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Pessoa B, Leite J, Ferreira A, Ramalhão J, Poças J, José D, Coelho C, Figueira J, Meireles A, Beirão JM. Oct biomarkers for early prognosis in diabetic macular edema treatment with ranibizumab. Eur J Ophthalmol 2024; 34:1141-1148. [PMID: 37919940 DOI: 10.1177/11206721231210753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
BACKGROUND Diabetic macular edema is the main cause of vision loss in patients with diabetic retinopathy. In this work, we aimed to assess the role of Optical Coherence Tomography (OCT) biomarkers in patients treated with ranibizumab. METHODS A prospective study enrolling 46 eyes with DME under ranibizumab intravitreal therapy with 12 months of follow-up. The primary endpoint was to assess the association between OCT biomarkers at baseline and the type of treatment response. RESULTS Good responders, compared with partial/non responders, had lower number of inner nuclear layer cysts (INLc) at baseline, (26.5% vs 73.5%, p = 0.035) and presented, at 12 months of follow-up, lower percentage of disorganization of retinal inner layers (12.0% vs 88.0%, p = 0.001), lower disruption of outer plexiform layer (8.7% vs 91.3%, p < 0.001) and lower outer nuclear layer cysts (17.4% vs 82.6%, p = 0.013). At the end of follow-up, it was observed a higher frequency of inner nuclear layer cysts in patients with higher glycated haemoglobin (p = 0.028). CONCLUSION This study showed the value and importance of OCT parameters, such as absence of INLc, as a prognostic therapeutic response. A normalization of the macular anatomy with ranibizumab is more likely to happen in early complete responders. The association between INLc and higher glycated haemoglobin levels showed the importance of systemic metabolic control in systemic diabetic manifestations. Clinicaltrials.gov NCT04387604.
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Affiliation(s)
- Bernardete Pessoa
- Department of Ophthalmology, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Department of Ophthalmology, Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal
| | - João Leite
- Department of Ophthalmology, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - André Ferreira
- Department of Ophthalmology, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine of University of Porto, Portugal
| | - João Ramalhão
- Department of Ophthalmology, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - João Poças
- Department of Ophthalmology, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Diana José
- Department of Ophthalmology, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Constança Coelho
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - João Figueira
- Faculty of Medicine of the University of Coimbra, Coimbra, Portugal
- Association for Innovation and Biomedical Research on Light and Image, Coimbra, Portugal
| | - Angelina Meireles
- Department of Ophthalmology, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Department of Ophthalmology, Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal
| | - João Melo Beirão
- Department of Ophthalmology, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Department of Ophthalmology, Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal
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Morozova C, Humayun LL, Kasper J, Morozov A, Tabandeh H, Boyer DS, Dayani PN, Rahhal FM. Real-World Outcomes of the 0.19 mg Fluocinolone Acetonide Intravitreal Implant for Diabetic Macular Edema. JOURNAL OF VITREORETINAL DISEASES 2024; 8:394-400. [PMID: 39148560 PMCID: PMC11323504 DOI: 10.1177/24741264241247624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
Purpose: To evaluate the real-world clinical and safety outcomes of a 0.19 mg fluocinolone acetonide intravitreal implant to treat diabetic macular edema (DME). Methods: This retrospective analysis comprised patients treated with a single fluocinolone acetonide intravitreal implant for the clinical indication of ME secondary to diabetic retinopathy. Primary outcomes included changes in best-corrected visual acuity (BCVA), central subfield thickness (CST), and the frequency of DME-related treatments 12 months before and up to 36 months after fluocinolone acetonide administration. Safety outcomes were also assessed. Results: One hundred forty-eight eyes (115 patients) were followed for a mean (±SD) of 12.3 ± 4.2 months before and 29.4 ± 14.5 months after fluocinolone acetonide administration. A 0.8-letter decrease (Early Treatment Diabetic Retinopathy Study) in the mean BCVA was observed at month 24. The BCVA was 70 letters (20/40 Snellen equivalent) or more in 20.6% of eyes at baseline and in 23.7% of eyes 24 months after implant administration. The mean CST was 379.9 μm and 323.7 μm, respectively. The CST was 300 μm or less in 58.7% of eyes at month 24 (P < .001). The mean frequency of intravitreal antivascular endothelial growth factor injections or laser photocoagulation decreased from 4.9 to 1.5 per year after fluocinolone acetonide administration (P < .001). Implant migration to the anterior chamber occurred in 3 eyes, 2 of which were vitrectomized and later required removal. Conclusions: The 0.19 mg fluocinolone acetonide intravitreal implant provided long-term stabilization of VA and macular anatomy in patients with DME, despite a significant reduction in treatment frequency.
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Affiliation(s)
| | - Lucas L. Humayun
- Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA
| | | | - Andy Morozov
- Retina Vitreous Associates Medical Group, Los Angeles, CA, USA
| | | | - David S. Boyer
- Retina Vitreous Associates Medical Group, Los Angeles, CA, USA
| | - Pouya N. Dayani
- Retina Vitreous Associates Medical Group, Los Angeles, CA, USA
- Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA
| | - Firas M. Rahhal
- Retina Vitreous Associates Medical Group, Los Angeles, CA, USA
- Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA
- David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
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Boscia F, Veritti D, Iaculli C, Lattanzio R, Freda S, Piergentili B, Varano M. Management of treatment-naïve diabetic macular edema patients: Review of real-world clinical data. Eur J Ophthalmol 2024:11206721241237069. [PMID: 38462923 DOI: 10.1177/11206721241237069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
The high prevalence of Diabetic macular edema (DME) is a real global health problem. Its complex pathophysiology involves different pathways. Over the last decade, the introduction of intravitreal treatments has dramatically changed the management and prognosis of DME. Among the different treatment options, inhibitors of vascular endothelial growth factor (anti-VEGF) and intravitreal steroids implants represent the first-line therapy of DME. We conducted a review of electronic databases to compile the available evidence about the clinical management of DME in a clinical setting, with a special focus on treatment-naïve patients. Anti-VEGF therapies represent a valuable option for treating DME patients. However, many patients do not respond properly to this treatment and, due to its administration regimen, many patients receive suboptimal treatment in real life. Current evidence demonstrated that in patients with DME, DEX-i improved significantly both anatomic and visual outcomes. Besides eyes with insufficient anti-VEGF respond or recalcitrant DME cases, DEX-i can be effectively and safely used in treatment-naïve DME patients as first line therapy. DEX-i may be considered first line therapy in different clinical scenarios, such as DME eyes with a greater inflammatory component, patients with cardiovascular events, vitrectomized eyes, or those requiring cataract surgery. In conclusion, there are still many points for improvement pending in the clinical management of the patient with DME. Since DME treatment must follow a patient-tailored approach, selecting the best therapeutic approach for each patient requires a good understanding of the pathophysiology of DME.
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Affiliation(s)
- Francesco Boscia
- Department of Translational Medicine and Neurosciences (DiBraiN), University of Bari, Bari, Italy
| | - Daniele Veritti
- Department of Medicine - Ophthalmology, University of Udine, Udine, Italy
| | - Cristiana Iaculli
- Department of Ophthalmology, Policlinico Riuniti Di Foggia, University of Foggia, 71122, Foggia, Italy
| | - Rosangela Lattanzio
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Simona Freda
- AbbVie S.r.l., SR 148 Pontina, 04011, Campoverde, LT
| | | | - Monica Varano
- Ophthalmology Department, IRCCS - Fondazione Bietti, Rome, Italy
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Salvetat ML, Pellegrini F, Spadea L, Salati C, Musa M, Gagliano C, Zeppieri M. The Treatment of Diabetic Retinal Edema with Intravitreal Steroids: How and When. J Clin Med 2024; 13:1327. [PMID: 38592149 PMCID: PMC10932454 DOI: 10.3390/jcm13051327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/13/2024] [Accepted: 02/21/2024] [Indexed: 04/10/2024] Open
Abstract
Diabetic macular edema (DME) is a common complication of diabetes mellitus and a leading cause of visual impairment worldwide. It is defined as the diabetes-related accumulation of fluid, proteins, and lipids, with retinal thickening, within the macular area. DME affects a significant proportion of individuals with diabetes, with the prevalence increasing with disease duration and severity. It is estimated that approximately 25-30% of diabetic patients will develop DME during their lifetime. Poor glycemic control, hypertension, hyperlipidemia, diabetes duration, and genetic predisposition are recognized as risk factors for the development and progression of DME. Although the exact pathophysiology is still not completely understood, it has been demonstrated that chronic hyperglycemia triggers a cascade of biochemical processes, including increased oxidative stress, inflammation, activation of vascular endothelial growth factor (VEGF), cellular dysfunction, and apoptosis, with breakdown of the blood-retinal barriers and fluid accumulation within the macular area. Early diagnosis and appropriate management of DME are crucial for improving visual outcomes. Although the control of systemic risk factors still remains the most important strategy in DME treatment, intravitreal pharmacotherapy with anti-VEGF molecules or steroids is currently considered the first-line approach in DME patients, whereas macular laser photocoagulation and pars plana vitrectomy may be useful in selected cases. Available intravitreal steroids, including triamcinolone acetonide injections and dexamethasone and fluocinolone acetonide implants, exert their therapeutic effect by reducing inflammation, inhibiting VEGF expression, stabilizing the blood-retinal barrier and thus reducing vascular permeability. They have been demonstrated to be effective in reducing macular edema and improving visual outcomes in DME patients but are associated with a high risk of intraocular pressure elevation and cataract development, so their use requires an accurate patient selection. This manuscript aims to provide a comprehensive overview of the pathology, epidemiology, risk factors, physiopathology, clinical features, treatment mechanisms of actions, treatment options, prognosis, and ongoing clinical studies related to the treatment of DME, with particular consideration of intravitreal steroids therapy.
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Affiliation(s)
- Maria Letizia Salvetat
- Department of Ophthalmology, Azienda Sanitaria Friuli Occidentale, 33170 Pordenone, Italy; (M.L.S.)
| | - Francesco Pellegrini
- Department of Ophthalmology, Azienda Sanitaria Friuli Occidentale, 33170 Pordenone, Italy; (M.L.S.)
| | - Leopoldo Spadea
- Eye Clinic, Policlinico Umberto I, “Sapienza” University of Rome, 00142 Rome, Italy
| | - Carlo Salati
- Department of Ophthalmology, University Hospital of Udine, 33100 Udine, Italy
| | - Mutali Musa
- Department of Optometry, University of Benin, Benin City 300238, Edo State, Nigeria
| | - Caterina Gagliano
- Faculty of Medicine and Surgery, University of Enna “Kore”, Piazza dell’Università, 94100 Enna, Italy
- Eye Clinic, Catania University, San Marco Hospital, Viale Carlo Azeglio Ciampi, 95121 Catania, Italy
| | - Marco Zeppieri
- Department of Ophthalmology, University Hospital of Udine, 33100 Udine, Italy
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Capone L, Airaghi P, Aragona P, Castellino N, Cicinelli MV, Ciucci F, Coppola M, Gaetano CD, Lattanzio R, Lorusso M, Maceroni M, Malvasi ME, Marco L, Marraffa M, Martini G, Mastropasqua R, Minnella AM, Nikolopulou E, Ortisi E, Pacella E, Papa V, Pennesi C, Reibaldi M, Rizzo S, Toto L, Trombetta L, Bandello F. Real-world experience with fluocinolone acetonide intravitreal implant in patients with diabetic macular edema. Eur J Ophthalmol 2024:11206721241235266. [PMID: 38396370 DOI: 10.1177/11206721241235266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
OBJECTIVES to evaluate long-term effectiveness and safety of fluocinolone acetonide (FAc) implant used as second-line treatment in patients with persistent diabetic macular edema (DME). METHODS retrospective data chart review of 241 pseudophakic eyes of 178 patients treated with FAc from July 2017 to December 2021 in 10 medical retinal units in Italy. The primary endpoint was the change of best-corrected visual acuity (BCVA) and central macular thickness (CMT) at 2 years. A Student's paired t-test was used. Additional therapies for DME and intraocular pressure (IOP)-related events were also evaluated. RESULTS efficacy of FAc was assessed in a subset of 111 eyes with at least 24 months of follow-up. Mean BCVA increased at 2 years by 5.1 ETDRS letters (95%CI = 2.6-7.5; p < 0.001) while mean CMT decreased by 189 µm (95% CI 151-227; p < 0.001). Thirty-eight of these eyes (34.2%) needed additional intravitreal treatments, mainly anti-VEGF. Safety was evaluated on the entire cohort of 241 eyes treated with FAc. Overall, 66 eyes (27.4%) required emergent IOP-lowering medications (typically within the first-year post FAc) while 14 eyes (5.8%) underwent trabeculectomy, mostly during the second year of follow-up. CONCLUSION FAc implant provides a substantial long-term functional and anatomical benefit when used as second-line treatment in eyes with DME. IOP rise can be adequately managed with topical agents although some eyes may require IOP-lowering surgery.
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Affiliation(s)
- Luigi Capone
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute-School of Medicine, Vita-Salute San Raffaele University Milan, Milano, Italy
| | - Pietro Airaghi
- Ophthalmology Unit, IRCCS S. Gerardo dei Tintori, Monza, Italy
| | - Pasquale Aragona
- Department of Biomedical Sciences, Ophthalmology Clinic, University of Messina, Messina, Italy
| | | | - Maria Vittoria Cicinelli
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute-School of Medicine, Vita-Salute San Raffaele University Milan, Milano, Italy
| | - Francesco Ciucci
- Ophthalmology Unit, San Pietro Fatebenefratelli Hospital, Rome, Italy
| | - Michele Coppola
- Ophthalmology Unit, IRCCS S. Gerardo dei Tintori, Monza, Italy
| | | | - Rosangela Lattanzio
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute-School of Medicine, Vita-Salute San Raffaele University Milan, Milano, Italy
| | - Massimo Lorusso
- Department of Ophthalmology, Ente Ecclesiastico F. Miulli Hospital, Bari, Italy
| | - Martina Maceroni
- Institute of Ophthalmology, Università Cattolica del Sacro Cuore-Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
| | | | | | - Michele Marraffa
- Department of Ophthalmology, ULSS 9 Scaligera, Orlandi Hospital, Bussolengo, Verona, Italy
| | - Gaia Martini
- Department of Ophthalmology, ULSS 9 Scaligera, Orlandi Hospital, Bussolengo, Verona, Italy
| | - Rodolfo Mastropasqua
- Ophthalmology Clinic, Department of Medicine and Science of Ageing, University G. D'Annunzio Chieti-Pescara, Chieti, Italy
| | - Angelo Maria Minnella
- Institute of Ophthalmology, Università Cattolica del Sacro Cuore-Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
| | - Eleni Nikolopulou
- Department of Ophthalmology, Ente Ecclesiastico F. Miulli Hospital, Bari, Italy
| | - Elina Ortisi
- Department of Ophthalmology, University of Catania, Catania, Italy
| | - Elena Pacella
- Department of Sense Organs, Sapienza University of Rome, Rome, Italy
| | | | - Claudio Pennesi
- Ophthalmology Unit, IRCCS S. Gerardo dei Tintori, Monza, Italy
| | - Michele Reibaldi
- Department of Surgical Sciences, Eye Clinic Section, University of Turin, Turin, Italy
| | - Stanislao Rizzo
- Institute of Ophthalmology, Università Cattolica del Sacro Cuore-Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
| | - Lisa Toto
- Ophthalmology Clinic, Department of Medicine and Science of Ageing, University G. D'Annunzio Chieti-Pescara, Chieti, Italy
| | - Luigi Trombetta
- Department of Biomedical Sciences, Ophthalmology Clinic, University of Messina, Messina, Italy
| | - Francesco Bandello
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute-School of Medicine, Vita-Salute San Raffaele University Milan, Milano, Italy
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Eichenbaum D, Gonzalez VH, Roth D, Fortun J, Radcliffe NM, Cutino A, Kasper J, Coughlin BA, Arevalo JF. Ocular, Visual, and Anatomical Outcomes in Eyes Requiring Incisional Intraocular Pressure-Lowering Surgery Following the 0.19-mg Fluocinolone Acetonide Intravitreal Implant. Ophthalmic Surg Lasers Imaging Retina 2024; 55:22-23. [PMID: 38189802 DOI: 10.3928/23258160-20231109-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND AND OBJECTIVE To assess ocular, visual, and anatomical outcomes following the 0.19-mg fluocinolone acetonide (FAc) intravitreal implant (ILUVIEN®) and incisional intraocular pressure (IOP)-lowering surgery in diabetic macular edema. PATIENTS AND METHODS From a 36-month, phase 4, open-label, observational study (N = 202 eyes, 159 patients), 8 eyes (7 patients) required IOP-lowering surgery post-FAc; eyes were segregated by FAc-induced (n = 5, 2.47%) versus neovascular glaucoma (NVG)-related (n = 3, 1.49%) IOP elevations and assessed for IOP, best corrected visual acuity (BCVA), central subfield thickness (CST), and cup-to-disc ratio (c/d). RESULTS Changes at 36 months were +5.4 letters BCVA (P > 0.05) and +0.09 c/d (P = 0.0217); IOP and CST were unchanged. FAc-induced-group eyes required fewer IOP-lowering medications than NVG-group eyes (2.0 versus 4.0; P < 0.01) but for longer duration (15.2 versus 2.6 months; P < 0.001). CONCLUSIONS Post-FAc IOP-lowering surgery, regardless of cause, largely did not affect the outcomes measured; these procedures, then, may not meaningfully threaten positive outcomes. [Ophthalmic Surg Lasers Imaging Retina 2024;55:22-29.].
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Roth DB, Eichenbaum D, Malik D, Radcliffe NM, Cutino A, Small KW. The 0.19-mg Fluocinolone Acetonide Intravitreal Implant for Diabetic Macular Edema: Intraocular Pressure-Related Effects over 36 Months. Ophthalmol Retina 2024; 8:49-54. [PMID: 37586482 DOI: 10.1016/j.oret.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/27/2023] [Accepted: 08/07/2023] [Indexed: 08/18/2023]
Abstract
PURPOSE To evaluate effects of the 0.19-mg fluocinolone acetonide (FAc) intravitreal implant (ILUVIEN) on intraocular pressure (IOP) in patients with diabetic macular edema (DME). DESIGN Secondary analysis of a 36-month, phase IV, nonrandomized, open-label, observational study. PARTICIPANTS The study included 202 eyes from 159 patients who received the 0.19-mg FAc implant after a successful prior steroid challenge per the United States label indication. METHODS Study eyes were assessed for IOP values, incidence of IOP elevations, and best-corrected visual acuity (BCVA) for up to 36 months post-FAc implant. RESULTS Mean IOP was stable over 36 months post-FAc; IOP change from baseline peaked at 2.12 mmHg at 9 months, then declined to baseline levels. At 36 months, eyes had a 32.5% cumulative probability of an IOP event > 25 mmHg and a 15.6% probability of an IOP event > 30 mmHg (Kaplan-Meier). The probability of requiring IOP-lowering medication at any time by month 36 was 38.3%. A total of 78% of eyes did not have IOP elevations > 25 mmHg if similar values were seen with the previous steroid challenge. Although 7.4% of eyes had an IOP > 30 mmHg during a scheduled study visit, most exceeded this threshold only once (60%). Regardless of IOP status, mean BCVA remained stable. CONCLUSIONS Over 36 months, the 0.19-mg FAc implant was associated with relatively stable IOPs in patients with DME, and there was no significant impact of IOP elevations identified regarding their effects on long-term visual outcomes. The probability that a prior corticosteroid challenge will not predict an IOP elevation > 25 mmHg over 36 months post-FAc is 22%; therefore, routine IOP monitoring should be scheduled. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Daniel B Roth
- Department of Ophthalmology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.
| | | | - Deepika Malik
- Ophthalmic Consultants of Long Island, New York, New York; Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Kent W Small
- Macula and Retina Institute, Glendale, California and Molecular Insight Research Foundation, Los Angeles and Glendale, California
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Ruiz-Moreno JM, Adán A, Lafuente M, Asencio Durán M, Arias Barquet L, García Layana A, Araiz Iribarren J. Effectiveness and safety of fluocinolone acetonide intravitreal implant in diabetic macular edema patients considered insufficiently responsive to available therapies (REACT): a prospective, non-randomized, and multicenter study. Int Ophthalmol 2023; 43:4639-4649. [PMID: 37697082 PMCID: PMC10724319 DOI: 10.1007/s10792-023-02864-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/20/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVE To assess the effectiveness and safety of the intravitreal fluocinolone-acetonide implant (FAc-i) in patients with chronic diabetic macular edema who did not sufficiently respond to other available therapies. METHODS This was a multicenter, prospective, non-randomized, and phase-IV observational study conducted on patients with recurrent-DME who were insufficient responders to currently available therapies (REACT-Study). The primary end-point was the mean change in best-corrected-visual-acuity from baseline to month-24 values. RESULTS Thirty-one eyes from 31 patients were included in the study. Mean age was 68.0 ± 7.7 years, and 10 (32.3%) were women. Study patients had received 5.3 ± 7.3 previous DME treatments before starting the study. In the overall study sample, BCVA improved from 56.1 ± 12.3 letters at baseline to 62.4 ± 17.0 letters at month-24 (p = 0.0510). The eyes with a baseline BCVA < 70 ETDRS letters had a significant improvement in BCVA from 53.2 ± 10.2 letters at baseline to 61.5 ± 17.9 letters at month-24 (p = 0.0165). In the overall study population, central-subfoveal-thickness (CST) was significantly reduced from 474.0 ± 135.1 µm at baseline to 333.4 ± 135.6 at month-24 (p < 0.0001). Similarly, macular-volume (MV) was significantly reduced from 10.7 ± 2.7 mm3 at baseline to 9.6 ± 2.9 mm3 (p = 0.0027) at month-24. Among the 31 study eyes, 19 (61.3%) required an additional treatment for DME. Throughout the study, 9 (29.0%) eyes required ocular hypotensive medication for controlling their intraocular-pressure and 5 (16.1%) eyes underwent cataract surgery. CONCLUSIONS In DME eyes who did not sufficiently respond to previous therapies, the FAc-i was associated with an improvement in visual and anatomic outcomes. There were no unexpected adverse-events. TRIAL REGISTRATION NUMBER EudraCT identifier: 2016-001680-37.
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Affiliation(s)
- José María Ruiz-Moreno
- Puerta de Hierro-Majadahonda University Hospital, Joaquín Rodrigo, 2, 28222, Majadahonda, Madrid, Spain.
- Department of Ophthalmology, Castilla La Mancha University, Albacete, Spain.
- , Miranza, Spain.
| | | | - María Lafuente
- Virgen de la Arraixaca University Hospital, Murcia, Spain
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Dot C, Poli M, Aptel F, Labbe A, Kodjikian L, Baillif S, Bodaghi B, Denis P. Ocular hypertension and intravitreal steroids injections, update in 2023. French guidelines of the French glaucoma society and the French ophthalmology society. J Fr Ophtalmol 2023; 46:e249-e256. [PMID: 37302867 DOI: 10.1016/j.jfo.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 06/13/2023]
Abstract
These guidelines are a consensus of French glaucoma and retina experts on the management of ocular hypertension (OHT) observed in a third of the cases after corticosteroid implant intravitreal injections. They update the first guidelines published in 2017. Two implants are marketed in France: the dexamethasone implant (DEXi) and the fluocinolone acetonide implant (FAci). It is essential to assess the pressure status before injecting a patient with a corticosteroid implant. A molecule-specific monitoring of the intraocular pressure is needed throughout the follow-up and at the time of reinjections. Real-life studies have allowed optimizing the management algorithm by significantly increasing the safety of these implants. Corticosteroid testing with DEXi should be performed before switching to FAci to optimize pressure tolerance of FAci. Beyond topical hypotensive treatments, selective laser trabeculoplasty may be considered in the therapeutic arsenal for the management of steroid-induced OHT and subsequent injections.
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Affiliation(s)
- C Dot
- HIA Desgenettes/CHU E. Herriot, Lyon, France.
| | - M Poli
- Pôle vision, Ecully, France
| | | | - A Labbe
- CHNO des XV-XX, Paris, France
| | | | | | - B Bodaghi
- CHU de Pitié Salpétrière, Paris, France
| | - P Denis
- CHU de Croix-Rousse, Lyon, France
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Dot C, Poli M, Aptel F, Labbe A, Kodjikian L, Baillif S, Bodaghi B, Denis P. [Intraocular pressure elevation and intravitreal steroid implant injection: State of the art in 2023. Recommendations of the French Glaucoma Society and French Ophthalmology Society [French version]]. J Fr Ophtalmol 2023; 46:803-810. [PMID: 37481449 DOI: 10.1016/j.jfo.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 07/24/2023]
Abstract
These are the recommendations of French glaucoma and retina experts on the management of ocular hypertension (OHT) observed in 1/3 of cases after intravitreal steroid implant injections. They are an update to the recommendations first published in 2017. There are two implants on the French market: the dexamethasone (DEXi) and fluocinolone acetonide (FAci) implants. It is important to know the pressure status before injecting a patient with a steroid implant. Monitoring of the IOP adapted to the specific drug is necessary throughout follow-up and reinjections. Real-life studies have made it possible to optimize the management algorithm by significantly increasing the safety of use of these implants. A corticosteroid test with DEXi is necessary before switching to FAci to optimize the pressure tolerance of the latter. In addition to topical glaucoma medications, SLT laser can be considered in the therapeutic arsenal for the management of steroid-induced OHT and future injections.
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Affiliation(s)
- C Dot
- HIA Desgenettes, CHU É.-Herriot, Lyon, France.
| | - M Poli
- Pôle vision, Écully, France
| | | | - A Labbe
- CHNO des XV-XX, Paris, France
| | | | | | - B Bodaghi
- CHU Pitié-Salpêtrière, Paris, France
| | - P Denis
- CHU Croix-Rousse, Lyon, France
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Gonzalez VH, Luo C, Almeida DRP, Cutino A, Coughlin B, Kasper J, Kiernan DF. BETTER BASELINE VISION LEADS TO BETTER OUTCOMES AFTER THE 0.19-mg FLUOCINOLONE ACETONIDE INTRAVITREAL IMPLANT IN DIABETIC MACULAR EDEMA. Retina 2023; 43:1301-1307. [PMID: 37130434 DOI: 10.1097/iae.0000000000003827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
PURPOSE Analysis of a 3-year, Phase 4, open-label, observational study evaluating the association of baseline best-corrected visual acuity (BCVA) with visual, treatment burden, and retinal thickness variability (RTV) outcomes and intraocular pressure (IOP)-related events after the 0.19-mg fluocinolone acetonide (FAc) intravitreal implant. METHODS Data from patients with diabetic macular edema (DME) who did not have a clinically significant rise in IOP after previous corticosteroid treatment (N = 202 eyes from 159 patients) were segregated by baseline BCVA of ≥20/40 or <20/40 and analyzed for BCVA, number of yearly supplemental DME treatments, RTV, and incidence of IOP-related events. RESULTS At 36 months post-FAc, eyes with better baseline BCVA (≥20/40) maintained baseline BCVA, whereas vision in eyes with worse baseline BCVA (<20/40) increased by approximately 7 letters to 61.34 letters (Snellen equivalent approximately 20/60; P < 0.05). Treatment burden and RTV decreased post-FAc regardless of baseline BCVA. Eyes with better baseline BCVA (≥20/40) had numerically fewer IOP-related events post-FAc versus eyes with worse baseline BCVA (<20/40), including a lower incidence of incisional IOP-lowering surgery. CONCLUSION The 0.19-mg FAc implant improved RTV and treatment burden regardless of baseline BCVA. Better baseline BCVA (≥20/40) was associated with long-term BCVA maintenance. Although eyes with worse baseline BCVA (<20/40) experienced significantly improved BCVA, it never rose to the level of those with better baseline BCVA. These data indicate that early, effective intervention in DME, before significant vision loss occurs, is key to maintaining visual outcomes.
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Affiliation(s)
| | - Caesar Luo
- Bay Area Retina Associates, Walnut Creek, California
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Merrill PT, Holekamp N, Roth D, Kasper J, Grigorian R. The 0.19-mg Fluocinolone Acetonide Intravitreal Implant Reduces Treatment Burden in Diabetic Macular Edema. Am J Ophthalmol 2023; 248:16-23. [PMID: 36223849 DOI: 10.1016/j.ajo.2022.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 09/12/2022] [Accepted: 09/17/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE To assess treatment burden in patients with diabetic macular edema (DME) after the 0.19-mg fluocinolone acetonide (FAc) intravitreal implant (ILUVIEN). DESIGN Prospective and retrospective analyses of a 36-month, phase 4, open-label, observational study. METHODS Setting: Multicenter. PATIENT POPULATION Included patients had DME and previously received corticosteroid treatment without a clinically significant rise in intraocular pressure (IOP) (N = 202 eyes in 159 patients). Patients were not randomized. OBSERVATION PROCEDURES Prospective, observational treatment burden data were analyzed for their relationship to safety and functional efficacy outcomes across 36 months. MAIN OUTCOME MEASURES Outcomes included the mean number of yearly treatments, supplemental-free probability over time, best-corrected visual acuity, and monitoring of IOP-related events. RESULTS Over 36 months, the mean number of yearly treatments decreased from 3.5 before FAc to 1.7 after FAc; at 36 months, 68.3% of patients required 0 to 2 treatments per year. After FAc, the percentage of eyes requiring supplemental therapy decreased vs before FAc (P < .0001 for each). Through 36 months, 25% of FAc-treated eyes did not require supplemental treatment. At 36 months, mean best-corrected visual acuity increased by 4.5 letters vs a decline of 6.4 letters in the 36 months before FAc. IOP elevations >25 mm Hg occurred in 18.2% of eyes that did not receive supplemental treatment after FAc vs 27.2% of eyes that received supplemental treatments, which included additional intraocular steroids. CONCLUSIONS Over 36 months, the FAc implant is associated with improved visual outcomes and better disease control as measured by a significant reduction in yearly treatment burden in patients with DME.
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Affiliation(s)
- Pauline T Merrill
- From the Department of Ophthalmology, Rush University, Chicago, Illinois (P.T.M.).
| | | | - Daniel Roth
- Department of Ophthalmology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey (D.R.)
| | | | - Ruben Grigorian
- Northeast Louisiana Retina Eye Center, West Monroe, Louisiana (R.G.), USA
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El Rayes EN, Leila M. Visual function and retinal morphological changes after single suprachoroidal delivery of fluocinolone acetonide (Iluvien®) implant in eyes with chronic diabetic macular edema. Int J Retina Vitreous 2023; 9:20. [PMID: 36991493 PMCID: PMC10053734 DOI: 10.1186/s40942-023-00458-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND To assess the efficacy and safety of supra-choroidal (SC) Iluvien in the management of chronic diabetic macular edema (DME). METHODS A retrospective interventional non-comparative consecutive case series including patients with chronic DME who received an SC Iluvien implant. All patients had persistent central macular thickness (CMT) ≥ 300µ after previous treatment with anti-vascular endothelial growth factor (VEGF) agents or laser photocoagulation. The main outcome measures were improvement of best-corrected visual acuity (BCVA), reduction of CMT, and detection of ocular hypertension/glaucoma or cataract formation. Friedman's two-way ANOVA was used to analyze BCVA, intraocular pressure (IOP), and DME across different time points. P-value = 0.05. RESULTS The study included 12 eyes of 12 patients. Six patients (50%) were males. The median age was 58 years (range 52-76 years). The median duration of DM was 13 years (range 8-20 years). Ten patients (83.3%) were phakic and 2 patients (17%) were pseudophakic. The median pre-operative BCVA was 0.07 (range 0.05-0.8). The median pre-operative CMT was 544µ (range 354-745µ). The median pre-operative IOP was 17 mmHg (range 14-21mmHg). The median follow-up period was 12 months, range (12-42). Post-operatively, the median final BCVA was 0.15 (range 0.03-1), p 0.02, the median CMT was 404µ (range 213-747), p 0.4 and the median IOP was 19.5 mmHg (range 15-22), p 1. Two out of 10 phakic patients (20%) developed nuclear sclerosis grade I by 12 months. Six patients (50%) developed a transient rise in IOP < 10 mmHg from the baseline that resolved within 3 weeks with antiglaucoma drops. CONCLUSION SC Iluvien is potentially effective in improving visual function, reducing macular edema, and reducing the incidence of steroid-induced cataracts and glaucoma.
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Affiliation(s)
- Ehab N El Rayes
- Retina department, Research Institute of Ophthalmology (RIO), 35 Salah Salem St., (El Borg), Suite 702, El-Obour bldg., Cairo, 11371, Egypt.
| | - Mahmoud Leila
- Retina department, Research Institute of Ophthalmology (RIO), 35 Salah Salem St., (El Borg), Suite 702, El-Obour bldg., Cairo, 11371, Egypt
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Kolomeyer AM, Eichenbaum DA, Kiernan DF, Suñer IJ, Hariprasad SM. The 0.19-mg Fluocinolone Acetonide Implant for the Treatment of Diabetic Macular Edema: An Expert Consensus. Ophthalmic Surg Lasers Imaging Retina 2023; 54:166-173. [PMID: 36944067 DOI: 10.3928/23258160-20230215-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND AND OBJECTIVE To better understand the level of agreement among retina specialists on the role of inflammation in diabetic retinopathy (DR) and diabetic macular edema (DME), and the use of 0.19-mg fluocinolone acetonide (FAc) implant in DME treatment, a consensus survey was drafted and disseminated to retina specialists across the United States. MATERIALS AND METHODS Using the modified Delphi method, a list of 12 consensus statements were generated by the coauthors based on short-answer responses to an initial survey. In total, 56 retina specialists completed the entire consensus survey. Except for two multiple-choice questions, there were 10 consensus statements that used a modified Likert scale to indicate their level of agreement to the statement: Agree = 3, Mostly Agree = 2, Mostly Disagree = 1, Disagree = 0. Percentage agreement and 95% confidence intervals (CIs) were calculated, and a consensus threshold was set at > 80% agreement for each statement. RESULTS Seven of 10 consensus statements using the modified Likert scale reached consensus, including those on the role of inflammation in pathophysiology of DR/DME, injection burden and patient adherence, and efficacy and safety of the FAc implant. The remaining three statements displayed high agreement with average scores > 80%, but the 95% CIs were below threshold. These included the impact of the FAc implant on DR progression, FAc as baseline therapy for DME, and the effectiveness of the steroid challenge to mitigate intraocular pressure risk after FAc use. Two multiple-choice questions focused on clinical situations in which corticosteroids would be used as baseline therapy for DME (pseudophakic eye [73%], recent stroke/myocardial infarction [66%], and pregnancy/breastfeeding [66%]) and which delivery route satisfies the steroid challenge for the FAc implant (intravitreal [100%], sub-tenon/periocular [73%], and topical [57%]). CONCLUSIONS Physicians highly agreed on the role of inflammation in pathophysiology of DR/DME, injection burden and patient adherence, and efficacy and safety of the FAc implant. However, full consensus was not found on the impact of the FAc implant on DR progression, FAc as baseline therapy for DME, and the effectiveness of the steroid challenge to mitigate intraocular pressure risk after FAc use. [Ophthalmic Surg Lasers Imaging Retina. 2023;54(3):166-173.].
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Cicinelli MV, Rabiolo A, Capone L, Di Biase C, Lattanzio R, Bandello F. Factors associated with the response to fluocinolone acetonide 0.19 mg in diabetic macular oedema evaluated as the area-under-the-curve. Eye (Lond) 2023; 37:242-248. [PMID: 35094025 PMCID: PMC9873740 DOI: 10.1038/s41433-021-01921-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES The area-under-the-curve (AUC) measures the average drug effect over time. We investigated the impact of baseline clinical and optical coherence tomography (OCT) factors on the response to fluocinolone acetonide (FAc) 0.19 mg implant in patients with diabetic macular oedema (DMO) as the AUC over 36 months. METHODS Retrospective study of DMO eyes undergoing FAc with follow-up from 12 to 36 months. The AUC of the best-corrected visual acuity (BCVA) and the central macular thickness (CMT) were calculated with the trapezoidal rule. Demographic and clinical data at the time of FAc administration were collected, and associations with BCVA and CMT changes were investigated with linear mixed models. RESULTS Eighty-nine eyes of 63 patients were enroled; median follow-up was 26 months. Mean±standard deviation (SD) AUCBCVA and AUCCMT after FAc injection were 0.24 ± 0.17 LogMAR/month and 179.6 ± 54.3 μm/month, respectively. Worse baseline BCVA (β = 0.30 LogMAR/month, p < 0.001), higher AUCCMT after FAc administration (β = 0.08 LogMAR/month, p < 0.001), diagnosis of type 1 diabetes (β = -0.04 LogMAR/month, p = 0.04), and absent ELM/EZ layers (β = 0.06 LogMAR/month, p = 0.01) were associated with worse vision over time (higher AUCBCVA). Eyes with higher CMT at baseline (β = 9.61 μm/month, p < 0.001) and those with tractional DMO (β = 24.7 μm/month, p = 0.01) had worse anatomic outcomes (higher AUCCMT). The need for additional treatments after FAc was also associated with higher AUCCMT (β = 33.9 μm/month, p = 0.001). CONCLUSION Baseline better visual acuity, lower macular thickness, and photoreceptors' layers integrity are associated with better functional response to FAc in DMO. Eyes with severe DMO at the time of implant or tractional oedema have worse anatomic response. These findings might guide clinicians in a more informed decisional algorithm in treating DMO.
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Affiliation(s)
- Maria Vittoria Cicinelli
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Alessandro Rabiolo
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Ophthalmology, Gloucestershire Hospitals NHS, Cheltenham, UK
| | - Luigi Capone
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Di Biase
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Rosangela Lattanzio
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Bandello
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Mathis T, Kodjikian L. Do new drugs for diabetic macular edema offer a safer option? Expert Opin Drug Saf 2022; 21:1453-1457. [PMID: 36576309 DOI: 10.1080/14740338.2022.2160442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The last decade has witnessed important advances in retinal drug discovery, administered intravitreally, allowing high intraocular concentration and low systemic passage. However, local and systemic adverse events have been described and should be discussed before proposing treatment. In diabetes mellitus specifically, the choice of molecule and treatment regimen should limit the therapeutic burden, avoiding the need for frequent ophthalmological appointments, in patients receiving multi-disciplinary care. AREAS COVERED We aim to review and discuss the risk/benefit ratio of the main intravitreal therapies currently proposed for diabetic macular edema (DME), and how these treatments could be tailored to each individual patient. EXPERT OPINION Anti-VEGF injections and steroid implants are currently the two therapeutic options proposed in cases of DME. New molecules in these two classes have recently been approved and are currently being studied under phase IV observations to establish their efficacy and tolerance. The preferred therapeutic option is determined based on the ocular condition and the patient profile. As new treatments are developed, new adverse events will also enter into consideration, and retinal physicians must therefore be able to call on a range of therapeutic options and question the risk/benefit ratio of each of them before proposing a treatment.
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Affiliation(s)
- Thibaud Mathis
- Department of Ophthalmology, Croix-Rousse University Hospital, Hospices Civils de Lyon, 69004 Lyon, France.,UMR5510 MATEIS, CNRS, INSA Lyon, Université Lyon 1, 69100 Villeurbanne, France
| | - Laurent Kodjikian
- Department of Ophthalmology, Croix-Rousse University Hospital, Hospices Civils de Lyon, 69004 Lyon, France.,UMR5510 MATEIS, CNRS, INSA Lyon, Université Lyon 1, 69100 Villeurbanne, France
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Baillif S, Staccini P, Weber M, Delyfer MN, Le Mer Y, Gualino V, Collot L, Merite PY, Creuzot-Garcher C, Kodjikian L, Massin P. Management of Patients with Diabetic Macular Edema Switched from Dexamethasone Intravitreal Implant to Fluocinolone Acetonide Intravitreal Implant. Pharmaceutics 2022; 14:pharmaceutics14112391. [PMID: 36365209 PMCID: PMC9693281 DOI: 10.3390/pharmaceutics14112391] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/13/2022] [Accepted: 10/20/2022] [Indexed: 11/09/2022] Open
Abstract
To assess anatomical and functional outcomes after switching from dexamethasone implant (DEXi) to fluocinolone acetonide implant (FAci) in 113 diabetic macular edema eyes, a multicentric retrospective observational study was conducted. Seventy-five eyes (73.5%) were switched 1−8 weeks after their last DEXi. The mean best-corrected visual acuity improved to 59.8 letters at month 4 and remained stable during the follow-up. The mean central macular thickness (CMT) significantly decreased during the follow-up, with a minimum of 320.9 μm at month 3. The baseline CMT was higher in eyes that received the last DEXi >8 weeks versus <8 weeks before the first FAci (p < 0.021). After FAci injection, additional treatments were needed in 37 (32.7%) eyes. A longer diabetes duration (p = 0.009), a longer time between the last DEXi and the first FAci (p = 0.035), and a high baseline CMT (p = 0.003) were risk factors for additional treatments. The mean intraocular pressure was <19 mmHg at all timepoints, with no difference between eyes receiving the last DEXi ≤8 weeks or >8 weeks before the switch. Switching from DEXi to FAci in DME is effective and safe. A short time between the last DEXi and the first FAci reduced CMT fluctuations and the need for early additional treatments.
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Affiliation(s)
- Stéphanie Baillif
- Department of Ophthalmology, Hôpital Pasteur 2, Centre Hospitalier Universitaire de Nice, Université Côte d’Azur, 30 Voie Romaine, 06000 Nice, France
- INSERM DR2 U1065, C3M, 151 Avenue Saint-Antoine de Ginestière, 06024 Nice, France
- Correspondence:
| | - Pascal Staccini
- Research Unit RETINES (Risks, Epidemiology, Territories, Information and Education for Health), Université Côte d’Azur, Faculté de Médecine, 28 Avenue de Valombrose, CEDEX 2, 06107 Nice, France
| | - Michel Weber
- Department of Ophthalmology, Centre Hospitalier Universitaire de Nantes, 44000 Nantes, France
| | - Marie-Noëlle Delyfer
- Department of Ophthalmology, Bordeaux University Hospital, 33000 Bordeaux, France
- INSERM, BPH, UMR1219, Bordeaux University, 33000 Bordeaux, France
| | - Yannick Le Mer
- Department of Ophthalmology, A. de Rothschild Ophthalmologic Foundation, 75019 Paris, France
| | - Vincent Gualino
- Clinique Honoré Cave, Department of Ophthalmology, 82000 Montauban, France
- Ophthalmology Department, AP-HP, Hôpital Lariboisière, Université de Paris, 75014 Paris, France
| | - Laurence Collot
- Centre Médico-Chirurgical de Chaumont, 17 Avenue des États-Unis, 52000 Chaumont, France
| | - Pierre-Yves Merite
- Centre D’ophtalmologie, 44 Avenue de Lattre de Tassigny, 13090 Aix-en-Provence, France
| | | | - Laurent Kodjikian
- Department of Ophthalmology, Croix-Rousse University Hospital, Hospices Civils de Lyon, 69002 Lyon, France
- UMR-CNRS 5510 Matéis, University of Lyon, 69622 Villeurbanne, France
| | - Pascale Massin
- Ophthalmic Centre of Breteuil, 14 avenue de Breteuil, 75007 Paris, France
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Elbarky A. Effectiveness and tolerability of the fluocinolone acetonide implant in patients with diabetic macular edema in the UAE: 24 and 36-month outcomes. Eur J Ophthalmol 2022; 33:11206721221128671. [PMID: 36168254 DOI: 10.1177/11206721221128671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The effectiveness and safety of the fluocinolone acetonide (FAc) implant was evaluated at Month 24 and, in some sustained for up to 36 months, in patients with diabetic macular edema (DME) and a pseudophakic lens treated in the UAE following prior anti-vascular endothelial growth factor and dexamethasone (DEX) implant. METHODS This was a retrospective, observational audit study conducted between September 2017-September 2020 in which 22 patients were treated with the FAc implant and outcomes monitored for up to 36 months. Effectiveness outcomes were: best-corrected visual acuity (BVCA) and central macular thickness (CMT). Safety was assessed by monitoring intraocular pressure (IOP). All outcomes were measured at Months 1, 3, 6, 12, 24, and 36. RESULTS Significant improvements in mean BCVA were observed versus baseline from Month 1, which were maintained up to Month 24 (P < 0.0001 versus baseline). In all five patients completing 36 months follow-up, the improvements in BVCA were maintained through to Month 36 P < 0.005 versus baseline. Similarly, mean CMT improved versus baseline at Month 1 through to Month 24 (P < 0.0001 versus baseline), with significant improvements also noted in the 5 patients completing 36 months follow-up (P < 0.005 versus baseline). An IOP rise to 32 mmHg was observed in one eye, but returned to normal values at next measure. Five eyes required IOP lowering drops and one required IOP-lowering surgical intervention. CONCLUSION The FAc intravitreal implant is effective for 24 months, and sustained for 36 months, in a UAE population previously treated with a DEX implant, with tolerability profile in-line with previous reports.
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Affiliation(s)
- Ahmed Elbarky
- 37532Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
- Ophthalmology, Benha Faculty of Medicine, Benha University, Benha, Egypt
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O'Brien Laramy MN, Nagapudi K. Long-acting ocular drug delivery technologies with clinical precedent. Expert Opin Drug Deliv 2022; 19:1285-1301. [PMID: 35912841 DOI: 10.1080/17425247.2022.2108397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Ocular long-acting injectables and implants (LAIIs) deliver drug at a controlled release rate over weeks to years. A reduced dose frequency eases the treatment burden on patients, minimizes the potential for treatment-related adverse effects, and improves treatment adherence and persistence. AREAS COVERED This review provides a comprehensive landscape of ocular LAII drug delivery technologies with clinical precedent, including eight commercial products and 27 clinical programs. Analysis of this landscape, and the specific technologies with the greatest precedent, provides instructive lessons for researchers interested in this space and insights into the direction of the field. EXPERT OPINION Further technological advancement is required to create biodegradable LAIIs with extended release durations and LAIIs that are compatible with a broader array of therapeutic modalities. In the future, ocular LAII innovations can be applied to diseases with limited treatment options, prophylactic treatment at earlier stages of disease, and cost-effective treatment of ocular diseases in global health settings.
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Affiliation(s)
- Matthew N O'Brien Laramy
- Small Molecule Pharmaceutical Sciences, Genentech Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Karthik Nagapudi
- Small Molecule Pharmaceutical Sciences, Genentech Inc., 1 DNA Way, South San Francisco, CA 94080, USA
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Lebrize S, Arnould L, Bourredjem A, Busch C, Rehak M, Massin P, Barbosa-Breda J, Lupidi M, Mariotti C, Hamza M, Grise-Dulac A, Gabrielle PH, Baillif S, Creuzot-Garcher C. Intraocular Pressure Changes After Intravitreal Fluocinolone Acetonide Implant: Results from Four European Countries. Ophthalmol Ther 2022; 11:1217-1229. [PMID: 35426623 PMCID: PMC9114211 DOI: 10.1007/s40123-022-00504-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/21/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The 0.19 mg fluocinolone acetonide (FAc) intravitreal implant delivers a continuous intravitreal corticosteroid dose for the treatment of refractory diabetic macular oedema (DMO). The aim of this study was to assess the impact of an FAc intravitreal implant on intraocular pressure (IOP). METHODS We retrospectively collected anonymised data on the patients' characteristics, DMO treatment, and IOP and IOP-lowering treatments before and after the FAc intravitreal implant between September 2013 and March 2020 in several European centres. RESULTS A total of 221 eyes from 179 patients were included. The mean follow-up duration was 13.4 (± 12.5, range 2.4-33.5) months. Overall, 194 eyes (88.2%) had received an intravitreal dexamethasone injection before the FAc intravitreal implant. For 25 eyes (11.3%) there was a history of glaucoma, and 52 eyes (23.5%) had previous IOP-lowering treatment. Mean IOP before injection was 14.7 (3.4) mmHg and increased to 16.9 (3.7) mmHg 12 months after injection (P < 0.0001). During follow-up, 55 eyes (24.9%) required the addition or initiation of topical IOP-lowering medication, only one patient (0.5%) had laser trabeculoplasty and one patient (0.5%) a minimally invasive glaucoma surgery, and no patient required incisional IOP-lowering surgery. CONCLUSION The FAc intravitreal implant led to substantial IOP elevation. This elevation was monitored most of the time with addition or initiation of topical IOP-lowering medication.
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Affiliation(s)
- Sarah Lebrize
- Department of Ophthalmology, Dijon University Hospital, 14 Rue Gaffarel, 21000, Dijon, France
| | - Louis Arnould
- Department of Ophthalmology, Dijon University Hospital, 14 Rue Gaffarel, 21000, Dijon, France
| | | | - Catharina Busch
- Department of Ophthalmology, University Hospital, Leipzig, Germany
| | - Matus Rehak
- Department of Ophthalmology, University Hospital, Leipzig, Germany
| | | | - Joao Barbosa-Breda
- Department of Ophthalmology, São João University Hospital, Porto, Portugal
- Cardiovascular R&D Center, Faculty of Medicine of the University of Porto, Porto, Portugal
- Research Group Ophthalmology, Department of Neurosciences, KULeuven, Leuven, Belgium
| | - Marco Lupidi
- Eye Clinic, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Cesare Mariotti
- Eye Clinic, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Mahmoud Hamza
- Department of Ophthalmology, Le Raincy-Montfermeil Hospital, Montfermeil, France
| | - Alice Grise-Dulac
- Department of Ophthalmology, Fondation A. de Rothschild, Paris, France
| | - Pierre-Henry Gabrielle
- Department of Ophthalmology, Dijon University Hospital, 14 Rue Gaffarel, 21000, Dijon, France
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Extended real-world experience with the ILUVIEN® (fluocinolone acetonide) implant in the United Kingdom: 3-year results from the Medisoft® audit study. Eye (Lond) 2022; 36:1012-1018. [PMID: 33972705 PMCID: PMC8107780 DOI: 10.1038/s41433-021-01542-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/24/2021] [Accepted: 04/06/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND This study aimed to assess the long-term effectiveness of the 0.2 μg/day fluocinolone acetonide (FAc) implant over ≥3 years for patients with diabetic macular oedema. METHODS A retrospective audit of pseudo-anonymised data from patients with chronic diabetic macular oedema (cDMO) and treated with the FAc implant across 14 UK clinical sites. Safety and clinical effectiveness were measured. RESULTS Two-hundred and fifty-six eyes had ≥3 years of follow-up (mean 4.28 years), during which a mean of 1.14 FAc implants were used per eye. Mean best-recorded visual acuity (BRVA) increased from 52.6 to 56.7 letters at month 3 and remained stable thereafter; this trend was also seen in pseudophakic eyes. The proportion of patients attaining a BRVA ≥6/12 increased from 17% at baseline to 27% 1 month after FAc implant and remained stable above 30% from month 12 onwards. Eyes with no prior history of intraocular pressure (IOP)-related events required significantly less treatment-emergent IOP-lowering medication than those with a prior history of IOP events (17.9% vs. 50.0% of eyes; p < 0.001). The incidence of an IOP increase of ≥10 mmHg, use of IOP-lowering medication, laser trabeculoplasty and IOP-lowering surgery was 28.9%, 29.7%, 0.8% and 2.7%, respectively, for the whole cohort. There were significant reductions in mean central foveal thickness and macular volume (p < 0.001). CONCLUSIONS The FAc implant was well tolerated, with predictable and manageable IOP-related events while delivering a continuous microdose of corticosteroid to eyes with cDMO, providing prolonged vision preservation and a reduced number of treatments.
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22
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Mathis T, Papegaey M, Ricard C, Rezkallah A, Matonti F, Sudhalkar A, Vartin C, Dot C, Kodjikian L. Efficacy and Safety of Intravitreal Fluocinolone Acetonide Implant for Chronic Diabetic Macular Edema Previously Treated in Real-Life Practice: The REALFAc Study. Pharmaceutics 2022; 14:pharmaceutics14040723. [PMID: 35456557 PMCID: PMC9025285 DOI: 10.3390/pharmaceutics14040723] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/15/2022] [Accepted: 03/24/2022] [Indexed: 12/10/2022] Open
Abstract
Diabetic macular edema (DME) is the main cause of visual impairment in diabetic patients and a chronic disease requiring long-term treatments. The fluocinolone acetonide (FAc) implant has recently been approved to treat DME in patients considered insufficiently responsive to available therapies. This study evaluates the functional and anatomical efficacy of the FAc implant in real-life practice. A total of 62 eyes with chronic DME were included and followed for a mean of 13.9 (+7.5) months. Previous treatment included at least anti-vascular endothelial growth factor (VEGF) in 83.9% of eyes, dexamethasone implant (DEX-I) in 100% of eyes, vitrectomy in 29.0% of eyes, and laser photocoagulation (either panretinal or focal photocoagulation) in 75.8% of eyes. The mean baseline best corrected visual acuity (BCVA) was 64.0 (+/−17.2) letters (median: 67.5 letters) with a mean DME duration of 60.3 (+/−30.6) months. The maximum BCVA gain occurred at 21 months with a mean gain of 5.0 (+/−12.7) letters. A total of 50.0% of eyes gained ≥5 letters during follow-up. Patients with lower BCVA at baseline had the lowest final BCVA (p < 0.001) but the highest BCVA gain (p = 0.02). The best overall improvement in mean central macular thickness (CMT) occurred at 18 months (p < 0.0001). The improvement in BCVA was inversely associated with the decrease in CMT and showed a decrease when CMT increased (DME recurrence). According to the history of vitrectomy, we did not find any significant difference in mean final BCVA (p = 0.1) and mean BCVA gain (p = 0.2) between eyes previously vitrectomized or not. A total of 23 eyes (37.1%) required additional treatment for DME, and 17.7% required an IOP-lowering procedure during follow-up. In conclusion, this real-life observational study demonstrated the efficacy and safety of the FAc implant in patients with chronic DME already treated with other available therapies.
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Affiliation(s)
- Thibaud Mathis
- Service d’Ophtalmologie, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, 69004 Lyon, France; (M.P.); (A.R.); (C.V.)
- UMR-CNRS 5510 Matéis, Université Lyon 1, 69100 Villeurbanne, France
- Correspondence: (T.M.); (L.K.)
| | - Maxence Papegaey
- Service d’Ophtalmologie, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, 69004 Lyon, France; (M.P.); (A.R.); (C.V.)
| | | | - Amina Rezkallah
- Service d’Ophtalmologie, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, 69004 Lyon, France; (M.P.); (A.R.); (C.V.)
| | - Frédéric Matonti
- Centre Monticelli Paradis, 13008 Marseille, France;
- Institut Neuroscience Timone, Univeristé Aix Marseille, CNRS, INT, 13005 Marseille, France
- Groupe Almaviva Santé, Clinique Juge, 13008 Marseille, France
| | | | - Cristina Vartin
- Service d’Ophtalmologie, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, 69004 Lyon, France; (M.P.); (A.R.); (C.V.)
| | - Corinne Dot
- Service d’Ophtalmologie, Hôpital Militaire Desgenettes, 69003 Lyon, France;
- Hôpital D’instruction des Armées, Val-de-Grâce, 75005 Paris, France
| | - Laurent Kodjikian
- Service d’Ophtalmologie, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, 69004 Lyon, France; (M.P.); (A.R.); (C.V.)
- UMR-CNRS 5510 Matéis, Université Lyon 1, 69100 Villeurbanne, France
- Correspondence: (T.M.); (L.K.)
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23
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Kodjikian L, Bandello F, de Smet M, Dot C, Zarranz-Ventura J, Loewenstein A, Sudhalkar A, Bilgic A, Cunha-Vaz J, Dirven W, Behar-Cohen F, Mathis T. Fluocinolone acetonide implant in diabetic macular edema: International experts' panel consensus guidelines and treatment algorithm. Eur J Ophthalmol 2022; 32:1890-1899. [PMID: 35139688 DOI: 10.1177/11206721221080288] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Center-involving diabetic macular edema (DME) is a leading cause of vision impairment in working-age adults. While its management is particularly challenging in a poorly compliant population, continuous innovation and the advent of new molecules have improved its outcome. The control of glycemia and of systemic aggravating factors remain essential to slow down progression of disease complications including DME. The indications for macular laser photocoagulation has progressively been phased out as a standard of care and replaced by local intraocular anti-VEGFs biologics and glucocorticoids (GCs). Intravitreal GCs in controlled-release drug delivery systems have allowed to reduce injection frequency and treatment burden. The non biodegradable Fluocinolone Acetonide (FAc) implant allows a long-lasting stabilization of both functional and anatomic improvements. However, adequate patient selection and monitoring through regular follow-up are essential for optimal results. Based on their experience and the latest literature, the aim of the present review is to provide international expert panel consensus on the place of the FAc implant in the treatment algorithm of DME, as well as its safety profile and how to manage it.
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Affiliation(s)
- Laurent Kodjikian
- Department of Ophthalmology, 386696Croix-Rousse University Hospital, Hospices Civils de Lyon, University Lyon 1, Lyon, France.,UMR-CNRS 5510 Matéis, University Lyon 1, Villeurbane, France
| | - Francesco Bandello
- Department of Ophthalmology, Vita-Salute San Raffaele University Milan, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marc de Smet
- Department of Ophthalmology, 4496University of Leiden, Leiden, the Netherlands.,MicroInvasive Ocular Surgery Center, Lausanne, Switzerland
| | - Corrine Dot
- Department of Ophthalmology, Desgenettes Military Hospital, Lyon, France.,French Military Health Service Academy, Val de Grâce, Paris, France
| | - Javier Zarranz-Ventura
- Institut Clínic d'Oftalmologia (ICOF), 16493Hospital Clínic de Barcelona, Barcelona, Spain.,Institut de Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Anat Loewenstein
- Department of Ophthalmology, Tel Aviv Medical Center, Tel Aviv, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Alper Bilgic
- Sudhalkar Eye Hospital and Retina Centre, Baroda, India
| | - José Cunha-Vaz
- Faculty of Medicine, AIBILI - Association for Innovation and Biomedical Research on Light and Image, University of Coimbra, Coimbra, Portugal
| | - Werner Dirven
- Department of Ophthalmology, AZ Turnhout Hospital, Turnhout, Belgium
| | - Francine Behar-Cohen
- Department of Ophthalmology, 26935Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, AP-HP, Université de Paris, Paris, France.,Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Inserm, From physiopathology of retinal diseases to clinical advances, Paris, France
| | - Thibaud Mathis
- Department of Ophthalmology, 386696Croix-Rousse University Hospital, Hospices Civils de Lyon, University Lyon 1, Lyon, France.,UMR-CNRS 5510 Matéis, University Lyon 1, Villeurbane, France
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24
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Goñi FJ, Barton K, Dias JA, Diestelhorst M, Garcia-Feijoo J, Hommer A, Kodjikian L, Nicolò M. Intravitreal Corticosteroid Implantation in Diabetic Macular Edema: Updated European Consensus Guidance on Monitoring and Managing Intraocular Pressure. Ophthalmol Ther 2022; 11:15-34. [PMID: 34993882 PMCID: PMC8770785 DOI: 10.1007/s40123-021-00427-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/08/2021] [Indexed: 12/13/2022] Open
Abstract
Intravitreal therapy for diabetic macular edema can, in susceptible patients, increase intraocular pressure (IOP). As uncontrolled IOP can potentially be sight threatening, monitoring is an essential component of patient management. It can be challenging for retina specialists to ensure that monitoring is rigorous enough to detect and resolve any potential problems at the earliest opportunity without it also being overburdensome for patients who have the lowest risk of developing an IOP rise. We have developed dynamic algorithms that: (1) tailor the frequency and extent of monitoring according to individual susceptibility and current IOP and (2) assist retina specialists in deciding when they should consider a referral to a glaucoma specialist. One algorithm is for patients with a relatively low susceptibility to developing an IOP rise (those whose baseline IOP is < 22 mmHg and who do not have a history of IOP events). Depending on their first post-implantation IOP check, the algorithm classifies them as: low risk if IOP remains < 22 mmHg; medium risk if IOP is 22-25 mmHg and any rise from baseline is < 10 mmHg; or high risk if IOP is > 25 mmHg or any rise from baseline is ≥ 10 mmHg. Thereafter, the algorithm guides on the frequency and extent of monitoring required in each of these groups and, if IOP rises or falls during treatment, patients may move up or down the risk groups accordingly. A different algorithm is provided for patients who are more susceptible to developing an IOP rise (those with a baseline IOP of ≥ 22 mmHg or a prior history of an IOP event). These patients need monitoring more closely so this algorithm has only medium- or high-risk classifications. These algorithms update the previous monitoring guidance by Goñi et al. (Goñi et al. in Ophthalmol Ther 5:47-61, 2016).
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Affiliation(s)
- Francisco J. Goñi
- Ophthalmology Department, Mollet Hospital, Ronda dels Pinetons 6, 08100 Mollet del Vallès, Barcelona, Spain
| | - Keith Barton
- Glaucoma Service, Moorfields Eye Hospital, London, UK
| | | | | | - Julián Garcia-Feijoo
- Ophthalmology Department, Complutense University, San Carlos Hospital, Madrid, Spain
| | | | - Laurent Kodjikian
- Department of Ophthalmology, Croix-Rousse University Hospital, Lyon, France
- UMR-CNRS 5510 Matéis, University Lyon 1, Villeurbane, France
| | - Massimo Nicolò
- University Eye Clinic, DINOGMI, Ospedale Policlinico San Martino IRCCS, Genoa, Italy
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25
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Singer MA, Sheth V, Mansour SE, Coughlin B, Gonzalez VH. Three-year safety and efficacy of the 0.19-mg fluocinolone acetonide intravitreal implant for diabetic macular edema: the PALADIN study. Ophthalmology 2022; 129:605-613. [DOI: 10.1016/j.ophtha.2022.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/07/2022] [Accepted: 01/12/2022] [Indexed: 12/30/2022] Open
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26
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Enhanced topical corticosteroids delivery to the eye: A trade-off in strategy choice. J Control Release 2021; 339:91-113. [PMID: 34560157 DOI: 10.1016/j.jconrel.2021.09.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/16/2021] [Accepted: 09/18/2021] [Indexed: 12/19/2022]
Abstract
Topical corticosteroids are the primary treatment of ocular inflammation caused by surgery, injury, or other conditions. Drug pre-corneal residence time, drug water solubility, and drug corneal permeability coefficient are the major factors that determine the ocular drug bioavailability after topical administration. Although growing research successfully enhanced local delivery of corticosteroids utilizing various strategies, rational and dynamic approaches to strategy selection are still lacking. Within this review, an overview of the various strategies as well as their performance in retention, solubility, and permeability coefficient of corticosteroids are provided. On this basis, the tradeoff of strategy selection is discussed, which may shed light on the rational choice and application of ophthalmic delivery enhancement strategies.
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27
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Arrigo A, Aragona E, Capone L, Di Biase C, Lattanzio R, Bandello F. Intraocular Pressure Changes Are Predictive of Ocular Hypertension Onset After Fluocinolone Acetonide Implant: Significant Cutoffs and the Role of Previous DEX Implant. Front Med (Lausanne) 2021; 8:725349. [PMID: 34490313 PMCID: PMC8416620 DOI: 10.3389/fmed.2021.725349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 07/30/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Fluocinolone acetonide (FAc) implant represents a long-term strategy for the management of diabetic macular edema (DME). Because of the 3-year duration, the careful monitoring of the intraocular pressure (IOP) is necessary. The main aim of the study was to provide quantitative IOP cutoffs associated with the onset of IOP increases. Methods: The study was retrospectively conducted with 2-year of follow-up. We separately considered eyes with good IOP control (Group 1), eyes requiring IOP-lowering medications (Group 2) and eyes undergoing IOP-lowering surgery (Group 3). The statistical analysis assessed Delta% IOP changes over the 2-year follow-up. ROC analysis was performed to detect significant cutoffs associated with Group 2 and Group 3. IOP changes occurring after a previously administered dexamethasone (DEX) implant were also evaluated. Results: We included 48 eyes (48 patients), stratified as follows: Group 1 (25/48; 52%), Group 2 (19/48; 40%) and Group 3 (4/48; 8%). ROC analysis performed on IOP values detected 2-months later DEX implant showed a mean Delta IOP increase>24% significantly associated with IOP-lowering medications after FAc implant, whereas a mean Delta IOP increase>35% was significantly associated with IOP-lowering surgery after FAc implant. With respect to IOP changes occurred after FAc implant, our ROC analysis showed a mean Delta IOP increase>8% significantly associated with IOP-lowering medications, whereas a mean Delta IOP increase>15% was significantly associated with IOP-lowering surgery. DEX-related IOP changes showed 52% sensitivity and 100% specificity of FAc-related IOP increases. Conclusions: IOP changes provides clinically relevant cutoffs associated with the onset of FAc-related IOP increases.
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Affiliation(s)
- Alessandro Arrigo
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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28
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Mushtaq B, Bhatnagar A, Palmer H. Real-World Outcomes in Diabetic Macular Edema for the 0.2 µg/Day Fluocinolone Acetonide Implant: Case Series from the Midlands, UK. Clin Ophthalmol 2021; 15:2935-2943. [PMID: 34262254 PMCID: PMC8274235 DOI: 10.2147/opth.s283561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 02/09/2021] [Indexed: 11/23/2022] Open
Abstract
Aim To investigate real-world effectiveness and safety of fluocinolone acetonide (FAc) implant over three years of treatment in eyes with diabetic macular edema (DME) in a population with large ethnic diversity. Methods This audit of three large treatment centres in the UK involved retrospective collection of outcome data (best recorded visual acuity [BRVA] by Early Treatment Diabetic Retinopathy Study [ETDRS] letters, central retinal thickness [CRT], intraocular pressure [IOP] and use of supplementary treatments) from patients with DME treated with 0.2 µg/day FAc intravitreal implant with three-year follow-up expected. Results A total of 96 eyes were included. Ninety (93.8%) eyes had received prior intravitreal treatment. Increases in mean BRVA were significant at one, two and three years (p<0.05). Overall, 78.1% of eyes gained or maintained BRVA; just over 50% gained ≥5 letters, representing a functional response. Eleven (11.6%) patients lost ≥10 letters by year three. Decreases in central retinal thickness (CRT) nearing 200 µm in the first year were sustained to three years (p < 0.0001). Patients with baseline VA ≥60 letters maintained their BRVA throughout follow-up, while significant improvements at month 12 (p<0.0001) in those with baseline BRVA <60 letters were maintained through month 36 (p < 0.005). Fifty-three (55.2%) eyes required no supplementary therapy during follow-up. Increases in IOP to ≥30 mmHg and ≥25 mmHg were seen in 12 (12.5%) and 23 (24.0%) eyes, respectively. Conclusion This study confirms the effectiveness and tolerability of FAc implant up to 36 months in a real-world setting, highlighting the importance of early treatment for sustaining functional vision for patients.
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Affiliation(s)
- Bushra Mushtaq
- Birmingham Midland Eye Centre, City Hospital SWBH NHS Trust, Birmingham, UK
| | - Ajay Bhatnagar
- Department of Ophthalmology, New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Helen Palmer
- Ophthalmology Department, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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29
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Riemann CD, Eaton AM, Cutino A. Reduction in Retinal Thickness Fluctuations After Treatment With Fluocinolone Acetonide Implant for DME: A Post-Hoc Analysis of the USER Study. Ophthalmic Surg Lasers Imaging Retina 2021; 51:298-306. [PMID: 32511735 DOI: 10.3928/23258160-20200501-09] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/02/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Assess fluocinolone acetonide implant (FAc) effects on diabetic macular edema (DME) retinal thickness fluctuations. PATIENTS AND METHODS A post-hoc chart review of the real-world USER study analyzed patients receiving 0.2 μg/day FAc implant. The percentage of eyes with central subfield thickness (CST) of 300 µm or less were compared pre- and post-FAc implant; mean retinal thickness amplitude (RTA), retinal thickness standard deviation (RTSD), and two case studies were analyzed. RESULTS One hundred thirty patients (mean age: 69.6 years) presented; CST was available for 120 of 160 treated eyes. Mean RTA decreased significantly post-FAc implant (P < .001) regardless of baseline visual acuity (VA). Correlations with last-observed VA (R2) were: RTA, 0.1197; retinal thickness standard deviation (RTSD), 0.1526; and area under the CST-time curve (AUC CST), 0.0981. After FAc implant, the percentage of eyes with CST of 300 μm or less was significantly greater versus baseline (P < .05). CONCLUSIONS Retinal thickness fluctuations significantly declined after FAc and correlated with improvement in VA. Both RTSD and RTA measures correlated more closely to last observed VA than AUC CST itself. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:298-306.].
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30
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Fallico M, Maugeri A, Lotery A, Longo A, Bonfiglio V, Russo A, Avitabile T, Furino C, Cennamo G, Barchitta M, Agodi A, Marolo P, Ventre L, Caselgrandi P, Reibaldi M. Fluocinolone acetonide vitreous insert for chronic diabetic macular oedema: a systematic review with meta-analysis of real-world experience. Sci Rep 2021; 11:4800. [PMID: 33637841 PMCID: PMC7910468 DOI: 10.1038/s41598-021-84362-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 02/04/2021] [Indexed: 02/06/2023] Open
Abstract
We conducted a meta-analysis of real-world studies on the 0.19 mg Fluocinolone Acetonide (FAc) intravitreal implant for chronic diabetic macular oedema (DMO), comparing these findings with the Fluocinolone Acetonide for Diabetic Macular Edema (FAME) study. The primary outcome was mean change of best corrected visual acuity (BCVA) at 24 months. Secondary outcomes were 36-month mean BCVA, mean central macular thickness (CMT) change, rates of eyes receiving supplementary intravitreal therapy, cataract surgery, intraocular pressure (IOP)-lowering drops and glaucoma surgery. Mean differences (MDs) with 95% confidence intervals (CIs) were calculated. Nine real-world studies were included. The FAc implant yielded a significantly improved BCVA at 24 and 36 months (24-month MD = 4.52; 95% CI 2.56–6.48; 36-month MD = 8.10; 95% CI 6.34–9.86). These findings were comparable with the FAME study. The FAc implant yielded significantly reduced 24- and 36-month CMT. Pooled proportions of cataract surgery, IOP-lowering drops and glaucoma surgery were 39%, 27% and 3%, respectively, all lower than the FAME study. Pooled estimate of supplementary intravitreal therapy was 39%, higher than the 15.2% of the FAME study. This meta-analysis of real-world studies confirms favorable visual and anatomical outcomes following FAc insert for chronic DMO. In real-life studies more than one third of patients received supplementary intravitreal therapy, an issue that needs to be further explored.
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Affiliation(s)
- Matteo Fallico
- Department of Ophthalmology, University of Catania, Via S. Sofia 78, 95123, Catania, Italy.
| | - Andrea Maugeri
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Via S. Sofia 87, 95123, Catania, Italy.
| | - Andrew Lotery
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Antonio Longo
- Department of Ophthalmology, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - Vincenza Bonfiglio
- Department of Experimental Biomedicine and Clinical Neuroscience, Ophthalmology Section, University of Palermo, 90127, Palermo, Italy
| | - Andrea Russo
- Department of Ophthalmology, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - Teresio Avitabile
- Department of Ophthalmology, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - Claudio Furino
- Department of Ophthalmology, University of Bari, 70124, Bari, Italy
| | - Gilda Cennamo
- Department of Public Health, University of Naples Federico II, 80131, Naples, Italy
| | - Martina Barchitta
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Via S. Sofia 87, 95123, Catania, Italy
| | - Antonella Agodi
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Via S. Sofia 87, 95123, Catania, Italy
| | - Paola Marolo
- Department of Surgical Sciences, Eye Clinic Section, University of Turin, 10122, Turin, Italy
| | - Luca Ventre
- Department of Surgical Sciences, Eye Clinic Section, University of Turin, 10122, Turin, Italy
| | - Paolo Caselgrandi
- Department of Surgical Sciences, Eye Clinic Section, University of Turin, 10122, Turin, Italy
| | - Michele Reibaldi
- Department of Surgical Sciences, Eye Clinic Section, University of Turin, 10122, Turin, Italy
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31
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Cicinelli MV, Rosenblatt A, Grosso D, Zollet P, Capone L, Rabiolo A, Lattanzio R, Loewenstein A, Bandello F. The outcome of fluocinolone acetonide intravitreal implant is predicted by the response to dexamethasone implant in diabetic macular oedema. Eye (Lond) 2021; 35:3232-3242. [PMID: 33479485 DOI: 10.1038/s41433-020-01373-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 11/15/2020] [Accepted: 12/09/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND/OBJECTIVES To investigate if the visual and anatomic response to the first dexamethasone implant (DEX) predicts the 12-month clinical outcome after shifting to fluocinolone acetonide (FAc) implant in patients with diabetic macular oedema (DMO). METHODS Retrospective cohort study including pseudophakic patients with previously treated DMO, undergone one or more DEX injections before FAc. Functional and morphologic response to DEX was defined based on the best-corrected visual acuity (BCVA) and central macular thickness (CMT) changes after the first DEX, respectively. Steroid-response was defined as intraocular pressure (IOP) elevation ≥5 mmHg or IOP > 21 mmHg after any previous DEX exposure. Pairwise comparisons for BCVA, CMT, and IOP after FAc were performed with linear mixed models and a repeated-measure design. RESULTS Forty-four eyes of 33 patients were included. Patients were shifted to FAc after a mean ± standard deviation of 4.6 ± 3.2 DEX injections. Overall, BCVA and CMT improved during the first 12 months after switching to FAc (p = 0.04 and p < 0.001, respectively). Only eyes with a good morphologic response to DEX had a significant CMT reduction after FAc (p < 0.001), while no significant relationship was found between BCVA improvement after DEX and after FAc. IOP elevation occurred in 9 eyes (20%) following DEX implant. These eyes carried a 20-fold increased risk of having an IOP rise after FAc (p < 0.001), with a non-linear relationship between the IOP increase after DEX and the one after FAc. CONCLUSION The response to previous DEX may anticipate the morphologic response to subsequent FAc. Eyes with steroid-induced IOP elevation after DEX are at a high risk of IOP increase after FAc. The visual response after FAc was not associated with the visual response to previous steroids, indicating that FAc may have a role also in patients refractory to DEX implant.
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Affiliation(s)
- Maria Vittoria Cicinelli
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy. .,Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Amir Rosenblatt
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Domenico Grosso
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Piero Zollet
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Capone
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Rabiolo
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Department of Ophthalmology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, United Kingdom
| | - Rosangela Lattanzio
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anat Loewenstein
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Francesco Bandello
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.,Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Elbarky AM. Effectiveness and tolerability of the fluocinolone acetonide implant in patients with diabetic macular edema in UAE: 12-Month results. Eur J Ophthalmol 2021; 31:3196-3202. [PMID: 33426902 DOI: 10.1177/1120672120982948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION To evaluate 12-month outcomes following fluocinolone acetonide (FAc 0.2 μg/day) implant in pseudophakic patients with diabetic macular edema (DME) that persists or recurs despite previous treatment with anti-vascular endothelial growth factors (anti-VEGF) and dexamethasone implant (DEX) in a UAE population. METHODS A retrospective, observational, single-center, 12-month audit study, where 22 pseudophakic eyes (22 patients) with DME were treated with the FAc intravitreal implant according to licensed UAE indications. Outcome measurements at baseline and at months 1, 3, 6, and 12 included best-corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP). RESULTS Post-FAc implantation, mean BCVA significantly improved at 1, 3, and 12 months (+10.4 ± 16.1, +22.8 ± 13.6, and +25.5 ± 13.0 letters, respectively; p < 0.0001), with 86% of eyes gaining ⩾15 letters at month 12. Similarly, CMT reduced significantly at month 1, and stabilized thereafter at months 3-12 (-171.5 ± 72.5 µm, -240.9 ± 74.2 µm, and -246.2 ± 93.4 µm, respectively; p < 0.0001). By month 12, 64% (n = 14/22) of eyes had a CMT below 300 µm. Only 1 eye had an IOP ⩾ 21 mmHg at baseline and month 12. Five eyes required IOP lowering drops and 1 required IOP-lowering surgical intervention. CONCLUSION In pseudophakic patients with DME FAc implant provide a substantial functional and anatomical benefits for up to 12 months.
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Affiliation(s)
- Ahmed Mohammed Elbarky
- Faculty of Medicine, Benha University, Benha, Egypt.,Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
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Kodjikian L, Baillif S, Creuzot-Garcher C, Delyfer MN, Matonti F, Weber M, Mathis T. Real-World Efficacy and Safety of Fluocinolone Acetonide Implant for Diabetic Macular Edema: A Systematic Review. Pharmaceutics 2021; 13:pharmaceutics13010072. [PMID: 33430389 PMCID: PMC7827527 DOI: 10.3390/pharmaceutics13010072] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 12/24/2020] [Accepted: 01/04/2021] [Indexed: 12/18/2022] Open
Abstract
To assess real-world outcomes of fluocinolone acetonide (FAc) implant in treating diabetic macular edema (DME), a systematic literature review was conducted on PubMed in order to identify publications assessing the efficacy and safety of the FAc implant in DME in daily practice. Case reports and randomized controlled trials were excluded. Twenty-two observational real-world studies analyzing a total of 1880 eyes were included. Mean peak visual gain was +8.7 letters (11.3 months post-FAc injection) and was greater for lower baseline best corrected visual acuity (BCVA) and for more recent DME. Mean central retinal thickness (CRT) decreased 34.3% from baseline. 77.0% of the analyzed studies reported both BCVA improvement of at least five letters and a CRT decrease by 20% or more. Rescue therapy was needed more frequently when FAc was administered for chronic DME. FAc-induced ocular hypertension was reported in 20.1% of patients but only 0.6% needed surgery. Cataract extraction was performed in 43.2% of phakic patients. Adequate patient selection is essential for optimal FAc response and better safety profile. Currently positioned as second- or third-line treatment in the management algorithm, FAc implant decreases treatment burden and provides better letter gain when administered for more recent DME.
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Affiliation(s)
- Laurent Kodjikian
- Department of Ophthalmology, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon 1, 69004 Lyon, France;
- CNRS-UMR 5510 Mateis, University of Lyon 1, 69100 Villeurbane, France
- Correspondence: ; Tel.: +33-(0)4-26-10-94-31
| | - Stephanie Baillif
- Department of Ophthalmology, Pasteur 2 University Hospital, 06000 Nice, France;
| | - Catherine Creuzot-Garcher
- Department of Ophthalmology, Dijon-Bourgogne University Hospital, 21000 Dijon, France;
- Eye and Nutrition Research Group, CSGA, UMR1324 INRA, 6265 CNRS, Burgundy, 21000 Dijon, France
| | - Marie-Noëlle Delyfer
- Department of Ophthalmology, Bordeaux 2 University Hospital, 33000 Bordeaux, France;
- Bordeaux Population Health Research Center, Team LEHA, 33000 Bordeaux, France
| | - Frédéric Matonti
- Monticelli Paradis Center, 13000 Marseille, France;
- Institut de Neurosciences de la Timone-UMR 7289, University of Aix-Marseille, 13000 Marseille, France
| | - Michel Weber
- Department of Ophthalmology, Nantes University Hospital, 44000 Nantes, France;
- Clinical Investigation Centre CIC1413, INSERM and Nantes University Hospital, 44000 Nantes, France
| | - Thibaud Mathis
- Department of Ophthalmology, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon 1, 69004 Lyon, France;
- CNRS-UMR 5510 Mateis, University of Lyon 1, 69100 Villeurbane, France
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Singer MA, Wykoff CC, Grewal DS. Effects of Long-Term DME Control With 0.2 µg/Day Fluocinolone Acetonide Implant on Quality of Life: An Exploratory Analysis From the FAME Trial. Ophthalmic Surg Lasers Imaging Retina 2020; 51:658-667. [PMID: 33231701 DOI: 10.3928/23258160-20201104-10] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 09/03/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Exploratory investigation of the effect of diabetic macular edema (DME) control with the 0.2 µg/day fluocinolone acetonide (FAc) intravitreal implant on quality of life (QOL) outcomes. PATIENTS AND METHODS Post-hoc analysis of patients from the FAME study who received the FAc implant and had answered the National Eye Institute Visual Function Questionnaire 25 (NEI-VFQ-25) at baseline and Year 3 (N = 324). Patients were divided into quartiles (area under the curve [AUC]-central subfield thickness [CST]/day; n = 81/quartile). NEIVFQ-25 and best-corrected visual acuity (BCVA) changes were analyzed per quartile during a period of 3 years. RESULTS NEI-VFQ-25 scores were significantly higher in patients with low AUC-CST/day (Quartiles 1 [P < .001] and 2 [P = .004]). Increases in NEIVFQ-25 subscale scores correlated with AUC-CST/day quartiles. BCVA significantly improved in patients with the lowest AUC-CST/day (Quartiles 1 and 2 [P < .001]). CONCLUSION There was a positive and sustained correlation between the long-term control of DME and patient-reported QOL outcomes for up to 3 years following a single FAc implant in patients with controlled DME. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:658-667.].
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Zimmermann L, Kneifel C, Grajewski L, Ciernik IF, Krause L. Treatment of radiation-induced maculopathy with fluocinolone acetonide. Graefes Arch Clin Exp Ophthalmol 2020; 258:2535-2539. [PMID: 32661701 DOI: 10.1007/s00417-020-04804-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/04/2020] [Accepted: 06/13/2020] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Chronic macular oedema is a well-known presentation of radiation-induced maculopathy (RM) following external beam photon therapy, plaque radiotherapy and proton beam radiotherapy for choroidal tumours. Current therapies vary in respect of efficacy and clinical benefit. The potential of fluocinolone acetonide (FAc) slow-release implants is unknown. We hypothesised that local continuous delivery of low-dose corticosteroids might improve symptoms of RM. METHODS Five-two male and three female-patients from 37 to 68 years presented with RM following 106Ru-plaque brachytherapy or stereotactic radiation therapy (STx) with photons using a hypofractionated schedule of 5 × 10 Gy. All were treated with triamcinolone injections in first line and proofed to be refractory to steroids. In addition, two patients had received Ozurdex® implants as a second-line treatment, though without any clinical benefit. FAc slow-release implants were injected, and patients were followed up to monitor clinical improvement. RESULTS All patients responded to therapy by means of a decrease in macular oedema. In four of five (80%) patients, visual acuity improved, and one patient showed stable visual acuity. No toxic effects or complications were observed. CONCLUSION Slow-release implants of FAc are a promising therapeutic potent steroid treatment option to benefit anatomical structures of the fovea and visual function. Slow-release implants with FAc reduce the frequency of intravitreal injections and the therapeutic burden.
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Affiliation(s)
- Lena Zimmermann
- Akademisches Lehrkrankenhaus der Medizinischen Hochschule Brandenburg Theodor Fontane, Städtisches Klinikum Dessau, Klinik für Augenheilkunde, Auenweg 38, 06847, Dessau, Germany.
| | - Christiane Kneifel
- Akademisches Lehrkrankenhaus der Medizinischen Hochschule Brandenburg Theodor Fontane, Städtisches Klinikum Dessau, Klinik für Augenheilkunde, Auenweg 38, 06847, Dessau, Germany
| | - Luise Grajewski
- Akademisches Lehrkrankenhaus der Medizinischen Hochschule Brandenburg Theodor Fontane, Städtisches Klinikum Dessau, Klinik für Augenheilkunde, Auenweg 38, 06847, Dessau, Germany
| | - Ilja F Ciernik
- Akademisches Lehrkrankenhaus der Medizinischen Hochschule Brandenburg Theodor Fontane, Städtisches Klinikum Dessau, Klinik für Strahlentherapie und Radioonkologie, Dessau, Germany.,University of Zürich, Zürich, Switzerland
| | - Lothar Krause
- Akademisches Lehrkrankenhaus der Medizinischen Hochschule Brandenburg Theodor Fontane, Städtisches Klinikum Dessau, Klinik für Augenheilkunde, Auenweg 38, 06847, Dessau, Germany
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Ahmed M, Putri C, Quhill H, Quhill F. Evaluation of 0.2 µg/day fluocinolone acetonide (ILUVIEN) implant in a cohort of previously treated patients with diabetic macular oedema (DMO): a 36-month follow-up clinical case series. BMJ Open Ophthalmol 2020; 5:e000484. [PMID: 32656358 PMCID: PMC7337879 DOI: 10.1136/bmjophth-2020-000484] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/21/2020] [Accepted: 06/01/2020] [Indexed: 12/22/2022] Open
Abstract
Objective To assess the real-world effectiveness and safety of single injection of a fluocinolone acetonide (FAc) implant in previously treated patients with recurrent diabetic macular oedema (DMO) over a 36-month follow-up period. Methods and Analysis This is a retrospective study conducted at a single ophthalmology department at the Royal Hallamshire Hospital, Sheffield, UK. Data were collected using electronic medical records to identify all patients treated with a FAc implant for DMO between March 2014 and November 2014, followed with a 36-month clinic follow-up. Outcomes measured included mean change in best-recorded visual acuity (BRVA) and central macular thickness (CMT) over the period of 36 months, treatment burden pre-implant and post-implant, and functional and anatomical responder rates. Results Twenty-six eyes (n=22 patients) were treated with single intravitreal FAc implant followed with 36 months of follow-up. At 24 and 36 months, 86.4% and 75.0% of patients maintained or gained vision post-FAc implant in routine clinical practice. The mean BRVA increased from 41.8 to 54.6 letters at month 24 and 45.8 letters at month 36, with 50.0% and 33.3% of patients achieving a ≥15 letter improvement at months 24 and 36, respectively. The mean CMT reduced from 600.8 µm at baseline to 351.0 µm and 392.5 µm at months 24 and 36, respectively. Overall, a mean of one treatment every 13.33 months post-FAc implant (vs 3.24 months pre-FAc implant) was reported. Eleven eyes had an increased intraocular pressure of ≥10 mm Hg and 12 eyes had an increase to ≥25 mm Hg from baseline. Conclusion These results further support the effectiveness and safety of FAc implant in previously treated patients with persistent or recurrent DMO in a real-world clinical practice.
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Affiliation(s)
- Muna Ahmed
- Ophthalmology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, Yorkshire, UK
| | - Christine Putri
- Ophthalmology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, Yorkshire, UK
| | - Hibba Quhill
- Ophthalmology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, Yorkshire, UK
| | - Fahd Quhill
- Ophthalmology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, Yorkshire, UK
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Persistent or Recurrent Diabetic Macular Edema After Fluocinolone Acetonide 0.19 mg Implant: Risk Factors and Management. Am J Ophthalmol 2020; 215:14-24. [PMID: 32209341 DOI: 10.1016/j.ajo.2020.03.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/15/2020] [Accepted: 03/16/2020] [Indexed: 01/12/2023]
Abstract
PURPOSE To investigate baseline characteristics of patients undergoing additional antivascular endothelial growth factor (VEGF) injections for residual or recurrent diabetic macular edema (DME) in the first year after 0.19-mg fluocinolone acetonide (FAc) implant. DESIGN Prospective cohort study. METHODS Ninety-four eyes of 66 patients received an FAc implant. Eyes with persistent or recurrent DME were managed with pro re nata anti-VEGF agents. Demographic data and medical history were collected at baseline. Best-corrected visual acuity and central macular thickness were measured every 2 months. The 3 outcomes explored were 1) the risk factors for administration of additional anti-VEGF agents, 2) the interval from FAc to first anti-VEGF injection; and 3) the number of anti-VEGF doses required to maintain regression of DME. RESULTS Eighteen eyes (19.1%) of 13 patients received 1.3 ± 0.6 anti-VEGF injections. These eyes had significantly thicker central macular thickness at baseline and over the entire follow-up period (P < .001); best-corrected visual acuity was similar at every time point to eyes that were not receiving extra DME treatments. Eyes without preexistent panretinal photocoagulation (PRP) had a higher risk to undergo supplemental treatments (hazard ratio 1.5 [95% confidence interval 1.1-2.5, P = .03). The interval between FAc implant and the first anti-VEGF had a significant linear positive relationship with the number of dexamethasone implants before FAc implant (P = .002, R2 = 0.47). No association was found between baseline factors and the number of injections given. CONCLUSION Anti-VEGF agents are efficient treatment to maintain visual acuity in residual/recurrent DME after FAc. Patients with higher baseline central macular thickness and with no previous central macular thickness are more likely to require additional treatments to control DME.
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Carneiro A, Meireles A, Castro Sousa JP, Teixeira C. Clinical impact of the 0.2 µg/day fluocinolone acetonide intravitreal implant: outcomes from the ILUVIEN ® clinical evidence study in Portugal. Ther Adv Ophthalmol 2020; 12:2515841420917768. [PMID: 32548568 PMCID: PMC7249555 DOI: 10.1177/2515841420917768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 03/12/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction: The ILUVIEN® (fluocinolone acetonide) Clinical Evidence in
Portugal (ICE-PT) study is a retrospective, multicenter, observational study
evaluating the effectiveness and safety of the FAc implant in patients with
diabetic macular edema. Methods: Patients included in this study had received the 0.2 µg/day fluocinolone
acetonide implant for the treatment of diabetic macular edema and had
measurements of visual acuity and retinal thickness assessed by optical
coherence tomography for at least 12 months pre- and post-fluocinolone
acetonide implant administration, with ⩾2 follow-up visits. Outcomes
measured included visual acuity, central foveal thickness, and intraocular
pressure. Results: There was a significant increase in mean visual acuity compared with baseline
at 3, 6, 9, and 12 months post-fluocinolone acetonide in both the overall
study population and the pseudophakic subgroup (p < 0.05
at all time points in both groups). A significant reduction in mean central
foveal thickness compared with baseline was seen in the overall study
population at 3, 6, 9, and 12 months post-fluocinolone acetonide
(p < 0.05 at all time points). At 12-month
post-fluocinolone acetonide, a small but significant intraocular pressure
increase of 1.0 mmHg was seen in the overall study population. Conclusion: The results of this analysis show that switching from the current standard of
care to the fluocinolone acetonide implant leads to beneficial effects in
terms of vision and retinal structure in patients with diabetic macular
edema and that patients benefited from FAc implant administration,
regardless of lens status.
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Affiliation(s)
- Angela Carneiro
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Department of Ophthalmology of Centro Hospitalar Universitário São João, 4200-319 Porto, Portugal
| | - Angelina Meireles
- Department Ophthalmology of Centro Hospitalar Universitário do Porto, Porto Portugal
| | | | - Carla Teixeira
- Department of Ophthalmology of Hospital Pedro Hispano, Matosinhos, Portugal
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Byun M, Osher J, Riemann CD. Fluocinolone acetonide (0.19 mg) intravitreal implant reduces treatment burden and improves practice resource utilisation for patients with diabetic macular oedema. BMJ Open Ophthalmol 2020; 5:e000416. [PMID: 32518834 PMCID: PMC7254114 DOI: 10.1136/bmjophth-2019-000416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/20/2020] [Accepted: 01/25/2020] [Indexed: 11/03/2022] Open
Abstract
Objective Patients with diabetic macular oedema (DME) are known to have significantly greater medical treatment burden than patients with non-DME. Frequent injections and office visits can have a substantial impact on patient adherence and quality of life. This analysis assesses the impact of the 0.19 mg fluocinolone acetonide (FAc) implant (or injection) on treatment burden and practice resource utilisation in patients with DME. Methods and analysis This study is a single-centre retrospective chart review of 30 eyes (23 patients) that received a single FAc implant. Data was collected for a 12-month period pre-injection and post-injection of the FAc implant. Primary outcomes included the frequency of injections and ophthalmology office visits. Secondary outcomes included visual acuity (VA), intraocular pressure (IOP) and central subfield thickness (CSFT). Results The injection frequency significantly decreased from one injection every 2.6 months pre-injection to one injection every 8.8 months post-injection of the FAc implant (p<0.001). Sixty-three percent of the subjects did not require additional injections post-FAc implant. The mean number of ophthalmology office visits significantly decreased from 12.7 visits pre-FAc to 9.3 visits post-FAc implant (p<0.001). The mean VA (p=0.24) and CSFT (p=0.39) showed a mild numerical improvement that was not statistically significant. Thirty-seven percent of the eyes required additional IOP lowering drops. No eyes required incisional glaucoma surgeries. Conclusions The FAc implant significantly decreased the treatment burden and improved practice resource utilisation while maintaining or improving VA and CSFT. IOP events were mostly well-controlled with drops and no eyes required incisional glaucoma surgery.
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Affiliation(s)
- Matthew Byun
- Retina, University of Illinois at Chicago, Chicago, Illinois, United States.,University Retina and Macula Associates, Oak Forest, Illinois, United States
| | - James Osher
- Retina, Cincinnati Eye Institute, Cincinnati, Ohio, United States.,Retina, University of Cincinnati, Cincinnati, Ohio, United States
| | - Christopher D Riemann
- Retina, Cincinnati Eye Institute, Cincinnati, Ohio, United States.,Retina, University of Cincinnati, Cincinnati, Ohio, United States
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Holden SE, Habib M, Currie CJ. Retinal thickness fluctuations in patients receiving fluocinolone acetonide implant for diabetic macular edema. Curr Med Res Opin 2020; 36:959-965. [PMID: 32267790 DOI: 10.1080/03007995.2020.1754183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objectives: To evaluate central foveal thickness (CFT) variability and accompanying changes in visual acuity (VA) 12 months before and after treatment with the 190 mcg fluocinolone acetonide (FAc) intravitreal implant for diabetic macular edema (DME).Methods: The Iluvien Clinical Evidence cohort study in the United Kingdom (ICE-UK) investigated the effectiveness of the FAc implant in people treated at 13 hospitals from April 2013 to April 2015. The following parameters were calculated for CFT for each patient: mean, standard deviation (SD), retinal thickness amplitude (RTA, the difference between maximum and minimum values), and coefficient of variation (CV).Results: In 149 eyes with ≥2 CFT observations both before and after FAc implantation, the median VA was 50 ETDRS letters at implantation. Mean CFT was 487 µm at implantation and 135 µm at 12 months post-implant. Before implantation, the mean CV and mean SD for CFT were 24.6% and 112 µm, respectively; the mean RTA was 254 µm. A statistically significant (p < .001) decrease in all three parameters was observed after implantation (18.3%, 68.2 μm and 146 μm, respectively). There was an association between CFT change between extremes and the corresponding change in VA (Pearson's correlation coefficient, r = -0.292, p < .001, prior to the implant; r = -0.379, p < .001, post-implant).Conclusions: After accounting for the reduction in CFT, retinal thickness stabilized following FAc implantation. There might be VA benefits in reducing variability in CFT over time. This merits further exploration but would require more frequent CFT observations in order to properly determine patterns of retinal thickness variability.
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Affiliation(s)
| | | | - Craig J Currie
- Pharmatelligence, Cardiff, UK
- Institute of Population Medicine, Cardiff University, Cardiff, UK
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Mansour SE, Kiernan DF, Roth DB, Eichenbaum D, Holekamp NM, Kaba S, Werts E. Two-year interim safety results of the 0.2 µg/day fluocinolone acetonide intravitreal implant for the treatment of diabetic macular oedema: the observational PALADIN study. Br J Ophthalmol 2020; 105:414-419. [PMID: 32461262 PMCID: PMC7907551 DOI: 10.1136/bjophthalmol-2020-315984] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/07/2020] [Accepted: 04/21/2020] [Indexed: 01/11/2023]
Abstract
Background The 0.2 µg/day fluocinolone acetonide (FAc) implant delivers continuous, low-dose, intravitreal corticosteroid for the treatment of diabetic macular oedema (DMO). This ongoing, 3-year, observational clinical trial provides long-term, ‘real-world’ safety results for the FAc implant in DMO. Methods This 24-month interim analysis of a prospective, observational study investigated patients with DMO receiving the commercially available intravitreal 0.2 µg/day FAc implant. The primary outcome was incidence of intraocular pressure (IOP)-lowering procedures. Other IOP-related signals and their relationship to previous corticosteroid exposure, best-corrected visual acuity, central subfield thickness (CST), ocular adverse events and frequency of other treatments were also measured. Results Data were collected from 95 previously steroid-challenged patients (115 study eyes) for up to 36 months pre-FAc and 24 months post-FAc implant. Mean IOP for the overall population remained stable post-FAc compared with pre-FAc implant. IOP-related procedures remained infrequent (two IOP-lowering surgeries pre-FAc; two trabeculoplasties and four IOP-lowering surgeries post-FAc). Mean visual acuity was stable post-FAc (mean improvement of 1–3 letters) and fewer DMO treatments were required per year following FAc implant. Mean CST was significantly reduced at 24 months post-FAc implant (p<0.001) and the percentage of patients with CST ≤300 µm was significantly increased (p=0.041). Conclusion Few IOP-related procedures were reported during the 24 months post-FAc implant. Positive efficacy outcomes were noted after treatment, with stabilisation of vision and reduction in inflammation, demonstrated by CST. The FAc implant has a favourable benefit–risk profile in the management of DMO, especially when administered after a prior steroid challenge. Trial registration number NCT02424019.
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Affiliation(s)
- Sam E Mansour
- Ophthalmology, George Washington University, Washington, District of Columbia, USA .,Virginia Retina Center, Warrenton, Virginia, USA
| | - Daniel F Kiernan
- Ophthalmic Consultants of Long Island, Rockville Center, New York, New York, USA
| | - Daniel B Roth
- Ophthalmology, Rutger Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - David Eichenbaum
- Retina Vitreous Associates of Florida, St Petersburg, Florida, USA.,Ophthalmology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | | | - Samer Kaba
- Alimera Sciences, Alpharetta, Georgia, USA
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Elbarky AM. Rapid Structural and Functional Improvements with the 0.19 mg Fluocinolone Acetonide Intravitreal Implant for Patients with DME and Low Visual Acuity: 6-Month Data from the UAE. Clin Ophthalmol 2020; 14:823-830. [PMID: 32214793 PMCID: PMC7083643 DOI: 10.2147/opth.s238740] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 01/28/2020] [Indexed: 12/26/2022] Open
Abstract
Purpose The 0.19 mg fluocinolone acetonide (FAc) intravitreal implant is approved in the United Arab Emirates (UAE) for treating diabetic macular edema (DME) in patients previously treated with a course of corticosteroids and that did not have a clinically significant rise in intraocular pressure (IOP). This ongoing study is assessing its effectiveness and safety in pseudophakic patients with DME in clinical practice from a single center in the UAE. Methods A retrospective, ongoing 6-month audit study (NCT03590587), in which 22 eyes from 22 patients were treated with a single FAc intravitreal implant after treatment with a prior course of corticosteroids. Outcomes assessed included mean changes in best-corrected visual acuity (BCVA), central macular thickness (CMT), and IOP. Six-month follow-up data are presented. Results After FAc implantation, mean BCVA improved rapidly, increasing by 25.4 ± 3.0 letters (mean±SEM) from baseline to Month 6 (p<0.0001). At 6 months, BCVA had improved by 15 letters or more in 91% of eyes (n=20/22). Mean CMT decreased by 267.0 ± 20.1 µm from baseline to Month 6 (p<0.0001). Over 85% of eyes (n=19/22) had a CMT less than 300 µm at 6 months. Mean IOP increased by 2.9 ± 0.7 mmHg from baseline to Month 6 (p<0.001). All eyes except 2 had an IOP of 21 mmHg or lower. At Month 6, five eyes (23%) needed IOP-lowering therapy. Conclusion Injection of the FAc intravitreal implant rapidly and significantly improved BCVA and CMT within 6 months. These rapid and significant improvements exceed those reported in other real-world studies. Safety signals were consistent with corticosteroid class effects. The FAc implant may be a useful treatment option for patients in the UAE, particularly those with sight threatening DME requiring rapid functional improvements.
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Affiliation(s)
- Ahmed Mohammed Elbarky
- Vitreoretinal consultant, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates.,Department of Ophthalmology, Benha Faculty of Medicine, Benha University, Benha, Egypt
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Cicinelli MV, Cavalleri M, Lattanzio R, Bandello F. The current role of steroids in diabetic macular edema. EXPERT REVIEW OF OPHTHALMOLOGY 2020. [DOI: 10.1080/17469899.2020.1729743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Maria Vittoria Cicinelli
- Department of Ophthalmology, Scientific Institute San Raffaele, Vita-Salute University, Milan, Italy
| | - Michele Cavalleri
- Department of Ophthalmology, Scientific Institute San Raffaele, Vita-Salute University, Milan, Italy
| | - Rosangela Lattanzio
- Department of Ophthalmology, Scientific Institute San Raffaele, Vita-Salute University, Milan, Italy
| | - Francesco Bandello
- Department of Ophthalmology, Scientific Institute San Raffaele, Vita-Salute University, Milan, Italy
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Adams OE, Schechet SA, Hariprasad SM. Discontinuous to continuous therapy for persistent diabetic macular edema leads to reduction in treatment frequency. Eur J Ophthalmol 2020; 31:612-619. [PMID: 31964171 DOI: 10.1177/1120672120901691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate, in the setting of persistent diabetic macular edema, the impact that continuous fluocinolone acetonide delivery has on treatment burden, visual acuity, central retinal thickness, and intraocular pressure. MATERIALS AND METHODS A single-center, retrospective, cohort study of patients with persistent diabetic macular edema, previously treated with anti-vascular endothelial growth factor injections, dexamethasone implants, or focal laser, who were subsequently treated with fluocinolone acetonide was conducted. All retinal visits were analyzed prior to fluocinolone acetonide, until the most recent follow-up visit. Primary outcomes were pre- and post-fluocinolone acetonide changes in the best-corrected visual acuity and number of treatments required for diabetic macular edema. Secondary outcomes included changes in the central retinal thickness and intraocular pressure. RESULTS A total of 19 eyes with persistent diabetic macular edema were included and followed for a mean (SD) of 399.3 (222.9) days. Post-fluocinolone acetonide, the mean best-corrected visual acuity improved by 0.4 ETDRS letters for all eyes (p = 0.895) and the central retinal thickness decreased by 34.2 µm (p = 0.077). After fluocinolone acetonide, the number of treatments decreased from an average of one treatment every 2.7 months to one every 6 months (p = 0.009). Furthermore, post-fluocinolone acetonide, 10/19 eyes (52.6%) did not require additional treatment due to a dry macula, and those who did experienced a non-statistically significant reduction of treatments, from one every 2.6 months pre-fluocinolone acetonide, to one every 2.8 months post-fluocinolone acetonide (p = 0.622). CONCLUSIONS In the setting of persistent diabetic macular edema, fluocinolone acetonide significantly reduces the therapeutic burden, while maintaining best-corrected visual acuity and improving the central retinal thickness. In patient-centered discussions, judiciously employing fluocinolone acetonide should be performed to mitigate this therapeutic burden for patients.
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Affiliation(s)
- Olufemi E Adams
- Pritzker School of Medicine, The University of Chicago, Chicago, IL, USA.,Department of Ophthalmology and Visual Science, The University of Chicago Medicine & Biological Sciences, Chicago, IL, USA
| | - Sidney A Schechet
- Department of Ophthalmology and Visual Science, The University of Chicago Medicine & Biological Sciences, Chicago, IL, USA
| | - Seenu M Hariprasad
- Department of Ophthalmology and Visual Science, The University of Chicago Medicine & Biological Sciences, Chicago, IL, USA
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Chawan-Saad J, Wu M, Wu A, Wu L. Corticosteroids for Diabetic Macular Edema. Taiwan J Ophthalmol 2019; 9:233-242. [PMID: 31942428 PMCID: PMC6947754 DOI: 10.4103/tjo.tjo_68_19] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 09/28/2019] [Indexed: 12/11/2022] Open
Abstract
Diabetic macular edema (DME) is a chronic condition with a multifactorial pathogenesis. Vascular endothelial growth factor (VEGF) and several inflammatory mediators are upregulated in eyes with DME. VEGF inhibitors and corticosteroids have all been used successfully in the management of DME. Currently available corticosteroids include triamcinolone acetonide (TA), the dexamethasone (DEX) intravitreal implant, and the fluocinolone acetonide (FA) intravitreal implant. The response to treatment can vary substantially with each treatment modality. Some cases of DME are VEGF driven, and in others, inflammation plays a key role. Chronicity appears to favor corticosteroid treatment. There are no clear guidelines to guide switching from an anti-VEGF to a corticosteroid. Combination therapy of an anti-VEGF drug and a corticosteroid does not appear to provide additional benefit over monotherapy with either drug. The main advantage of corticosteroids over VEGF inhibitors is their longer duration of action. Vitrectomy does not affect the pharmacokinetics of the corticosteroid implants. Common adverse events of corticosteroids include cataract formation, cataract progression, and ocular hypertension. TA may cause a sterile endophthalmitis and pseudoendophthalmitis. Migration of the intravitreal DEX and FA implants into the anterior chamber can be problematic. Because of their less favorable safety profile, corticosteroids are generally used as a second-line treatment for DME. Advantages of using an intravitreal corticosteroid implant include the reduction of treatment burden and predictable pharmacokinetics even in vitrectomized eyes. Pseudophakic eyes, previously vitrectomized eyes and eyes with long-standing DME, particularly of patients who have difficulty in maintaining a monthly appointment, may benefit from primary treatment with a corticosteroid intravitreal implant.
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Affiliation(s)
- Jorge Chawan-Saad
- Ophthalmology Department, Mexico Hospital, Costa Rican Social Security, San Jose, Costa Rica, USA
| | - Max Wu
- College of Enginnering, Cornell University, Ithaca, NY, USA.,Macula, Vitreous and Retina Associates of Costa Rica, San Jose, Costa Rica, USA
| | - Andres Wu
- Macula, Vitreous and Retina Associates of Costa Rica, San Jose, Costa Rica, USA
| | - Lihteh Wu
- Macula, Vitreous and Retina Associates of Costa Rica, San Jose, Costa Rica, USA.,Illinois Eye and Ear Infirmary, University of Illinois, Chicago, IL, USA
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Vaz-Pereira S, Castro-de-Sousa JP, Martins D, Prates Canelas J, Reis P, Sampaio A, Urbano H, Kaku P, Nascimento J, Marques-Neves C. The Outcomes of Switching from Short- to Long-Term Intravitreal Corticosteroid Implant Therapy in Patients with Diabetic Macular Edema. Ophthalmic Res 2019; 63:114-121. [PMID: 31801148 DOI: 10.1159/000503036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 08/30/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND First-line treatment for diabetic macular edema (DME) is usually with antivascular endothelial growth factor agents, followed by intravitreal corticosteroids as a second-line treatment option. Long-term corticosteroids may offer quality of life and effectiveness benefits over short-term implants. OBJECTIVES To evaluate outcomes of patients with persistent or recurrent DME who switched from a short-term (dexamethasone) to a long-term (fluocinolone acetonide, FAc) corticosteroid intravitreal implant in a real-world setting. METHODS This is a retrospective study in 9 Portuguese centers. An FAc intravitreal implant was administered according to product labeling. Effectiveness outcomes were mean change in visual acuity (VA; ETDRS letters), central retinal thickness (CRT; µm), and macular volume (MV; mm3). The safety outcome was mean change in intraocular pressure (IOP; mm Hg). All were analyzed at months 1 and 3, and then quarterly until month 24 after implantation. RESULTS Forty-four eyes from 36 patients were analyzed. Mean duration of DME was 3.3 ± 1.9 years, and mean follow-up was 8 months. From baseline following FAc implantation, VA increased significantly at months 1 and 6 (mean +6.82 and +13.02 letters, respectively; p = 0.005), and last observation carried forward (LOCF; mean +8.3 letters; p = 0.002). CRT improved significantly at months 1 and 6 (mean -71.81 and -170.77 µm, respectively; p = 0.001), and LOCF (mean -121.46 µm; p = 0.001). MV was consistently, but not significantly, decreased from baseline to LOCF (mean -0.69 mm3; p = 0.062). The mean change in IOP was -0.25 and +0.88 mm Hg at months 1 and 6, respectively (p = 0.268), and +1.86 mm Hg at LOCF (p = 0.036). Increases were controlled with topical medication in most cases. CONCLUSIONS The FAc intravitreal implant is effective in patients previously treated with short-term corticosteroid implants. Thus, after a suboptimal response to antiangiogenics or a short-term corticosteroid, a single FAc implant may be considered an effective and tolerable treatment that can improve long-term outcomes for patients with sight-threatening DME.
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Affiliation(s)
- Sara Vaz-Pereira
- Department of Ophthalmology, Centro Hospitalar Universitário de Lisboa Norte, EPE - Hospital de Santa Maria, Lisbon, Portugal, .,Department of Ophthalmology, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal,
| | - João Paulo Castro-de-Sousa
- Department of Ophthalmology, Centro Hospitalar de Leiria, Leiria, Portugal.,CICS-UBI, Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal.,Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | - David Martins
- Department of Ophthalmology, Centro Hospitalar de Setúbal, Setúbal, Portugal
| | - Joaquim Prates Canelas
- Department of Ophthalmology, Centro Hospitalar Universitário de Lisboa Norte, EPE - Hospital de Santa Maria, Lisbon, Portugal.,Department of Ophthalmology, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Pedro Reis
- Department of Ophthalmology, Hospital das Forças Armadas, Lisbon, Portugal
| | | | - Helena Urbano
- Department of Ophthalmology, Centro Hospitalar de Lisboa Ocidental - Hospital Egas Moniz, Lisbon, Portugal
| | - Paulo Kaku
- Department of Ophthalmology, Hospital da Cruz Vermelha Portuguesa, Lisbon, Portugal
| | | | - Carlos Marques-Neves
- Department of Ophthalmology, Centro Hospitalar Universitário de Lisboa Norte, EPE - Hospital de Santa Maria, Lisbon, Portugal.,Department of Ophthalmology, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,ALM Oftalmolaser, Lisbon, Portugal
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Lynch SK, Lee K, Chen Z, Folk JC, Schmidt-Erfurth U, Gerendas BS, Wahle A, Wykoff CC, Abràmoff MD. Intravitreal Fluocinolone Acetonide May Decelerate Diabetic Retinal Neurodegeneration. Invest Ophthalmol Vis Sci 2019; 60:2134-2139. [PMID: 31100106 PMCID: PMC6528841 DOI: 10.1167/iovs.18-24643] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose There is no prevention or treatment for diabetic retinal neurodegeneration (DRN), which is a complication of diabetes that can occur independently of diabetic retinopathy (DR). We hypothesized that an intravitreal fluocinolone acetonide (FAc) implant may affect the rate of DRN when used in patients with diabetic macular edema (DME). Methods In this retrospective analysis, optical coherence tomography with neuroretinal analysis was obtained at 3-month intervals from 130 patients in the USER study both before (mean duration 903 days, range 35-4005 days) and after administration of FAc (mean 408 days, range 7 to 756 days). The rate of DRN was defined as the change over time on inner neuroretinal thickness using logistic regression. A DRN rate was calculated independently for two areas: region 1 located within 1.5 mm of the fovea, and region 2 from 1.5 mm to 3.0 mm from the fovea. Results In regions of the macula more than 1.5 mm from the central fovea, there was a statistically significant decrease in the rate of DRN in the post-FAc period. The pre-FAc neuroretinal loss in this area occurred at 4.0 μm/y, compared with a post-FAc loss rate of 1.1 μm/y (P = 0.001). Conclusions This retrospective study suggests that FAc may decelerate the rate of inner retinal thinning in patients with persistent DME. Further prospective studies are necessary to determine the effects of FAc on the rate of DRN in patients with DME.
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Affiliation(s)
- Stephanie K Lynch
- Department of Ophthalmology and Visual Sciences, University of Iowa, Carver College of Medicine, Iowa City, Iowa, United States
| | - Kyungmoo Lee
- Department of Electrical and Computer Engineering, University of Iowa, Iowa City, Iowa, United States
| | - Zhi Chen
- Department of Electrical and Computer Engineering, University of Iowa, Iowa City, Iowa, United States
| | - James C Folk
- Department of Ophthalmology and Visual Sciences, University of Iowa, Carver College of Medicine, Iowa City, Iowa, United States.,IDx, Coralville, Iowa, United States
| | - Ursula Schmidt-Erfurth
- Department of Ophthalmology and Optometry, Vienna Reading Center, Medical University of Vienna, Vienna, Austria
| | - Bianca S Gerendas
- Department of Ophthalmology and Optometry, Vienna Reading Center, Medical University of Vienna, Vienna, Austria
| | - Andreas Wahle
- Department of Electrical and Computer Engineering, University of Iowa, Iowa City, Iowa, United States
| | - Charles C Wykoff
- Retina Consultants of Houston, Blanton Eye Institute, Houston, Texas, United States
| | - Michael D Abràmoff
- Department of Ophthalmology and Visual Sciences, University of Iowa, Carver College of Medicine, Iowa City, Iowa, United States.,Department of Electrical and Computer Engineering, University of Iowa, Iowa City, Iowa, United States.,IDx, Coralville, Iowa, United States.,Iowa Institute for Vision Research, Iowa City, Iowa, United States.,Veterans Affairs Medical Center, Iowa City, Iowa, United States
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Coney JM. Fluocinolone acetonide 0.19 mg intravitreal implant improves foveal thickness and reduces treatment burden for up to 1 year in eyes with persistent diabetic macular edema. Int Med Case Rep J 2019; 12:161-169. [PMID: 31213929 PMCID: PMC6549741 DOI: 10.2147/imcrj.s192524] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 03/28/2019] [Indexed: 12/20/2022] Open
Abstract
Objective: To assess the effectiveness, safety, and treatment burden in eyes with persistent diabetic macular edema (DME) for up to 1 year after administration of 0.19 mg fluocinolone acetonide (FAc) implant (Iluvien®). Methods: This retrospective study at one private practice in the US included 40 eyes from 33 patients treated with an FAc implant. Eyes had previously been treated with VEGF antagonists, dexamethasone, or focal laser. The primary outcome was change in central foveal thickness from baseline. Data were also collected on demographics, visual acuity, intraocular pressure (IOP), use of IOP-lowering drugs for elevated IOP, lens clarity, and treatment burden before and after the implant. Results: Average duration of diabetes and DME at baseline was 19 and 5 years, respectively, and average glycated hemoglobin was 7.21%. Severity of diabetic retinopathy before the implant had a slight bimodal distribution: moderate nonproliferative diabetic retinopathy (35%) and proliferative diabetic retinopathy (40%). Improvements in central foveal thickness from baseline were evident at 3 months (mean change –74.2 µm, P<0.001) and sustained through 12 months (–55.3 µm; P=0.005) for most eyes. Mean visual acuity remained stable (66.2 letters at baseline versus 67.2 letters at 12 months, roughly equivalent to 20/50 vision; P=0.855). On average, eyes required one anti-VEGF injection every 1.9 months before and one every 6.6 months after the implant, while 60% of eyes did not require additional anti-VEGF injections. Small but significant increases in IOP at months 3, 6, and 9 were not sustained to month 12, and mean IOP was normal throughout follow-up. Conclusion: In patients with DME previously treated with a steroid, and treated according to licensed indications in the US, an FAc implant not only reduces the burden of disease in the real-world setting, but also the burden of injections and office visits for patients.
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Zur D, Iglicki M, Loewenstein A. The Role of Steroids in the Management of Diabetic Macular Edema. Ophthalmic Res 2019; 62:231-236. [DOI: 10.1159/000499540] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 03/09/2019] [Indexed: 11/19/2022]
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50
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Schechet SA, Adams OE, Eichenbaum DA, Hariprasad SM. Macular thickness amplitude changes when switching from discontinuous to continuous therapy for diabetic macular oedema. BMJ Open Ophthalmol 2019; 4:e000271. [PMID: 31179398 PMCID: PMC6528757 DOI: 10.1136/bmjophth-2019-000271] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE To investigate if the mean central retinal thickness (CRT) amplitude, measured between visits, is consistently decreased when switching from discontinuous to continuous therapy for diabetic macular oedema (DME) following fluocinolone acetonide (FAc) administration. METHODS AND ANALYSIS In this retrospective cohort study, all patients with DME treated with FAc at a single centre were included. The primary outcome was CRT amplitude changes measured at each visit prior to and after FAc administration. Secondary outcomes included average number of DME treatments before and after FAc injection, visual acuity and intraocular pressure changes. RESULTS Nineteen eyes were included. The mean (SD) follow-up after FAc was 399 (222) days. The mean (SD) CRT amplitude before FAc was 194.6 (114.90) µm, and following FAc administration, the amplitude decreased to 70.8 (94.23) µm (95% CI -189.5 to -58.1; p≤0.001). After FAc, the number of treatments required per month significantly decreased from an average of 1 treatment every 2.7 months to every 6 months (p=0.009). CONCLUSION In patients with DME, the CRT amplitude values and number of treatments significantly decrease following FAc administration while maintaining vision. Further studies are needed to evaluate the significance of these interesting findings.
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Affiliation(s)
- Sidney A Schechet
- Ophthalmology and Visual Science, University of Chicago, Chicago, Illinois, USA
| | - Olufemi E Adams
- Ophthalmology and Visual Science, University of Chicago, Chicago, Illinois, USA
| | - David A Eichenbaum
- Partner, Retina Vitreous Associates of Florida, St Petersburg, Florida, USA
- Ophthalmology, USF Health Morsani College of Medicine, Tampa, Florida, USA
| | - Seenu M Hariprasad
- Ophthalmology and Visual Science, University of Chicago, Chicago, Illinois, USA
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