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Cho WJ, Shin HJ, Kim M, Bae HW, Kim CY, Choi W. Clinical prediction nomogram for steroid-induced ocular hypertension risk in patients with intravitreal dexamethasone implant. Heliyon 2024; 10:e34635. [PMID: 39130483 PMCID: PMC11315130 DOI: 10.1016/j.heliyon.2024.e34635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 07/10/2024] [Accepted: 07/12/2024] [Indexed: 08/13/2024] Open
Abstract
Background Recognizing the risk factors and understanding the mechanisms underlying steroid-induced ocular hypertension (SIOH) are vital to prevent potent vision loss and ensure the safety and effectiveness of dexamethasone (DEX) injections. The study aimed to develop a novel nomogram for predicting the risk of SIOH and determining safety zones for steroid injections. Methods This single-center, retrospective, case-control study included a total of 154 eyes with available measured axial length that had undergone AS-OCT and DEX implantation at the Yonsei University Health System. The eyes were categorized into the SIOH (n = 39) and post-steroid normal IOP (n = 115) groups. We measured intraocular pressure (IOP) for all eyes prior to DEX implantation, at 1 week post-implantation, and at 1, 2, 3, 6, and 12 months thereafter. We used AS-OCT to analyze the trabecular meshwork (TM) height and ocular parameters. Results The predictive nomogram, including TM height, yielded an AUC of 0.807 (95 % confidence interval [CI], 0.737-0.877) and demonstrated significantly higher predictive accuracy than that of previous nomograms, which did not consider TM height and had an AUC of 0.644 (95 % CI, 0.543-0.745) (p = 0.031). The calibration plot demonstrated a strong predictive accuracy for a predicted value of approximately 0.4. We established cutoff values to ensure different levels of sensitivity and specificity within the safety zone following DEX implantation. Conclusion Our improved nomogram incorporating TM height as a newly identified risk factor, established a safety threshold for intravitreal DEX implantation, helping identify safe individuals from those who require caution.
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Affiliation(s)
- Won Jeong Cho
- Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, South Korea
| | - Hye Jung Shin
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, South Korea
| | - Min Kim
- Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyoung Won Bae
- Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, South Korea
| | - Chan Yun Kim
- Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, South Korea
| | - Wungrak Choi
- Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, South Korea
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Meng L, Yang M, Jiang X, Li Y, Han X. Comparing ranibizumab, dexamethasone implant, and combined therapy for macular edema secondary to branch retinal vein occlusion: a clinical trial. Int Ophthalmol 2024; 44:262. [PMID: 38913192 DOI: 10.1007/s10792-024-03158-x] [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: 11/17/2023] [Accepted: 06/15/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND Macular edema (ME) is a common complication following branch retinal vein occlusion (BRVO) and is also the main reason for visual impairment. This study aimed to compare the efficacy and safety of intravitreal ranibizumab (IVR) or dexamethasone implant (IDI) monotherapy, as well as the combination of IVR and IDI injections, in patients with ME secondary to branch retinal vein occlusion (BRVO). METHODS This multicenter, prospective, and comparative study included 292 patients with unilateral ME involvement (total of 292 eyes) secondary to BRVO. The patients were randomly assigned to three groups and followed up for 12 months. Patients in group 1 (n = 96) were treated with 3-dose loading IVR injections followed by a pro re nata (PRN) regimen. Patients in group 2 (n = 98) received IVR combined with IDI injection, followed by IVR PRN regimen. Patients in group 3 (n = 98) were treated with IDI injection, followed by repeated IDI injection based on clinical necessity. Best corrected visual acuity (BCVA), central retinal thickness (CRT), complications, and frequency of injections were recorded and compared between the three groups. RESULTS At baseline, the three groups did not differ in age, gender, duration of ME, BCVA, IOP, and CRT (P > 0.05). Mean number of total injections per eye within 12 months were 7.1 ± 2.3 (range 4-9) in group 1, 3.7 ± 1.5 (range 2-6) in group 2, and 1.8 ± 0.4 (range 1-3) in group 3. There was a statistical difference in the number of injections between group 1 and group 2 (P = 0.037). Eyes in group 3 received fewer injections than those in group 2, but the difference was not statistically significant (P = 0.052). BCVA improvement and CRT reduction were achieved in all groups and there was no significant difference between the three groups at the end of the 12th month. However, IOP elevation and cataract progression were more frequent in group 3, especially in those patients who received repeated IDI injections. CONCLUSION Three therapeutic regimens had comparable efficacy in treating ME secondary to BRVO. Combination therapy had an advantage in maintaining good effect with fewer re-injections and complications. TRIAL REGISTRATION INFORMATION The study complied with the principles of the Declaration of Helsinki and was approved by Xi'an Aier Ancient City Eye Hospital, Xi'an Aier Eye Hospital, and Xianyang Aier Eye Hospital ethics committees (2022SF-367).
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Affiliation(s)
- Li Meng
- Xi'an Aier Ancient City Eye Hospital, [59# Ziqiang West Rd], Xi'an, 710014, Shaanxi Province, China
| | - Min Yang
- Xi'an Aier Ancient City Eye Hospital, [59# Ziqiang West Rd], Xi'an, 710014, Shaanxi Province, China
| | - Xuguang Jiang
- Xi'an Aier Ancient City Eye Hospital, [59# Ziqiang West Rd], Xi'an, 710014, Shaanxi Province, China
| | - Yanlong Li
- Xi'an Aier Ancient City Eye Hospital, [59# Ziqiang West Rd], Xi'an, 710014, Shaanxi Province, China
| | - Xiaodong Han
- Xi'an Aier Ancient City Eye Hospital, [59# Ziqiang West Rd], Xi'an, 710014, Shaanxi Province, China.
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Karimi S, Karrabi N, Hassanpour K, Amirabadi A, Daneshvar K, Nouri H, Abtahi SH. The additive effect of intravitreal dexamethasone combined with bevacizumab in refractory diabetic macular edema. J Fr Ophtalmol 2023; 46:1019-1029. [PMID: 37481454 DOI: 10.1016/j.jfo.2023.04.001] [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: 08/31/2022] [Revised: 04/20/2023] [Accepted: 04/26/2023] [Indexed: 07/24/2023]
Abstract
PURPOSE To evaluate the short-term structural and visual outcomes and side effects associated with intravitreal dexamethasone (IVD) combined with bevacizumab (IVB) in treating patients with diabetic macular edema (DME) and an inadequate response to anti-vascular endothelial growth factor (anti-VEGF) agents. METHODS In this prospective interventional case series, a total of 81 eyes of 81 patients with type 2 diabetes mellitus (T2DM) and refractory DME were included and assigned to one of two groups: I) those receiving three monthly intravitreal injections of combined bevacizumab and dexamethasone (IVB+IVD) and II) those receiving three monthly intravitreal injections of bevacizumab alone (IVB). The primary outcome was the inter-group difference in central macular thickness (CMT); secondary outcomes included best-corrected visual acuity (BCVA), baseline optical coherence tomography (OCT) biomarkers, and intraocular pressure (IOP) one month after the last injection. RESULTS Reduction in CMT and improvement in BCVA were significantly greater in the IVB+IVD group than the IVB group (109.88±156.25 vs. 43±113.67, respectively, P=0.03; and -0.13±0.23 vs. -0.01±0.17, respectively, P=0.008). Presence of neurosensory retinal detachment (NSD) (P<0.001) and complete inner segment/outer segment junction (IS-OS) disruption (P=0.049) on baseline OCT scans were associated with further CMT reductions in response to IVD. Conversely, identifiable epiretinal membrane (ERM) (P=0.002) and multiple hyperreflective foci (>20) (P=0.049) were associated with smaller reductions in CMT. Vitreomacular traction correlated with worse visual outcomes in the IVB+IVD group (P=0.003). The intergroup IOP difference was not clinically significant. CONCLUSION In patients with refractory DME, addition of IVD to the standard IVB regimen can improve visual and structural outcomes without increasing the risk of endophthalmitis, IOP rise, or intraocular inflammation. Patients with NSD are more likely to respond well to IVD. The presence of ERM may predict poor treatment response.
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Affiliation(s)
- S Karimi
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Ophthalmology, Torfe Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Clinical Research Development Unit of Torfe Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - N Karrabi
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Ophthalmology, Torfe Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Clinical Research Development Unit of Torfe Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Ophthalmology, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - K Hassanpour
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Ophthalmology, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - A Amirabadi
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - K Daneshvar
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - H Nouri
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran; School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - S-H Abtahi
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Ophthalmology, Torfe Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Clinical Research Development Unit of Torfe Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Cho WJ, Kim Y, Kim JD, Kim EW, Bae HW, Kim CY, Choi W. Association of trabecular meshwork height with steroid-induced ocular hypertension. Sci Rep 2023; 13:9143. [PMID: 37277443 DOI: 10.1038/s41598-023-36329-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 06/01/2023] [Indexed: 06/07/2023] Open
Abstract
It is important to identify at-risk patients prior to administering steroid injections to prevent avoidable irreversible blindness inducted by steroid-induced ocular hypertension (SIOH). We aimed to investigate the association of SIOH following intravitreal dexamethasone implantation (OZURDEX) using anterior segment optical coherence tomography (AS-OCT). We conducted a retrospective case control study to assess the association between trabecular meshwork and SIOH. A total of 102 eyes that underwent both AS-OCT and intravitreal dexamethasone implant injection were divided into the post-steroid ocular hypertension and normal intraocular pressure groups. Ocular parameters that can contribute to intraocular pressure were measured using AS-OCT. Univariable logistic regression analysis was used to calculate the odds ratio of the SIOH and significant variables were further analyzed using a multivariable model. Trabecular meshwork (TM) height was significantly shorter in the ocular hypertension group (716.13 ± 80.55 μm) than that in the normal intraocular pressure group (784.27 ± 82.33 μm) (p < 0.001). The receiver operating characteristic curve technique analysis showed that the optimal cut-off of ≥ 802.13 μm for TM height specificity was 96.2%, and TM height with < 646.75 μm had a sensitivity of 94.70%. The odds ratio of the association was 0.990 (p = 0.001). TM height was identified as a newly observed association with SIOH. TM height can be assessed using AS-OCT, with acceptable sensitivity and specificity. Caution must be exercised while injecting steroids in patients with short TM height (especially < 646.75 μm) as it may cause SIOH and irreversible blindness.
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Affiliation(s)
- Won Jeong Cho
- Department of Ophthalmology, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea
| | - Yitak Kim
- Department of Ophthalmology, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Dong Kim
- Department of Ophthalmology, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Woo Kim
- Department of Ophthalmology, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea
| | - Hyoung Won Bae
- Department of Ophthalmology, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea
| | - Chan Yun Kim
- Department of Ophthalmology, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea
| | - Wungrak Choi
- Department of Ophthalmology, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea.
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Zhang W, Liu Y, Sang A. Efficacy and effectiveness of anti-VEGF or steroids monotherapy versus combination treatment for macular edema secondary to retinal vein occlusion: a systematic review and meta-analysis. BMC Ophthalmol 2022; 22:472. [PMID: 36474156 PMCID: PMC9727869 DOI: 10.1186/s12886-022-02682-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Retinal vein occlusion (RVO) is the main cause of retinal vascular blindness. Laser photocoagulation therapy is the regarded as the standard treatment for branch retinal vein occlusion (BRVO) in the guidelines, but it is not effective for macular edema (ME) secondary to central retinal vein occlusion (CRVO). As anti-VEGF (vascular endothelial growth factor) or steroids monotherapy has been used to treat RVO, but each has its advantages and disadvantages. Our purpose was to evaluate the efficacy and safety of intraocular injection of anti-VEGF combined with steroids versus anti-VEGF or steroids monotherapy for ME secondary to RVO. METHODS We systematically searched trials on Pubmed, Embase, Cochrane Library, Web of Science and China National Knowledge Infrastructure (CNKI) for RCTs (random clinical trials) or non-RCTs, comparing anti-VEGF or steroids monotherapy to their combination. The primary outcomes were changes in best-corrected visual acuity (BCVA), central macular thickness (CMT) and intraocular pressure (IOP). The pooled data was analyzed by random effects model. FINDINGS A total of 10 studies selected from 366 studies were included in this meta-analysis. Our results favored anti-VEGF with steroids combination therapy in comparison with anti-VEGF {pooled SMD (standardized mean difference), 95% CI, -0.16 [-0.28, -0.04], P = 0.01} or steroids (pooled SMD, 95% CI, -0.56 [-0.73, -0.40], P < 0.00001) alone on changes of BCVA. Compared with anti-VEGF monotherapy group, the combination therapy also had a better effect {pooled MD (mean difference), 95% CI, -9.62 [-17.31, -1.93], P = 0.01)} at improvements on CMT. On the changes of IOP, assessment favored that combination therapy was associated with a better relief of IOP compared to steroids monotherapy group (pooled MD, 95% CI, -5.93 [-7.87, -3.99],P < 0.00001). What's more, the incidence of ocular hypertension was lower in the combined treatment group compared with control group treated with steroids alone (Odds Ratio, 95% CI, 0.21 [0.06, 0.77], P = 0.02). Results also showed that the combination group can prolong the average time to first anti-VEGF reinjection (MD, 95% CI, 1.74 [0.57, 2.90], P = 0.003) compared to control group treated with anti-VEGF alone. CONCLUSION Anti-VEGF with steroids combination treatment can enable a better achievement of improving BCVA, CMT, reducing the risk of increased IOP and improving patient prognosis compared to anti-VEGF or steroids therapy alone, lengthening the average time to anti-VEGF reinjection with reducing the injections during follow-up.
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Affiliation(s)
- Wuyue Zhang
- grid.440642.00000 0004 0644 5481Eye Institute, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Yuan Liu
- grid.440642.00000 0004 0644 5481Eye Institute, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Aimin Sang
- grid.440642.00000 0004 0644 5481Eye Institute, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
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6
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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: 8] [Impact Index Per Article: 4.0] [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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7
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Mah FS, Karpecki PM. Review of Loteprednol Etabonate 0.5%/Tobramycin 0.3% in the Treatment of Blepharokeratoconjunctivitis. Ophthalmol Ther 2021; 10:859-875. [PMID: 34708391 PMCID: PMC8589901 DOI: 10.1007/s40123-021-00401-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 09/23/2021] [Indexed: 11/25/2022] Open
Abstract
Use of a combination corticosteroid and antibiotic in a single formulation is common in the treatment of ocular inflammatory conditions for which corticosteroid therapy is indicated and there exists a risk of superficial bacterial infection. Loteprednol etabonate (LE) is a corticosteroid engineered to maintain potent anti-inflammatory activity while minimizing the risk of undesirable class effects of corticosteroids, such as elevated intraocular pressure and cataract. Tobramycin is a broad-spectrum aminoglycoside antibiotic that is considered generally safe and well tolerated. An ophthalmic suspension combining LE 0.5% and tobramycin 0.3% (LE/T) is approved in the US and several other countries. Use of a combination therapy increases convenience, which may promote patient adherence. A systematic literature review was conducted to examine the efficacy and safety of LE/T for ocular inflammatory conditions within the scope of its labeled indications. Results of published studies indicate that LE/T is effective in the treatment of blepharokeratoconjunctivitis in adults, with similar efficacy as dexamethasone 0.1%/tobramycin 0.3%, but is associated with a lower risk of clinically significant increases in intraocular pressure as demonstrated in both efficacy and safety studies and studies with healthy volunteers. Furthermore, studies in children with blepharitis or blepharoconjunctivitis indicate LE/T was well tolerated in this population, although efficacy vs vehicle was not demonstrated, potentially due to improvements in all groups overall and/or limited sample size. Separately, tobramycin demonstrated potent in vitro activity against most bacterial species associated with blepharitis. In conclusion, published data demonstrate the utility of LE/T for the treatment of the various clinical manifestations of blepharokeratoconjunctivitis in adults.
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Affiliation(s)
- Francis S Mah
- Refractive Surgery Service, Scripps Clinic, 10710 N. Torrey Pines Road, MS 214, La Jolla, CA, 92037, USA.
| | - Paul M Karpecki
- Kentucky Eye Institute, 601 Perimeter Dr, Suite 100, Lexington, KY, USA
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Sudhalkar A, Bilgic A, Vasavada S, Kodjikian L, Mathis T, de Ribot FM, Papakostas T, Vasavada V, Vasavada V, Srivastava S, Bhojwani D, Ghia P, Sudhalkar A. Current intravitreal therapy and ocular hypertension: A review. Indian J Ophthalmol 2021; 69:236-243. [PMID: 33463565 PMCID: PMC7933876 DOI: 10.4103/ijo.ijo_1028_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
To determine the effect of commonly used intravitreal agents on immediate and long-term IOP elevations and their association, if any, with glaucoma. Literature searches in PubMed and the Cochrane databased in January 2020 yielded 407 individual articles. Of these, 87 were selected for review based on our inclusion criteria. Based on the evidence provided, 20 were assigned level I, 27 level II, and 22 level III. Eight articles were rejected because of poor quality, insufficient clarity, or irrelevance based on standardized protocols set out by the American Academy of Ophthalmology. The studies that reported on short-term IOP elevation (i.e., between 0 and 60 min) showed that an immediate increase in IOP is seen in all patients who receive anti-VEGF agents or triamcinolone acetonide when measured between 0 and 30 min of intravitreal injection and that the IOP elevation decreases over time. The data on long-term IOP elevation were mixed; Pretreatment with glaucoma medications, anterior chamber tap, vitreous reflux, longer intervals between injections, and longer axial lengths were associated with lower IOP elevations after injection of anti-VEGF agents, while the position of the implant vis-à-vis, the anterior chamber was important for steroid therapy. Data were mixed on the relationship between IOP increase and the type of intravitreal injection, number of intravitreal injections, preexisting glaucoma, and globe decompression before injection. There were no data on the onset or progression of glaucoma in the studies reviewed in this assessment. However, some studies demonstrated RNFL thinning in patients receiving chronic anti-VEGF therapy. Most, if not all, intravitreal agents cause ocular hypertension, both in the short term and long term. The functional consequences of these observations are not very clear.
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Affiliation(s)
- Aditya Sudhalkar
- Alphavision Augenzentrum, Bremerhaven, Germany; Raghudeep Eye Hospital, Ahmedabad; MS Sudhalkar Medical Research Foundation, Baroda, India
| | | | | | - Laurent Kodjikian
- Croix Rousse University Hospital, Hospices Civils de Lyon, Université Lyon 1, Lyon, France; UMR-CNRS 5510 Matéis, Villeurbane, France, Universitat de Autonoma, Barcelona, Spain
| | - Thibaud Mathis
- Croix Rousse University Hospital, Hospices Civils de Lyon, Université Lyon 1, Lyon, France; UMR-CNRS 5510 Matéis, Villeurbane, France, Universitat de Autonoma, Barcelona, Spain
| | | | | | | | | | | | | | - Pooja Ghia
- MS Sudhalkar Medical Research Foundation, Baroda, India
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9
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Battiston K, Parrag I, Statham M, Louka D, Fischer H, Mackey G, Daley A, Gu F, Baldwin E, Yang B, Muirhead B, Hicks EA, Sheardown H, Kalachev L, Crean C, Edelman J, Santerre JP, Naimark W. Polymer-free corticosteroid dimer implants for controlled and sustained drug delivery. Nat Commun 2021; 12:2875. [PMID: 34001908 PMCID: PMC8129133 DOI: 10.1038/s41467-021-23232-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 04/08/2021] [Indexed: 12/30/2022] Open
Abstract
Polymeric drug carriers are widely used for providing temporal and/or spatial control of drug delivery, with corticosteroids being one class of drugs that have benefitted from their use for the treatment of inflammatory-mediated conditions. However, these polymer-based systems often have limited drug-loading capacity, suboptimal release kinetics, and/or promote adverse inflammatory responses. This manuscript investigates and describes a strategy for achieving controlled delivery of corticosteroids, based on a discovery that low molecular weight corticosteroid dimers can be processed into drug delivery implant materials using a broad range of established fabrication methods, without the use of polymers or excipients. These implants undergo surface erosion, achieving tightly controlled and reproducible drug release kinetics in vitro. As an example, when used as ocular implants in rats, a dexamethasone dimer implant is shown to effectively inhibit inflammation induced by lipopolysaccharide. In a rabbit model, dexamethasone dimer intravitreal implants demonstrate predictable pharmacokinetics and significantly extend drug release duration and efficacy (>6 months) compared to a leading commercial polymeric dexamethasone-releasing implant.
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Affiliation(s)
| | - Ian Parrag
- Ripple Therapeutics, Toronto, ON, Canada
| | | | | | | | | | - Adam Daley
- Ripple Therapeutics, Toronto, ON, Canada
| | - Fan Gu
- Ripple Therapeutics, Toronto, ON, Canada
| | | | | | - Ben Muirhead
- School of Biomedical Engineering, McMaster University, Hamilton, ON, Canada
| | - Emily Anne Hicks
- Department of Chemical Engineering, McMaster University, Hamilton, ON, Canada
| | - Heather Sheardown
- School of Biomedical Engineering, McMaster University, Hamilton, ON, Canada
- Department of Chemical Engineering, McMaster University, Hamilton, ON, Canada
| | - Leonid Kalachev
- Department of Mathematical Sciences, University of Montana, Missoula, MT, USA
| | | | | | - J Paul Santerre
- Ripple Therapeutics, Toronto, ON, Canada
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- Translational Biology and Engineering Program, Ted Rogers Centre for Heart Research, Toronto, ON, Canada
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10
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Pranata R, Vania A, Vania R, Victor AA. Intravitreal ranibizumab versus dexamethasone implant in macular edema due to branch retinal vein occlusion: Systematic review and meta-analysis. Eur J Ophthalmol 2020; 31:1907-1914. [PMID: 32757629 DOI: 10.1177/1120672120947595] [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
PURPOSE Intravitreal ranibizumab (RNB) and dexamethasone intravitreal implant (DII) were developed in the recent past and has been widely used for macular edema secondary to BRVO. We aimed to assess the efficacy and safety of intravitreal ranibizumab (RNB) compared to dexamethasone intravitreal implant (DII) in patients with macular edema secondary to branch retinal vein occlusion (BRVO). METHODS We performed a comprehensive search on topics that assess RNB and DII in patients with macular edema secondary to BRVO from several electronic databases. RESULTS There were 678 subjects from five studies. Ranibizumab was associated with a greater increase in best-corrected visual acuity (BCVA; mean difference 9.13, I2: 0%) compared to DII. Ranibizumab also demonstrated a greater ⩾10 (OR 2.76, I2: 0%) and ⩾15 letters (OR 2.78, I2: 0%) gain. RNB has better BCVA (logMAR scale) improvement at 6 months' follow up (mean difference -0.15, I2: 64%) in favor of RNB. Higher IOP was found in DII group on follow-up (mean difference -2.92, I2: 89%) and RNB has lesser IOP ⩾10 mmHg increase compared to DII (OR 0.08, I2: 0%). Cataract formation and/or progression was less in RNB (OR 0.53, I2: 75%). The need for rescue laser was similar the two groups. CONCLUSION Intravitreal RNB was more effective with less pronounced effect on IOP and cataract formation and/or progression compared to DII for patients with macular edema secondary to BRVO.
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Affiliation(s)
| | - Amelinda Vania
- Universitas Kristen Krida Wacana, West Jakarta, Indonesia
| | - Rachel Vania
- Universitas Pelita Harapan, Tangerang, Banten, Indonesia
| | - Andi Arus Victor
- Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia, Dr Cipto Mangunkusumo National General Hospital, Jakarta, Daerah Istimewa Jakarta, Indonesia
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Iovino C, Mastropasqua R, Lupidi M, Bacherini D, Pellegrini M, Bernabei F, Borrelli E, Sacconi R, Carnevali A, D’Aloisio R, Cerquaglia A, Finocchio L, Govetto A, Erba S, Triolo G, Di Zazzo A, Forlini M, Vagge A, Giannaccare G. Intravitreal Dexamethasone Implant as a Sustained Release Drug Delivery Device for the Treatment of Ocular Diseases: A Comprehensive Review of the Literature. Pharmaceutics 2020; 12:pharmaceutics12080703. [PMID: 32722556 PMCID: PMC7466091 DOI: 10.3390/pharmaceutics12080703] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 12/13/2022] Open
Abstract
Drug delivery into the vitreous chamber remains a great challenge in the pharmaceutical industry due to the complex anatomy and physiology of the eye. Intravitreal injection is the mainstream route of drug administration to the posterior segment of the eye. The purpose of this review is to assess the current literature about the widening use of the intravitreal 0.7 mg dexamethasone (Dex) implant, and to provide a comprehensive collection of all the ocular disorders that benefit from Dex administration. Although anti-vascular endothelial growth-factors (VEGFs) have been largely indicated as a first-choice level, the Dex implant represents an important treatment option, especially in selected cases, such as vitrectomized eyes or patients in whom anti-VEGF failed or are contraindicated. In this article, the safety profile as well as the list of the possible complications related to intravitreal Dex injection are also discussed.
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Affiliation(s)
- Claudio Iovino
- Department of Surgical Sciences, Eye Clinic, University of Cagliari, 09124 Cagliari, Italy
- Correspondence: ; Tel.: +39-070-609-2319
| | - Rodolfo Mastropasqua
- Institute of Ophthalmology, University of Modena and Reggio Emilia, 41121 Modena, Italy;
| | - Marco Lupidi
- Department of Surgical and Biomedical Sciences, Section of Ophthalmology, University of Perugia, S. Maria della Misericordia Hospital, 06129 Perugia, Italy; (M.L.); (A.C.)
- Fondazione per la Macula Onlus, DINOMGI., University Eye Clinic, 16132 Genova, Italy
- Centre de l’Odéon, 113 Boulevard St Germain, 75006 Paris, France
| | - Daniela Bacherini
- Department of Neurosciences, Psychology, Drug Research and Child Health, Eye Clinic, University of Florence, AOU Careggi, 50139 Florence, Italy; (D.B.); (L.F.)
| | - Marco Pellegrini
- Ophthalmology Unit, S. Orsola-Malpighi University Hospital, University of Bologna, 40138 Bologna, Italy; (M.P.); (F.B.)
| | - Federico Bernabei
- Ophthalmology Unit, S. Orsola-Malpighi University Hospital, University of Bologna, 40138 Bologna, Italy; (M.P.); (F.B.)
| | - Enrico Borrelli
- Department of Ophthalmology, Hospital San Raffaele, University Vita Salute San Raffaele, 20132 Milan, Italy; (E.B.); (R.S.)
| | - Riccardo Sacconi
- Department of Ophthalmology, Hospital San Raffaele, University Vita Salute San Raffaele, 20132 Milan, Italy; (E.B.); (R.S.)
| | - Adriano Carnevali
- Department of Ophthalmology, University “Magna Graecia,” 88100 Catanzaro, Italy; (A.C.); (G.G.)
| | - Rossella D’Aloisio
- Department of Medicine and Science of Ageing, Ophthalmology Clinic, University “G. d’Annunzio” Chieti-Pescara, 66100 Chieti, Italy;
| | - Alessio Cerquaglia
- Department of Surgical and Biomedical Sciences, Section of Ophthalmology, University of Perugia, S. Maria della Misericordia Hospital, 06129 Perugia, Italy; (M.L.); (A.C.)
| | - Lucia Finocchio
- Department of Neurosciences, Psychology, Drug Research and Child Health, Eye Clinic, University of Florence, AOU Careggi, 50139 Florence, Italy; (D.B.); (L.F.)
- Moorfields Eye Hospital NHS Foundation Trust, London EC1V2PD, UK
| | - Andrea Govetto
- Fatebenefratelli-Oftalmico Hospital, ASST-Fatebenefratelli-Sacco, 63631 Milan, Italy; (A.G.); (S.E.); (G.T.)
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol BS12LX, UK
| | - Stefano Erba
- Fatebenefratelli-Oftalmico Hospital, ASST-Fatebenefratelli-Sacco, 63631 Milan, Italy; (A.G.); (S.E.); (G.T.)
| | - Giacinto Triolo
- Fatebenefratelli-Oftalmico Hospital, ASST-Fatebenefratelli-Sacco, 63631 Milan, Italy; (A.G.); (S.E.); (G.T.)
| | - Antonio Di Zazzo
- Ophthalmology Complex Operative Unit, Campus Bio Medico University Hospital, 00128, Rome, Italy;
| | | | - Aldo Vagge
- University Eye Clinic, DINOGMI, Polyclinic Hospital San Martino IRCCS, 16132 Genoa, Italy;
| | - Giuseppe Giannaccare
- Department of Ophthalmology, University “Magna Graecia,” 88100 Catanzaro, Italy; (A.C.); (G.G.)
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Cheng KJ, Hsieh CM, Nepali K, Liou JP. Ocular Disease Therapeutics: Design and Delivery of Drugs for Diseases of the Eye. J Med Chem 2020; 63:10533-10593. [PMID: 32482069 DOI: 10.1021/acs.jmedchem.9b01033] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The ocular drug discovery field has evidenced significant advancement in the past decade. The FDA approvals of Rhopressa, Vyzulta, and Roclatan for glaucoma, Brolucizumab for wet age-related macular degeneration (wet AMD), Luxturna for retinitis pigmentosa, Dextenza (0.4 mg dexamethasone intracanalicular insert) for ocular inflammation, ReSure sealant to seal corneal incisions, and Lifitegrast for dry eye represent some of the major developments in the field of ocular therapeutics. A literature survey also indicates that gene therapy, stem cell therapy, and target discovery through genomic research represent significant promise as potential strategies to achieve tissue repair or regeneration and to attain therapeutic benefits in ocular diseases. Overall, the emergence of new technologies coupled with first-in-class entries in ophthalmology are highly anticipated to restructure and boost the future trends in the field of ophthalmic drug discovery. This perspective focuses on various aspects of ocular drug discovery and the recent advances therein. Recent medicinal chemistry campaigns along with a brief overview of the structure-activity relationships of the diverse chemical classes and developments in ocular drug delivery (ODD) are presented.
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Affiliation(s)
- Kuei-Ju Cheng
- School of Pharmacy, College of Pharmacy, Taipei Medical University, 250 Wuxing Street, Taipei 11031, Taiwan.,Department of Pharmacy, Taipei Municipal Wanfang Hospital, Taipei Medical University, No. 111, Section 3, Xing-Long Road, Taipei 11696, Taiwan
| | - Chien-Ming Hsieh
- School of Pharmacy, College of Pharmacy, Taipei Medical University, 250 Wuxing Street, Taipei 11031, Taiwan
| | - Kunal Nepali
- School of Pharmacy, College of Pharmacy, Taipei Medical University, 250 Wuxing Street, Taipei 11031, Taiwan
| | - Jing-Ping Liou
- School of Pharmacy, College of Pharmacy, Taipei Medical University, 250 Wuxing Street, Taipei 11031, Taiwan
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Preoperative, Intraoperative and Postoperative Corticosteroid Use as an Adjunctive Treatment for Rhegmatogenous Retinal Detachment. J Clin Med 2020; 9:jcm9051556. [PMID: 32455658 PMCID: PMC7290919 DOI: 10.3390/jcm9051556] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 12/19/2022] Open
Abstract
The treatment for rhegmatogenous retinal detachment (RRD) is surgery, including pars plana vitrectomy (PPV) and scleral buckling (SB). Despite surgical advances, degeneration of the photoreceptors and post-operative complications, such as proliferative vitreoretinopathy (PVR), often occurs as the result of inflammation, preventing complete visual recovery or causing RRD recurrence. There is increasing evidence that in the presence of RRD, the activation of inflammatory processes occurs and the surgery itself induces an inflammatory response. This comprehensive review focuses on the use of different formulations of corticosteroids (CCS), as an adjunctive treatment to surgery, either PPV or SB, for RRD repair. The purpose was to review the efficacy and safety of CCS in improving functional and anatomical outcomes and in preventing postoperative complications. This review is organized according to the timing of CCS administration: preoperative, intraoperative, and postoperative. The evidence reviewed supported the role of the pre-operative use of CCS in the treatment of combined RRD and choroidal detachment (CD), reducing CD height. No solid consensus exists on intraoperative and postoperative use of CCS to treat and prevent postoperative complications. However, a large randomized clinical trial including more than 200 eyes suggested that oral prednisone after surgery decreases the rate of postoperative grade B PVR.
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Intravitreal Injections for Macular Edema Secondary to Retinal Vein Occlusion: Long-Term Functional and Anatomic Outcomes. J Ophthalmol 2020; 2020:7817542. [PMID: 32104597 PMCID: PMC7040414 DOI: 10.1155/2020/7817542] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/13/2020] [Indexed: 11/18/2022] Open
Abstract
Purpose To report the long-term visual and anatomic outcomes of intravitreal injections for macular edema (ME) secondary to retinal vein occlusion (RVO) in a real-life clinical setting. Design Retrospective interventional case series. Methods A total of 223 consecutive eyes with ME secondary to RVO, treated with the first three intravitreal Ranibizumab or dexamethasone injections between August 2008 and September 2018, were enrolled in the study. Subsequent retreatment was guided by best-corrected visual acuity (BCVA) and central macular thickness (CMT) measurements, aimed at achieving macular fluid regression and BCVA stability. BCVA and CMT were recorded at baseline and at subsequent annual time points. The mean number of injections administered each year and the incidence of adverse events were recorded. Results The mean BCVA and CMT at baseline were 0.79 logMar (SD 0.71) and 615.7 μm (SD 257.5), respectively. The mean follow-up (FU) period was 47.8 months (min 12–max 120). At 12 months, the mean BCVA and CMT had significantly improved to 0.62 logMar (SD 0.68; p < 0.0001) and 401.04 μm (SD 257.5), respectively. The mean follow-up (FU) period was 47.8 months (min 12–max 120). At 12 months, the mean BCVA and CMT had significantly improved to 0.62 logMar (SD 0.68; p < 0.0001) and 401.04 Conclusion Intravitreal Ranibizumab and/or dexamethasone injections were found to be effective at inducing a long-lasting improvement of BCVA and CMT in a real-life clinical setting. A safety profile similar to that already well-established in Ranibizumab and dexamethasone treatment was observed, as well as a steady decrease in the number of intraocular injections required. The results support intravitreal treatments for BRVO and CRVO in patient populations with similar characteristics in similar settings.
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Steroid-induced glaucoma: Epidemiology, pathophysiology, and clinical management. Surv Ophthalmol 2020; 65:458-472. [PMID: 32057761 DOI: 10.1016/j.survophthal.2020.01.002] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 12/31/2019] [Accepted: 01/02/2020] [Indexed: 12/17/2022]
Abstract
Glucocorticoids are a class of anti-inflammatory drugs commonly used to treat various ocular and systemic conditions. Although the role of glucocorticoids in the treatment of numerous serious inflammatory diseases is pivotal, their prolonged use may increase intraocular pressure resulting in steroid-induced glaucoma. We provide a detailed update on steroid-induced glaucoma as a preventable cause of blindness in the adult and pediatric population and describe its epidemiology, social impact, and risk factors. Furthermore, we explore the propensity of different steroids to increase the intraocular pressure, the role of different routes of steroid administration, dosage and duration of treatment, as well as the clinical features, genetics, and management of steroid-induced glaucoma.
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