Clinical Outcomes of Intravitreal Preservative-Free Triamcinolone Preparation (Triesence®) for Cystoid Macular Oedema and Inflammation in Patients with Uveitis

Review of Risk Factors and Complications of Anterior Migration of Ozurdex Implant: Lessons Learnt from the Previous Reports

Purpose: Ozurdex had shown promising anatomical and functional outcomes in managing refractory Irvine-Gass syndrome over the years. Burgeoning usage of Ozurdex has prompted the study of its related complications, particularly the anterior chamber migration of the implant. Methods: Literature reviews on the anterior chamber migration of the Ozurdex via PubMed, EBSCO, and TRIP databases were searched from 2012 to 2020. The predisposing factors, outcomes, and management of such cases were evaluated. Results: A total of 54 articles consisting of 105 cases of anterior migration of Ozurdex were included in this analysis. The vitrectomized eye and compromised posterior capsule were highly associated with this complication. About 81.9% of the cases had cornea edema upon presentation, with 31.4% of them ending up with cornea decompensation despite intervention. Although there was high intraocular pressure reported initially in 22 cases, only 2 cases required glaucoma filtration surgeries in which they had preexisting glaucoma. Numerous techniques of repositioning or surgical removal of the implant were described but they were challenging and the outcomes varied. Conclusions: A noninvasive method of manipulating the Ozurdex into the vitreous cavity via the "Trendelenburg position, external pressure with head positioning" maneuvers is safe yet achieves a favorable outcome. Precaution must be taken whenever offering Ozurdex to the high-risk eyes. Prompt repositioning or removal of the implant is crucial to deter cornea decompensation. Clinical Trial Registration number: NMRR-22-02092-S9X (from the Medical Research and Ethics Committee (MREC), Ministry of Health, Malaysia).

Safety and effectiveness of intravitreal dexamethasone implant in patients with ocular toxocariasis

AIMS

To evaluate the safety and effectiveness of intravitreal dexamethasone (DEX) implant in patients with active uveitis due to ocular toxocariasis (OT).

METHODS

Seventy-eight patients with OT were recruited in this retrospective study, including 51 patients in DEX group treated with intravitreal DEX implant and 27 patients in control group without intervention. The reduction of vitreous haze scores (VHS), the best-corrected visual acuity (BCVA) changes, intraocular pressure (IOP) and cataract progression and formation were recorded at baseline (V0), 1 (V1), 3 (V3) and 6 months (V6) after treatment in DEX group, and V0 and V6 in control group.

RESULTS

There was no change in VHS and BCVA in control group between V0 and V6. Better VHS (p=0.001) and BCVA (p=0.022) was achieved in DEX group; the rate of VHS=0 was 0%, 67.4%, 42.9% and 44.9% at V0, V1, V3 and V6, respectively (p＜0.001), and the mean BCVA was improved from logMAR 1.5±0.9 to 1.2±0.9 at V1, 1.4±1.0 at V3 and 1.4±1.2 at V6. A favourable BCVA at V1 was associated with older age (p=0.038) and uninvolved macula (p=0.000) in DEX group. No significant difference in IOP elevation ≥10 mm Hg, cataract progression and formation between groups. More eyes needed retinal surgery in control group (p<0.001).

CONCLUSIONS

This was the first study to investigate use of intravitreal DEX implant in OT patients, which can efficiently reduce ocular inflammation and improve BCVA in macular uninvolved patients.

Intravitreal Fluocinolone 0.19mg Implant in the Management of Chronic Non-Infectious Uveitis: 12-Month Outcomes from a Single Tertiary Centre

AIM

To present efficacy and safety of 0.19 mg fluocinolone acetonide insert (FAi) to treat chronic noninfectious uveitis (NIU) in a single referral center.

METHODS

A retrospective observational clinical study of 11 eyes with NIU complicated by chronic cystoid macular edema (CMO).

RESULTS

The main indication for treatment was chronic CMO in all 11 eyes. The mean central retinal thickness (CRT) at baseline was 435 μm ± 176, improving to 296 μm ± 67 at 12 months. Raised intraocular pressure (IOP) was the commonest adverse event. An IOP >21 mmHg was observed in three eyes, and >30 mmHg in one eye, managed with topical therapy. The mean best corrected visual acuity (BCVA) was stable at 12 months. There were no observed recurrences of uveitis. Two eyes received adjunctive treatment for worsening CRT.

CONCLUSIONS

Our results suggest FAi is an effective maintenance treatment for NIU with favorable functional and anatomical outcomes.

The Challenge of Treating the Severest Forms of Chronic Noninfectious Posterior and Panuveitis

BACKGROUND

Noninfectious posterior and panuveitis may exhibit a chronic relapsing clinical course and are challenging to treat. Most affected patients are continuously treated with systemic immunosuppressive therapy, which is potentially associated with significant adverse side effects.

METHODS

A cohort of 18 patients presenting with severe noninfectious posterior or panuveitis were evaluated with respect to the clinical course of the disease, with particular focus on best-corrected visual acuity (BCVA), treatment duration, remission rates, reported negative side effects, and the necessity for switching medication.

RESULTS

The mean follow-up was 27.8 months. Although BCVA improved significantly, complete or partial remission was observed in only 66.7% of patients. Of the patients, 72.2% underwent a change in medical treatment due to either adverse events or inefficacy of medication.

CONCLUSION

Despite new immunosuppressive therapies, effective treatment of severe noninfectious posterior and panuveitis remains a major challenge. We discuss the urgent need for novel treatment strategies in order to prevent systemic adverse effects, and to improve visual outcome and quality of life.

Progress in the pharmacotherapy of uveitis: the art of personalized care

INTRODUCTION

Uveitis is a heterogeneous group of inflammatory intraocular disorders which can lead to blindness, but prompt diagnosis and management can improve visual outcomes and reduce treatment burden.

AREAS COVERED

In this review, the authors provide an overview of commonly used treatments of the management of non-infectious uveitis.

EXPERT OPINION

Initially, the treatment of non-infectious uveitis was limited to corticosteroids which have a broad range of adverse ocular and systemic effects. Now new options, such as biological response modulators, are a novel yet exciting addition to this armory and have the potential to change the course of treatment as well as prognostic outcomes for uveitis patients. Additionally, further research is needed to evaluate the efficacy of this novel class of immunomodulators in uveitis therapy.

Practice patterns regarding regional corticosteroid treatment in noninfectious Uveitis: a survey study

Background

Regional corticosteroid therapy for noninfectious uveitis is well-established but usage patterns have not been studied extensively. This study aims to assess practice patterns of retina and uveitis specialists regarding their preferences on the use of local corticosteroid therapy.

Methods

A 13-question survey was developed regarding the practice patterns of regional corticosteroid use in specific situations and populations. The survey was distributed to both the American Uveitis Society and Macula Society.

Results

Responses from 87 ophthalmologists were analyzed. The two most commonly used drugs were the dexamethasone intravitreal implant (Ozurdex®) and posterior sub-tenon’s triamcinolone (also known as posterior sub-Tenon’s Kenalog, or PSTK). Regional corticosteroids were used more frequently as first-line treatment in more than half of posterior uveitis cases when compared to anterior uveitis (39.1–46.0% vs 10.3%, respectively). Respondents were more willing to use regional corticosteroids in more than half of unilateral uveitis cases than in bilateral cases (54.7% vs 18.6%, respectively). A majority of respondents (67.1%) stated that they would avoid using regional corticosteroids in patients under 8 years old.

Conclusions

Our results demonstrate more frequent regional corticosteroid use in posterior segment uveitis, unilateral cases, and avoidance in younger pediatric patients. Overall, the variability in these responses highlights the need for guidelines regarding regional corticosteroid use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12348-021-00281-z.

New pharmacotherapy options for noninfectious posterior uveitis

INTRODUCTION

Noninfectious inflammation of the posterior eye segment represents an important cause of visual impairment. It often affects relatively young people and causes a significant personal and social impact. Although steroids and nonbiologic- Disease-Modifying Antirheumatic Drugs (nbDMARDs) are effective both in acute and long- lasting diseases, however they are increasingly being replaced by biologic (DMARDs). bDMARD. This article therefore aims to identify recent advances in the therapy of noninfectious posterior segment uveitis.

METHODS

A Medline-search was conducted using the terms: nbDMARD, bDMARD, posterior uveitis, intermediate uveitis, treatment, corticosteroid. In addition, clinical studies were included as registered at ClinicalTrials.gov.

RESULTS

Currently two major lines of treatments can be identified: (1) the intraocular application of anti-inflammatory agents and (2) the introduction of new agents, e.g., (bDMARDs) and small-molecule-inhibitors. Whereas intravitreal treatments have the advantage to avoid systemic side effects, new systemic agents are progressively earning credit on the basis of their therapeutic effects.

CONCLUSION

Even when current treatment strategies are still hampered by the limited number of randomized controlled trials, promising progress and continuous efforts are seen.

Evaluating the Safety, Efficacy and Patient Acceptability of Intravitreal Fluocinolone Acetonide (0.2mcg/Day) Implant in the Treatment of Non-Infectious Uveitis Affecting the Posterior Segment

Long-acting, slow-release injectable fluocinolone intravitreal implants have been approved for the treatment of non-infectious uveitis affecting the posterior segment. We summarise the development of intravitreal fluocinolone implants and discuss the technology including pharmacokinetics. We conducted a systematic review of evidence for the efficacy, safety and patient acceptability of fluocinolone 0.18 mg and 0.19 mg injectable implants. We summarise evidence from the pivotal phase 3 studies that lead to the approval of these implants and evaluate real-world including disease-specific evidence. Safety including injection-related events and long-term adverse events is presented.

Subconjunctival injections of triamcinolone acetonide to treat uveitic macular edema

AIM

To evaluate the efficacy and safety of subconjunctival triamcinolone acetonide (TA) injections for treating uveitic macular edema (UME).

METHODS

This retrospective case series study included patients with UME who received subconjunctival TA injections with a minimum follow-up period of 6mo. The main outcome measure was central macular thickness (CMT). The secondary outcome measures included best-corrected visual acuity (BCVA), recurrence rate and intraocular pressure (IOP).

RESULTS

In total, 65 patients (80 eyes), mainly including idiopathic uveitis in 33 patients (50.77%) and Vogt-Koyanagi-Harada (VKH) syndrome in 19 patients (29.23%), were enrolled in this study. The mean CMT decreased from 457.6±173.0 µm at baseline to 325.9±176.8, 302.7±148.2, 332.2±177.3 and 270.6±121.6 µm at 1-, 2-, 3- and 6-months postinjection, respectively (all P<0.001). BCVA increased from logMAR 0.5±0.3 at baseline to logMAR 0.4±0.3, 0.4±0.3, 0.4±0.4 and 0.4±0.3 at the 1-, 2-, 3- and 6-months postinjection visits, respectively (all P<0.001). Twenty-one (21/80, 26.25%) eyes underwent relapse of UME within 6mo. A total of 20/80 (25%) eyes exhibited elevated IOPs, of which 13 eyes were controlled with topical IOP-lowering agents and 7 eyes underwent surgical removal of subconjunctival TA deposit.

CONCLUSION

Subconjunctival TA injections appear to be safe and effective for UME.

Perioperative Management of Uveitic Cataracts

Uveitis patients represent a unique subset of the population undergoing cataract surgery and pose several challenges that require special consideration and strategy. Maintenance of disease quiescence for at least three months prior to surgery maximizes postoperative outcomes, though these patients remain at increased risk for pseudophakic cystoid macular edema, which can be refractory to the traditional steroid treatments. In this review, we detail the pillars of preoperative optimization, intraoperative considerations, and postoperative management of uveitic cataracts, with special attention on the evidence surrounding prevention and treatment of refractory postoperative cystoid macular edema.

Miliary tuberculosis developing during adalimumab treatment for Behçet's disease with uveitis

Tumour necrosis factor-alpha (TNF-α) is a key proinflammatory cytokine in non-infective uveitis (NIU). Adalimumab, an anti-TNF-α monoclonal antibody, is approved for the treatment of severe NIU by the European Medicines Agency. There is a recognised risk of serious infections, including tuberculosis (TB), during anti-TNF-α therapy in systemic immune-mediated diseases. We describe miliary pulmonary TB during adalimumab therapy for severe NIU. To our knowledge, this is the first detailed report of this complication in a patient with uveitis. We present the challenges of managing vision-threatening uveitis during life-threatening infection necessitating withdrawal of adalimumab and oral immunosuppression therapy. Uveitis activity was controlled during anti-TB therapy with oral corticosteroid therapy.

Management of chronic ocular sarcoidosis: challenges and solutions

Background

Sarcoidosis constitutes one of the leading causes of ocular inflammation. Chronic ocular sarcoidosis can affect any segment of the eye and its adnexa, producing a wide range of clinical manifestations and severity. If left untreated, permanent visual impairment or even blindness may ensue. Treatment approaches vary from topical therapy to systemic agents that induce immunosuppression to different levels according to disease severity.

Objective

To review the published literature on the management options for chronic ocular sarcoidosis and provide a comprehensive list of available treatment strategies, including the newer biologics.

Summary

Ocular disease remains a challenging aspect of sarcoidosis and may even be the presenting sign of the disease. Prompt and effective therapy may reverse visual damage and prevent permanent loss of vision. Because of the complexity of the disease, a multidisciplinary approach is often required, with a view to addressing both the ocular and other systemic manifestations of sarcoidosis. Recent data suggest that achieving overall optimal systemic control is of paramount importance in controlling eye inflammation as well. Cytotoxic immunosuppressive agents for refractory chronic ocular disease, as well as biologic anti-TNFα therapies, have advanced the management of chronic disease and should be considered corticosteroid-sparing strategies before the onset of significant steroid-induced morbidity.