Early treatment of severe cystoid macular edema in central retinal vein occlusion with posterior sub-tenon triamcinolone acetonide

Novel pharmaceuticals for the management of retinal vein occlusion and linked disorders

INTRODUCTION

Retinal vein occlusion (RVO) is the second leading cause of blindness from retinal vascular disease behind diabetic retinopathy. Anti-vascular endothelial growth factor (VEGF) and glucocorticoid therapy are the cornerstones of pharmaceutical treatment for RVO. There is considerable interest in developing new pharmaceuticals in and out of these two classes to reduce costs, lower injection burden, and treat the occlusion itself, rather than the complications.

AREAS COVERED

In this review, we discuss novel pharmaceuticals for the treatment of RVO outside of current standard of care. We performed a comprehensive literature search encompassing pharmaceuticals that have recently been approved or have shown promising results in early clinical trials or animal models.

EXPERT OPINION

Anti-VEGF therapy remains the most efficacious treatment for RVO with a very favorable side effect profile. New biosimilars reduce costs while maintaining efficacy. Novel glucocorticoids may be a useful therapy in patients for whom anti-VEGF therapy has failed, or as an adjunct. Pharmaceuticals in other drug classes, particularly those with neuroprotective or regenerative properties, as well as those geared toward treating the occlusion itself, represent exciting options for early RVO therapy, but are likely years away from clinical relevance.

Parsplana vitrectomy alone versus parsplana vitrectomy combined with phacoemulsification for the treatment of rhegmatogenous retinal detachment: a randomized study

BACKGROUND

To compare parsplana vitrectomy (PPV) with and without phacoemulsification to treat rhegmatogenous retinal detachment (RRD).

METHODS

Subjects aged 48-65 years with RRD in a phakic eye due to superior retinal tears with an overall extension of retinal breaks < 90° underwent to PPV alone (group A); or PPV plus phacoemulsification (phacovitrectomy, PCV, group B). Post-operative follow-up visits occurred at 1 week, 1 month (m1), 3 months (m3), and 6 months (m6) after surgery. The main outcome was the rate of retinal reattachment. Secondary outcomes included best-corrected visual acuity (BCVA), intraocular pressure (IOP), central macular thickness (CMT), and cataract progression (in the lens-sparing [PPV-alone] group).

RESULTS

In this initial phase of the study a total of 59 patients (mean age: 55 years, 59 eyes) were enrolled: 29 eyes in group A and 30 eyes in group B. Both groups had similar gas tamponade. During the follow-up there were three cases of RRD recurrence in group A and one in group B. The relative risk of recurrence in group A was 3.22 times higher but the difference was not significant (p = 0.3). The two groups were also similar in terms of BCVA and IOP variation. At m3, CMT was significantly higher in group B (p = 0.014). In group A, cataract progression was significant at m6 (p = 0.003).

CONCLUSIONS

In a cohort of RRD patients selected according to their preoperative clinical characteristics, PPV was comparable to PCV in terms of the rate of retinal reattachment after 6 months.

TRIAL REGISTRATION

ISRCTN15940019 . Date registered: 15/01/2021 (retrospectively registered).

Intraocular pressure elevation after subtenon triamcinolone acetonide injection; Multicentre retrospective cohort study in Japan

Purpose

To evaluate real-world evidence for intraocular pressure (IOP) elevation after subtenon triamcinolone acetonide injection (STTA) in 1252 Japanese patients (1406 eyes) in the Japan Clinical REtina STudy group (J-CREST).

Methods

This was a multicentre retrospective study of the medical records of 1252 patients (676 men (758 eyes); mean age: 63.8 ± 12.9 years) who received STTA in participating centres between April 2013 and July 2017.

Results

IOP elevation was observed in 206 eyes (14.7%) and IOP increase ≥ 6 mmHg was found in 328 eyes (23.3%). In total, 106 eyes (7.5%) needed medication and two eyes (0.14%) needed surgical procedures. Younger age, higher baseline IOP, and steroid dose were risk factors associated with IOP elevation. Risk factors associated with IOP increase ≥ 6 mmHg were younger age, lower baseline IOP, steroid dose, and higher incidences of diabetic macular oedema (DME) and uveitis. In contrast, with steroid dose fixed at 20 mg, a lower incidence of DME was a risk factor for increased IOP, suggesting that STTA had dose-dependent effects on IOP increase, especially in patients with DME.

Conclusion

Our real-world evidence from a large sample of Japanese patients who received STTA showed that the incidence of IOP elevation after STTA was 14.7%, and was associated with younger age, higher baseline IOP, and steroid dose. Thus, IOP should be monitored, especially in patients with younger age, higher baseline IOP, and higher incidences of DME and uveitis.

Comparison between intravitreal bevacizumab and posterior sub-tenon injection of triamcinolone acetonide in macular edema secondary to retinal vein occlusion

Aim

To compare the efficacy and safety between posterior sub-tenon injection of triamcinolone acetonide (PSTA) and intravitreal injection of bevacizumab (Avastin) (IVIA) in the treatment of macular edema secondary to retinal vein occlusion.

Patients and methods

A total of 45 eyes were retrospectively enrolled (23 eyes with intravitreal bevacizumab and 22 eyes with posterior sub-tenon triamcinolone acetonide). Main endpoints included logMAR of best-corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP) before and after treatment at 6 months.

Results

The mean logMAR improved from 0.78 to 0.56 at 6 months for intravitreal bevacizumab (p=0.001), and from 0.91 to 0.79 and 0.87 at 3 and 6 months (p=0.038 and 0.13), respectively, for sub-tenon triamcinolone acetonide. At 6 months, the BCVA was significantly better in the bevacizumab group (p=0.02). Both groups' mean CMT significantly improved, from 478 µm at baseline to 295 µm at 6 months in IVIA group (p<0.001) and from 419 µm at baseline to 350 µm in PSTA group (p=0.012); however, this was not different between the groups at 6 months (p=0.065). Recurrence of macular edema was not different between the groups either (p=0.08). Poorer final vision was associated with poorer baseline BCVA and diagnosis of central retinal vein occlusion after adjustment for age and sex (p<0.001 and 0.012, respectively). Significant elevation of IOP was noted at 3 months in the PSTA group, but declined at 6 months compared with baseline (p=0.002 and 0.41, respectively).

Conclusion

Intravitreal bevacizumab seemed to achieve better visual acuity compared with posterior sub-tenon injections of triamcinolone acetonide at 6 months, while CMT was comparable. PSTA still resulted in transient IOP elevation.

Characteristics of retinal vein occlusion with final vision better than 78 letters after sequential therapy with ranibizumab and triamcinolone acetate

AIM

To analyze the reasons that may lead to the different vision result by combining the ranibizumab and triamcinolone acetate (TA) in sequence to treat macular edema in retinal vein occlusion (RVO).

METHODS

Ranibizumab and TA were combined in sequence to treat 43 patients with macular edema secondary to RVO. Six months after the treatment, patients with central fovea thickness (CFT) less than 300 µm in optical coherence tomography (OCT) were collected into Groups I and II, based on vision acuity (VA) better than 78 letters or less than 60 letters. The age, baseline VA, duration from onset to treatment, CFT at the baseline, sub-retinal fluid (SRF), sub-foveal exudates and injection times of TA and ranibizumab were taken into comparison.

RESULTS

The mean age of the subjects was 46.4y in Group I but 57.5y in Group II. The difference of age was significant between groups (P<0.01). The mean baseline VA was 51.4 letters in Group I and 43.9 letters in Group II (P<0.05). The baseline CFT were 670.9 µm in Group I with SRF in 54.3% patients and 678.1 µm in Group II with SRF in 52.9% (P>0.05). The mean number of injections of TA was 0.9 and the mean number of injections of ranibizumab was 2.3 in Group I but 1.7 and 2.9 respectively in Group II. The treatment times of ranibizumab had no difference between the 2 groups (P>0.05) but the difference of TA injection times was significant, P<0.05. Subfoveal exudates at final stage happened in no subjects in Group I but in 45.83% subjects in Group II.

CONCLUSION

This combined treatment is safer than TA injection and cheaper than ranibizumab injection alone. Younger patients and earlier treatment will help to get better vision outcome. Subfoveal exudates at the final stage have significant relationship with vision outcome. No relationship existed between the baseline CFT, SRF and the vision outcome.

Periocular corticosteroid injections in uveitis: effects and complications

PURPOSE

To evaluate the benefits and complications of periocular depot corticosteroid injections in patients with ocular inflammatory disorders.

DESIGN

Multicenter, retrospective cohort study.

PARTICIPANTS

A total of 914 patients (1192 eyes) who had received ≥ 1 periocular corticosteroid injection at 5 tertiary uveitis clinics in the United States.

METHODS

Patients were identified from the Systemic Immunosuppressive Therapy for Eye Diseases Cohort Study. Demographic and clinical characteristics were obtained at every visit via medical record review by trained reviewers.

MAIN OUTCOME MEASURES

Control of inflammation, improvement of visual acuity (VA) to ≥ 20/40, improvement of VA loss attributed to macular edema (ME), incident cataract affecting VA, cataract surgery, ocular hypertension, and glaucoma surgery.

RESULTS

Among 914 patients (1192 eyes) who received ≥ 1 periocular injection during follow-up, 286 (31.3%) were classified as having anterior uveitis, 303 (33.3%) as intermediate uveitis, and 324 (35.4%) as posterior or panuveitis. Cumulatively by ≤ 6 months, 72.7% (95% CI, 69.1-76.3) of the eyes achieved complete control of inflammation and 49.7% (95% CI, 45.5-54.1) showed an improvement in VA from <20/40 to ≥ 20/40. Among the subset with VA <20/40 attributed to ME, 33.1% (95% CI, 25.2-42.7) improved to ≥ 20/40. By 12 months, the cumulative incidence of ≥ 1 visits with an intraocular pressure of ≥ 24 mmHg and ≥ 30 mmHg was 34.0% (95% CI, 24.8-45.4) and 15.0% (95% CI, 11.8-19.1) respectively; glaucoma surgery was performed in 2.4% of eyes (95% CI, 1.4-3.9). Within 12 months, among phakic eyes initially ≥ 20/40, the incidence of a reduction in VA to <20/40 attributed to cataract was 20.2% (95% CI, 15.9-25.6); cataract surgery was performed within 12 months in 13.8% of the initially phakic eyes (95% CI, 11.1-17.2).

CONCLUSIONS

Periocular injections were effective in treating active intraocular inflammation and in improving reduced VA attributed to ME in a majority of patients. The response pattern was similar across anatomic locations of uveitis. Overall, VA improved in one half of the patients at some point within 6 months. However, cataract and ocular hypertension occurred in a substantial minority.

Effect of posterior sub-tenon triamcinolone in macular edema due to non-ischemic vein occlusions

PURPOSE

To study the efficacy and safety of Posterior Sub-Tenon Triamcinolone acetonide (PSTT) in the treatment of macular edema in retinal vein occlusions. The efficacy is studied by anatomical and visual improvements.

BACKGROUND

Macular edema is the most common cause of visual loss in retinal vein occlusions. Many treatments have been advocated including laser, PSTT etc. The most recent trend is the usage of intravitreal Anti-VEGF (Vascular Endothelial Growth Factor) agents and steroids. Intravitreal injections have more complications.

METHODS

This study was a prospective interventional case series. 24 eyes of 24 patients (13 male and 11 female) with recent onset non-ischemic RVO (Retinal Vein Occlusion) underwent Posterior Sub-Tenon Triamcinolone (PSTT). Of the 24 eyes treated, 18 eyes were of BRVO (Branch Retinal Vein Occlusion) and 6 were CRVO (Central Retinal Vein Occlusion). All the eyes received 40 mg of Triamcinolone Acetonide (TA) in 1ml through posterior sub-tenon route. All the eyes were examined at baseline and after four weeks of being injected with TA. Changes in the best corrected visual acuity {letters of ETDRS (Early Treatment Diabetic Retinopathy Study) chart} and Central Macular Thickness (CMT) were studied. A gain of more than 5 letters was considered as effective. The eyes were examined for raised IOP (Intra-Ocular Pressure) and other complications.

RESULTS

Out of the 24 eyes 19 (79%) showed an improvement of more than 5 letters after a month of treatment. All the patients exhibited a certain degree of decrease in CMT. The mean BCVA increased from 30.08±10.16 to 40.21±8.93 (p<0.05). The mean CMT decreased from 575.08±131.55 to 282.08±163.99 (p<0.05). Out of them 3 eyes developed raised IOP of more than >21mmHg, which was controlled with medication. There were no other complications observed in any of the patients.

CONCLUSION

PSTT is an effective modality of treatment with minimal complications for macular edema associated with Non-Ischemic RVO with minimal complications. In view of the more severe complications associated with intravitreal injections, PSTT can be used as the first line of treatment before contemplating intravitreal injections. Multicenter randomised trials with longer periods of follow-up are needed to evaluate the long term safety and efficacy of this treatment. Furthermore, comparative studies are required to compare it with intravitreal Anti-VEGF or TA.

Comparison between Intravitreal Triamcinolone with Grid Laser Photocoagulation versus Bevacizumab with Grid Laser Photocoagulation Combinations for Branch Retinal Vein Occlusion

Purpose. To compare the efficacy of intravitreal triamcinolone (IVT) and intravitreal bevacizumab (IVB), both combined with grid laser photocoagulation (GLP) for macular edema (ME) secondary to branch retinal vein occlusion (BRVO). Methods. Retrospective, comparative study. The newly diagnosed patients with ME secondary to BRVO who were treated with IVT and GLP or IVB and GLP were included. The main outcome measures were changed in the best corrected visual acuity (BCVA) and central retinal thickness (CRT) from the baseline to month 24. Results. Ninety-nine eyes of 99 patients were included. The change in BCVA was not statistically different in any time points between the two groups (P > 0.05, for all). The change in CRT was not statistically different in any time points between the two groups (P > 0.05, for all). The mean number of injections at month 24 was 2.38 ± 1.06 in the IVT+GLP group and 4.17 ± 1.30 in the IVB+GLP group (P = 0.0001). The need for cataract surgery (P = 0.01) and secondary glaucoma (P = 0.03) occurrence were more common in IVT group. Conclusion. Both treatment modalities were effective in the treatment of ME secondary to BRVO. The number of injections was significantly lower in the IVT group than in the IVB group; however cataract and secondary glaucoma were more frequent in the IVT+GLP group than in the IVB+GLP group.

Influence of drug solubility and lipophilicity on transscleral retinal delivery of six corticosteroids

The influence of drug properties including solubility, lipophilicity, tissue partition coefficients, and in vitro transscleral permeability on ex vivo and in vivo transscleral delivery from corticosteroid suspensions was determined. Solubility, tissue/buffer partition coefficients for bovine sclera and choroid-retinal pigment epithelium (CRPE), and in vitro bovine sclera and sclera-choroid-retinal pigment epithelium (SCRPE) transscleral transport were determined at pH 7.4 for triamcinolone, prednisolone, dexamethasone, fluocinolone acetonide, triamcinolone acetonide, and budesonide in solution. Ex vivo and in vivo transscleral delivery was assessed in Brown Norway rats after posterior subconjunctival injection of a 1 mg/ml suspension of each corticosteroid. Corticosteroid solubility and partition coefficients ranged from ∼ 17 to 300 μg/ml and 3.0 to 11.4 for sclera and from 7.1 to 35.8 for CRPE, respectively, with the more lipophilic molecules partitioning more into both tissues. Transport across sclera and SCRPE was in the range of 3.9 to 10.7% and 0.3 to 1.8%, respectively, with the transport declining with an increase in lipophilicity. Ex vivo and in vivo transscleral delivery indicated tissue distribution in the order CRPE ≥ sclera > retina > vitreous. Tissue partitioning showed a positive correlation with drug lipophilicity (R(2) = 0.66-0.96). Ex vivo and in vivo sclera, CRPE, retina, and vitreous tissue levels of all corticosteroids showed strong positive correlation with drug solubility (R(2) = 0.91-1.0) but not lipophilicity (R(2) = 0.24-0.41) or tissue partitioning (R(2) = 0.24-0.46) when delivered as suspensions. In vivo delivery was lower in all eye tissues assessed than ex vivo delivery, with the in vivo/ex vivo ratios being the lowest in the vitreous (0.085-0.212). Upon exposure to corticosteroid suspensions ex vivo or in vivo, transscleral intraocular tissue distribution was primarily driven by the drug solubility.

Economic considerations of macular edema therapies

PURPOSE

To relate costs and treatment benefits for diabetic macular edema (DME), branch retinal vein occlusion (BRVO), and central retinal vein occlusion (CRVO).

DESIGN

A model of resource use, outcomes, and cost-effectiveness and utility.

PARTICIPANTS

None.

METHODS

Results from published clinical trials (index studies) of laser, intravitreal corticosteroids, intravitreal anti-vascular endothelial growth factor (VEGF) agents, and vitrectomy trials were used to ascertain visual benefit and clinical protocols. Calculations followed from the costs of 1 year of treatment for each treatment modality and the visual benefits as ascertained.

MAIN OUTCOME MEASURES

Visual acuity (VA) saved, cost of therapy, cost per line saved, cost per line-year saved, and costs per quality-adjusted life years (QALYs).

RESULTS

The lines saved for DME (0.26-2.02), BRVO (0.74-4.92), and CRVO (1.2-3.75) yielded calculations of costs/line of saved VA for DME ($1329-$11,609), BRVO ($494-$13,039), and CRVO ($704-$7611); costs/line-year for DME ($60-$561), BRVO ($25-$754), and CRVO ($45-$473); and costs/QALY ($824 to $25,566).

CONCLUSIONS

Relative costs and benefits should be considered in perspective when applying and developing treatment strategies.