INTRAVITREAL DEXAMETHASONE IMPLANT IN PATIENTS WITH RANIBIZUMAB PERSISTENT DIABETIC MACULAR EDEMA

Prospective, Observational, Multicenter, Real-World Study of the Efficacy, Safety, and Pattern of Use of the Dexamethasone Intravitreal Implant in Diabetic Macular Edema in France: Short-Term Outcomes of LOUVRE 3

INTRODUCTION

To evaluate real-world efficacy, safety, and treatment patterns with the dexamethasone intravitreal implant (DEX) in diabetic macular edema (DME) in France.

METHODS

In this prospective, multicenter, observational, noncomparative, post-reimbursement study, consecutively enrolled patients with DME had a baseline evaluation on day 0. Those treated with DEX on day 0 were to be reevaluated at week 6 and months 6, 12, 18, and 24. DEX retreatment and/or alternative therapies were allowed during follow-up. The primary outcome measure was the maximum best corrected visual acuity (BCVA) gain from baseline during follow-up. Secondary outcome measures included time to maximum BCVA gain, patients (%) with prespecified BCVA gains from baseline at each visit, maximum central retinal thickness (CRT) reduction from baseline, patients (%) with CRT reduction ≥ 20% from baseline at each visit, patients (%) with DME resolution (per investigator judgement), and adverse events (AEs).

RESULTS

Of 112 patients/eyes with DME for 3.5 years (mean) at baseline, 80 (including 86.1% previously treated) received DEX on day 0 and were analyzed for efficacy. Early study termination precluded collection of ≥ 12-month efficacy data. Patients received 1.4 DEX injections over 8.3 months (averages). The maximum BCVA gain from baseline was 3.6 letters, reached after 77.2 days (averages); 24.6% (week 6) and 15.0% (month 6) of patients experienced ≥ 10-letter BCVA gains from baseline. The mean maximum CRT reduction from baseline was -146.4 µm; 61.4% (week 6) and 36.0% (month 6) of patients had CRT reductions ≥ 20% from baseline, and 68.1% reported DME resolution at least once during follow-up. Ocular hypertension (n = 8, 12.1%) was the most frequent treatment-related AE.

CONCLUSIONS

LOUVRE 3 confirmed that DEX improves BCVA and CRT, even in a patient population that had predominantly received DEX before enrollment in the study, and showed that DME resolution was observed during follow-up. DEX tolerability was consistent with published data, supporting treatment benefits in DME.

CLINICALTRIALS

GOV IDENTIFIER

NCT03003416.

Efficacy and safety of the dexamethasone implant in vitrectomized and nonvitrectomized eyes with diabetic macular edema: A systematic review and meta-analysis

Purpose: To compare the efficacy and safety of the intravitreal dexamethasone (DEX) implant for the treatment of diabetic macular edema (DME) in vitrectomized and nonvitrectomized eyes.

Methods: We performed a literature search in four electronic databases (PubMed, EMBASE, MEDLINE, and Cochrane Library) from inception to 22 May 2022. Studies comparing the efficacy of the DEX implant in vitrectomized and nonvitrectomized eyes with DME with at least 3 months of follow-up were included. The main outcomes included comparison of the mean change in the best-corrected visual acuity (BCVA) and central macular thickness (CMT) from baseline to different follow-up endpoints between the vitrectomized and nonvitrectomized groups. The secondary outcomes were the mean duration of action for the first DEX implantation and the number of required injections throughout the follow-up period. Safety data were collected and compared.

Results: The final analysis included 7 studies involving 582 eyes, 208 vitrectomized eyes and 374 nonvitrectomized eyes. The mean between-group differences in BCVA improvement were not significant at any endpoint, with averages difference of −0.07 logarithm of the minimum angle of resolution (logMAR) (p = 0.088) at 1 month, −0.03 logMAR (p = 0.472) 3 months, −0.07 logMAR (p = 0.066) 6 months, and −0.04 logMAR (p = 0.486) 12 months. The mean between-group differences in CMT reduction were not statistically significant, with mean differences of 7.17 μm (p = 0.685) at 1 month, 20.03 μm (p = 0.632) 3 months, −1.80 μm (p = 0.935) 6 months, and −25.65 μm (p = 0.542) 12 months. However, the vitrectomized group had a significantly shorter duration of action during the first DEX implantation than the nonvitrectomized group, with a mean difference of 0.8 months (p = 0.005). No significant between-group differences were detected for the number of required injections or safety profile.

Conclusion: This meta-analysis showed similar efficacy and safety of the sustained-release DEX intravitreal implant for vitrectomized and nonvitrectomized eyes with DME. The intravitreal DEX implant could be considered an effective choice for DME treatment in eyes with prior vitrectomy.

Intravitreal corticosteroids for diabetic macular edema: a network meta-analysis of randomized controlled trials

BACKGROUND

To evaluate the efficacy and safety of different intravitreal corticosteroids for treating diabetic macular edema (DME).

METHODS

Four databases were systematically searched for randomized controlled trials comparing different intravitreal corticosteroids for treating DME. The primary outcome was the change in best-corrected visual acuity (BCVA) within 6 months after the first injection (short-term BCVA). Secondary outcomes were the change in BCVA over 1 year (long-term BCVA) and changes in central macular thickness (CMT) and intraocular pressure (IOP) within 6 months after the first injection. Network meta-analysis was performed to aggregate the results from the individual studies.

RESULTS

Nineteen trials involving 2839 eyes were included. Intravitreal triamcinolone acetonide (TA) injections (≥ 8 mg and 4-8 mg), fluocinolone acetonide (FA) implants (0.5 µg/day) and dexamethasone (DEX) implants (700 µg) improved short-term BCVA (mean changes in logMAR [95% confidence interval] - 0.27 [- 0.40, - 0.15]; - 0.12 [- 0.18, - 0.06]; - 0.10 [- 0.21, - 0.01]; and - 0.06 [- 0.11, - 0.01]). Intravitreal TA injections (4 mg, multiple times), FA implants (0.5 µg/day and 0.2 µg/day), and DEX implants (350 µg) improved long-term BCVA (mean changes in logMAR [95% confidence interval] - 0.11 [- 0.21, - 0.02]; - 0.09 [- 0.15, - 0.03]; - 0.09 [- 0.14, - 0.02]; and - 0.04 [- 0.07, - 0.01]). All intravitreal corticosteroids reduced CMT, and different dosages of TA did not show significant differences in increasing IOP.

CONCLUSIONS

Intravitreal corticosteroids effectively improved BCVA in DME patients, with higher dosages showing greater efficacies. TA was not inferior to FA or DEX and may be considered a low-cost alternative choice for DME patients. The long-term efficacy and safety of different corticosteroids deserve further investigation. Trial registration Prospectively registered: PROSPERO, CRD42020219870.

Efficacy and safety of single-dose dexamethasone implantation for patients with persistent diabetic macular edema: a systematic review and meta-analysis

PURPOSE

This meta-analysis was conducted to evaluate the efficacy and safety of single-dose dexamethasone implantation for treating persistent DME (diabetic macular edema) refractory to anti-VEGF (anti-vascular endothelial growth factor) drugs over a period of 6 months.

METHODS

All related clinical trials were reviewed by searching electronic databases of PubMed, Medline, Web of Science, Cochrane Library, and EMBASE. The primary outcome parameters were best-corrected visual acuity (BCVA) and central macular thickness (CMT). We performed this meta-analysis by using Stata15.0.

RESULTS

Ten clinical trials involving 362 eyes from 328 patients were eligible in the final analysis. After single-dose dexamethasone implantation, there was a significant improvement in BCVA from baseline to 1, 3, and 6 months with an average increase of - 0.15 logMAR (p < 0.001), - 0.14 logMAR (p < 0.001), and - 0.07 logMAR (p = 0.004), respectively. Further, mean CMT decreased significantly with an average reduction of 249.18 μm (p < 0.001), 217.66 μm (p < 0.001), and 91.56 μm (p < 0.001) at months 1, 3, and 6, respectively.

CONCLUSIONS

Our results indicate that switching to a dexamethasone implant could achieve significant anatomical and functional improvement among patients with refractory DME. Clinicians should be aware of this treatment option in refractory DME.

Visual/anatomical outcome of diabetic macular edema patients lost to follow-up for more than 1 year

To investigate the visual/anatomical outcome of diabetic macular edema (DME) patients lost to follow-up (LTFU) for more than 1 year during intravitreal anti-VEGF treatment. A retrospective review of 182 treatment-naïve DME patients was performed. Among them, we identified patients LTFU for more than 1 year during anti-VEGF treatment. Visual acuity and anatomic outcomes at the first visit, last visit before being LTFU, return visit, and after re-treatment were analyzed and compared with those of DME patients with regular follow-up. Patients who had continuous follow-up visits were assigned to the control group. Sixty patients (33%) with DME were LTFU for more than 1 year during anti-VEGF treatment. Multivariate analysis revealed that the ratio of male (p = 0.004), diabetes mellitus (DM) duration less than 5 years (p = 0.015), and poor early anatomic response (p = 0.012) were higher compared to the control group. Eighteen patients returned to the clinic and received re-treatment. After re-treatment with anti-VEGF, central subfield thickness (CST) was significantly improved to the CST of before LTFU. However, visual acuity did not recover to the level before LTFU (0.63 ± 0.26 vs. 0.45 ± 0.28, p = 0.003). About thirty percent of DME patients were LTFU for more than 1 year. Permanent visual loss was observed in these LTFU patients. Patients with a high risk of LTFU such as male, early DM, and poor response after initial injections should be treated more aggressively to improve the visual outcomes.

COMPARISON OF INTRAVITREAL DEXAMETHASONE IMPLANT AND AFLIBERCEPT IN PATIENTS WITH TREATMENT-NAIVE DIABETIC MACULAR EDEMA WITH SEROUS RETINAL DETACHMENT

PURPOSE

To compare the efficacy and safety of intravitreal dexamethasone (DEX) implant versus aflibercept in patients with treatment-naive diabetic macular edema with inflammatory biomarkers.

METHODS

Ninety-eight eyes of 62 treatment-naive patients with diabetic macular edema with serous retinal detachment and hyperreflective foci were enrolled. Each patient was randomized to receive either aflibercept or DEX implant treatment. The treatment protocol included 3 monthly injections of 2 mg of aflibercept as a loading phase in the anti-vascular endothelial growth factor group and 0.7 mg of DEX implant in the DEX group and then pro re nata treatment. Primary outcome measures were mean changes in visual acuity and central retinal thickness at the end of the 12-month follow-up.

RESULTS

Forty-eight eyes of 29 patients were received DEX implant, and 50 eyes of 33 patients received the aflibercept injection. Mean central retinal thickness decreased from 615.2 µm at baseline to 297.7 µm at 12 months in the DEX group (P < 0.001) and from 576.5 µm to 367.4 µm in the aflibercept group (P < 0.001). Except for the first month, mean central retinal thickness reduction was significantly higher in the DEX group (P < 0.05, Mann-Whitney U Test). Visual acuity improved significantly at the end of the follow-ups (46.3-52.7 Early Treatment Diabetic Retinopathy Study letters in the DEX group and 47.5-56.8 Early Treatment Diabetic Retinopathy Study letters in the aflibercept group at 12 months, P < 0.001, paired-sample t-test). Adjusting by baseline values, the increase in mean visual acuity during the 12-month follow-ups favored the aflibercept group (P < 0.01), 25% of the DEX-treated eyes and 42% of the aflibercept treated eyes experienced 10 or more Early Treatment Diabetic Retinopathy Study letters visual gain (P: 0.058). The DEX group received significantly fewer (2.6 vs. 7.2) injections (P: 0.001).

CONCLUSION

It was observed that the both of DEX implant and aflibercept were effective and safe in treatment-naive diabetic macular edema patients with inflammatory phenotype. Anatomical results were found to be better in the DEX group, and functional results were found to be better in the aflibercept group. In pseudophakic eyes, the functional superiority of aflibercept ceased to exist, and the low number of injections in the DEX implant group was seen as an advantage.

Differential response to intravitreal dexamethasone implant in naïve and previously treated diabetic macular edema eyes

Background

To identify different response patterns to intravitreal dexamethasone implants (IDI) in naïve and previously treated (PT) diabetic macular edema (DME) eyes in a real-life setting.

Methods

342 IDI injections (203 DME eyes) were included. Number of IDI injections, percentage (%) of eyes with 1, 2, 3 and ≥ 4 injections, time to reinjections, visual acuity (VA), intraocular pressure (IOP) and central retinal thickness (CRT) were evaluated for naïve and PT DME eyes over 24 months.

Results

Mean number of injections was significantly lower in naïve vs PT DME eyes (1.40 ± 0.9 vs 1.82 ± 0.9, p < 0.001). The percentage of eyes receiving 1 injection was significantly higher in naïve vs PT DME eyes (76.1 vs 47.7), (p < 0.001). However, it was significantly lower for 2 (16.4 vs 29.4), or 3 injections (1.4 vs 17.6) (both p < 0.001), with no differences in eyes receiving ≥4 injections (5.9 vs 5.1 respectively, p = 0.80). Mean time to reinjection was not significantly different between both groups for the second, third and fourth injection (9.6 ± 4.0 vs 10.0 ± 5.5, p = 0.75, 13.2 ± 4.0 vs 16.0 ± 3.5, p = 0.21 and 21.7 ± 3.8 vs 19.7 ± 5.8, p = 0.55). VA scores were consistently better in naïve vs PT DME eyes at all studied timepoints, with no significant differences in CRT reduction or adverse effect rates.

Conclusion

Naïve DME eyes received lower number of IDI injections and showed better VA levels than PT DME eyes for 24 months in a real-world setting. This data supports the IDI use in early DME stages and provide further evidence of better IDI response when used as first-line therapy.

Choroidal Thickness After Dexamethasone Implant or Aflibercept in Patients with Diabetic Macular Edema Persistent to Ranibizumab

Purpose: This study aims to compare subfoveal choroidal thicknesses (SFCTs) after intravitreal dexamethasone (IVD) or intravitreal aflibercept (IVA) treatment in patients with persistent diabetic macular edema (DME) unresponsive to intravitreal ranibizumab (IVR). Methods: The study consisted of patients with DME unresponsive to IVR treatment in which 37 were administered 1 dose IVD (group A) and 34 patients who were administered 3 doses of IVA (group B), as well as 35 healthy individuals (group C). Detailed ophthalmological examination and optical coherence tomography parameters of group A and group B, including central retinal thickness and SFCT, were retrospectively evaluated before and after treatment. Results from preinjection, and 1, 2, and 3 months after injection were analyzed. Results of group A and group B were compared within themselves and also compared with group C. Results: SFCT measurements were compared within group A and group B (1 = preinjection; 2 = 1 month postinjection; 3 = 2 months postinjection; 4 = 3 months postinjection). There was significant thinning in SFCT between 1-2, 1-3, 1-4, 2-3, 2-4, and 3-4 time intervals within both group A and group B (both P < 0.001). Comparison of SFCT measurements showed preinjection, 1-, and 2-month values of group A were significantly thicker than those of group C (P < 0.001), whereas there was no significant difference between 3-month values (P = 0.09). Preinjection, 1-, and 2-month values of group B were significantly thicker than those of group C (P < 0.001), whereas there was no significant difference between 3-month values (P = 0.06). Conclusions: Three month follow-up showed thinning in SFCT measurements in patients with persistent DME unresponsive to IVR who were applied IVD or IVA treatment.

Anatomical and functional changes after dexamethasone implant and ranibizumab in diabetic macular edema: a retrospective cohort study

AIM

To investigate the efficacy and safety of ranibizumab (RZB group) and dexamethasone implant (DEX group) intravitreal treatments in patients with treatment-naïve center involved diabetic macular edema (DME) by means of functional and morphological assessments.

METHODS

This retrospective cohort study included 50 eyes of 50 patients with DME treated either with RBZ or DEX. Best-corrected visual acuity (BCVA) and microperimetry were evaluated at baseline and during a 6-month follow-up. In addition, central macular thickness (CMT) by means of structural optical coherence tomography (OCT) and retinal capillary plexus density and choriocapillary density by means of OCT angiography were assessed in all cases.

RESULTS

Functional and morphological parameters significantly improved during the study period in both groups. BCVA improved significantly in both groups with a greater increase in the DEX group compared to the RBZ group (P=0.030). Microperimetry significantly differed during follow-up between the two treatments (P=0.031). In both groups CMT significantly decreased (P<0.001) without statistically significant differences between the two groups. A statistically significant increase of deep capillary plexus density was detected in both groups at 30d after therapy. The retreatment rate was 0.70±0.10 and 0.65±0.10 in the RBZ group and 0.65±0.10 and 0.50±0.11 in DEX group at 120 and 180d respectively. Two out of 25 patients in DEX group showed intraocular pressure increase requiring hypotonic eye drops.

CONCLUSION

Both treatments are very effective for DME treatment during 6mo of follow-up with a lower retreatment rate in DEX group.

Corticosteroids and Anti-Complement Therapy in Retinal Diseases

Corticosteroids are unique in that they are the one class of agents that acts upon most of the multiple processes in the pathophysiology of macular edema. Corticosteroids are capable of inhibiting prostaglandin and leukotriene synthesis as well as interfering with intercellular adhesion molecule-1 (ICAM-1), interleukin-6, VEGF-A, and stromal cell derived factor-1 pathways. Triamcinolone, dexamethasone, and fluocinolone have been extensively used in the treatment of retinal and choroidal vascular diseases. Sustained release implants of steroids have reduced the burden of repeated intravitreal injections necessary in most of the retinal diseases. Complement factors play an important role in the pathogenesis of age-related macular degeneration (AMD). Inhibitors of complement could provide a breakthrough in the treatment of dry AMD. Complement factor inhibitors, such as POT-4, lampalizumab, and eculizumab, have been tested in clinical trials for dry AMD with promising results. However, results of phase 3 trials are awaited.

Pharmacological Management of Diabetic Macular Edema in Real-Life Observational Studies

OBJECTIVES OF THE STUDY

of observational studies concerning the pharmacological management of diabetic macular edema (DME).

METHODS

A literature review was conducted using the PubMed database on 1 February 2018 to identify studies evaluating the efficacy of anti-VEGF and dexamethasone (DEX) implants for DME. Studies with more than 10 patients and follow-up of more than 6 months were selected. Analyses were carried out on the overall population and on subgroups defined according to baseline visual acuity (BVA) and the patients' naïve or non-naïve status.

RESULTS

Thirty-two studies evaluating the efficacy of anti-VEGF and 31 studies evaluating the efficacy of DEX-implants were retained, concerning 6,842 and 1,703 eyes, respectively. A mean gain of +4.7 letters for a mean of 5.8 injections (mean follow-up: 15.6 months) and +9.6 letters for a mean of 1.6 injections (10.3 months) was found in the anti-VEGF and DEX-implant studies, respectively. Final VA appears to be similar for both treatment (62 letters for anti-VEGF, 61.2 letters for DEX-implant), and BVA appears lower for DEX-implant, which may partially explain the greater visual gain. The DEX-implant studies show greater gains in VA compared to the anti-VEGF studies, especially for higher BVA. Indeed, mean gains for the subgroups of patients with BVA<50 letters, 5060 letters are +4.3, +5.8, and +3.1 letters, respectively, in the anti-VEGF studies and +10.5, +9.3, and +8.8 letters, respectively, in the DEX-implant studies. Regarding the patient's initial status, only naïve status appears to confer the best functional response in DEX-implant studies.

CONCLUSION

Observational studies investigating DEX-implant report clinically similar final VA when compared to anti-VEGF, but superior visual gains in real-life practice. This latter difference could be due to the better BVA, but also to the fact that less injections were administered in the anti-VEGF observational studies than in the interventional studies.

Comparison of Intravitreal Aflibercept and Ranibizumab following Initial Treatment with Ranibizumab in Persistent Diabetic Macular Edema

Purpose

To compare the visual and anatomic outcomes in patients with persistent diabetic macular edema (DME) who switched from ranibizumab to aflibercept with those who continued with previous ranibizumab therapy.

Methods

In this retrospective comparative study, medical records of consecutive patients with center-involved DME ≥ 350 μm who had at least three recent consecutive monthly ranibizumab injections followed by as-needed therapy with either aflibercept or ranibizumab were reviewed. Data were collected at presentation (preinjection), at the intermediary visit, and at the last visit (at the end of the follow-up period).

Results

Forty-three eyes of 43 patients were divided into two groups: the switch group (n = 20) and the ranibizumab group (n = 23). Though no significant improvement was found in the mean BCVA from the intermediary visit to the last visit, there was a difference in the mean CMT in the switch group and the ranibizumab group (p < 0.001 and p = 0.03, resp.). The mean CMT decreased after the intermediary visit by 188.6 ± 120.5 μm in the switch group and by 60.3 ± 117.1 μm in the ranibizumab group (p = 0.003).

Conclusions

Both aflibercept and ranibizumab decreased CMT in patients with persistent DME who showed a poor response to ranibizumab injections. However, switching to aflibercept provided only morphologic improvement.

Diabetic Macular Edema: Current Understanding, Pharmacologic Treatment Options, and Developing Therapies

Diabetic retinopathy and diabetic macular edema comprise a major source of visual disability throughout the developed world. The etiology and pathogenesis of macular edema is intricate and multifactorial, in which the hyperglycemic state in diabetes induces a microangiopathy. Through several inflammatory and vasogenic mediators, including vascular endothelial growth factor (VEGF) upregulation and inflammatory cytokines and chemokines, pathologic changes are induced in the vascular endothelium triggering breakdown of the blood retinal barrier, causing extravasation of fluid into the extracellular space and manifesting clinically as macular edema, resulting in visual loss. The advent of medications targeting the VEGF pathway has led to great clinical improvements compared with the previous standard of care of laser therapy alone, as shown in studies such as RISE, RIDE, VIVID, VISTA, and DRCR. However, analyses have shown that many patients have inadequate response or are nonresponders to anti-VEGF therapy, demonstrating the need for additional therapies to more comprehensively treat this disease. Although corticosteroid treatments and implants have demonstrated some efficacy in adjunctive and supplemental treatment, the need to more adequately treat macular edema remains. Our knowledge of diabetic macular edema continues to grow, leading to new currently available and emerging pharmacotherapies to further enhance our treatment and restore vision in those affected by diabetic macular edema. This review will discuss the pathogenesis of diabetic macular edema and the pharmacologic therapies available for its treatment, including anti-VEGF, steroids, and newer therapies still in development, such as angiopoietin antagonists, Tie2 agonists, kallikrein inhibitors, interleukin inhibitors, and others.

Dexamethasone Intravitreal Implant in Diabetic Macular Edema: Real-Life Data from a Prospective Study and Predictive Factors for Visual Outcome

INTRODUCTION

The purpose of the study was to evaluate the long-term anatomical and functional outcomes in patients with diabetic macular edema (DME) treated with intravitreal dexamethasone implant and to determine the predictive factors for the final visual outcome.

METHODS

The study included 54 patients with DME refractory to previous antivascular endothelial growth factor (anti-VEGF) who were treated with intravitreal dexamethasone implant. Predictive factors for visual outcome were assessed. In addition, the change in best-corrected visual acuity (BCVA) and the percentage of patients with edema resolution were evaluated.

RESULTS

At the end of the 12-month follow-up, patients with DME gained + 5.2 letters (about 1 Snellen line), while 57.4% of patients presented total resolution of macular edema. Negative predictive factors for the final visual outcome were found to be increasing age, increasing macular thickness, phakic status, the presence of intraretinal fluid, hyperreflective foci, hard exudates, as well as external limiting membrane and ellipsoid zone disruption. The mean number of injections was 2.1.

CONCLUSIONS

The various predictive factors that determine the visual outcome and possibly define patient prognosis after dexamethasone intravitreal implant in DME cases have been studied. The long follow-up showed that dexamethasone intravitreal implant seems to be a safe and effective treatment for this disease, requiring a limited number of injections.

Outcomes of Intravitreal Dexamethasone Implant in the Treatment of Recalcitrant Diabetic Macular Edema

Objectives:

To investigate the efficacy and safety of intravitreal dexamethasone (OZURDEX®) implantation in patients with recalcitrant diabetic macular edema.

Materials and Methods:

This is a retrospective non-randomized study of patients who underwent intravitreal dexamethasone implantation for recalcitrant diabetic macular edema. Main outcome measures included changes in best corrected visual acuity (BCVA), central macular thickness (CMT), and incidence of ocular side effects.

Results:

Fifty-seven eyes of thirty-eight patients (20 females, 18 males; mean age 65±7 years) were included in the study. The mean hemoglobin A1c level was 7.9±1.7%. Before entering the study, patients had undergone 5.71±3.40 anti-vascular endothelial growth factor (anti-VEGF) and 3.44±2.46 intravitreal triamcinolone acetonide injections. The mean duration of diabetes and diabetic macular edema was 17.2±6.4 years and 60.2±17.6 months, respectively. At baseline, mean CMT was 506.76±166.74 µm, and the mean BCVA was 0.68±0.38 LogMAR. Mean CMT significantly decreased to 341.36±146.26 µm (p<0.001), 324.41±114.58 µm (p<0.001), and 384.82±151 µm (p<0.001) at 1, 3, and 4 months of follow-up and increased again to 462.29±152.87 µm at 5 months. Sixteen eyes (28%) received second injections after mean of 7.4±2.3 months and mean CMT was again significantly decreased at 7, 8, and 9 months. Significant improvement in mean BCVA (0.54±0.41 LogMAR; p<0.001) occurred only at 1 month after implantation. However, subgroup analysis revealed significant BCVA improvement in the pseudophakic group at 1, 3, and 4 months. Among phakic patients, 50% showed cataract progression and 28% had elevated intraocular pressure increase which was managed medically.

Conclusion:

Intravitreal dexamethasone implantation was effective for the first 4 months in eyes with recalcitrant diabetic macular edema. However, it is hard to displace anti-VEGF agents as first-line therapy due to steroid-related complications.

REAL-LIFE STUDY IN DIABETIC MACULAR EDEMA TREATED WITH DEXAMETHASONE IMPLANT: The Reldex Study

PURPOSE

To evaluate the efficacy and safety of intravitreal implant of dexamethasone (Ozurdex) in diabetic macular edema in real-life practice.

METHODS

In this bicentric retrospective study, the authors reviewed 128 eyes of 89 patients. Main outcome measures included changes in best-corrected visual acuity, central macular thickness, time to retreatment, and incidence of adverse effects. Linear mixed-effects models were used to study changes in best-corrected visual acuity and central macular thickness over the 3-year follow-up.

RESULTS

Best-corrected visual acuity increased by a mean of 3.6 letters at Month 2 (P = 0.005), 4.2 letters at Month 12 (P = 0.006), 5.3 at Month 24 (P = 0.007), and 9.5 letters at Month 36 (P = 0.023). The proportion of eyes achieving at least a 15-letter improvement from baseline was 25.4% at Month 36. Central macular thickness decreased from 451 μm to 289 μm at Month 2 (P < 0.001), 370 μm at Month 12 (P < 0.001), 377 μm at Month 24 (P = 0.004), and 280 μm at Month 36 (P = 0.001). A mean of 3.6 injections were administered over the 3-year follow-up. Ten percent of eyes developed a transient increase in intraocular pressure (IOP ≥ 25 mmHg), and cataract was removed from 47% of phakic eyes.

CONCLUSION

This large case series study showed favorable 3-year outcomes when using Ozurdex to treat diabetic macular edema. Intravitreal Ozurdex provides substantial long-term benefits in the treatment of diabetic macular edema in real-life.

Switching to Aflibercept in Diabetic Macular Edema Not Responding to Ranibizumab and/or Intravitreal Dexamethasone Implant

Purpose

To assess short-term functional and anatomical outcomes of refractory diabetic macular edema (DME) following a switch from ranibizumab or dexamethasone to aflibercept.

Methods

We included retrospectively eyes with persistent DME after at least 3 ranibizumab and/or one dexamethasone implant intravitreal injections (IVI). The primary endpoint was the mean change in visual acuity (VA) at month 6 (M6) after switching.

Results

Twenty-five eyes were included. Before switching to aflibercept, 23 eyes received a median of 9.5 ranibizumab, and among them, 6 eyes received one dexamethasone implant after ranibizumab and 2 eyes received only one dexamethasone implant. Baseline VA, before any IVI, was 52.9 ± 16.5 letters, and preswitch VA was 57.1 ± 19.6 letters. The mean VA gain was +8 letters (p = 0.01) between preswitch and M6. The mean central retinal thickness was 470.8 ± 129.9 μm before the switch and 303.3 ± 59.1 μm at M6 (p = 0.001).

Conclusion

Switching to aflibercept in refractory DME results in significant functional and anatomical improvement. The study was approved by the France Macula Federation ethical committee (FMF 2017-138).

Combined Intravitreal Dexamethasone Implant And Micropulse Yellow Laser For Treatment Of Anti-VEGF Resistant Diabetic Macular Edema

Purpose:

To report the efficacy and safety of combined intravitreal dexamethasone implant and micropulse laser for anti-VEGF resistant diabetic macular edema.

Patients and Methods:

Prospective, non-controlled study that was conducted for twenty eyes with center-involved diabetic macular edema not responding to anti-VEGF therapy. Ozurdex intravitreal implant was injected to all eyes with subsequent micropulse yellow laser one month after the injection. All eyes were followed up after one, three, four, six, nine and twelve months. The primary outcome measure is the change in best corrected visual acuity (BCVA) after one year and secondary outcome measures are central macular thickness (CMT) change and safety of both dexamethasone implant and micropulse laser. Reinjection was done for those eyes with recurrent edema.

Results:

The mean age was 58.8 ±7.94 years. The mean BCVA was 0.6± 0.14, 0.57 ±0.12, 0.51±0.15, 0.59±0.12, 0.6± 0.12 and 0.59±0.14 after one, three, four, six, nine and twelve months in comparison to 0.45± 0.14 as initial BCVA [SS,P<0.05]. The CMT was 302.5±30.01, 330.6±20.24, 357.6±32.15, 285.4±19.95, 292.9±25.07 and 285.2±14.99 after one ,three, four ,six , nine and twelve months µm in comparison to initial CMT of 420.7 ±38.74µm [HS, P<0.01]. Cataract occurred in 6 eyes from 14 phakic eyes (42.8%). Transient ocular hypertension occurred in 6 eyes (30%). Reinjection was done for eight eyes (40%).

Conclusion:

Intravitreal dexamethasone implant and micropulse laser are both effective and safe treatment options for anti-VEGF resistant diabetic macular edema.

TPL2 (Therapeutic Targeting Tumor Progression Locus-2)/ATF4 (Activating Transcription Factor-4)/SDF1α (Chemokine Stromal Cell-Derived Factor-α) Axis Suppresses Diabetic Retinopathy

RATIONALE

Diabetic retinopathy is characterized by vasopermeability, vascular leakage, inflammation, blood-retinal barrier breakdown, capillary degeneration, and neovascularization. However, the mechanisms underlying the association between diabetes mellitus and progression retinopathy remain unclear.

OBJECTIVE

TPL2 (tumor progression locus 2), a serine-threonine protein kinase, exerts a pathological effect on vascular angiogenesis. This study investigated the role of N^ε-(carboxymethyl)lysine, a major advanced glycation end products, and the involved TPL2-related molecular signals in diabetic retinopathy using models of in vitro and in vivo and human samples.

METHODS AND RESULTS

Serum N^ε-(carboxymethyl)lysine levels and TPL2 kinase activity were significantly increased in clinical patients and experimental animals with diabetic retinopathy. Intravitreal administration of pharmacological blocker or neutralizing antibody inhibited TPL2 and effectively suppressed the pathological characteristics of retinopathy in streptozotocin-induced diabetic animal models. Intravitreal VEGF (vascular endothelial growth factor) neutralization also suppressed the diabetic retinopathy in diabetic animal models. Mechanistic studies in primary human umbilical vein endothelial cells and primary retinal microvascular endothelial cells from streptozotocin-diabetic rats, db/db mice, and samples from patients with diabetic retinopathy revealed a positive parallel correlation between N^ε-(carboxymethyl)lysine and the TPL2/chemokine SDF1α (stromal cell-derived factor-α) axis that is dependent on endoplasmic reticulum stress-related molecules, especially ATF4 (activating transcription factor-4).

CONCLUSIONS

This study demonstrates that inhibiting the N^ε-(carboxymethyl)lysine-induced TPL2/ATF4/SDF1α axis can effectively prevent diabetes mellitus-mediated retinal microvascular dysfunction. This signaling axis may include the therapeutic potential for other diseases involving pathological neovascularization or macular edema.

Prognostic factors of short-term outcomes of intravitreal ranibizumab in diabetic macular edema

AIM

To evaluate the prognostic factors for short-term visual and anatomical improvement of intravitreal ranibizumab (IVR) for diabetic macular edema (DME).

METHODS

Fifty-one eyes from 35 patients that received three consecutive monthly IVR for DME with moderate visual loss were retrospectively recruited; all cases had their baseline best-corrected visual acuity (BCVA) between 20/400 and 20/40. BCVA and central subfield thickness (CST) at baseline and month 3 were collected. Linear mixed models were used to evaluate the prognostic factors for visual and anatomical improvement at month 3.

RESULTS

Younger age, poorer baseline BCVA and proliferative diabetic retinopathy (PDR) were correlated with better visual improvement at month 3 (P=0.002, 0.0001 and 0.007, respectively). Thicker CST and the presence of subretinal fluid at baseline were correlated with a greater reduction in CST (P<0.0001 and P=0.018, respectively). The presence of epiretinal membrane or previous posterior subtenon injection of triamcinolone acetonide (PSTA) were associated with a smaller reduction in CST (P=0.029 and 0.018, respectively), but had no significant effects in visual improvement at month 3 (P>0.05 for both).

CONCLUSION

For eyes with DME and moderate visual loss, those with younger age, poorer baseline BCVA or PDR tend to have better visual improvement after three consecutive monthly IVR. Epiretinal membrane or previous PSTA result in less resolution of CST, but do not significantly affect visual improvement.

Therapeutic Options in Refractory Diabetic Macular Oedema

Diabetic macular oedema (DMO) results from alterations of several biochemical pathways in diabetic eyes. Centre-involving DMO is an important cause of visual loss in diabetes. Anti-vascular endothelial growth factor agents are now the mainstay of centre-involving DMO treatment. Oedema that does not achieve optimal response to these agents occurs in a sizeable proportion of eyes and is called refractory or persistent DMO. Management of refractory DMO is challenging. In this paper, the pathophysiology of DMO, and the definitions used in various studies are summarised. Therapeutic options for refractory DMO management including corticosteroids, laser, combination therapies, and surgery are explored. Novel agents on the horizon for DMO control that are being investigated at present are discussed as well. A literature review was performed and a summary of the research studies for each of the agents is provided in order to guide the reader regarding the existing evidence for their application in DMO. Importance of early recognition of disease and prompt treatment to achieve best visual outcome is discussed. Utility of optical coherence tomography to guide disease diagnosis and monitoring is highlighted. An algorithmic approach for DMO management is described. Finally, the impact that personalized medicine and genetics might have on DMO management is assessed.

Use of Corticosteroids in the Treatment of Patients With Diabetic Macular Edema Who Have a Suboptimal Response to Anti-VEGF: Recommendations of an Expert Panel

BACKGROUND AND OBJECTIVE

Guidance on the use of corticosteroids in the treatment of diabetic macular edema (DME) is lacking. This study aimed to develop a clinically recommended treatment paradigm for DME with emphasis on the role of corticosteroids.

PATIENTS AND METHODS

An expert panel of nine retinal specialists in the United States developed consensus recommendations for DME treatment through a modified Delphi process.

RESULTS

The panelists typically use intravitreal injections of vascular endothelial growth factor (VEGF) antagonists as first-line treatment of DME and switch patients with an inadequate response to anti-VEGF therapy (failure of best-corrected visual acuity to improve to 20/40 or better because of edema after three to six monthly injections, or a less-than-50% reduction in excess macular thickness after three to four monthly injections) to intravitreal corticosteroid treatment.

CONCLUSION

Intravitreal corticosteroids have a potentially useful role in the treatment of patients with DME who have an inadequate response to intravitreal anti-VEGF therapy. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:291-301.].

Intravitreal Aflibercept for Patients With Diabetic Macular Edema Refractory to Bevacizumab or Ranibizumab: Analysis of Response to Aflibercept

PURPOSE

To investigate the short-term efficacy and safety of intravitreal aflibercept in a case series of patients with diabetic macular edema (DME) refractory to ranibizumab or bevacizumab.

DESIGN

A retrospective chart review.

METHODS

From September 2013 to March 2016, we identified patients with DME who developed resistance to bevacizumab or ranibizumab. Three monthly intravitreal aflibercept injections were administered in refractory cases. Nonresponse to aflibercept was defined as a paradoxical increase in central foveal thickness (CFT) and gain in best-corrected visual acuity (BCVA) of less than 1 line at 1 month after treatment compared with before aflibercept administration.

RESULTS

Out of a total of 72 eyes in 72 refractory patients, 42 eyes (58.3%) responded to aflibercept injections. The BCVA and CFT were 0.65 ± 0.32 logMAR and 438.5 ± 80.1 μm, respectively, before aflibercept treatment and significantly improved to 0.31 ± 0.17 logMAR (P = 0.0008) and 297.9 ± 19.1 μm (P = 0.0004), respectively, 1 month after 3 aflibercept injections in responders. No differences in baseline characteristics, including age, sex, glycosylated hemoglobin, serum creatinine, total cholesterol, lens status, grades of diabetic retinopathy, and CFT/BCVA before aflibercept management (P > 0.05), were observed between responders and nonresponders. There were 17 vitrectomized eyes in 30 nonresponders (56.7%), a significantly higher rate than among the 42 responders (0%; P = 0.00001).

CONCLUSIONS

Three monthly intravitreal aflibercept injections had benefit in nearly two thirds of cases with DME resistant to bevacizumab or ranibizumab over short-term follow-up. Vitrectomized eyes responded poorly to aflibercept treatment.

Moving Past Anti-VEGF: Novel Therapies for Treating Diabetic Retinopathy

Diabetic retinopathy is the leading cause of blindness in working age adults, and is projected to be a significant future health concern due to the rising incidence of diabetes. The recent advent of anti-vascular endothelial growth factor (VEGF) antibodies has revolutionized the treatment of diabetic retinopathy but a significant subset of patients fail to respond to treatment. Accumulating evidence indicates that inflammatory cytokines and chemokines other than VEGF may contribute to the disease process. The current review examines the presence of non-VEGF cytokines in the eyes of patients with diabetic retinopathy and highlights mechanistic pathways in relevant animal models. Finally, novel drug targets including components of the kinin-kallikrein system and emerging treatments such as anti-HPTP (human protein tyrosine phosphatase) β antibodies are discussed. Recognition of non-VEGF contributions to disease pathogenesis may lead to novel therapeutics to enhance existing treatments for patients who do not respond to anti-VEGF therapies.

Diabetic macular oedema: pathophysiology, management challenges and treatment resistance

Diabetic macular oedema (DMO) is the leading cause of vision loss in patients living with diabetes. DMO results from hyperglycaemia-induced activation of pathways that lead to oxidative stress and release of cytokines, impairing the inner and outer blood-retinal barriers. Improved understanding of the pathophysiological mechanisms leading to DMO have led to the development of effective therapies, including vitreoretinal surgery, laser photocoagulation, intravitreal anti-vascular endothelial growth factor drugs and corticosteroids. Advances in imaging, including fluorescein angiography and optical coherence tomography, have also enhanced diagnosis and management of the condition. Despite these advances, there remain patients who do not respond completely to therapy, reflecting the complex pathophysiology of DMO. These patients may be considered treatment-resistant. In this review, we summarise the pathophysiology of DMO, as well as the available treatments and their mechanism of action. Additionally, we focus on treatment-resistant disease and review the literature on potential options for managing this complication of diabetes.

Intravitreal injection of methotrexate in persistent diabetic macular edema: a 6-month follow-up study

PURPOSE

To evaluate the efficacy of intravitreal injection of methotrexate (MTX) in patients with persistent diabetic macular edema (DME) nonresponsive to intravitreal bevacizumab.

METHODS

In this prospective, interventional study, intravitreal injection of 400 μg MTX was performed in eyes with persistent center-involving DME unresponsive to at least three consecutive bevacizumab injections or two consecutive bevacizumab injections plus macular photocoagulation. Best-corrected visual acuity (BCVA), central subfield thickness (CST), and maximum retinal thickness (MRT) were recorded before and 1, 3, and 6 months after injections.

RESULTS

Eighteen eyes of 16 patients with a mean age of 61.1 ± 6.7 years were included. Mean number of intravitreal bevacizumab injections was 3.9 ± 1.8 (range 2-8). The mean change in BCVA was -0.09 ± 0.19, -0.1 ± 0.19, and -0.1 ± 0.19 LogMAR at 1, 3, and 6 months after intravitreal MTX injections, respectively (all P = 0.04). Three eyes (16.6 %) had improvement of at least two lines of BCVA and no eye lost visual acuity. Mean change in CST was -23.7 ± 66.7, -28.7 ± 82.2 and 26.5 ± 83.4 μm at 1, 3, and 6 months after MTX injections, respectively (all P = 0.1). A decrease in CST was found in 13 eyes (72.2 %) at 1 and 3 months, and seven eyes (38.8 %) at 6 months of follow-up. Other eyes showed an increase in CST measurements. Mean change in MRT was -35.1 ± 76.4, -40.6 ± 86.3, and 29.8 ± 68.6 μm at 1, 3, and 6 months after MTX injections, respectively (P = 0.06, P = 0.06, and P = 0.08, respectively). No complication attributable to intravitreal MTX occurred.

CONCLUSION

In this study, intravitreal injection of MTX resulted in anatomical improvement in a significant proportion of eyes with persistent DME. Significant visual improvement was found in 16.6 % of eyes.

Role of implants in the treatment of diabetic macular edema: focus on the dexamethasone intravitreal implant

Diabetic macular edema (DME) is the leading cause of sight-threatening complication in diabetic patients, and several treatment modalities have been developed and evaluated to treat this pathology. Intravitreal agents, such as anti-vascular endothelial growth factors (anti-VEGF) or corticosteroids, have become more popular in recent years and are widely used for treating DME. Sustained release drugs appear to be mentioned more often nowadays for extending the period of intravitreal activity, and corticosteroids play a key role in inhibiting the inflammatory process in DME. A potent corticosteroid, dexamethasone (Ozurdex(®)), in the form of an intravitreal implant, has been approved for various ocular etiologies among which DME is also one. This review evaluates the role of implants in the treatment of DME, mainly focusing on the dexamethasone intravitreal implant.