Successful treatment of cystoid macular edema with valdecoxib

Selective COX-2 Inhibitors: Road from Success to Controversy and the Quest for Repurposing

The introduction of selective COX-2 inhibitors (so-called 'coxibs') has demonstrated tremendous commercial success due to their claimed lower potential of serious gastrointestinal adverse effects than traditional NSAIDs. However, following the repeated questioning on safety concerns, the coxibs 'controversial me-too' saga increased substantially, inferring to the risk of cardiovascular complications, subsequently leading to the voluntary withdrawal of coxibs (e.g., rofecoxib and valdecoxib) from the market. For instance, the makers (Pfizer and Merck) had to allegedly settle individual claims of cardiovascular hazards from celecoxib and valdecoxib. Undoubtedly, the lessons drawn from this saga revealed the flaws in drug surveillance and regulation, and taught science to pursue a more integrated translational approach for data acquisition and interpretation, prompting science-based strategies of risk avoidance in order to sustain the value of such drugs, rather than their withdrawal. Looking forward, coxibs are now being studied for repurposing, given their possible implications in the management of a myriad of diseases, including cancer, epilepsy, psychiatric disorders, obesity, Alzheimer's disease, and so on. This article briefly summarizes the development of COX-2 inhibitors to their market impression, followed by the controversy related to their toxicity. In addition, the events recollected in hindsight (the past lessons), the optimistic step towards drug repurposing (the present), and the potential for forthcoming success (the future) are also discussed.

Comparison of topical nepafenac 0.1% with intravitreal dexamethasone implant for the treatment of Irvine-Gass syndrome

AIM

To compare safety and efficacy of intravitreal dexamethasone (IVD) implant with topical nepafenac (TN) 0.1% in previously untreated Irvine-Gass syndrome (IGS) in clinical practice.

METHODS

This was a retrospective study of 62 eyes with IGS after phacoemulsification with posterior chamber intraocular lens (IOL) implantation. None of the patients used treatment before IVD or TN. Best-corrected visual acuity (BCVA) with Early Treatment Diabetic Retinopathy Study chart (ETDRS), slit-lamp, intraocular pressure (IOP) measurement, fundus examination, spectral-domain optical coherence tomography (OCT) and fundus florescein angiography were performed to all subjects at baseline, 1, 3 and 6mo.

RESULTS

The mean BCVA of the IVD group was 49.3±6.8, and the mean BCVA of the TN group was 32.9±7.3 ETDRS letters in post-treatment month 6. The mean central macular thickness (CRT) of IVD group was 266.6±53.5 µm and the mean CRT of TN group was 364.9±56.3 µm in post-treatment month 6. Baseline BCVA has correlation with final BCVA in TN group however there was no correlation between baseline BCVA and final BCVA in IVD group.

CONCLUSION

IVD is found to be better than TN in controlling pseudophakic macular edema and improving visual acuity. IVD group also has significantly lower CRT however IOP is not significantly different between two groups in post-treatment month 6.

Anterior chamber migration of dexamethasone intravitreal implant (Ozurdex®) through basal iridectomy (Ando) in a pseudophakic patient

PURPOSE

Intravitreal implantation of dexamethasone implant (Ozurdex®) is being widely used for the treatment of macular edema (ME) after branch or central retinal vein occlusion, diabetic ME, and persistent ME associated with uveitis or Irvine-Gass syndrome. We describe a complication: migration of the dexamethasone implant into the anterior chamber through basal iridectomy (Ando) in a pseudophakic patient with development of corneal edema and secondary high intraocular pressure.

METHODS

This is a case report of migration of Ozurdex® through basal iridectomy in a pseudophakic patient with iris claw lens.

CONCLUSIONS

Pseudophakic patients, with a history of vitrectomy, even those with a basal iridectomy (Ando), are at high risk for migration of the Ozurdex® into the anterior chamber and development of corneal edema.

Comparison of Subtenon Triamcinolone Acetonide Injection with Topical Nepafenac for the Treatment of Pseudophakic Cystoid Macular Edema

PURPOSE

To compare the efficacy and safety of subtenon triamcinolone acetonide (TA) injection with topical nepafenac 0.1% for the treatment of pseudophakic cystoid macular edema (CME).

METHODS

In this prospective study, the TA group comprised 24 eyes and the nepafenac group 24 eyes. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), intraocular pressure measurements, and slit-lamp fundoscopy were performed in all subjects at baseline, 1, 2, 3, and 6 months.

RESULTS

Changes in BCVA and CRT over four follow-up visits were statistically significant (p<0.001). The mean CRT decreased from 513.3 to 318.9 μm in the TA group and from 483.7 to 278.0 μm in the nepafenac group. This reduction was statistically significant (p<0.001 for both groups).

CONCLUSIONS

Our visual and OCT results suggest that both treatment modalities are effective with few side-effects. However, nepafenac is more efficacious than subtenon TA in terms of visual gain and its correlation with the reduction in CRT.

Lipid-Based Therapy for Ocular Surface Inflammation and Disease

Ocular surface diseases such as dry eye, allergic keratoconjunctivitis, and infection are very prevalent conditions and involve ocular surface stress and inflammation. Recently, various lipid-based therapies have been advocated for the modulation of ocular surface inflammation. Here we review the latest developments and challenges of these strategies. These include administration of essential fatty acids, cyclooxygenase (COX) inhibitors and resolvin analogs. Lipids form part of the tear film and are crucial for tear film stability; loss of tear film stability can aggravate ocular surface inflammation. Strategies to replenish tear film lipids - namely, eyelid warming and eye drops containing natural or synthetic lipids - are evaluated. Recent advances in the use of lipids as ocular drug delivery vehicles, antioxidants, and diagnostic markers are discussed.

Topical nepafenac 0.1% alone versus prednisolone acetate 1% as postoperative anti-inflammatory agents in small gauge vitrectomy

AIM

To compare the efficacy of postoperative topical nepafenac (0.1%) with prednisolone acetate (1%) as anti-inflammatory agents in eyes undergoing Transscleral Sutureless Vitrectomy (TSV).

SETTINGS AND DESIGN

Prospective, double-blind, randomized, single center clinical study.

MATERIALS AND METHODS

Eighty eyes of 76 subjects, who underwent small gauge vitrectomy, were included in the study. The subjects who fulfilled the inclusion criteria were randomized to either topical nepafenac only (Group 1) or prednisolone acetate only (Group 2), to be used as postoperative anti-inflammatory agents. The subjects were reviewed on days 1, 30, and 90. Ocular and adnexal inflammation was appropriately graded using the standardized classification. Grading of ocular pain was done on the Visual Analog Scale (VAS).

STATISTICAL ANALYSIS

The Wilcoxon rank-sum test, using two-sided analysis, was used.

RESULTS

During the follow-up, both Group 1 and Group 2 did not have a significant difference related to the grade of the anterior chamber inflammation (P > 0.05) or adnexal inflammation (P > 0.05). Pain perception was less in the subjects in Group 1 as compared to subjects in Group 2, but was not statistically significant (P > 0.05).

CONCLUSION

Postoperative topical nepafenac was non-inferior to prednisolone acetate in reducing postoperative ocular inflammation in eyes undergoing TSV.

Short-term safety and efficacy of intravitreal 0.7-mg dexamethasone implants for pseudophakic cystoid macular edema

AIMS

To determine the feasibility, safety, and clinical efficacy of intravitreal 0.7-mg dexamethasone implants (Ozurdex) in patients with refractory cystoid macular edema after uncomplicated cataract surgery.

METHODS AND MATERIALS

In this study, 11 eyes of 11 patients affected by pseudophakic cystoid macular edema refractory to medical treatment were treated with a single intravitreal injection of a dexamethasone implant. Follow-up visits involved Early Treatment Diabetic Retinopathy Study visual acuity testing, optical coherence tomography imaging, and ophthalmoscopic examination.

RESULTS

The follow-up period was six months. The mean duration of cystoid macular edema before treatment with Ozurdex was 7.7 months (range, 6-10 months). The baseline mean best corrected visual acuity (BCVA) was 0.58 ± 0.17 logarithm of the minimum angle of resolution (logMAR). The mean BCVA improved to 0.37 ± 0.16 logMAR (p = 0.008) and 0.20 ± 0.13 logMAR (p = 0.001) after 1 and 3 months, respectively. At the last follow-up visit (6-month follow-up), the mean BCVA was 0.21 ± 0.15 logMAR (p = 0.002). The mean foveal thickness at baseline (513.8 μm, range, 319-720 μm) decreased significantly (308.0 μm; range, 263-423 μm) by the end of the follow-up period (p < 0.0001). Final foveal thickness was significantly correlated with baseline BCVA (r = 0.57, p = 0.002). No ocular or systemic adverse events were observed.

CONCLUSIONS

Short-term results suggest that the intravitreal dexamethasone implant is safe and well tolerated in patients with pseudophakic cystoid macular edema. Treated eyes had revealed a significant improvement in BCVA and decrease in macular thickness by optical coherence tomography.

Pseudophakic cystoid macular edema associated with extrafoveal vitreoretinal traction

Purpose:

To describe an association between extrafoveal vitreoretinal traction and intractable chronic pseudophakic cystoid macular edema (CME) by the use of optical coherence tomography (OCT).

Methods:

In a retrospective case series study, charts and OCT findings of patients who had postoperative recalcitrant pseudophakic CME for at least 6 months and vitreoretinal traction membranes were analyzed. Excluded were eyes that either had another vitreoretinopathy that could affect the analysis or had undergone an intravitreal intervention.

Results:

Three eyes (three patients) with macular edema following uneventful cataract surgery were detected to be associated with multifocal extrafoveal vitreoretinal traction sites in each. Retinal edema that was underlying each of the traction sites in all eyes was in continuum in at least one site per eye with the central macular edema, thus manifesting as diffuse macular edema.

Conclusion:

Chronic pseudophakic macular edema may be related to extrafoveal vitreoretinal traction.

Chronic macular edema associated with extrafoveal vitreoretinal traction

AIM

To describe an association between extrafoveal vitreoretinal traction and chronic macular edema, either diffuse (DiME) or cystoid (CME), by the use of optical coherence tomography (OCT).

METHODS

Charts and OCT findings of two patients with persistent DiME or persistent DiME accompanied by CME, both associated with extrafoveal vitreous traction membranes were analyzed. Excluded were eyes that either had another vitreoretinopathy that could affect the analysis, had undergone pars plana vitrectomy or that had been treated by intravitreal medications. An age-matched normal control group for OCT (n=12) allowed for the quantification of the normal macular thicknesses.

RESULTS

One patient (one eye) following perforating ocular injury and one patient (one eye) of idiopathic origin, both with chronic macular edema refractive to conventional treatment, were found to be associated with extrafoveal vitreoretinal traction in each eye. Retinal edema that was underlying the traction site in each eye was in continuum with the central macular edema, thus manifesting as diffuse macular edema. The automatic central 6-radial lines program in the OCT enabled the detection of the traction site in one eye, while in the other eye the diagnosis was achieved only with the additional use of the Line group program.

CONCLUSION

Chronic diffuse macular edema might be related to extrafoveal vitreoretinal traction. Careful search with the diverse OCT programs should be made in order to detect extrafoveal traction sites. Further studies and a larger cohort are required to compare the efficacy of early vitrectomy or pharmacologic vitreolysis versus the current therapeutic approaches in these situations.