OCULAR HYPERTENSION AFTER INTRAVITREAL DEXAMETHASONE (OZURDEX) SUSTAINED-RELEASE IMPLANT

Changes in intraocular pressure following intravitreal dexamethasone implant in patients with history of glaucoma filtration surgery

PURPOSE

This study aimed to evaluate changes in intraocular pressure following intravitreal dexamethasone implant injection, specifically in patients undergoing glaucoma filtration surgery.

METHODS

The degree of increase in intraocular pressure was compared retrospectively among three groups. Group 1 comprised patients who underwent prior glaucoma filtration surgery (54 eyes). Group 2 included patients with or suspected glaucoma without such surgical history (20 eyes). Group 3 included patients without glaucoma (33 eyes). Pressure measurements were taken before the injection and at 1, 2, 3, and 6 months post-injection. A subgroup analysis was performed for pressure > 35 mmHg, > 30 mmHg, > 25 mmHg, and a difference > 10 mmHg between the peak and baseline pressure.

RESULTS

Group 1 consistently displayed lower pressures compared with Group 2, with significant difference at both 1- and 6-month post-injections (15.09 mmHg vs. 18.10 mmHg, P = 0.042 and 13.91 mg vs. 17.25 mmHg, P = 0.040). The proportion of patients in Group 1 and Group 3 with pressures > 25 mmHg, > 30 mmHg, and a difference > 10 mmHg did not significantly differ (15.6% vs. 9.5%, P = 0.231; 3.1% vs. 2.3%, P = 0.867; and 17.1% vs. 7.1%, P = 0.231). Notably, Group 2 exhibited a significantly higher proportion within each category (> 25 mmHg, 24.0%; > 30 mmHg, 20.0%; > 10 mmHg difference, 28.0%).

CONCLUSION

Intravitreal dexamethasone implant did not increase the risk of elevated intraocular pressure in patients with a history of glaucoma filtration surgery compared with patients with suspected glaucoma; the risk was similar to those without glaucoma.

Safety and Efficiency of Anti-VEGF with Dexamethasone Intravitreal Implant for Non-Ischemic Retinal Vein Occlusion: A Prospective, Case-controlled, Cohort Study

OBJECTIVE

This study aimed to assess the efficacy and safety of anti-VEGF combined with dexamethasone implant for the retinal vein occlusion patients with macular edema.

METHODS

In this prospective, case-controlled, cohort clinical trial (Register ID: ChiCTR2400080048), patients with non-ischemic retinal vein occlusion were enrolled from the Sanmenxia Central Hospital from August 2020 to April 2023. The patients were randomized into two groups. All the patients received ranibizumab intravitreal injection in the first 3 consecutive months. For the ranibizumab group, anti-VEGF injections were as needed thereafter in case of recurrence of macular edema; For the combination group, the patients received an intravitreal dexamethasone implant injection at 15 days after the first ranibizumab injection. The primary outcome measurements were improvement in best corrected visual acuity (BCVA) and reduction in central macular thickness (CMT). The secondary outcomes were recurrence of macular edema, number of intravitreal injections, and injection interval. Safety profiles were also recorded.

RESULTS

A total of 124 patients were included, of which 73 patients completed all follow-ups. Both the ranibizumab monotherapy and the combination therapy significantly improved BCVA at all time points, compared to the baseline. The combined group achieved more BCVA improvement in 3 months, 6 months, and 12 months, compared to the ranibizumab alone group. Compared to the baseline, both groups achieved significant reductions in CMT at all follow-ups. However, the combination group showed more CMT reduction at 1 week post injection, compared to the ranibizumab group. The combination group had a significantly longer injection interval, lower injection time, and recurrence of macular edema. Ocular hypertension was the most common adverse events. Lastly, intraocular pressure was all well controlled by 1-3 glaucoma medications without surgical intervention.

CONCLUSION

The combination therapy could significantly improve the BCVA and reduce the CMT with a good safety profile.

Incidence and treatment approach of intraocular pressure elevation after various types of local steroids for retinal diseases

PURPOSE

For the treatment of macular edema, in addition to the use of antivascular endothelial growth factors, steroids are also used intravitreally and sub-Tenon. Side effects include among others cataract formation and elevation of intraocular pressure (IOP). The aim of this retrospective study was to elicit the IOP elevation after administration of various steroidal medication, the time of onset, and the efficacy of the administered IOP-lowering therapies.

METHODS

We included 428 eyes with a postoperative (n = 136), diabetic (n = 148), uveitic macular edema (n = 61), and macular edema after retinal vein occlusion (n = 83). These patients were treated with one or more diverse steroidal agents once or multiple times. These drugs included: triamcinolone acetonide (TMC) as intravitreal injection (TMC IVI) or sub-Tenon (TMC ST), as well as dexamethasone (DXM) and fluocinolone acetonide (FA) intravitreally. An increase of IOP of ≥ 25 mmHg was designated as pathological. A steroid response in anamnesis, the time of onset of IOP rise from the first administration, and the therapy administered were documented.

RESULTS

Of 428 eyes, 168 eyes (39.3%) had IOP elevation up to a mean of 29.7 (SD ± 5.6) mmHg, which occurred at a median of 5.5 months. Steroids most frequently leading to rise of IOP included DXM (39.1% of all eyes receiving that drug), TMC IVI (47.6%), TMC ST combined with DXM (51.5%), DXM with FA (56.8%), and TMC IVI with DXM (57.4%). A Kaplan-Meier analysis and the Log Rank test showed a significant difference (p < 0.001). IOP rise was treated as follows: 119 conservatively (70.8%), and 21 surgically (12.5%, cyclophotocoagulation 8.3%, filtering surgery 1.8%, in 4 the steroidal drug implant was removed 2.4%), and 28 eyes received no therapy (16.7%). Sufficient IOP regulation was achieved in 82 eyes (68.9%) with topical therapy. In 37 eyes (31.1%) with persistently elevated intraocular pressure, topical therapy had to be continued over the follow-up of 20 ± 7 months.

CONCLUSIONS

IOP increases after any type of steroid application are not rare. Results of our study let us suspect that especially therapy with intravitreal dexamethasone, either as a monotherapy or in combination with another steroid, tends to increase IOP more than other steroids. Regular IOP checks are necessary after each steroid administration, with possible initiation of long-term conservative and/or surgical therapy if necessary.

Small RNA Sequencing Reveals a Distinct MicroRNA Signature between Glucocorticoid Responder and Glucocorticoid Non-Responder Primary Human Trabecular Meshwork Cells after Dexamethasone Treatment

Glucocorticoids (GCs) are known to regulate several physiological processes and are the mainstay in the management of inflammatory eye diseases. The long-term use of GC causes raised intraocular pressure (IOP) or ocular hypertension (OHT) in about 30-50% of the susceptible individuals depending on the route of administration, and can lead to steroid-induced secondary glaucoma. The present study aims to understand the role of microRNAs (miRNAs) in differential glucocorticoid (GC) responsiveness in human trabecular meshwork (HTM) cells using small RNA sequencing. The human organ-cultured anterior segment (HOCAS) model was used to identify whether donor eyes were from GC-responders (GC-R; n = 4) or GC-non-responders (GC-NR; n = 4) following treatment with either 100 nM dexamethasone (DEX) or ethanol (ETH) for 7 days. The total RNA was extracted from cultured HTM cells with known GC responsiveness, and the differentially expressed miRNAs (DEMIRs) were compared among the following five groups: Group #1: ETH vs. DEX-treated GC-R; #2: ETH vs. DEX-treated GC-NR; #3: overlapping DEGs between Group #1 and #2; #4: Unique DEMIRs of GC-R; #5: Unique DEMIRs of GC-NR; and validated by RT-qPCR. There were 13 and 21 DEMIRs identified in Group #1 and Group #2, respectively. Seven miRNAs were common miRNAs dysregulated in both GC-R and GC-NR (Group #3). This analysis allowed the identification of DEMIRs that were unique to GC-R (6 miRNAs) and GC-NR (14 miRNAs) HTM cells, respectively. Ingenuity Pathway Analysis identified enriched pathways and biological processes associated with differential GC responsiveness in HTM cells. This is the first study to reveal a unique miRNA signature between GC-R and GC-NR HTM cells, which raises the possibility of developing new molecular targets for the management of steroid-OHT/glaucoma.

Biomaterial Drug Delivery Systems for Prominent Ocular Diseases

Ocular diseases, such as age-related macular degeneration (AMD) and glaucoma, have had a profound impact on millions of patients. In the past couple of decades, these diseases have been treated using conventional techniques but have also presented certain challenges and limitations that affect patient experience and outcomes. To address this, biomaterials have been used for ocular drug delivery, and a wide range of systems have been developed. This review will discuss some of the major classes and examples of biomaterials used for the treatment of prominent ocular diseases, including ocular implants (biodegradable and non-biodegradable), nanocarriers (hydrogels, liposomes, nanomicelles, DNA-inspired nanoparticles, and dendrimers), microneedles, and drug-loaded contact lenses. We will also discuss the advantages of these biomaterials over conventional approaches with support from the results of clinical trials that demonstrate their efficacy.

Choroidal thickness as a possible predictor of non-response to intravitreal bevacizumab for macular edema after retinal vein occlusion

To evaluate outcomes of intravitreal bevacizumab (IVB) treating macular edema (ME) after retinal vein occlusion (RVO) following pro re nata (PRN) regimen and investigate potential predictors of non-response. Retrospective analysis of 126 treatment-naive eyes with ME after RVO. Eyes were treated initially with IVB of 1.25 mg/ml. Therapy was switched in case of non-response. Outcome measures included best-corrected visual acuity (BCVA) and central macular thickness (CMT), which were recorded over 4 years of treatment. BCVA improved significantly during first 2 years. CMT decreased significantly during the 4-year follow-up period. Switching was required in 42 eyes (33%). 34 eyes (26.9%) were switched to steroids, while 8 eyes (6.3%) were switched to other anti-VEGF due to diagnosed glaucoma. Switching occurred after 12.4 ± 8.3 months and an average of 8 ± 4.1 IVBs. Compared with the treatment-responsive group, the treatment-unresponsive group had significantly worse BCVA, higher CMT and subfoveal choroidal thickness (SFCT) at baseline. Treatment IVB following PRN regimen showed significant functional and anatomic improvement in patients with ME after RVO. Switching was required in more than one third of eyes. Higher baseline SFCT could be considered as predictor for non-response to such therapy and thus an indicator of early switching.

Safety and Effectiveness of Intravitreal Dexamethasone Implant (Ozurdex®) for the Treatment of Refractory Cystoid Macular Oedema (CMO) in Galway University Hospital

Aim:

The aim of this study is to assess the real-life effectiveness and safety of intravitreal Ozurdex in an Irish setting.

Background:

Ozurdex is an intravitreal dexamethasone implant that is used for the treatment of macular oedema secondary to retinal vein occlusion and diabetic macular oedema.

Methods:

This was a retrospective observational study of adult patients in University Hospital Galway who received an intravitreal dexamethasone implant (Ozurdex) for the treatment of cystoid macular oedema secondary to diabetic eye disease or retinal vein occlusion. The main outcome was the mean change in best-corrected visual acuity 3-6 months after the treatment.

Results and Discussion:

36 patients were included in the study. Overall, there was a 1.66 mean letter gain (SD 11.8) 3-6 months post-treatment. The proportion of patients who gained >10 letters was 15.6%. The mean reduction in CST was 110.6um (SD 255.7), and in the linear regression analysis, no variables were found to be significantly associated with a change in visual acuity. In terms of adverse events, 14.3% of patients had significant cataract progression and 20.6% of patients had a significant rise in IOP following intravitreal Ozurdex implant.

Conclusion:

Intravitreal Ozurdex was found to be safe and effective, supporting it as an appropriate second-line treatment in patients with refractory macular oedema secondary to diabetic eye disease and retinal vein occlusion. Further studies should be carried out to evaluate the possible predictors of visual acuity outcome.

Ocular hypertension and its predictor after a single Ozurdex implant: One-year follow-up in Asian Indian eyes

BACKGROUND

To determine the incidence and risk factors for an increase in the intraocular pressure (IOP) after a single dexamethasone intravitreal implant (Ozurdex).

MATERIALS AND METHODS

Medical records of 41 consecutive eyes who had received a single 0.7 mg Ozurdex implant for the various vitreoretinal pathology, between March 2015 and April 2016 were reviewed retrospectively. Ocular hypertension (OHT) was defined as IOP of >22 mmHg or an increase in the IOP of >6 mmHg from the baseline. Univariate regression analysis was used to measure the predictor of OHT after the implant.

RESULTS

Among the 41 eyes, who received a single Ozurdex intravitreal implant, 6/41 (14.6%) of the injected eyes had OHT, with the peak of IOP at 1 month after the injection when compared with the baseline IOP. Eight eyes (19.5%) had preexisting glaucoma or OHT, and 4/8 (50%) of them developed sustained elevation of IOP after the injection. Two eyes had transient OHT, a day after the implant, which did not require any treatment. All the eyes were managed with topical antiglaucoma medications and none required surgery to control the IOP. Preexisting OHT or glaucoma was found to be a significant risk factor for OHT after the Ozurdex injection (P < 0.0001).

CONCLUSION

Patients with preexisting OHT or glaucoma have an increased risk of OHT following the Ozurdex implant and hence needs to be informed of the possible risk. Follow-up at a regular interval is mandatory to monitor and recognize OHT early and treat it appropriately.

[Secondary open-angle glaucoma: uveitic secondary glaucoma, steroid-induced glaucoma, posttraumatic and postoperative glaucoma, tumor-related glaucoma and glaucoma due to elevated episcleral venous pressure]

Secondary open-angle glaucomas are a heterogeneous group of diseases in which a variety of pathophysiological mechanisms result in an elevation of intraocular pressure (IOP). In contrast to primary open-angle glaucoma in many cases besides IOP reduction a causal treatment is possible. This article is the second part of a review of the more frequently encountered forms of secondary open-angle glaucoma. Uveitic glaucoma, steroid-induced glaucoma, posttraumatic and postoperative glaucoma, glaucoma due to intraocular tumors and caused by elevated episcleral venous pressure are covered. The underlying pathophysiological mechanisms, characteristic clinical findings and treatment options are discussed.

Intraocular pressure fluctuation following intravitreal dexamethasone implant and incidence of secondary ocular hypertension: a Zambian perspective

Introduction

to evaluate the effect of dexamethasone biodegradable implant (DEX-I), on intraocular pressure (IOP), to determine the incidence of secondary ocular hypertension (OHT) and to analyze the IOP changes as per the treatment indication in Zambian cohort.

Methods

retrospective consecutive case series of patients receiving one DEX-I between January 2016 and September 2018 with a minimum follow-up of four months in a tertiary care centre in Zambia. The IOP was recorded before the injection and at 1^st week, 1^st, 2^nd, 3^rd and 4^th month after the injection. Ocular hypertension was defined as IOP ≥ 21 mmHg or an increase of ≥ 10 mmHg from baseline.

Results

the effects of 122 injections given to ninety - nine patients (65 male: 65%; mean age 57.3) were included. The main indications for treatment were diabetic macular edema (DME, 52%), retinal vein occlusion (18%), post-surgical macular edema (18%) and non-infectious posterior uveitis (10%). Mean IOP before the injection was was 14.7mmHg and at 1^st week, 1^st, 2^nd, 3^rd and 4^th months after the injection it was 14.4 (p=0.08), 16.1 (p=0.01), 17.5 (p<0.001), 15.7 (p=0.006) and 14.9 (p=0.06) mmHg, respectively. The incidence of secondary OHT was 30.32% in this cohort. Peak incidence of OHT was between 1 - 2 months, with majority of cases in DME group (75%) and 43% diabetic eyes followed by 23% non-infectious posterior uveitis cases developing OHT post injection. OHT was well managed with anti-glaucoma medications only.

Conclusion

DEX-I showed a good pressure tolerance in this cohort. Secondary ocular hypertension developed in one-third of patients receiving injection which was transient and successfully managed with topical anti-glaucoma medications only. Diabetic eyes are more prone to develop ocular hypertension and therefore needs close monitoring following injection.

Current intravitreal therapy and ocular hypertension: A review

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.

Multifunctional nanocomposite eye drops of cyclodextrin complex@layered double hydroxides for relay drug delivery to the posterior segment of the eye

Topical drug delivery system to the posterior segment of the eye is facing many challenges, such as rapid drug elimination, low permeability, and low concentration at the targeted sites. To overcome these challenges, Multifunctional nanocomposite eye drops of dexamethasone-carboxymethyl-β-cyclodextrin@layered double hydroxides-glycylsarcosine (DEX-CM-β-CD@LDH-GS) were developed for relay drug delivery. Herein, our studies demonstrated that DEX-CM-β-CD@LDH-GS could penetrate through human conjunctival epithelial cells with an intact structure and exhibited integrity in the sclera of rabbits' eyes with in vivo fluorescence resonance energy transfer imaging. Consequently, tissue distribution indicated that DEX-CM-β-CD@LDH-GS nanocomposite eye drops could maintain the effective therapeutic concentration of DEX in choroid-retina within 3 h. As a relay drug delivery system, drug-CD@LDH nanocomposites offer an efficient strategy for drug delivery from ocular surface to the posterior segment.

Effects of Repeated Intravitreal Injections of Dexamethasone Implants on Intraocular Pressure: A 4-Year Study

Purpose

Dexamethasone and other corticosteroids are administered intravitreally to treat a variety of retinal diseases. As a side effect, they can alter intraocular pressure (IOP). The purpose of this study is to describe the incidence, severity, and management of ocular hypertension following the administration of multiple intravitreal injections of dexamethasone implants.

Materials and Methods

A total of 78 eyes of 78 subjects (males 62%; females 38%; mean age 67 ± 13 years SD) received a total of 152 intravitreal injections of 0.7 mg dexamethasone implants over 4 years. Indications included retinal vein occlusion (87%), diabetic macular edema (9%), wet-type age-related macular degeneration (4%). Ocular hypertension was defined as intraocular pressure above 23 mmHg or any pressure increase of 10 mmHg or more from baseline values. IOP was measured by applanation tonometry before the injection (T0), as well as one week (T1), one month (T2), and three months (T3) afterwards.

Results

Five percent (4/78) of subjects developed ocular hypertension after the 1st injection. On the second and third rounds, additional 7.2% (3/42) and 4.2% (1/24) of subjects developed the same side effect. Among the 8 subjects who received a fourth injection, none was found with OHT. Pressure elevations were detected at T2 and T3. In all patients, topical medical therapy was sufficient to lower the IOP below threshold. Mean pressure variations following the first injection as compared to previous recorded values were +0.97 mmHg (T1), +0.92 mmHg (T2), and -0.41 mmHg (T3) (p < 0.05). Mean pressure variations following the second injection were +0.54 mmHg (T1), +0.23 mmHg (T2) and -0.66 mmHg (T3) (p < 0.05).

Conclusion

Ocular hypertension is a recognized side effect of intravitreal dexamethasone. Some patients develop it right after the first injection, while others develop it subsequently, on the 2nd or 3rd round. This side effect becomes most apparent 30-90 days following the implantation procedure and responds well to topical pressure-lowering medications.

Comparison of Anatomical and Functional Outcomes of Intravitreal Dexamethasone Implant between Phakic and Pseudophakic Eyes with Diabetic Macular Edema

Purpose

To compare the effectiveness of dexamethasone (DEX) intravitreal implants for the treatment of diabetic macular edema between phakic and pseudophakic eyes after a follow-up.

Methods

A total of 79 eyes in 79 patients with diabetic macular edema who were insufficiently responsive to the previous anti-vascular endothelial growth factor treatment and applied intravitreal DEX implant were included in this retrospective study. The patients were divided into two groups according to their type of lenses: pseudophakic (group 1) and phakic (group 2). Best-corrected visual acuity, intraocular pressure (IOP), retinal nerve fiber layer thickness, and central macular thickness changes in the two groups were compared.

Results

Group 1 comprised 42 eyes in 42 patients with a mean age of 64.02 ± 3.79 years, while group 2 comprised 37 eyes in 37 patients with a mean age of 64.19 ± 5.08 years. In both groups, best-corrected visual acuity improved significantly with a significant decrease in central macular thickness (p < 0.001). In both lens types, the IOP values decreased significantly on the first day but subsequently increased significantly compared to baseline from one week to six months. Increases in IOP values were significantly higher in group 1 at the first week, 1st month, and 6th month compared with group 2. During follow-up, the inferior quadrant retinal nerve fiber layer showed a significant decrease in both groups.

Conclusions

In both phakic and pseudophakic eyes, intravitreal DEX implantation is an effective treatment method with low-risk complications. In our study, the pseudophakic group experienced a significantly earlier increase in IOP and at higher levels than did the phakic group. In light of these data, we suggest that in patients with pseudophakic eyes, follow-ups for IOP should be stricter and started earlier after intravitreal DEX treatment.

The Effect of Selective Laser Trabeculoplasty on Intraocular Pressure in Patients with Dexamethasone Intravitreal Implant-Induced Elevated Intraocular Pressure

Introduction

To assess the safety and efficacy of selective laser trabeculoplasty (SLT) for ocular hypertension (OHT) induced by a dexamethasone (DEX) intravitreal implant.

Materials and Methods

We performed a retrospective study of patients who underwent an SLT procedure for ocular hypertension induced by injection of a DEX intravitreal implant. Patients had, at least, one injection of the DEX-implant for symptomatic macular edema. SLT was delivered to 360° of the trabecular meshwork in two sessions. The primary outcome was a decrease in IOP, evaluated at one, three, and six months after the SLT procedure.

Results

Twenty-six eyes of 22 patients were included. The mean intraocular pressure (IOP) measured after DEX-implant injection was 25.4 ± 5.4 mmHg, and the mean increase in IOP was 35.8 ± 14.6%. The mean follow-up after SLT was 18.3 ± 7.7 months. After SLT, the mean IOP dropped by 30.9% at one month (16.9 ± 4.5 mmHg, p=0.01), 33.6% at three months (16.0 ± 2.7 mmHg, p < 0.01), and 34.9% at six months (15.6 ± 2.1 mmHg, p < 0.01). Each patient had a minimum follow-up of 6 months after SLT. Eight eyes (31%) received a second DEX-implant injection after the SLT procedure without experiencing an increase in the IOP above 21 mmHg or >20%. No glaucoma surgery was required during the follow-up. The mean number of medications (1.65 ± 1.36) was significantly reduced at one (1.19 ± 1.20, p=0.04), three (0.96 ± 1.03, p < 0.01), and six months (0.77 ± 0.95, p < 0.01) after SLT.

Conclusion

SLT is an effective and safe procedure to control OHT following DEX-implant intravitreal injection.

Association between Early Anatomic Response and Intraocular Pressure Change after Intravitreal Dexamethasone Implant: An Optical Coherence Tomography Study

Purpose: To investigate the associations between early anatomical responses and intraocular pressure (IOP) changes in macular edema (ME) due to retinal vascular diseases treated with an intravitreal dexamethasone (DEX) implant. Methods: A retrospective review was conducted involving ME patients who underwent intravitreal DEX implantation. The eyes were divided into increased IOP (IIOP) or non-IIOP (nIIOP) groups according to the presence or absence of significant IOP elevation. Significant IOP elevation was defined by both the absolute value of IOP elevation (5 mmHg or higher) and an elevation percentage of the baseline IOP (an increase equal to 30% of the pre-injection IOP or higher). We analyzed the difference in central subfield thickness (CST) change according to the IOP elevation after DEX implantation. Relationships between IOP change and CST reduction after intravitreal DEX implantation were analyzed by Pearson correlation coefficients. Results: A total of 49 eyes, 29 with diabetic ME and 20 with ME due to retinal vein occlusion (RVO), were included in this study. Of the 49 eyes, 18 eyes (36.7%) were classified as IIOP group and 31 (63.3%) as nIIOP group. Significant differences in mean CST reductions over baseline one week after DEX implantation were observed between the groups. The degree of CST reduction from baseline to 1 week was significantly correlated with the degree of IOP change from baseline at 1 week and 1 month after intravitreal DEX implantation. Conclusions: In patients with ME due to retinal vascular diseases, we noted an early anatomical response significantly correlated with IOP change after intravitreal DEX implantation. Therefore, patients with favorable early anatomical responses to DEX implantation should be carefully monitored for IOP elevation.

Assessment of single nucleotide polymorphisms associated with steroid-induced ocular hypertension

AIM

To access the association of forty-eight single nucleotide polymorphisms (SNPs) identified from Caucasian population with steroid-induced ocular hypertension (OHT) in India population.

METHODS

Fifty-four triamcinolone-acetonide (TA) and forty-seven dexamethasone (Dex) administered subjects were enrolled in the study after a written consent. Intraocular pressure (IOP) values were recorded for a period of 6-month post steroid injections and patients were grouped as steroid-responders (SR: IOP≥21 mm Hg) and non-responders (NR: IOP≤20 mm Hg). Genomic DNA was isolated from peripheral venous blood. Forty-eight SNPs identified in TA treated Caucasian patients by genome wide association study (GWAS) were genotyped using iPLEX™ MassARRAY among TA as well as Dex administered Indian patients. Genotyping data of 48 general subjects from a previous study were considered as reference controls for statistical analysis. Genotypic frequencies were calculated and P-value, Chi-square and odds ratio at 95% confidence-interval of group A (steroid treated vs controls), group B (SR vs NR), group C (phenotype correlation: influence of time, severity and gender on IOP rise), were calculated. P<0.05 was considered to be statistically significant.

RESULTS

OHT was observed in 50% of TA and 26% of Dex administered patients, respectively. IOP rise was mostly severe (>30 mm Hg) and immediate (<1wk) among TA-SR patients while it was noticed to be mild (<30 mm Hg) and between 1-2mo among Dex-SR patients. Logistic regression for risk factor correlation with OHT remained non-significant, hence these factors were not considered as confounding parameters for further analysis. rs133, rs34016742, rs274554, rs10936746, rs274547, rs804854, rs7751500, rs359498, and rs7547448 SNPs significantly varied even after Bonferroni corrections (P<0.0025; group A). rs1879370 (TA) and rs6559662 (Dex) were significantly (P<0.05) associated with OHT (group B). rs133 (severe IOP rise), rs11047639 and rs1879370 (male gender), and rs11171569 (immediate IOP rise) significantly (P<0.05) influenced the phenotype correlation only among TA-OHT patients. However, the significance of these SNPs in group B and phenotype analysis (group C) was lost upon Bonferroni corrections (P<0.0025).

CONCLUSION

Prevalence of OHT in study population is observed to be similar to other studies both in TA and Dex treated patients. We can correlate rs34016742 involved in diabetes signaling pathway to the occurrence of ocular edematous and inflammatory conditions. Except rs133 that is involved in neuro-degeneration and myopia occurrence, none of the other SNPs identified in Caucasian population possess any correlation with OHT incidence in TA and Dex administered Indian subjects.

Intravitreal Dexamethasone Implant as a Sustained Release Drug Delivery Device for the Treatment of Ocular Diseases: A Comprehensive Review of the Literature

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.

Secondary ocular hypertension post intravitreal dexamethasone implant (OZURDEX) managed by pars plana implant removal along with trabeculectomy in a young patient

We report a case of refractory secondary ocular hypertension after insertion of dexamethasone implant (OZURDEX) for posterior uveitis in a young patient, which necessitated removal of the implant through pars plana vitrectomy along with a trabeculectomy. A young male developed secondary ocular hypertension following dexamethasone implant (OZURDEX) injection for control of posterior uveitis. As the implant was still present in the vitreous cavity, we successfully performed a pars plana removal of the implant along with trabeculectomy with mitomycin C. Early intervention is essential to prevent glaucomatous optic neuropathy in young uveitic patients receiving OZURDEX implant.

Evaluation of Functional Outcomes and OCT-Biomarkers after Intravitreal Dexamethasone Implant for Postoperative Cystoid Macular Edema in Vitrectomized Eyes

Purpose

To evaluate the efficacy of dexamethasone implant (DEX) for the treatment of postoperative cystoid macular edema (PCME) in vitrectomized eyes and to investigate visual and morphological OCT predictive factors.

Methods

In this retrospective study, eyes with PCME after vitrectomy were treated with at least one DEX injection and were observed over 12 months. Indications for surgery were epiretinal membrane (ERM) or rhegmatogenous retinal detachment (RRD) without macular involvement. Prior treatments, if any, were noted. Best corrected visual acuity (BCVA), central foveal thickness (CFT), and OCT morphology including the presence of intraretinal cysts/fluid or subretinal fluid (IRF/SRF) and ellipsoid zone (EZ) continuity were evaluated. Correlations between OCT measures and visual outcomes were analyzed by the generalized estimating equations procedure.

Results

Forty-six eyes with ERM and 15 eyes with RRD were enrolled. The ERM group was more likely to gain BCVA than RRD (odds ratio (OR), 1.168; 95% confidence interval (CI), 1.003–1.360; p=0.046). The absence of SRF (OR, 0.860; 95% CI, 0.743–0.995; p=0.043) was predictive of worse BCVA, whereas the integrity of EZ (OR, 1.094; 95% CI, 0.951–1.257; p=0.209) or naïve status (OR, 0.946; 95% CI, 0.871–1.137, p=0.853) was not. Eyes with a worse baseline BCVA were more likely to gain >1 line after 12 months (OR, 1.485; 95% CI, 1.171–1.884; p=0.001).

Conclusion

The efficacy of the treatment of PCME in vitrectomized eyes seems to be affected by baseline BCVA, the absence of SRF, and the indication for surgery. Naïve status appears not to play any significant role in the prediction of BCVA. This trial is registered with DRKS00018955.

Intravitreal Injections for Macular Edema Secondary to Retinal Vein Occlusion: Long-Term Functional and Anatomic Outcomes

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.

Steroid-induced glaucoma: Epidemiology, pathophysiology, and clinical management

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.

Intraocular pressure (IOP) after intravitreal dexamethasone implant (Ozurdex) amongst different geographic populations-GEODEX-IOP study

PURPOSE

To analyse the intraocular pressure rise after intravitreal dexamethasone implant (Ozurdex) amongst different geographic populations.

METHODS

The medical charts of 294 dexamethasone implants between February 2011 and 2017 were reviewed retrospectively. South Asian (India), White (Europe, US and Israel) Latino (Argentina and Brazil) patient data was included in the study. Ocular hypertension (OHT) was defined as intraocular pressure of >25 mmHg or an increase of at least 10 mmHg from baseline. The main indications for treatment were diabetic macular edema (ME) (65.6%), retinal vein occlusion (26.5%), uveitis (7.8%).

RESULTS

Amongst 294 intravitreal implants, ocular hypertension (>25 mmHg) was recorded in 0, 8 and 9.5% in White, Latino, and South Asian groups, respectively. However, IOP > 20 mmHg was recorded in 14%, 28% and 27% in White, Latino, and South Asian groups, respectively. Incidence of very high IOP (>35 mmHg) was lower in all geographical groups. It was 3% in Latino followed by 2% in South Asian group.

CONCLUSION

Latino and South Asian groups have higher IOP rise compared to White population. Most patients with elevated IOP fluctuate between 20-25 mmHg.

INTRAOCULAR DEXAMETHASONE IMPLANT POSITION IN SITU AND OCULAR HYPERTENSION

PURPOSE

To determine the association between the dexamethasone implant position in the vitreous cavity and ocular hypertension (OHT).

METHODS

Retrospective review of patients with at least one intravitreal dexamethasone implant injection between 2012 and 2016. Patients who had a minimum follow-up for 6 months and documented evidence of the implant position were included in the study. Steroid responders, glaucoma patients, vitrectomized eyes, and eyes with liquefied vitreous were excluded. Relevant data were collected from patient charts. Three positions (P1, P2, and P3) were identified: P1 (in contact with the pars plana/ciliary body region), P2 (anterior to vortex veins), and P3 (posterior to vortex veins). Ocular hypertension was defined as absolute intraocular pressure > 25 mmHg and/or intraocular pressure rise > 10 mmHg. The relationship between implant position and intraocular pressure rise after factoring in other characteristics was the outcome measure. Appropriate statistical analysis was performed.

RESULTS

A total of 377 patients (432 eyes; 257 males; 677 injections) were eligible for analysis. The median age was 57.24 (±6.32) years. Eighty-eight eyes had OHT. Of these, 54 eyes had the implant in P1. P1 was associated with high intraocular pressure response (>15 mmHg; P = 0.004) and early (<15 days) onset OHT (r = 0.84, P < 0.001).

CONCLUSION

Anterior position of dexamethasone implant in situ increases the risk of OHT.

Intraocular pressure change after injection of intravitreal dexamethasone (Ozurdex) implant in Korean patients

BACKGROUND/AIMS

To analyse intraocular pressure (IOP) changes over a period of 1 year after intravitreal dexamethasone (DEX, Ozurdex) implant injection and to compare the results with those of previously published studies that involved non-Asian populations.

METHODS

A retrospective observational study was conducted. A total of 540 eyes of 503 patients who received DEX implant injection and were diagnosed with macular oedema (ME) due to various retinal diseases were examined. IOP was measured prior to injection and at 1 week, 1 month, 2 months, 3 months, 6 months and 12 months after DEX implant injection. IOP elevation was divided into four categories: postinjection IOP of >35 mm Hg, >30 mm Hg and >25 mm Hg, and an IOP elevation of >10 mm Hg, relative to the baseline measurement.

RESULTS

The mean baseline IOP was 13.45±2.95. The mean IOP gradually increased until 2 months postinjection (IOP=16.85±5.96 mm Hg, p<0.001) and then gradually decreased until 12 months postinjection (IOP=13.80±4.04mm Hg, p=0.16). IOP was >25 mm Hg in 57 eyes (10.6%), >30mm Hg in 29 eyes (5.4%) and >35mm Hg in 9 eyes (1.7%); IOP exhibited >10 mm Hg elevation from the baseline IOP in 61 eyes (11.3%). Overall, the incidence rate of IOP elevation after DEX treatment was 12.6% (68 eyes). Among the 68 eyes (12.6%) with elevated IOP, 60 (11.1%) required treatment: 59 (10.9%) required IOP-lowering medication and 1 (0.2%) ultimately required surgical interventions.

CONCLUSIONS

The incidence of adverse IOP elevation requiring the prolonged use of IOP-lowering medication and surgical intervention after DEX implantation was significantly lower than the incidence reported in previous Western population-based studies. Intravitreal DEX injection may therefore be an effective and relatively safe treatment modality for ME in Asian patients.

Phaco-non-penetrating deep sclerectomy in ocular hypertension secondary to dexamethasone intravitreal implant

PURPOSE

To evaluate the characteristics and progression of patients treated with a 0.7mg dexamethasone intravitreal implant (Ozurdex^®) and required glaucoma filtering surgery (phaco-non-penetrating deep sclerectomy) to control ocular hypertension (OHT).

METHODS

A retrospective observational study including patients treated with Ozurdex^® in a tertiary-care university hospital from May 2011 to April 2016.

RESULTS

In five years of follow-up, 1.10% (4/363) of patients treated with 0.7mg dexamethasone intravitreal implant required phaco-non-penetrating deep sclerectomy (PNPDS) to control OHT refractory to topical treatment. All four patients started or increased previous antihypertensive topical treatment since the first dexamethasone intravitreal implant. Three or more dexamethasone intravitreal implants were injected in the four cases before intraocular pressure (IOP) became uncontrolled and PNPDS was performed. All four patients have a successfully controlled IOP without treatment after PNPDS. Two patients required additional treatment with dexamethasone intravitreal implants after PNPDS, maintaining IOP under control without treatment.

CONCLUSIONS

To the best of our knowledge, this is the first study describing the successful results of PNPDS in OHT secondary to dexamethasone intravitreal implant. All four patients have achieved controlled IOP without treatment. Re-treatment with dexamethasone intravitreal implant in those patients who underwent PNPDS is also possible, and IOP remains controlled.

Concurrent injection of dexamethasone intravitreal implant and anti-angiogenic agent in patients with macular edema: A retrospective cohort study

To evaluate the safety and efficiency in macular edema patients who concurrently received a single injection of a dexamethasone intravitreal implant (DEX, 0.7 mg) and ranibizumab (2.3 mg).A retrospective cohort study was conducted, and medical records from 2012 to 2016 were reviewed. Patients who received concurrent DEX and ranibizumab injections with a follow-up period of at least 3 months were enrolled in the study group. An age and gender-matched group received ranibizumab injections and was designated the control group. The best-corrected visual acuity (BCVA), central macular thickness (CMT) and intraocular pressure (IOP) were included in the analysis. Steroid-induced ocular hypertension (SIOH) is defined as either an elevation of more than 10 mmHg from baseline or a single IOP measurement of more than 30 mmHg.A total of 26 patients were enrolled in the current study with 13 patients in each group. Both the BCVA (P = .04) and CMT (P < .01) achieved significant improvement after the follow-up period in the study group. The IOP increased after the injection but no significant elevation was observed throughout the follow-up period in the study group (P = .15). For SIOH, 1 patient in the study group had an elevated IOP of 10 mmHg (7.7%) at 2 postoperative months, and no single IOP measurement of more than 30 mmHg was obtained. Five patients (38.5%) in the study group received medical treatment that successfully retarded their IOP elevation, and no individuals required surgical management. In the control group, there were no significant fluctuations concerning BCVA, CMT, and IOP, and no ocular hypertension was observed. According to the inter-group analysis, the CMT and BCVA recovered more significantly in the study group than in the control group.Concurrent injection of DEX and ranibizumab is a preliminary method that shows effectiveness in treating ME. Furthermore, safety is also guaranteed, with moderate levels of severity and transient IOP elevation being observed. A future large-scale study is necessary to evaluate the long-term effects and safety of this combined treatment.