Intravitreal pegaptanib sodium for refractory pseudophakic macular oedema

Current management options for the treatment of refractory postoperative cystoid macular edema: A systematic review

Post-operative cystoid macular edema (PCME) is an important complication following intraocular surgery that often resolves spontaneously without treatment. In some cases, PCME may persist despite initial medical therapy, which can adversely impact visual outcomes. Various topical, intraocular and systemic treatments exist for the prevention and management of cystoid macular edema; however, there is no consensus on treatment of refractory cases in the postoperative setting. In accordance with the PRISMA guidelines, we systematically reviewed 68 articles describing management options and their outcomes for treatment-resistant cases of PCME. The most commonly reported treatments included steroid (39 studies) and biological-based (17 studies) therapies. We provide an overview of the treatment options for refractory PCME.

Ocular Injectable Treatment Options for Post-Cataract Macular Edema: A Systematic Review of Current Literature

ABSTRACT

The incidence of pseudophakic cystoid macular edema (PCME) ranges from 0.1% to 20% and is the most common cause of post-procedure vision loss. Currently there is no widely accepted treatment for PCME. Topical non-steroidal anti-inflammatory (NSAID) drops given alone or in combination with topical corticosteroids are often used; however, there is a growing body of literature surrounding the off-label use of various ocular injectable medications. The purpose of this systematic literature review was to characterize the current evidence surrounding these treatments and conduct qualitative analysis to assess the risk for bias of each study. Eighteen total studies were found and evaluated to have moderate (n=3, 17%) to high risk (n=15, 83%) of bias. Although the growing body of real-world data favors improvements in visual acuity and anatomical outcomes with these injectable treatments, larger studies with better study design are needed to demonstrate their role in the management of PCME.

[Modern approaches to treatment of postsurgical macular edema]

Postsurgical macular edema, known as Irvine-Gass syndrome, is one of the possible causes of reduced visual acuity in ophthalmic surgery. The article reviews and summarizes data on the main approaches to the treatment of this pathology, discusses the main groups of drugs used to manage postoperative macular edema.

EFFECT OF AN INTRAVITREAL DEXAMETHASONE IMPLANT ON DIABETIC MACULAR EDEMA AFTER CATARACT SURGERY

PURPOSE

To analyze the effects of a dexamethasone intravitreal implant (DEX; Ozurdex 700 μg; Allergan) administered immediately after cataract surgery in diabetic patients.

METHODS

This prospective, single-arm, open label study (NCT01748487 at ClinicalTrials.gov) involved Type 2 diabetic patients with at least mild diabetic retinopathy (DR) who underwent cataract surgery and DEX insertion after phacoemulsification, and intraocular lens implantation were enrolled. Best-corrected visual acuity and central retinal thickness (CRT) measured by spectral-domain optical coherence tomography were recorded at 1 week preoperatively, and 1 week, 1 month, and 3 months after surgery. Adverse events were also recorded.

RESULTS

Twenty-four eyes of 24 patients (17 [70.8%] men; mean age 63.7 ± 8.7 years) with mild nonproliferative DR (41.7%), moderate nonproliferative DR (33.3%), severe nonproliferative DR (16.7%), or treated proliferative DR (8.3%) were selected. After DEX treatment, mean CRT changed from 241.1 μm (95% confidence interval, 227.5-254.6 μm) at baseline to 236.9 μm (95% confidence interval, 223.9-249.9 μm) at 1 week (P = 0.09), 238.9 μm (95% confidence interval, 225.5-252.3 μm) at 1 month (P = 0.44), and 248 μm (95% confidence interval, 232.4-260.8 μm) at 3 months (P = 0.15). No eyes showed a postoperative increase >50 μm in the CRT at any visit. A 10% increase in CRT was found in 8.3% of eyes. Mean best-corrected visual acuity significantly improved from 0.37 (20/50) at baseline to 0.19 (20/30) at 1 week, 0.12 (20/25) at 1 month, and 0.12 (20/25) at 3 months (P < 0.001 for each comparison). Mean intraocular pressure before surgery was 13.8 mmHg, and none of the patients developed an intraocular pressure ≥22 mmHg at any visit. None of the patients developed any serious adverse events during the follow-up.

CONCLUSION

These short-term results suggest that a single DEX injection intraoperatively after phacoemulsification could avoid an increase in CRT after cataract surgery in diabetic patients.

Management of pseudophakic cystoid macular edema

Pseudophakic cystoid macular edema (PCME) is a common complication following cataract surgery. Acute PCME may resolve spontaneously, but some patients will develop chronic macular edema that affects vision and is difficult to treat. This disease was described more than 50 years ago, and there are multiple options for clinical management. We discuss mechanisms, clinical efficacy, and adverse effects of these treatment modalities. Topical non-steroidal anti-inflammatory agents and corticosteroids are widely used and, when combined, may have a synergistic effect. Intravitreal corticosteroids and anti-vascular endothelial growth factor (anti-VEGF) agents have shown promise when topical medications either fail or have had limited effects. Randomized clinical studies evaluating anti-VEGF agents are needed to fully evaluate benefits and risks. When PCME is either refractory to medical therapy or is associated with significant vitreous involvement, pars plana vitrectomy has been shown to improve outcomes, though it is associated with additional risks.

Prophylaxis of pseudophakic cystoid macular edema with intraoperative pegaptanib

PURPOSE

The purpose of this study was to determine the efficacy of an intraoperative intravitreal pegaptanib injection during phacoemulsification in preventing the development of pseudophakic cystoid macular edema (CME) following cataract surgery.

METHODS

This prospective, controlled pilot study was carried out at the Department of Ophthalmology, Nuevo Hospital Universitario y Politécnico La Fe, Valencia (Spain). Five hundred patients with cataract and healthy retina were included in the study. Patients were assigned in a 1:1 ratio to receive an intraoperative intravitreal pegaptanib injection (n=250) or not (control group, n=250) associated with standardized phacoemulsification surgery and postoperative treatment. Any surgical complication was considered as an exclusion criterion. The main outcome measure was the incidence of CME at 4 weeks postsurgery, defined as a central foveal thickness greater than 350 μm as measured by spectral-domain optical coherence tomography with associated cystoid changes.

RESULTS

The incidence of CME by the fourth postoperative week was 0.4% (n=1) in the pegaptanib group and 4.4% (n=11) in the control group (P=0.009).

CONCLUSIONS

Prophylactic use of intravitreal pegaptanib immediately after phacoemulsification was effective in preventing CME by the fourth postoperative week. The inclusion of intravitreal pegaptanib injection in the prophylaxis of pseudophakic CME will be considered for complicated cases in forthcoming studies.

Visual perceptions induced by intravitreous injections of therapeutic agents

PURPOSE

The purpose of this study was to conduct a questionnaire-based survey of subjective visual perceptions induced by intravitreous (IVT) injections of therapeutic agents.

PATIENTS AND METHODS

Patients undergoing an IVT injection of ranibizumab, pegaptanib sodium, or triamcinolone acetonide were administered a questionnaire in the immediate post-injection period and at 2 weeks of follow-up.

RESULTS

In the immediate post-injection period (75 IVT injections, 75 eyes, 75 patients), lights and floaters were reported after 20 (27%) and 24 (32%) IVT injections, respectively. In comparison, at the 2-week follow-up, the incidence of reported lights (11; 15%) was similar (P>0.05), but the incidence of reported floaters was higher (48; 64%; P=0.00). Subgroup analysis for various injection subgroups (no previous injection vs previous injection(s) in the study eye; injections in study eyes with good VA (logarithm of minimal angle of resolution [logMAR] ≤ 0.3) vs moderate VA (0.7 <logMAR>0.3) vs poor VA (logMAR ≥ 0.7); injections according to pharmacological agent (ranibizumab vs pegaptanib vs triamcinolone acetonide); injections in study eyes with choroidal neovascularization (of various causes) vs study eyes with macular edema (of various causes); and injections in phakic vs pseudophakic eyes) did not reveal any statistically significant associations. Visual perceptions experienced following 15% of IVT injections gave cause for concern to the patient (mean visual analog scale score (± SD): 4.5 (± 1.7)), and in 64% of cases, the patients believed that preoperative counseling would have averted the concern.

CONCLUSIONS

Lights and floaters are frequent visual perceptions following IVT injections of therapeutic agents. They can give rise to concern that could be alleviated with preinjection counseling.