Bromfenac alone or with single intravitreal injection of bevacizumab or triamcinolone acetonide for treatment of uveitic macular edema

Non-steroidal intravitreal injection for noninfectious uveitic cystoid macular edema: Systematic review and meta-analysis

PURPOSE

To systematically review the published manuscripts on the non-steroidal intravitreal injection for treatment of noninfectious uveitic cystoid macular edema (CME).

METHODS

The PubMed, Scopus, and Web of Science, Science Direct, ProQuest, Cochrane Library, ProQuest, Embase, Clinical Key, and Springer were searched for relevant articles published until May 2022. The random-effects models were used to estimate the mean difference (MD) and 95% confidence interval (CI) for postoperative central macular thickness (CMT) and visual acuity (VA) changes. VA was transformed into the logarithm of the minimum angle of resolution (LogMAR). Meta-regression was conducted for adjusting the effects of potential confounders.

RESULTS

A total of 17 relevant studies (258 eyes) were included in this meta-analysis. A significant improvement was observed in CMT in the last follow up (350.89 ± 108.43) compared to the baseline (452.3 ± 112.67) (Log MD = 1.82, 95% CI = 1.62, 2.02; I2 = 57.7%; P = 0.002). Additionally, VA also significantly improved in the last follow up (0.56 ± 0.29) compared to the baseline (0.75 ± 0.3) (Exponential MD = 0.82, 95% CI = 0.69, 0.95; I2 = 0.0%; P = 0.98). The subgroups analyzed included ten studies on anti-vascular endothelial growth factors (VEGF), three studies on infliximab, two studies on methotrexate (MTX), and two studies on diclofenac. All subgroups showed a significant improvement in both CMT and VA at the last follow-up (P < 0.05).

CONCLUSION

Non-steroidal intravitreal injection including bevacizumab, ranibizumab, infliximab, MTX and diclofenac appears to be an effective treatment option for noninfectious uveitic CME.

SER recommendations for the treatment of uveitis

OBJECTIVE

To develop evidence-based expert-consensus recommendations for the management of non-infectious, non-neoplastic, non-demyelinating disease associated uveitis.

METHODS

Clinical research questions relevant to the objective of the document were identified, and reformulated into PICO format (patient, intervention, comparison, outcome) by a panel of experts selected based on their experience in the field. A systematic review of the available evidence was conducted, and evidence was graded according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria. Subsequently, recommendations were developed.

RESULTS

Three PICO questions were constructed referring to uveitis anterior, non-anterior and complicated with macular edema. A total of 19 recommendations were formulated, based on the evidence found and/or expert consensus.

CONCLUSIONS

Here we present the first official recommendations of the Spanish Society of Rheumatology for the treatment of non-infectious and non-demyelinating disease associated uveitis. They can be directly applied to the Spanish healthcare system as a tool for assistance and therapeutic homogenisation.

Topical Anti-Inflammatory Agents for Non-Infectious Uveitis: Current Treatment and Perspectives

Non-infectious uveitis represents a heterogenous group of immune-mediated ocular diseases, which can be associated with underlying systemic disease. While the initial choice of treatment of non-infectious uveitis depends on a number of factors such as anatomical location and degree of inflammation, topical therapies often remain the initial choice of non-invasive therapy. In this narrative review, we aim to describe the literature on non-infectious uveitis, with specific focus on the current perspective on topical anti-inflammatory therapy.

Bromfenac 0.09% for the Treatment of Macular Edema Secondary to Noninfectious Uveitis

PURPOSE

The topical nonsteroidal anti-inflammatory drug bromfenac 0.09% has a potential benefit in uveitic macular edema (UME) with a safe side effect profile. The aim of the study is to assess the efficacy of bromfenac sodium solution in the treatment of UME.

METHODS

The charts of 10 patients with macular edema due to noninfectious uveitis treated with bromfenac 0.09% were reviewed retrospectively. The main outcomes studied were the best-corrected visual acuity (BCVA) and the central retinal thickness (CRT) compared 4 months before bromfenac initiation, at the time of its initiation, and 4 months later.

RESULTS

Twelve eyes of 10 patients were included. BCVA and CRT were unchanged 4 months befoew bromfenac compared to the time of bromfenac initiation (P = 1.0 and P = 0.2, respectively). There were a significant improvement in BCVA after 4 months of bromfenac treatment (P = 0.043) and a significant decrease in CRT (P = 0.002). Subretinal fluid resolved completely in 8/9 eyes, and 4/9 eyes had a complete resolution of cystoid macular edema at 4 months.

CONCLUSION

Bromfenac may be a useful addition to the treatment of UME.

Update on the Management of Uveitic Macular Edema

Uveitic macular edema (ME) is a frequent complication in 8.3% of uveitis patients and is a leading cause of serious visual impairment in about 40% of cases. Despite the numerous available drugs for its treatment, at least a third of patients fail to achieve satisfactory improvement in visual acuity. First-line drugs are steroids administered by various routes, but drug intolerance or ineffectiveness occur frequently, requiring the addition of other groups of therapeutic drugs. Immunomodulatory and biological drugs can have positive effects on inflammation and often on the accompanying ME, but most uveitic randomized clinical trials to date have not aimed to reduce ME; hence, there is no clear scientific evidence of their effectiveness in this regard. Before starting therapy to reduce general or local immunity, infectious causes of inflammation should be ruled out. This paper discusses local and systemic drugs, including steroids, biological drugs, immunomodulators, VEGF inhibitors, and anti-infection medication.

A Review of Local Therapy for the Management of Cystoid Macular Edema in Uveitis

ABSTRACT

Uveitic macular edema is a significant cause of visual impairment in most uveitis types. Treatment options of uveitis have advanced remarkably in recent years. Up to now, corticosteroids remain the mainstay of treatment. Nonsteroidal immunomodulators, and recently the biologic agents, which can reinforce efficacy and enable discontinuation or reduction of steroids to maintenance doses, are becoming increasingly popular in the management of uveitic macular edema. Several medications can be used in intraocular delivery and more and more sustained releasing implants are being developed. This review will briefly focus on the review of local therapy for the management of cystoid macular edema in uveitis, as many of these novel approaches are currently being evaluated in clinical trials.

Use of topical bromfenac for treating ocular pain and inflammation beyond cataract surgery: a review of published studies

Topical ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat postoperative inflammation and pain following cataract surgery and for treatment and prophylaxis of pseudophakic cystoid macular edema (CME). Bromfenac is a brominated NSAID with strong in vitro anti-inflammatory potency. Like other ophthalmic NSAIDs, bromfenac is often used outside of the cataract surgery setting. This paper provides an overview of bromfenac’s preclinical ocular pharmacology and pharmacokinetics, followed by a review of 23 published clinical studies in which various marketed bromfenac formulations were used for conditions other than cataract surgery or pseudophakic CME. These include: post-refractive eye surgery; macular edema associated with diabetes, uveitis, or retinal vein occlusion; inflammation associated with age-related macular degeneration; pain related to intravitreal injections; and other ocular anterior segment and surface disorders with an inflammatory component. The published evidence reviewed supports the safety and effectiveness of bromfenac in these additional ophthalmic indications. Bromfenac was well tolerated when given alone or in combination with intravitreal anti-vascular endothelial growth factor agents, topical corticosteroids, or topical mast-cell stabilizers. The most common adverse event reported was ocular irritation. No serious adverse events (ie, corneal epithelial disorders) were reported, although the majority of studies did not systematically evaluate potential side effects. Corneal complications, such as melts reported with diclofenac and ketorolac, were not observed with bromfenac in the studies. In summary, published study data support the clinical utility of bromfenac in various ocular disorders beyond post-cataract surgery. Additional studies are warranted to further define the potential role of bromfenac ophthalmic solution in clinical practice.

Dexamethasone intravitreal implant (OZURDEX®) for macular edema secondary to noninfectious uveitis: a review of the literature

Macular edema (ME) is the leading cause of visual loss in uveitis and may persist long after ocular inflammation has been resolved. Local steroids are the first line treatment for uveitis and uveitic ME. Dexamethasone intravitreal implant (OZURDEX®; Allergan, Inc., CA, USA) has been used to treat diabetic ME and ME secondary to retinal vein occlusion. Recent studies have also demonstrated that Ozurdex may be effective treatment for patients with persistent uveitic ME. In this review, we present the results of the real word studies concerning the efficacy and safety of Ozurdex for the treatment of uveitic ME.

The Effectiveness of Pharmacological Agents for the Treatment of Uveitic Macular Edema (UMO): A Systematic Review

Purpose: To conduct a systematic review of effectiveness of pharmacological therapies for treatment of Uveitic Macular Edema (UMO). Method/Design: Comparative studies of pharmacological therapies in patients with UMO were identified in Cochrane CENTRAL/MEDLINE/EMBASE/CINAHL/trials registers (February 2017). PROSPERO registration: CRD42015019170. Results: Thirty-one studies were included. Corticosteroids were the most frequently studied (n = 20). Corticosteroids (all forms) were consistently of greater/equal efficacy to active comparators; for anti-VEGF (n = 4) improvement, best-corrected visual acuity (BCVA) and central macular thickness (CMT) were mostly less than local corticosteroid injection; for interferon (n = 1) improvement BCVA and CMT were greater than the comparator of methotrexate; for topical indomethacin (n = 1) improvement, BCVA and CMT were greater than placebo. Non-steroidal anti-inflammatory drugs, carbonic anhydrase inhibitors, and vitamin E (n = 5) were not effective for these outcomes. Conclusion: The review highlights areas where the evidence base is still lacking, and appropriately focused trials are needed to inform best treatment to tackle this sight-threatening condition.

Update in treatment of uveitic macular edema

Macular edema (ME) represents the most common cause for visual loss among uveitis patients. The management of uveitic macular edema (UME) may be challenging, due to its often recalcitrant nature. Corticosteroids remain the mainstay of treatment, through their capability of effectively controlling inflammation and the associated ME. Topical steroids may be effective in milder cases of UME, particularly in edema associated with anterior uveitis. Posterior sub-Tenon and orbital floor steroids, as well as intravitreal steroids often induce rapid regression of UME, although this may be followed by recurrence of the pathology. Intra-vitreal corticosteroid implants provide sustained release of steroids facilitating regression of ME with less frequent injections. Topical nonsteroidal anti-inflammatory drugs may provide a safe alternative or adjuvant therapy to topical steroids in mild UME, predominantly in cases with underlying anterior uveitis. Immunomodulators including methotrexate, mycophenolate mofetil, tacrolimus, azathioprine, and cyclosporine, as well as biologic agents, notably the anti-tumor necrosis factor-α monoclonal antibodies adalimumab and infliximab, may accomplish the control of inflammation and associated ME in refractory cases, or enable the tapering of steroids. Newer biotherapies have demonstrated promising outcomes and may be considered in persisting cases of UME.

Difluprednate for the Treatment of Uveitic Cystoid Macular Edema

PURPOSE

To describe clinical outcomes associated with the use of topical difluprednate in treating uveitic cystoid macular edema.

DESIGN

Retrospective, interventional case series.

METHODS

Setting: Medical record review in a tertiary care uveitis center.

PATIENT POPULATION

Fifty-eight patients (72 eyes) with uveitic cystoid macular edema (CME) treated with difluprednate 0.05% ophthalmic solution between June 2012 and May 2016.

MAIN OUTCOME MEASURES

Macular central subfield thickness (CST) determined by optical coherence tomography, improvement of CME (≥20% reduction in CST or resolution), and resolution of CME (CST ≤ 320 μm with no cysts) at 30 days after starting treatment. Outcomes were assessed up to 90 days.

RESULTS

CST on average decreased by 17% (95% CI: -33%, -7%) for eyes using only difluprednate (n = 43) and by 6% (95% CI: -17%, -2%) for eyes in patients using concomitant systemic immunosuppressive therapy (n = 29) at 30 days, a 12% difference between groups (95% CI: 2%, 21%, P = .02). Of eyes on difluprednate alone, 76% had improvement and 48% had resolution of CME. In patients using systemic therapy, 37% of eyes had improvement and 17% had resolution. Eight eyes (11%) had an intraocular pressure (IOP) > 24 mm Hg within the first 30 days. By 90 days, CME had improved in 69% of all eyes and resolved in 43% of eyes, with only 9 patients starting or increasing systemic immunosuppressive medications and 2 patients receiving periocular corticosteroid injections.

CONCLUSIONS

Difluprednate was associated with an improvement in uveitic CME and could be a reasonable first-line therapy. IOP should be closely monitored.

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.

Topical dexamethasone-cyclodextrin nanoparticle eye drops for non-infectious Uveitic macular oedema and vitritis - a pilot study

PURPOSE

To evaluate the safety and efficacy of 1.5% dexamethasone nanoparticle (DexNP) drops in eyes with non-infectious uveitic macular oedema and vitritis.

METHODS

In a prospective pilot study, DexNP drops were administered four times a day for 4 weeks followed by drops tapering over a period of another 4 weeks. Follow-up time was 12 weeks.

RESULTS

Five eyes with macular oedema and three eyes with vitritis were included in the study. Best corrected visual acuity (BCVA) significantly improved from a median of 0.2 logMAR to a median of 0.15 logMAR at 4 weeks' time (p < 0.05). Median BCVA was 0.175 logMAR and 0.2 logMAR, at week 8 and 12, respectively (p > 0.05). Macular oedema significantly improved at all time-points as compared to baseline (p < 0.05) and resolved in all eyes during follow-up. One eye had macular oedema relapse at week 12. Vitritis improved in all eyes and resolved completely in two eyes. One eye had intraocular pressure (IOP) elevation which was well controlled with topical antihypertensive treatment, and one eye had cataract progression.

CONCLUSION

This short pilot study demonstrates favourable effect of 1.5% DexNP eye drops on eyes with non-infectious uveitic macular oedema and vitritis. Further comparative long-term studies are warranted to assess this effect.

The ocular distribution of (14)C-labeled bromfenac ophthalmic solution 0.07% in a rabbit model

PURPOSE

To evaluate the ocular distribution of an advanced formulation of bromfenac ophthalmic solution. Two studies were conducted in rabbits: 1) a 12-hour parallel-group study comparing the ocular distribution of (14)C-bromfenac ophthalmic solution 0.07%, pH 7.8 with that of (14)C-bromfenac ophthalmic solution 0.09%, pH 8.3, and 2) a 24-hour study evaluating the ocular distribution of (14)C-bromfenac ophthalmic solution 0.07%, pH 7.8.

METHODS

In the 12-hour study, rabbits were randomized to receive 50 μL of (14)C-bromfenac 0.07%, pH 7.8 or 50 μL (14)C-bromfenac 0.09%, pH 8.3 in one eye, whereas, in the 24-hour, study both eyes received 50 μL of (14)C-bromfenac 0.07%, pH 7.8. Ocular tissues were collected at 1, 2, 4, 8, 12 (both studies) and 24 hours (second study only) following drug instillation, and tissue radioactivity was determined using liquid scintillation chromatography.

RESULTS

Measureable levels of bromfenac were observed in all ocular tissues, with the exception of vitreous humor, regardless of formulation. In the 12-hour study, high concentrations of (14)C-bromfenac were found in the sclera, followed by the iris/ciliary body, aqueous humor, choroid, retina, and lens. There was no significant difference between the bromfenac 0.07%, pH 7.8 and bromfenac 0.09%, pH 8.3 formulations in any (14)C-bromfenac tissue levels at any time point, with the exception of in sclera at 2 hours post-instillation (0.451 μg eq/g versus 0.302 μg eq/g, respectively, P<0.001). There was also no significant difference in the total amount of (14)C-bromfenac in the tissues evaluated following instillation of the two formulations. In the 24-hour study evaluating bromfenac 0.07%, pH 7.8 only, high concentrations of (14)C-bromfenac were found 1 hour post-instillation in the cornea (2.402 μg eq/g) and conjunctiva (1.049 μg eq/g), two tissues not evaluated in the 12-hour study. The rank order of (14)C-bromfenac levels in the other ocular tissues was the same as that observed in the 12-hour study, with measureable amounts of (14)C-bromfenac detected through 24 hours in all tissues with the exception of vitreous humor.

CONCLUSION

Bromfenac ophthalmic solution 0.07%, pH 7.8 readily penetrated ocular tissues with levels similar to those of bromfenac ophthalmic solution 0.09%, pH 8.3.