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La Franca L, Rutigliani C, Checchin L, Lattanzio R, Bandello F, Cicinelli MV. Rate and Predictors of Misclassification of Active Diabetic Macular Edema as Detected by an Automated Retinal Image Analysis System. Ophthalmol Ther 2024; 13:1553-1567. [PMID: 38587776 PMCID: PMC11109071 DOI: 10.1007/s40123-024-00929-8] [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: 11/27/2023] [Accepted: 03/07/2024] [Indexed: 04/09/2024] Open
Abstract
INTRODUCTION The aim of this work is to estimate the sensitivity, specificity, and misclassification rate of an automated retinal image analysis system (ARIAS) in diagnosing active diabetic macular edema (DME) and to identify factors associated with true and false positives. METHODS We conducted a cross-sectional study of prospectively enrolled patients with diabetes mellitus (DM) referred to a tertiary medical retina center for screening or management of DME. All patients underwent two-field fundus photography (macula- and disc-centered) with a true-color confocal camera; images were processed by EyeArt V.2.1.0 (Woodland Hills, CA, USA). Active DME was defined as the presence of intraretinal or subretinal fluid on spectral-domain optical coherence tomography (SD-OCT). Sensitivity and specificity and their 95% confidence intervals (CIs) were calculated. Variables associated with true (i.e., DME labeled as present by ARIAS + fluid on SD-OCT) and false positives (i.e., DME labeled as present by ARIAS + no fluid on SD-OCT) of active DME were explored. RESULTS A total of 298 eyes were included; 92 eyes (31%) had active DME. ARIAS sensitivity and specificity were 82.61% (95% CI 72.37-89.60) and 84.47% (95% CI 78.34-89.10). The misclassification rate was 16%. Factors associated with true positives included younger age (p = 0.01), shorter DM duration (p = 0.006), presence of hard exudates (p = 0.005), and microaneurysms (p = 0.002). Factors associated with false positives included longer DM duration (p = 0.01), worse diabetic retinopathy severity (p = 0.008), history of inactivated DME (p < 0.001), and presence of hard exudates (p < 0.001), microaneurysms (p < 0.001), or epiretinal membrane (p = 0.06). CONCLUSIONS The sensitivity of ARIAS was diminished in older patients and those without DME-related fundus lesions, while the specificity was reduced in cases with a history of inactivated DME. ARIAS performed well in screening for naïve DME but is not effective in surveillance inactivated DME.
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Affiliation(s)
- Lamberto La Franca
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, IRCCS Ospedale San Raffaele, University Vita-Salute, Via Olgettina 60, 20132, Milan, Italy
| | - Carola Rutigliani
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Lisa Checchin
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, IRCCS Ospedale San Raffaele, University Vita-Salute, Via Olgettina 60, 20132, Milan, Italy
| | - Rosangela Lattanzio
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, IRCCS Ospedale San Raffaele, University Vita-Salute, Via Olgettina 60, 20132, Milan, Italy
| | - Francesco Bandello
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, IRCCS Ospedale San Raffaele, University Vita-Salute, Via Olgettina 60, 20132, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Maria Vittoria Cicinelli
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, IRCCS Ospedale San Raffaele, University Vita-Salute, Via Olgettina 60, 20132, Milan, Italy.
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
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Apuzzo A, Gravina S, Panozzo G, Lattanzio R, Cicinelli MV, Bandello F. From diagnosis to prognosis: A paradigm shift for multimodal imaging in assessing diabetic macular edema. Eur J Ophthalmol 2024; 34:7-10. [PMID: 37649341 DOI: 10.1177/11206721231199149] [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: 09/01/2023]
Abstract
Diabetic macular edema (DME) is one of the leading causes of visual impairment in patients with diabetes. Multimodal imaging (MMI) has allowed a shift from DME diagnosis to prognosis. Although there are no accepted guidelines, MMI may also lead to treatment customization. Several study groups have tried to identify structural biomarkers that can predict treatment response and long-term visual prognosis. The purpose of this editorial is to review currently proposed optical coherence tomography (OCT) and optical coherence tomography angiography (OCT-A) biomarkers.
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Affiliation(s)
- Aurelio Apuzzo
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Salvatore Gravina
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giacomo Panozzo
- Ophthalmology, ESASO European School of Advances Studies in Ophthalmology, Lugano, Switzerland
- Ophthalmology, Clinica San Francesco, Verona, Italy
| | - Rosangela Lattanzio
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Vittoria Cicinelli
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- 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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Leite J, Ferreira A, Castro C, Coelho J, Borges T, Correia N, Pessoa B. Retinal changes after fluocinolone acetonide implant (ILUVIEN®) for DME: SD-OCT imaging assessment using ESASO classification. Eur J Ophthalmol 2024; 34:233-244. [PMID: 37475207 DOI: 10.1177/11206721231183471] [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: 07/22/2023]
Abstract
INTRODUCTION A detailed understanding of the anatomical and structural changes occurring in the retina following intravitreal fluocinolone acetonide implantation may help improve the management and prognosis of persistent or recurrent diabetic macular edema (DME). METHODS Overall, 45 eyes (from 35 patients) with refractory center-involved DME received an intravitreal fluocinolone acetonide implant. They were monitored at baseline and at 6, 12, 24, and 36 months for best-corrected visual acuity (BCVA), central foveal thickness (CFT), and the seven retinal parameters used in the classification of diabetic maculopathy recently developed at the European School for Advanced Studies in Ophthalmology (ESASO). RESULTS Within 6 months of implantation, significant improvements were evident in BCVA, CFT, maculopathy stage, and the percentage of eyes with: intraretinal cysts; CFT > 30% above the upper normal value; and disrupted or absent ellipsoid zone (EZ) and/or external limiting membrane (ELM). Significant improvements were still maintained at 36 months post-implantation. At month 36, early treatment with the implant (i.e., after < 6 previous intravitreal injections for DME) trended toward being more effective than later treatment in improving BCVA, CFT, maculopathy stage, and the percentage of eyes with CFT > 30% above the upper normal value. However, statistical significance was not achieved. CONCLUSION In persistent or recurrent DME, fluocinolone acetonide implantation can be effective in improving maculopathy stage and reducing the percentage of eyes with: intraretinal cysts; CFT > 30% above the upper normal value; and disrupted or absent EZ and/or ELM. It can also increase BCVA and reduce CFT.
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Affiliation(s)
- João Leite
- Department of Ophthalmology, Hospital de Santo António, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - André Ferreira
- Department of Ophthalmology, Hospital de Santo António, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine of University of Porto, Porto, Portugal
- CINTESIS@RISE - Health Research Network, MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Catarina Castro
- Department of Ophthalmology, Hospital de Santo António, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - João Coelho
- Department of Ophthalmology, Hospital de Santo António, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Tânia Borges
- Department of Ophthalmology, Hospital de Santo António, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Nuno Correia
- Department of Ophthalmology, Hospital de Santo António, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Bernardete Pessoa
- Department of Ophthalmology, Hospital de Santo António, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Unit for Multidisciplinary Investigations in Biomedicine/Instituto de Ciências Biomédicas Abel Salazar/Universidade do Porto, (UMIB/ICBAS/UP), Porto, Portugal
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Dobler E, Mohammed BR, Chavan R, Lip PL, Mitra A, Mushtaq B. Clinical efficacy and safety of intravitreal fluocinolone acetonide implant for the treatment of chronic diabetic macular oedema: five-year real-world results. Eye (Lond) 2023; 37:2310-2315. [PMID: 36513858 PMCID: PMC9745701 DOI: 10.1038/s41433-022-02338-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 10/24/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/AIM To report 5-year real-world efficacy and safety data following the treatment of chronic diabetic macular oedema (DMO) with the intravitreal 0.19 mg fluocinolone acetonide implant(ILUVIEN). METHODS Retrospective cohort study of 31 eyes treated with ILUVIEN for chronic DMO at a tertiary centre in Birmingham (UK). Best corrected visual acuity (BCVA) and central retinal thickness (CRT) were recorded at baseline, and then at 1-,2-,3-, and 5-years. Safety was assessed based on intraocular pressure (IOP) -lowering medication, surgery, and other complications. RESULTS BCVA significantly improved 1-year post-ILUVIEN (+4.2 letters, p < 0.05) and gradually reverted to baseline levels over the 5-year period of follow-up (+0.2 letters at year-5). A significant and sustained CRT reduction was observed throughout the 5-years. The proportion of eyes on IOP-lowering medication increased from 16% at baseline, to 70% at 5-years (p < 0.001) with eyes on a mean of 1.3 medications. Laser trabeculoplasty (n = 2), cyclodiode laser (n = 1), and trabeculoplasty and trabeculotomy (n = 1, in the same eye; 3.2%) were required for uncontrolled IOP. Other complications included endophthalmitis (n = 1) and vitreous haemorrhage (n = 1). 58% of eyes required additional intravitreal injections, with a mean 29.2 months to first injection. We observed a 69% reduction in treatment burden following treatment with ILUVIEN implant. CONCLUSIONS Our real-world results confirm the efficacy of the ILUVIEN implant over 5 years, with two-thirds of eyes having improved or stable visual acuity 5 years after ILUVIEN, and an overall sustained improvement in anatomical outcome. Although the rate of IOP-lowering medications use was higher than previously reported, the rate of incisional IOP-lowering surgery and other complications remained low and in keeping with rates reported in larger studies.
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Affiliation(s)
| | | | | | - Peck Lin Lip
- Birmingham and Midland Eye Centre, Birmingham, UK
| | - Arijit Mitra
- Birmingham and Midland Eye Centre, Birmingham, UK
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Sorour OA, Levine ES, Baumal CR, Elnahry AG, Braun P, Girgis J, Waheed NK. Persistent diabetic macular edema: Definition, incidence, biomarkers, and treatment methods. Surv Ophthalmol 2023; 68:147-174. [PMID: 36436614 DOI: 10.1016/j.survophthal.2022.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
Intravitreal antivascular endothelial growth factor (anti-VEGF) treatment has drastically improved the visual and anatomical outcomes in patients with diabetic macular edema (DME); however, success is not always guaranteed, and a proportion of these eyes demonstrate persistent DME (pDME) despite intensive treatment. While standardized criteria to define these treatment-resistant eyes have not yet been established, many studies refer to eyes with no clinical response or an unsatisfactory partial response as having pDME. A patient is considered to have pDME if the retinal thickness improves less than 10-25% after 6 months of treatment. A range of treatment options have been recommended for eyes with pDME, including switching anti-VEGF agents, using corticosteroids and/or antioxidant drugs in adjunct with anti-VEGF therapy, and vitrectomy. In addition, multimodal imaging of DME eyes may be advantageous in predicting the responsiveness to treatment; this is beneficial when initiating alternative therapies. We explore the literature on persistent DME regarding its defining criteria, incidence, the baseline biological markers that may be useful in anticipating the response to treatment, and the available treatment options.
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Affiliation(s)
- Osama A Sorour
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA; Department of Ophthalmology, Tanta University, Tanta, Egypt
| | - Emily S Levine
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA; Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Caroline R Baumal
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Phillip Braun
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jessica Girgis
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Nadia K Waheed
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA.
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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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Bianco L, Arrigo A, Aragona E, Antropoli A, Berni A, Saladino A, Battaglia Parodi M, Bandello F. Neuroinflammation and neurodegeneration in diabetic retinopathy. Front Aging Neurosci 2022; 14:937999. [PMID: 36051309 PMCID: PMC9424735 DOI: 10.3389/fnagi.2022.937999] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/28/2022] [Indexed: 11/30/2022] Open
Abstract
Diabetic retinopathy (DR) is the most common complication of diabetes and has been historically regarded as a microangiopathic disease. Now, the paradigm is shifting toward a more comprehensive view of diabetic retinal disease (DRD) as a tissue-specific neurovascular complication, in which persistently high glycemia causes not only microvascular damage and ischemia but also intraretinal inflammation and neuronal degeneration. Despite the increasing knowledge on the pathogenic pathways involved in DR, currently approved treatments are focused only on its late-stage vasculopathic complications, and a single molecular target, vascular endothelial growth factor (VEGF), has been extensively studied, leading to drug development and approval. In this review, we discuss the state of the art of research on neuroinflammation and neurodegeneration in diabetes, with a focus on pathophysiological studies on human subjects, in vivo imaging biomarkers, and clinical trials on novel therapeutic options.
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Affiliation(s)
| | - Alessandro Arrigo
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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Kessler LJ, Łabuz G, Auffarth GU, Khoramnia R. Biomarkers to Predict the Success of Treatment with the Intravitreal 0.19 mg Fluocinolone Acetonide Implant in Uveitic Macular Edema. Pharmaceutics 2022; 14:pharmaceutics14040688. [PMID: 35456522 PMCID: PMC9028038 DOI: 10.3390/pharmaceutics14040688] [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: 02/21/2022] [Revised: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 12/10/2022] Open
Abstract
To predict the need for additional local corticosteroids after receiving the 0.19 mg fluocinolone acetonide (FAc) implant in patients with macular edema secondary to non-infectious uveitis previously treated with local peribulbar corticosteroids. The number of corticosteroids required prior FAc, visual acuity, central retinal thickness, ellipsoid zone reflectivity ratio (EZR), and choroidal vascularity index (CVI) were compared between patients who did and did not require additional corticosteroids after FAc implantation. Pearson’s correlation coefficient (R) between putative predictors and the number of adjunctive corticosteroids after FAc implantation were measured; significant candidates were included in a generalized regression model. Patients who required additional corticosteroids after FAc had higher CVI and central retinal thickness as well as worse EZR at subsequent visits (p < 0.05). The number of corticosteroids required prior to FAc implantation (R: 0.49), CVI change from baseline to 6 months (R: −0.41), and central retinal thickness at baseline (R: −0.36) correlated to the number of additional corticosteroids (all p < 0.05). A higher number of corticosteroids per year before FAc implantation was predictive for an increase in corticosteroids required after FAc (odds ratio = 2.65), while a decrease in CVI from baseline to 6 months was inversely correlated (odds ratio = 0.82). Our results suggest that the more corticosteroids prior to FAc and the greater the short-term CVI reducing effect, the less is the chance to get additional corticosteroids after FAc.
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Affiliation(s)
- Lucy Joanne Kessler
- Department of Ophthalmology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (L.J.K.); (G.Ł.); (G.U.A.)
- HEIKA–Heidelberg Karlsruhe Strategic Partnership, Department of Ophthalmology, Heidelberg University, 69120 Heidelberg, Germany
| | - Grzegorz Łabuz
- Department of Ophthalmology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (L.J.K.); (G.Ł.); (G.U.A.)
| | - Gerd U. Auffarth
- Department of Ophthalmology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (L.J.K.); (G.Ł.); (G.U.A.)
| | - Ramin Khoramnia
- Department of Ophthalmology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (L.J.K.); (G.Ł.); (G.U.A.)
- HEIKA–Heidelberg Karlsruhe Strategic Partnership, Department of Ophthalmology, Heidelberg University, 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-06221-56-4573
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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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10
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Ebrahimi M, Balibegloo M, Rezaei N. Monoclonal antibodies in diabetic retinopathy. Expert Rev Clin Immunol 2022; 18:163-178. [PMID: 35105268 DOI: 10.1080/1744666x.2022.2037420] [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 Diabetic retinopathy (DR), as one of the main complications of diabetes, is among the leading causes of blindness and visual impairment worldwide. AREAS COVERED Current clinical therapies include photocoagulation, vitrectomy, and anti-vascular endothelial growth factor (VEGF) therapies. Bevacizumab and ranibizumab are two monoclonal antibodies (mAbs) inhibiting angiogenesis. Intravitreal ranibizumab and bevacizumab can decrease the rate of blindness and retinal thickness, and improve visual acuity whether as monotherapy or combined with other treatments. They can increase the efficacy of other treatments and decrease their adverse events. Although administered intravitreally, they also might enter the circulation and cause systemic effects. This study is aimed to review our current knowledge about mAbs, bevacizumab and ranibizumab, in DR including superiorities, challenges, and limitations. Meanwhile, we tried to shed light on new ideas to overcome these limitations. Our latest search was done in April 2021 mainly through PubMed and Google Scholar. Relevant clinical studies were imported. EXPERT OPINION Future direction includes detection of more therapeutic targets considering other components of DR pathophysiology and shared pathogenesis of DR and neurodegenerative diseases such as Parkinson's disease and Alzheimer's disease, the treat-and-extend regimen, and new ways of drug delivery and other routes of ocular drug administration.
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Affiliation(s)
- Moein Ebrahimi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA),Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Maryam Balibegloo
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA),Universal Scientific Education and Research Network (USERN), Tehran, Iran.,Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA),Universal Scientific Education and Research Network (USERN), Tehran, Iran.,Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Starace V, Battista M, Brambati M, Cavalleri M, Bertuzzi F, Amato A, Lattanzio R, Bandello F, Cicinelli MV. The role of inflammation and neurodegeneration in diabetic macular edema. Ther Adv Ophthalmol 2021; 13:25158414211055963. [PMID: 34901746 PMCID: PMC8652911 DOI: 10.1177/25158414211055963] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 10/08/2021] [Indexed: 12/14/2022] Open
Abstract
The pathogenesis of diabetic macular edema (DME) is complex. Persistently high blood glucose activates multiple cellular pathways and induces inflammation, oxidation stress, and vascular dysfunction. Retinal ganglion cells, macroglial and microglial cells, endothelial cells, pericytes, and retinal pigment epithelium cells are involved. Neurodegeneration, characterized by dysfunction or apoptotic loss of retinal neurons, occurs early and independently from the vascular alterations. Despite the increasing knowledge on the pathways involved in DME, only limited therapeutic strategies are available. Besides antiangiogenic drugs and intravitreal corticosteroids, alternative therapeutic options tackling inflammation, oxidative stress, and neurodegeneration have been considered, but none of them has been currently approved.
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Affiliation(s)
- Vincenzo Starace
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Battista
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Brambati
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele Cavalleri
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federico Bertuzzi
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessia Amato
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Rosangela Lattanzio
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Bandello
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, ItalySchool of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Maria Vittoria Cicinelli
- Department of Ophthalmology, University Vita-Salute, IRCCS Ospedale San Raffaele, via Olgettina 60, 20132 Milan, ItalySchool of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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12
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Pacella F, Pacella E, Trovato Battagliola E, Malvasi M, Scalinci SZ, Turchetti P, Salducci M, Lucchino L, Arrico L. Efficacy and safety of intravitreal Fluocinolone Acetonide microimplant (ILUVIEN ®) in patients with chronic diabetic macular edema: 1 year follow-up. Eur J Ophthalmol 2021; 32:11206721211020203. [PMID: 34030511 DOI: 10.1177/11206721211020203] [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] [Indexed: 11/17/2022]
Abstract
PURPOSE Evaluate the efficacy and safety of intravitreal 0.19 mg fluocinolone acetonide (FAc) micro implant in patients with chronic diabetic macular edema (cDME). METHODS Prospective study recruiting subjects with cDME. Inclusion criteria: cDME for at least 2 years documented with OCT imaging; pseudophakia; previous treatments with laser photocoagulation and intravitreal injections of anti-VEGF and/or dexamethasone. Exclusion criteria: phakia; ocular hypertension; tractional component visible on OCT; glaucoma; previous vitrectomy. Outcome measures included best-corrected visual acuity (BVCA), intraocular pressure (IOP), and central macular thickness (CMT), measured 1, 3, 6, and 12 months post-injection. Data were compared with the Friedman test and significance was set at p < 0.05. RESULTS A total of 18 eyes with a median duration of cDME of 45 months (25-118 months). The 77% of subjects either maintained or improved their BVCA. About 17% and 33% of subjects showed an improvement of 15 ETDRS letters or more at 3 and 12 months respectively. The 17% and 28% of subjects showed a CMT <250 microns at 3 and 12 months, respectively. The median change in CMT thickness was of -370 and -373.5 microns at 3 and 12 months post-injection respectively (p-value is 0.025). Changes in median IOP at 3 and 12 months post-injection were not statistically significant (p-value is 0.210). Ocular hypertension (OHT) was detected in two eyes (11%). CONCLUSION The FAc micro implant has proved efficacy in improving and/or maintaining BVCA in 77% of patients with cDME up to 12 months post-injection. Ocular hypertension is the most common side effect but responds well to topical therapy.
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Affiliation(s)
- Fernanda Pacella
- Department of Sense Organs, La Sapienza University of Rome, Rome, Italy
| | - Elena Pacella
- Department of Sense Organs, La Sapienza University of Rome, Rome, Italy
| | | | | | | | - Paolo Turchetti
- National Institute for Health, Migration and Poverty (INMP/NIHMP), Rome, Italy
| | - Mauro Salducci
- Department of Sense Organs, La Sapienza University of Rome, Rome, Italy
| | - Luca Lucchino
- Department of Sense Organs, La Sapienza University of Rome, Rome, Italy
| | - Loredana Arrico
- Department of Sense Organs, La Sapienza University of Rome, Rome, Italy
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13
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Pessoa B, Ferreira A, Leite J, Figueira J, Meireles A, Beirão JM. Optical Coherence Tomography Biomarkers: Vitreous Status Influence in Outcomes for Diabetic Macular Edema Therapy with 0.19-mg Fluocinolone Acetonide Implant. Ophthalmic Res 2021; 64:639-647. [PMID: 33601389 DOI: 10.1159/000515306] [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: 12/13/2020] [Accepted: 02/14/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The 0.19-mg fluocinolone acetonide (FAc) implant (ILUVIEN®; Alimera Sciences Ltd., Hampshire, UK) was approved for the treatment of vision impairment associated with chronic and refractory diabetic macular edema (DME). OBJECTIVES To quantitatively assess functional and structural features in nonvitrectomized and vitrectomized DME patients after being treated with an FAc implant. METHODS Retrospective review of patients with DME receiving a single intravitreal injection of the FAc implant. The study was designed to analyze the presence of quantitative structural OCT biomarkers at baseline and 12 months after FAc therapy according to vitreous status. RESULTS A total of 41 eyes from 30 patients were included in this study. At 12 months after injection, vitrectomized patients had a lower central foveal thickness (p = 0.017) and fewer hyperreflective dots (p = 0.028) compared with nonvitrectomized. Thirty (73%) patients presented a significant functional improvement with 17 (42%) increasing at least 15 ETDRS letters. Overall, 22 (54%) eyes had a complete resolution of DME at the 12-month visit. Patients who needed additional therapy had a higher prevalence of subretinal fluid (42 vs. 3%, p = 0.005) at baseline. CONCLUSIONS This study supports the effectiveness of the FAc implant and reports significant changes at 12 months after FAc injection.
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Affiliation(s)
- Bernardete Pessoa
- Department of Ophthalmology, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Department of Ophthalmology, Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal
| | - André Ferreira
- Department of Ophthalmology, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Unit of Anatomy, Department of Biomedicine, Faculty of Medicine of University of Porto, Porto, Portugal
| | - João Leite
- Department of Ophthalmology, Centro Hospitalar Universitário do Porto, Porto, 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 do Porto, 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 do Porto, Porto, Portugal.,Department of Ophthalmology, Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal
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Chronopoulos A, Chronopoulos P, Ashurov A, Korb C, Pfeiffer N, Hattenbach LO. Switching to intravitreal fluocinolone acetonide implant for refractory diabetic macular edema: 12- and 24-month results. Eur J Ophthalmol 2021; 32:443-449. [PMID: 33601897 DOI: 10.1177/1120672121992982] [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] [Indexed: 02/06/2023]
Abstract
PURPOSE To report visual and anatomical outcomes of chronic/refractory diabetic macular edema (DME) treated with intravitreal fluocinolone acetonide implant. SETTING Retrospective, one arm, multicentric study. METHOD Between 2013 and 2018, 27 consecutive eyes of 25 patients with chronic/refractory DME were treated with a fluocinolone acetonide intravitreal implant. Best registered visual acuity (BRVA), central retinal thickness (CRT), and Goldmann tonometry intraocular pressure (IOP) were assessed at 12 and 24 months. The need for IOP lowering treatment as well as top-up therapy during the follow-up were also assessed. RESULTS The duration of DME prior to treatment in our study was 54 ± 24 months. The baseline mean BRVA of 0.7 ± 0.34 logMAR improved to 0.5 ± 0.3 (p = 0.01) at 12 months and 0.46 ± 0.3 (p = 0.04) at 24 months. At 12 months, BRVA improved in 14 eyes (52%), stabilized in 5 eyes (20%), and decreased in 3 eyes (11%). At 24 months, BRVA improved further in 6 eyes (24%), stabilized in 3 eyes (12%), and decreased in 6 eyes (24 %). Mean CRT decreased from 497 ± 176 to 349 ± 186 μm at 12 months (p = 0.0005) and to 267 ± 104 μm at 24 months (p = 0.001). Only five eyes required additional treatment for DME and only three eyes required treatment for raised IOP. DISCUSSION Our results show that the visual and the anatomical improvements achieved by a single injection of a fluocinolone acetonide implant were maintained up to 24 months with minimal additional therapy even in eyes with a long and heavy history; however, IOP monitoring remains essential.
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Affiliation(s)
| | - Panagiotis Chronopoulos
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Agharza Ashurov
- Department of Ophthalmology, Ludwigshafen Hospital, Ludwigshafen am Rhein, Germany
| | - Christina Korb
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Norbert Pfeiffer
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Lars-Olof Hattenbach
- Department of Ophthalmology, Ludwigshafen Hospital, Ludwigshafen am Rhein, Germany
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Arrigo A, Capone L, Lattanzio R, Aragona E, Zollet P, Bandello F. Optical Coherence Tomography Biomarkers of Inflammation in Diabetic Macular Edema Treated by Fluocinolone Acetonide Intravitreal Drug-Delivery System Implant. Ophthalmol Ther 2020; 9:971-980. [PMID: 32914324 PMCID: PMC7708540 DOI: 10.1007/s40123-020-00297-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Indexed: 12/14/2022] Open
Abstract
Introduction The fluocinolone acetonide (FAc) intravitreal drug-delivery system implant is a recent, second-line, intravitreal drug for the management of diabetic macular edema (DME). FAc acts against DME with a major anti-inflammatory effect. Despite the already proved efficacy, a number of patients still show persistent DME and require anti-VEGF retreatment. The main aim of the present study was to assess the relationship between quantitative biomarkers of inflammation and both DME recovery and the need for additional anti-VEGF in eyes treated by FAc implant. Methods The study was designed as prospective and interventional with 1 year of follow-up. We analyzed structural optical coherence tomography (OCT) quantitative biomarkers of inflammation, namely choroidal hyperreflective foci (HF) and the choroidal vascularity index (CVI), and we assessed the relationship with other clinically relevant biomarkers and the outcome achieved after 1 year. Moreover, we stratified DME eyes in good and poor responders to FAc implant to highlight clinically relevant differences. Results Our study included 50 eyes (50 patients) treated by FAc implant. We found significant best-corrected visual acuity (BCVA) and central macular thickness (CMT) improvements after 1 year. Good responders started with worse visual acuity and higher CMT than poor responders, but gained letters significantly at the end of the follow-up, whereas poor responders showed stable BCVA values. Good responders were characterized by significantly higher choroidal HF and lower CVI than poor responders. Poor responders required significantly higher additional anti-VEGF treatments. Conclusions Quantitative structural OCT biomarkers of inflammation allowed distinguishing different inflammatory profiles of DME. The inflammatory component helped to categorize DME eyes in good and poor responders to FAc implant.
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Affiliation(s)
- Alessandro Arrigo
- Department of Ophthalmology, Scientific Institute San Raffaele Hospital, Vita-Salute University, Milan, Italy.
| | - Luigi Capone
- Department of Ophthalmology, Scientific Institute San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Rosangela Lattanzio
- Department of Ophthalmology, Scientific Institute San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Emanuela Aragona
- Department of Ophthalmology, Scientific Institute San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Piero Zollet
- Department of Ophthalmology, Scientific Institute San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Francesco Bandello
- Department of Ophthalmology, Scientific Institute San Raffaele Hospital, Vita-Salute University, Milan, Italy
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