveitis that were treated with 61 dexamethasone implants.

METHODS

All eyes underwent dexamethasone pellet implantation. Anatomic and functional outcomes, as well as ocular complications, were noted.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA), central retinal thickness (CRT), vitreous haze score, and presence of increased intraocular pressure or cataract.

RESULTS

Average follow-up was 17.3 ± 1.8 months after the first implant (median, 13.3 months; range, 3-54.5 months; 54.65 eye-years), with 14 eyes (36.9%) receiving a single implant and 24 eyes (63.1%) receiving multiple implantations. After the first implantation, average BCVA improved significantly from 0.47 ± 0.05 logarithm of the minimum angle of resolution (logMAR) units (Snellen equivalent, 20/60) to 0.27 ± 0.07 logMAR (Snellen equivalent, 20/37; P<0.001); CRT decreased by 263 ± 44.22 μm (P = 0.003), although macular edema persisted in 50% of eyes, and the percentage of eyes achieving a vitreous haze score of 0 increased from 58% to 83% (P = 0.03). The median duration of therapeutic effect after the first injection was 6 months (range, 2-42 months), with a similar response achieved after each repeat implantation. The accumulated effect of repeat dexamethasone implants resulted in a continued improvement in BCVA (R(2) = 0.91; P<0.0001), with significant improvement and stabilization of CRT. After repeated implantations, 2 eyes had progression of posterior subcapsular opacities, although neither required surgery. There were 7 instances of increased intraocular pressure of more than 21 mmHg at a rate of 0.13 per eye-year, all of which responded to pharmacologic treatment.

CONCLUSIONS

The accumulated effect of repeat dexamethasone pellet implantations improves retinal thickness and resolves ocular inflammation, resulting in restoration of ocular function. Ocular complications were minimal, with no eyes requiring surgery for increased ocular pressure or progression of cataract.

Pediatric uveitis: new and future treatments

PURPOSE OF REVIEW

Pediatric uveitis is relatively uncommon, accounting for only 5-10% of all patients with uveitis. However, owing to high prevalence of complications and devastating outcomes, its lifetime burden can be significant.

RECENT FINDINGS

Immunomodulatory therapy has been associated with better outcomes in noninfectious pediatric uveitis. However, effective treatments are limited by medication-related complications, including multiorgan toxicities and systemic side effects.

SUMMARY

We review the current therapies available to treat pediatric uveitis, discuss novel and future therapies, and provide clinical recommendations utilizing these new agents. The consideration for treatment regimens in noninfectious pediatric uveitis is multifactorial. Understanding past, present, and future technology will aid in treatment of a complex and refractory disease.

New options for uveitis treatment

Uveitis is one of the most important causes of blindness worldwide. Its etiology and pathogenesis are complicated and have not been well understood. The treatment for uveitis is predominantly based on steroids and immunosuppressants. However, systemic side effects limit their clinical application. With the advancement of molecular biology, some intravitreal implants and biologic agents have been used for the treatment of uveitis. Additionally, novel techniques such as gene therapy and RNA interference are being studied for using as uveitis therapy. This paper reviews recent advances in uveitis treatment.