Dexamethasone intravitreal implant for treatment of uveitic persistent cystoid macular edema in vitrectomized patients. Retina. 2013;33:1435-1440. [PMID: 23514796 DOI: 10.1097/iae.0b013e31827e247b]

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

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

Intravitreal immunotherapy in non-infectious uveitis: an update

INTRODUCTION

In the past several years, there have been numerous advances in pharmacotherapeutics for the management of uveitis and other ocular inflammatory diseases, including newer therapeutic agents and ocular drug delivery systems. One of the most attractive modes of drug delivery is the intravitreal route since it has proven to be safe and efficacious and prevents unwanted systemic adverse events related to the agent.

AREAS COVERED

In this review, intravitreal delivery of various pharmacotherapeutic agents for noninfectious uveitis has been described. An extensive review of the literature was performed using specific keywords on the PubMed database to identify clinical studies employing various pharmacotherapeutic agents with intravitreal drug delivery for noninfectious uveitis. The mode of action, safety, efficacy, and tolerability of these drugs have also been elucidated.

EXPERT OPINION

Several agents, including biologic response modifier agents, have been found to be safe and efficacious for various indications of uveitis, such as cystoid macular edema, active uveitis, and other conditions such as retinal vasculitis and vitreous haze. The use of intravitreal biological therapies, especially infliximab, has been fraught with potential safety signals such as photoreceptor toxicity. However, pharmacotherapeutic agents such as corticosteroids and anti-vascular endothelial growth factor agents are now widely used in the clinical management of uveitis and its complications.

Treatment of Non-Infectious Posterior Uveitis with Dexamethasone Intravitreal Implants in a Real-World Setting

Purpose

The present study aimed to assess the efficacy and safety associated to the treatment of patients with non-infectious posterior uveitis with intravitreal dexamethasone (DEX) implants in a real-world clinical setting.

Patients and Methods

This is a retrospective, single center analysis of the data from 29 patients with non-infectious posterior uveitis in whom 38 eyes were treated with dexamethasone intravitreal implants in routine clinical practice between January 2012 and October 2017. The parameters of visual acuity (VA), intraocular pressure (IOP) and central retinal thickness (CRT) were recorded 6 weeks after the first implant was administered, in accordance with the clinical guidelines for the use of these implants, and after a 6-month follow-up period. In addition, the formation of cataracts was evaluated at 12 months.

Results

Treatment with the DEX implant caused a significant improvement in the VA from baseline at 6 weeks in eyes treated with 2-6 implants and for eyes without cataracts. A significant decrease in CRT was observed relative to the baseline at 6 weeks for eyes treated with 1 and 2-6 implants, which was maintained at 6 months for those eyes treated with 2-6 implants. This significant improvement in CRT at 6 weeks and 6 months was evident in eyes with and without cataracts. During the study period, the IOP was found to increase significantly from baseline at 6 weeks in some eyes but this was managed topically, and no surgical intervention was necessary.

Conclusion

Intravitreal DEX implants represent an effective and safe therapy for the treatment of non-infectious uveitis in routine clinical practice, producing favorable visual and anatomical outcomes after the administration of just 2-6 DEX implants.

A Comparison of Ocular Complications after 0.7 mg Dexamethasone Implant versus 2 mg of Intravitreal Triamcinolone in Vitrectomized Eyes

OBJECTIVE

To compare the rates of complications in eyes that received a dexamethasone (DEX) implant (0.7 mg) or intravitreal triamcinolone (IVT) (2 mg) to treat postvitrectomy macular edema (ME).

DESIGN

Retrospective, comparative, case series.

SUBJECTS

A total of 148 eyes (147 patients); 75 eyes (75 patients) in the DEX group and 73 eyes (72 patients) in the IVT group.

METHODS

The medical records of patients who received an intravitreal DEX 0.7 mg (Ozurdex) or triamcinolone (2 mg) (Triesence) for postvitrectomy ME between July 2014 and December 2021 with a minimum follow-up of 3 months were reviewed. Ocular hypotony and ocular hypertension were defined as intraocular pressure of < 6 mmHg and > 24 mmHg, respectively.

MAIN OUTCOME MEASURES

The rates of complications.

RESULTS

The follow-up duration was 2.5 ± 1.6 years, with no significant difference between the groups (P = 0.398). The rate of transient ocular hypotony per eye and per injection was significantly higher in the DEX group (10 eyes [13%], 30 of 443 injections [7%]) compared with the IVT group (2 eyes [3%], 2 of 262 injections [0.8%]) (P = 0.039 and < 0.001, respectively). Mean visual acuity significantly decreased at the time of ocular hypotony (P = 0.031), but returned to preinjection level after resolution of the hypotony after a median of 12 days. The incidence of ocular hypertension was higher in the DEX group (23 eyes [31%]) than the IVT group (16 eyes [22%]), but this was not statistically significant (P = 0.307). Ocular hypertension was controlled with observation or topical medication. There were no between-group differences in the incidence of vitreous hemorrhage (DEX, 3 eyes [4%]; IVT, 1 eye [1%]; P = 0.632) or rhegmatogenous retinal detachment (DEX, 3 eyes [4%]; IVT, 0 eyes [0%]; P = 0.253). Four eyes (5%) experienced migration of the DEX implant into the anterior chamber. No eye developed endophthalmitis.

CONCLUSION

The incidence of ocular hypotony, which causes transient visual impairment, was significantly higher in vitrectomized eyes treated with DEX compared with eyes treated with IVT. Injections other than the inferotemporal quadrant or rotating injection sites may be recommended.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

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.

Mid-term safety and effectiveness of intravitreal dexamethasone implant to treat persistent cystoid macular edema in vitrectomized eyes for bacterial endophthalmitis

PURPOSE

To evaluate the mid-term safety and effectiveness of intravitreal dexamethasone implant (DEX-i) for treating unresponsive to medical therapy cystoid macular edema (CME) in vitrectomized eyes for endophthalmitis.

METHODS

Retrospective and interventional case series study conducted on vitrectomized eyes for endophthalmitis that developed a CME that did not adequately respond to medical therapy, who underwent 0.7-mg DEX-i. Main outcome measures were changes in central retinal thickness (CRT) and best corrected visual acuity (BCVA).

RESULTS

Eleven eyes were included in the study. Microbiological findings of vitreous biopsies were 7 (63.6%) staphylococcus epidermidis; 3 (27.3%) Pseudomonas aeruginosa; and 1 (9.1%) Propionibacterium acnes. Median (interquartile range, IqR) duration of CME was 4.0 (3.0-4.0) months. Median (IqR) time between vitrectomy and DEX-i was 9.0 (9.0-11.0) months. Median CRT was significantly decreased from 548.0 (412.8-572.5) µm at baseline to 308.0 (281.3-365.5) µm at month 6 (p = 0.0009, Friedman test). Median BCVA significantly improved from 38.0 (30.5-44.8) letters at baseline to 50.0 (46.8-53.0) letters at month 6 (p < 0.0001, Friedman), with 9 (81.8%) eyes gaining ≥ 10 letters. Elevation of intraocular pressure was observed in one (9.1%) eye, which was successfully controlled with medical therapy. No recurrence of endophthalmitis or other complications was observed. Eight (72.7%) eyes required an additional DEX-i, while 3 (27.3%) were successfully controlled with only one DEX-i. CME recurrence occurred in 5 (62.5%) Gram-positive and 3 (100.0%) Gram-negative bacteria (p = 0.2357).

CONCLUSION

In vitrectomized eyes for endophthalmitis affected by CME unresponsive to medical therapy, DEX-i had an acceptable safety profile and achieved favorable outcomes. The possibility of suppressing mechanisms for infection control should be taken into account, although correct management of endophthalmitis and long time without reactivation before DEX-i reduce the risk.

Intravitreal 0.19 mg Fluocinolone Acetonide Implant in Non-Infectious Uveitis

The efficacy of the 0.19-mg fluocinolone acetonide (FAc) intravitreal implant (ILUVIEN) in the treatment of non-infectious uveitic macular edema (UME) was assessed on twenty-six patients (34 eyes) with non-infectious UME between 2013 and 2020, in a mean follow-up of 18 ± 19.3 (mean ± SD) months. Macular edema was resolved in 24 (70.6%) cases. Five of these eyes had a relapse after 23.2 ± 14 months. Three FAc reinjections were performed and a drying of the macula was observed. After FAc implantation, 24 eyes (70.6%) were completely dry; central retinal thickness (CRT) decreased in 6 eyes (17.6%), but residual intraretinal fluid was still evident. In 20 eyes (58.5%), visual acuity (VA) improved (from +1 to +5 lines) and remained stable in 9 eyes (26.5%). Thirty eyes (88.2%) were pseudophakic at baseline and four were phakic. Three of these eyes had a cataract prior to therapy and the other developed a cataract 2.5 years after the FAc implant was administered. There was an overall increase in intraocular pressure (IOP; +4.4 ± 3.7 mmHg) and eye drops were required in three eyes. The FAc implant led to long-term improvements in mean CRT and VA, and that the side-effect profile was manageable in a clinical setting in patients with non-infectious UME.

Intravitreal Dexamethasone Implants for Refractory Macular Edema in Eyes with Noninfectious Uveitis

Macular edema (ME) is a common cause of visual loss among eyes with uveitis, and its management can be challenging. Steroids are an effective treatment for ME, and intravitreal dexamethasone (DEX) implants provide sustained steroid release. The purpose of this study is to evaluate intravitreal DEX implant on refractory ME in eyes with noninfectious uveitis. A retrospective study including 52 eyes of 37 patients with refractory uveitic ME was conducted from January 2011 through August 2017 at Linkou Chang Gung Memorial Hospital in Taiwan. Patients’ demographic characteristics were collected. In addition, clinical information, including corrected visual acuity (VA), intraocular pressure (IOP), and central retinal thickness (CRT) on optical coherence tomography, was recorded and analyzed. During the study period, affected eyes received a total of 110 intravitreal DEX implants (range, one to six in each eye). After the first DEX implant injection in all eyes, VA significantly improved at one and two months. CRT significantly decreased one month after a single DEX implant, and the effect lasted for six months and waned over time. Patients receiving multiple DEX implants still showed significant decreases in CRT one month after the first implant. Increases in IOP were noted one month after the DEX implant, but the IOP could be medically controlled. Intravitreal DEX implants can effectively treat refractory uveitic ME, improving both VA and CRT with an acceptable safety profile. Further studies are necessary to evaluate the effect of multiple implants and long-term outcomes.

A Review of Ocular Drug Delivery Platforms and Drugs for Infectious and Noninfectious Uveitis: The Past, Present, and Future

Uveitis refers to a broad group of inflammatory disorders of the eye that often require medical and surgical management to improve or stabilize vision and prevent vision-threatening pathological changes to the eye. Drug delivery to the eye to combat inflammation and subsequent complications from uveitic conditions is complex as there are multiple barriers to absorption limiting availability of the needed drug in the affected tissues. As such, there has been substantial interest in developing new drugs and drug delivery platforms to help reduce intraocular inflammation and its complications. In this review, we discuss the challenges of drug delivery, novel technologies recently approved for uveitis patient care and promising drug delivery platforms for uveitis and sequelae of ocular inflammation.

A Review of Local Therapy for the Management of Cystoid Macular Edema in Uveitis

ABSTRACT

Uveitic macular edema is a significant cause of visual impairment in most uveitis types. Treatment options of uveitis have advanced remarkably in recent years. Up to now, corticosteroids remain the mainstay of treatment. Nonsteroidal immunomodulators, and recently the biologic agents, which can reinforce efficacy and enable discontinuation or reduction of steroids to maintenance doses, are becoming increasingly popular in the management of uveitic macular edema. Several medications can be used in intraocular delivery and more and more sustained releasing implants are being developed. This review will briefly focus on the review of local therapy for the management of cystoid macular edema in uveitis, as many of these novel approaches are currently being evaluated in clinical trials.

Initial Ten Years of Experience with the Intravitreal Dexamethasone Implant: A Retrospective Chart Review

Purpose

To evaluate the initial ten years of results from the intravitreal dexamethasone implant (DEX) in patients treated for retinal vein occlusion (RVO), diabetic macular edema (DME) or uveitis.

Methods

Retrospective chart review of patients receiving DEX since its FDA approval. Best-corrected visual acuity (BCVA), central macular thickness (CMT) on optical coherence tomography, intraocular pressure and cataract status were collected. Baseline data were collected from the initial DEX and post-treatment data at the visit at least four weeks after the last DEX.

Results

In total, 315 eyes received 1216 DEX over 63.9±4.6 weeks. In the branch RVO (n=90), central RVO (n=59) and DME (n=62) cohorts, BCVA improved significantly (p<0.05). The uveitis (n=154) cohort did not have a significant change in BCVA, 0.62±0.04 to 0.61±0.04 logMAR (p=0.34). Younger patients, vitrectomized eyes, and eyes without a history of glaucoma were associated with significantly better BCVA outcomes in the uveitis cohort (p<0.05). Overall, CMT decreased significantly from 376.6±6.8 to 322.7±5.0 µm (p<0.05). Intraocular pressure increased significantly (p<0.001) and the percentage of patients requiring anti-glaucoma medications increased from 33.0% to 67.6%. Of phakic eyes, 58.8% (n=63) had cataract progression or underwent surgery with those who underwent surgery experiencing a significant improvement in BCVA (p<0.05).

Conclusion

Repeated DEX over extended follow-up offers significant anatomic benefits to all cohorts. Visual benefits are only seen in RVO, DME and select uveitis demographics.

Effectiveness of the Dexamethasone Implant in Lieu of Oral Corticosteroids in Intermediate and Posterior Uveitis Requiring Immunosuppression

PURPOSE

To evaluate dexamethasone intravitreal implant effectiveness in lieu of high-dose oral prednisone for short-term treatment of noninfectious intermediate and posterior uveitis in patients requiring immunosuppression.

METHODS

This is a proof-of-concept, open-label, non-comparative clinical trial with 12-month follow-up. The primary outcome was uveitis control without additional prednisone at 6 and 12 months. Secondary outcomes were need for multiple implants or additional prednisone, and safety data.

RESULTS

20 patients (28 eyes) were enrolled- 16 eyes had control by 6 months; 20 by 12 months. No patients required high-dose prednisone. 6 patients enrolled on prednisone: 2 stopped; 4 tapered to 7.5 mg daily or less by 12 months. 16 eyes required multiple implants; five required cataract surgery; 12 required drops to control IOP; 2 underwent glaucoma surgery.

CONCLUSIONS

The dexamethasone implant was effective in lieu of high-dose prednisone although the majority required multiple implants. All patients decreased or discontinued prednisone during follow-up.

Outcome of Intravitreal Dexamethasone Implant Use in Uveitic Eyes Undergoing Pars Plana Vitrectomy Surgery

Purpose: To report the outcomes in eyes with noninfectious uveitis receiving dexamethasone implant at the time of pars plana vitrectomy (PPV).Methods: Retrospective analysis of visual acuity (VA), intraocular pressure (IOP), vitreous haze score (VHS), and central subfield thickness (CST) at baseline and follow-up visits.Results: Fourteen eyes received dexamethasone implant at the time of PPV. The CST was improved from 469 ± 182 µm at baseline to 320 ± 60 at 6 months (p = .0112) and 295 ± 46 at 12 months (p = .0728). Vitritis only recurred in 2 eyes at 6 months (18.2%) and 1 eye at 12 months (14.3%). The probability of VA improvement of ≥0.3 logMAR was 57% at 6 months and 66% at 12 months. Therapy for IOP rise was initiated in 6 eyes (42.9%).Conclusions: Local delivery of dexamethasone implant with PPV is a feasible method to counteract postoperative inflammation and macular thickening.

Ozurdex (dexamethasone intravitreal implant) for the treatment of intermediate, posterior, and panuveitis: a systematic review of the current evidence

Background

This study aims to determine if the intravitreal dexamethasone implant (DEX implant, Ozurdex; Allergan, Inc., Irvine, California) is effective for treating intermediate, posterior, and panuveitis as a monotherapy or adjunctive treatment to systemic immunomodulatory therapies.

Methods

A systematic review using MEDLINE, EMBASE, and PubMed database searches was conducted with the Oxford Centre for Evidence-based Medicine Levels of Evidence criteria to select publications. Available background information and patient data from each study was tabulated. Outcomes studied were central retinal thickness (CRT), best corrected visual acuity, intraocular inflammation (anterior chamber cells, vitreous haze), number of patients with prior and concomitant immunomodulatory treatments, intraocular pressure (IOP) elevation (≥ 25 mmHg), and other adverse effects associated with the implant.

Results

One hundred ninety-five (61.51%) patients had previous immunomodulatory treatment while 232 (64.8%) were treated with concomitant immunomodulatory therapy with the DEX implant. CRT decreased by an average of 198.65 μm (42.74%). Visual acuity improved to an average of 0.451 (logMAR) or 20/57 (Snellen) which is a 43.11% improvement from baseline. One hundred seventy-three (59%) of eyes were quiescent at the end of the trials, of which 40 (13.7%) previously inflamed eyes became quiescent. Elevated IOP occurred in 91 (20.6%). The most common adverse events were cataract/posterior subcapsular opacities in 47 (11.03%) patients and conjunctival hemorrhage in 24 (5.44%) patients.

Conclusions

The DEX implant is an effective medication for the treatment of posterior segment uveitis, uveitic macular edema, and results in improved visual acuity. Development of elevated IOP and cataract should be closely monitored as they are tangible risks associated with the DEX implant. This study was not able to determine whether the DEX implant was more effective as a monotherapy or as an adjunctive therapy to systemic immunomodulatory treatment.

Corticosteroids for Diabetic Macular Edema

Diabetic macular edema (DME) is a chronic condition with a multifactorial pathogenesis. Vascular endothelial growth factor (VEGF) and several inflammatory mediators are upregulated in eyes with DME. VEGF inhibitors and corticosteroids have all been used successfully in the management of DME. Currently available corticosteroids include triamcinolone acetonide (TA), the dexamethasone (DEX) intravitreal implant, and the fluocinolone acetonide (FA) intravitreal implant. The response to treatment can vary substantially with each treatment modality. Some cases of DME are VEGF driven, and in others, inflammation plays a key role. Chronicity appears to favor corticosteroid treatment. There are no clear guidelines to guide switching from an anti-VEGF to a corticosteroid. Combination therapy of an anti-VEGF drug and a corticosteroid does not appear to provide additional benefit over monotherapy with either drug. The main advantage of corticosteroids over VEGF inhibitors is their longer duration of action. Vitrectomy does not affect the pharmacokinetics of the corticosteroid implants. Common adverse events of corticosteroids include cataract formation, cataract progression, and ocular hypertension. TA may cause a sterile endophthalmitis and pseudoendophthalmitis. Migration of the intravitreal DEX and FA implants into the anterior chamber can be problematic. Because of their less favorable safety profile, corticosteroids are generally used as a second-line treatment for DME. Advantages of using an intravitreal corticosteroid implant include the reduction of treatment burden and predictable pharmacokinetics even in vitrectomized eyes. Pseudophakic eyes, previously vitrectomized eyes and eyes with long-standing DME, particularly of patients who have difficulty in maintaining a monthly appointment, may benefit from primary treatment with a corticosteroid intravitreal implant.

Intravitreal dexamethasone implants for non-infectious uveitis

IMPORTANCE

Inflammatory-mediated cystoid macular oedema (CMO) is the most common inflammatory-mediated threat to vision in non-infectious uveitis (NIU). Corticosteroid therapy is the cornerstone to the management of CMO in NIU. Sustained-release dexamethasone (DEX) implant devices provide localized therapy.

BACKGROUND

The authors present a series documenting the efficacy of DEX implants for NIU in an Australian cohort.

DESIGN

A single centre, retrospective case series patients receiving DEX implants for NIU from 2012 to 2018 in a New South Wales tertiary eye hospital.

PARTICIPANTS

Twenty eyes of 17 patients receiving DEX implants for confirmed cases of NIU of varying aetiologies.

METHODS

Cases from March 2012 and March 2018 were retrospectively selected with follow-up assessment data recorded and analysed. All patients were seen at 1, 2 and 4 weeks post implant, then monthly. Minimum duration of follow-up was 32 weeks.

MAIN OUTCOME MEASURES

The primary outcome was change in central retinal thickness (CRT) of >20% at two consecutive visits. Secondary outcomes included change in best-corrected visual acuity (BCVA), intraocular pressure and medication regimens.

RESULTS

Ninety-five percent of patients achieved significant CRT reduction at 4, 8 and 16 weeks (P < .01). Sixty-one percent demonstrated improved BCVA at week 8 (P < .05). Ninety percent of patients taking systemic corticosteroid therapy at commencement reduced their dose to below 7.5 mg/day. Adverse event frequency was low.

CONCLUSIONS AND RELEVANCE

In keeping with larger studies, the authors suggest that DEX implants may effectively control uveitis refractory to other therapy, while improving BCVA and CRT. In addition, DEX usage has demonstrably reduced systemic steroid burden within the observed cohort.

Recent advances in intraocular sustained-release drug delivery devices

Topical eye-drop administration and intravitreal injections are the current standard for ocular drug delivery. However, patient adherence to the drug regimen and insufficient administration frequency are well-documented challenges to this field. In this review, we describe recent advances in intraocular implants designed to deliver therapeutics for months to years, to obviate the issues of patient adherence. We highlight recent advances in monolithic ocular implants in the literature, the commercialization pipeline, and approved for the market. We also describe design considerations based on material selection, active pharmaceutical ingredient, and implantation site.

Dexamethasone intravitreal implant (OZURDEX®) for macular edema secondary to noninfectious uveitis: a review of the literature

Macular edema (ME) is the leading cause of visual loss in uveitis and may persist long after ocular inflammation has been resolved. Local steroids are the first line treatment for uveitis and uveitic ME. Dexamethasone intravitreal implant (OZURDEX®; Allergan, Inc., CA, USA) has been used to treat diabetic ME and ME secondary to retinal vein occlusion. Recent studies have also demonstrated that Ozurdex may be effective treatment for patients with persistent uveitic ME. In this review, we present the results of the real word studies concerning the efficacy and safety of Ozurdex for the treatment of uveitic ME.

Update in treatment of uveitic macular edema

Macular edema (ME) represents the most common cause for visual loss among uveitis patients. The management of uveitic macular edema (UME) may be challenging, due to its often recalcitrant nature. Corticosteroids remain the mainstay of treatment, through their capability of effectively controlling inflammation and the associated ME. Topical steroids may be effective in milder cases of UME, particularly in edema associated with anterior uveitis. Posterior sub-Tenon and orbital floor steroids, as well as intravitreal steroids often induce rapid regression of UME, although this may be followed by recurrence of the pathology. Intra-vitreal corticosteroid implants provide sustained release of steroids facilitating regression of ME with less frequent injections. Topical nonsteroidal anti-inflammatory drugs may provide a safe alternative or adjuvant therapy to topical steroids in mild UME, predominantly in cases with underlying anterior uveitis. Immunomodulators including methotrexate, mycophenolate mofetil, tacrolimus, azathioprine, and cyclosporine, as well as biologic agents, notably the anti-tumor necrosis factor-α monoclonal antibodies adalimumab and infliximab, may accomplish the control of inflammation and associated ME in refractory cases, or enable the tapering of steroids. Newer biotherapies have demonstrated promising outcomes and may be considered in persisting cases of UME.

Injectable 0.19-mg fluocinolone acetonide intravitreal implant for the treatment of non-infectious uveitic macular edema

Background

A retrospective observational clinical study to evaluate the safety and effectiveness of the injectable 0.19-mg fluocinolone acetonide intravitreal implant (ILUVIEN) in the treatment of non-infectious uveitic macular edema.

Results

Data are presented from eight patients (11 eyes) with non-infectious uveitic macular edema who were treated with a 0.19-mg fluocinolone acetonide implant. Nine out of 11 eyes were pseudophakic prior to implantation of fluocinolone acetonide implant, and both phakic eyes required cataract surgery during the follow-up period (the median follow-up was 19 months; range, 8–42 months). Effectiveness and safety were assessed from changes in central retinal thickness (measured using spectral domain optical coherence tomography), corrected distance visual acuity, uveitic activity, and intraocular pressure.

The main outcome measures were changes in central retinal thickness, corrected distance visual acuity, uveitic activity, and intraocular pressure. In 11/11 eyes, central retinal thickness improved between months 1 and 3. The mean maximum decrease of central retinal thickness throughout the follow-up period was 168 ± 202 μm (± standard deviation). Nine out of 11 eyes showed an improvement in corrected distance visual acuity (between + 1 and + 8 lines), and 2/11 eyes lost corrected distance visual acuity (− 1 and − 3 lines, respectively). Nine out of 11 eyes presented with inactive inflammation during the follow-up period, and in 1/11 eyes, there was a relapse at month 42. Four out of 11 eyes presented with a relapse of macular edema between months 3 and 8. The mean increase in intraocular pressure was 2.1 ± 4.7 mmHg. Nine eyes were pseudophakic prior to implantation of the injectable fluocinolone acetonide intravitreal implant. Both phakic patients developed a cataract that was treated with cataract surgery in the follow-up period.

Conclusions

In this small case series with long-term follow-up, treatment of non-infectious uveitic macular edema with the injectable fluocinolone acetonide implant was associated with improved central retinal thickness and corrected distance visual acuity and a manageable safety profile. The advantage of this device is the long-term drug release and the fact that it can be injected into the vitreous as a minor surgical procedure, which is in contrast to other treatment options.

Long-term probability of intraocular pressure elevation with the intravitreal dexamethasone implant in the real-world

PURPOSE

To evaluate the long-term cumulative probability of intraocular pressure (IOP) elevation with the intravitreal dexamethasone implant (IDI) when used to treat different indications: diabetic macular edema, uveitis, retinal vein occlusion.

METHODS

705 IDI injections (429 eyes) were assessed and Kaplan-Meier graphs were generated to assess: the probability of different levels of IOP elevation (IOP≥21, ≥25 or ≥35 mmHg), IOP change ≥10 mmHg, initiation of IOP-lowering treatment, glaucoma surgery, IOP change with repeat injections and IOP elevation in eyes with glaucoma and ocular hypertension (OHT).

RESULTS

The cumulative probability of IOP ≥21, ≥25 and ≥35 mmHg was 50%-60%, 25%-30% and 6%-7% at 12-24 months, respectively. The probability of initiating IOP-lowering medication was 31%-54% at 12-24 months. Glaucoma and OHT eyes had a higher probability of mild IOP elevation (≥21 mmHg, 65.1%, 75% and 57.8%, p = 0.01), yet a similar moderate (≥25 mmHg, 22.3%, 28% and 30.2%, p = 0.91) and severe elevation of IOP (≥35 mmHg, 3.7%, 7.1% and 4%, p = 0.71) as normal eyes. Glaucoma surgery was required in only 0.9% cases (4/429). At baseline, 8.8% of the treated eyes had glaucoma, 6.7% OHT and 16.9% were already on IOP-lowering medication.

CONCLUSIONS

In the long-term (24 months), IOP elevation is common, generally mild (30% IOP, ≥25 mmHg) and well-tolerated, resolving with topical treatment (54%) and rarely requiring surgery (0.9%).

Long-term efficacy and duration of action of dexamethasone implant, in vitrectomised and non-vitrectomised eyes with persistent diabetic macular oedema

PURPOSE

To evaluate the efficacy and duration of action of an intravitreal (dexamethasone (Ozurdex)) implant in vitrectomised and non-vitrectomised eyes with persistent diabetic macular oedema (DMO).

METHODS

We retrospectively analysed the records for 18 eyes that had or had not been vitrectomised but required an intravitreal dexamethasone implant for DMO after a poor response to anti-vascular endothelial growth factor. Optical coherence tomography and visual acuity (VA) examinations were performed before and 1, 3 and 6 months after implantation. The six months following implantation constituted one treatment round; up to three rounds were studied.

RESULTS

Ten of 18 eyes had undergone vitrectomy. Best-corrected visual acuity (BCVA) and central macular thickness (CMT) were significantly improved by months 1-3 after implantation of the Ozurdex device in all rounds of treatment. The BCVA and CMT deteriorated gradually after month 3 through to month 6 post implantation. There were no statistically significant differences between the vitrectomised and non-vitrectomised groups at any time point. When the implantation interval was <6 weeks from the end of each treatment round, the improvement in BCVA and CMT was obvious even after 18 months of treatment.

CONCLUSIONS

Vitrectomy did not have a negative effect on the duration of action or efficacy of the Ozurdex implant in patients with persistent DMO. The implant started working from the first month after implantation regardless of whether vitrectomy had or had not been performed. The maximum functional and anatomic improvement was achieved in the first 3 months post implantation in all treatment rounds.

Intravitreal therapeutic agents in noninfectious uveitic macular edema

The management of uveitis is challenging for most treating ophthalmologists. The treatment of uveitis often requires the use of high dose of systemic corticosteroid and immunosuppressive agents, which are almost always associated with potential side effects. Intravitreal medications have become a popular mode of drug administration in uveitis patients as they provide high volume of drug to the target tissues, eliminating the risk of systemic toxicity. There has been tremendous development in the intravitreal therapeutics over the last few years. With the advent of sustained-release technique, increasing patient compliance, biodegradable nature of the implant, and introduction of newer agents with better safety profile, the intravitreal medications have become more popular in recent years. This review presents evidence in the scientific literature supporting the use of intravitreal medications for the management of uveitis and its complications.

A systematic review and economic evaluation of adalimumab and dexamethasone for treating non-infectious intermediate uveitis, posterior uveitis or panuveitis in adults

BACKGROUND

Non-infectious intermediate uveitis, posterior uveitis and panuveitis are a heterogeneous group of inflammatory eye disorders. Management includes local and systemic corticosteroids, immunosuppressants and biological drugs.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of subcutaneous adalimumab (Humira^®; AbbVie Ltd, Maidenhead, UK) and a dexamethasone intravitreal implant (Ozurdex^®; Allergan Ltd, Marlow, UK) in adults with non-infectious intermediate uveitis, posterior uveitis or panuveitis.

DATA SOURCES

Electronic databases and clinical trials registries including MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and the World Health Organization's International Clinical Trials Registry Platform were searched to June 2016, with an update search carried out in October 2016.

REVIEW METHODS

Review methods followed published guidelines. A Markov model was developed to assess the cost-effectiveness of dexamethasone and adalimumab, each compared with current practice, from a NHS and Personal Social Services (PSS) perspective over a lifetime horizon, parameterised with published evidence. Costs and benefits were discounted at 3.5%. Substantial sensitivity analyses were undertaken.

RESULTS

Of the 134 full-text articles screened, three studies (four articles) were included in the clinical effectiveness review. Two randomised controlled trials (RCTs) [VISUAL I (active uveitis) and VISUAL II (inactive uveitis)] compared adalimumab with placebo, with limited standard care also provided in both arms. Time to treatment failure (reduced visual acuity, intraocular inflammation, new vascular lesions) was longer in the adalimumab group than in the placebo group, with a hazard ratio of 0.50 [95% confidence interval (CI) 0.36 to 0.70; p < 0.001] in the VISUAL I trial and 0.57 (95% CI 0.39 to 0.84; p = 0.004) in the VISUAL II trial. The adalimumab group showed a significantly greater improvement than the placebo group in the 25-item Visual Function Questionnaire (VFQ-25) composite score in the VISUAL I trial (mean difference 4.20; p = 0.010) but not the VISUAL II trial (mean difference 2.12; p = 0.16). Some systemic adverse effects occurred more frequently with adalimumab than with placebo. One RCT [HURON (active uveitis)] compared a single 0.7-mg dexamethasone implant against a sham procedure, with limited standard care also provided in both arms. Dexamethasone provided significant benefits over the sham procedure at 8 and 26 weeks in the percentage of patients with a vitreous haze score of zero (p < 0.014), the mean best corrected visual acuity improvement (p ≤ 0.002) and the percentage of patients with a ≥ 5-point improvement in VFQ-25 score (p < 0.05). Raised intraocular pressure and cataracts occurred more frequently with dexamethasone than with the sham procedure. The incremental cost-effectiveness ratio (ICER) for one dexamethasone implant in one eye for a combination of patients with unilateral and bilateral uveitis compared with limited current practice, as per the HURON trial, was estimated to be £19,509 per quality-adjusted life-year (QALY) gained. The ICER of adalimumab for patients with mainly bilateral uveitis compared with limited current practice, as per the VISUAL trials, was estimated to be £94,523 and £317,547 per QALY gained in active and inactive uveitis respectively. Sensitivity analyses suggested that the rate of blindness has the biggest impact on the model results. The interventions may be more cost-effective in populations in which there is a greater risk of blindness.

LIMITATIONS

The clinical trials did not fully reflect clinical practice. Thirteen additional studies of clinically relevant comparator treatments were identified; however, network meta-analysis was not feasible. The model results are highly uncertain because of the limited evidence base.

CONCLUSIONS

Two RCTs of systemic adalimumab and one RCT of a unilateral, single dexamethasone implant showed significant benefits over placebo or a sham procedure. The ICERs for adalimumab were estimated to be above generally accepted thresholds for cost-effectiveness. The cost-effectiveness of dexamethasone was estimated to fall below standard thresholds. However, there is substantial uncertainty around the model assumptions. In future work, primary research should compare dexamethasone and adalimumab with current treatments over the long term and in important subgroups and consider how short-term improvements relate to long-term effects on vision.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016041799.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

DEXAMETHASONE INTRAVITREAL IMPLANT FOR THE TREATMENT OF RECALCITRANT MACULAR EDEMA AFTER RHEGMATOGENOUS RETINAL DETACHMENT REPAIR

PURPOSE

To investigate the efficacy of the intravitreal dexamethasone implant as the treatment for recalcitrant macular edema after successful rhegmatogenous retinal detachment repair.

METHODS

A retrospective review of the medical records was performed on 17 consecutive patients (17 eyes) with recalcitrant macular edema associated with rhegmatogenous retinal detachment repair who were treated with a single or multiple injections of an intravitreal dexamethasone 0.7-mg implant (Ozurdex; Allergan Inc) at two centers. Main outcomes of the study were change in logarithm of the minimum angle of resolution visual acuity, measurement of central foveal thickness, and macular cube volume as measured by spectral domain optical coherence tomography and frequency of complications.

RESULTS

The mean age was 67 years (range, 51-78 years). All 17 patients received previous topical therapy and 12 of them had previous administration of intravitreal triamcinolone with persistence of macular edema. Baseline mean best-corrected visual acuity was 20/100 (logarithm of the minimum angle of resolution 0.75; range, 0.18-1.3 ±0.37) in the affected eyes. There was a statistically significant improvement in best-corrected visual acuity at 1 month (P < 0.001) and 3 months (P = 0.01). Mean baseline central foveal thickness was 505 μm, and mean macular cube volume was 10.62 mm. There was a statistically significant decrease in central foveal thickness and macular cube volume at 1 month (505-290 μm, P = 0.013 and 10.62-9.13 mm, P < 0.0001) and 3 months (P = 0.01). All patients developed recurrence of macular edema at 3 months, which required retreatment. The average number of implants was 4 (range, 1-14). No adverse effects such as retinal detachment or endophthalmitis occurred. Two patients experienced an increase in intraocular pressure that was controlled with topical therapy.

CONCLUSION

Macular edema that occurs in eyes after successful repair of rhegmatogenous retinal detachment can be chronic and recalcitrant, and may be successfully and safely treated with the dexamethasone intravitreal implant.

Management of chronic ocular sarcoidosis: challenges and solutions

Background

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

Objective

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

Summary

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

PROSPECTIVE EVALUATION OF A SUSTAINED-RELEASE DEXAMETHASONE INTRAVITREAL IMPLANT FOR CYSTOID MACULAR EDEMA IN QUIESCENT UVEITIS

PURPOSE

To investigate dexamethasone intravitreal implant (DEX implant; OZURDEX, Allergan, Inc) in the treatment of uveitic cystoid macular edema that had persisted in the absence of intraocular inflammation.

METHODS

In this prospective interventional case series, 10 patients with uveitic cystoid macular edema and quiescent uveitis were treated with dexamethasone intravitreal implant at baseline and evaluated monthly for one year. Patients were retreated whenever cystoid macular edema recurred. The primary outcome measure was best-corrected visual acuity (BCVA) at day 90.

RESULTS

At day 90, mean improvement from baseline BCVA was 14.4 letters (P = 0.0003), 70% of patients had a ≥10 letter BCVA improvement, 50% of patients had a ≥15 letter BCVA improvement, and the mean decrease from baseline central subfield retinal thickness was 140 μm (P = 0.008). Improvements were maintained through day 360 with retreatment as needed. At day 360, mean improvement in BCVA was 16.5 letters (P = 0.006) and the mean decrease in central subfield retinal thickness was 158 μm (P = 0.002). One patient experienced intraocular pressure >25 mmHg (managed with topical medication). Two phakic patients (2/8; 25%) had worsening of lens opacity requiring cataract extraction.

CONCLUSION

Dexamethasone intravitreal implant may be an effective treatment for patients with persistent cystoid macular edema in quiescent uveitis.

Widening use of dexamethasone implant for the treatment of macular edema

Sustained-release intravitreal 0.7 mg dexamethasone (DEX) implant is approved in Europe for the treatment of macular edema related to diabetic retinopathy, branch retinal vein occlusion, central retinal vein occlusion, and non-infectious uveitis. The implant is formulated in a biodegradable copolymer to release the active ingredient within the vitreous chamber for up to 6 months after an intravitreal injection, allowing a prolonged interval of efficacy between injections with a good safety profile. Various other ocular pathologies with inflammatory etiopathogeneses associated with macular edema have been treated by DEX implant, including neovascular age-related macular degeneration, Irvine-Gass syndrome, vasoproliferative retinal tumors, retinal telangiectasia, Coats' disease, radiation maculopathy, retinitis pigmentosa, and macular edema secondary to scleral buckling and pars plana vitrectomy. We undertook a review to provide a comprehensive collection of all of the diseases that benefit from the use of the sustained-release DEX implant, alone or in combination with concomitant therapies. A MEDLINE search revealed lack of randomized controlled trials related to these indications. Therefore we included and analyzed all available studies (retrospective and prospective, comparative and non-comparative, randomized and nonrandomized, single center and multicenter, and case report). There are reports in the literature of the use of DEX implant across a range of macular edema-related pathologies, with their clinical experience supporting the use of DEX implant on a case-by-case basis with the aim of improving patient outcomes in many macular pathologies. As many of the reported macular pathologies are difficult to treat, a new treatment option that has a beneficial influence on the clinical course of the disease may be useful in clinical practice.

Interferon-alpha2a and Systemic Corticosteroid in Monotherapy in Chronic Uveitis: Results of the Randomized Controlled BIRDFERON Study

PURPOSE

Macular edema is the leading cause of vision loss in bilateral chronic noninfectious posterior uveitis, and is currently being treated using corticosteroids, immunosuppressive agents, and biotherapies. The aim of this trial was to assess and compare the efficacy and safety of corticosteroids and interferon-α (IFN-α) in adults with such conditions.

DESIGN

Randomized controlled trial.

METHODS

Subjects: Adult patients with bilateral posterior autoimmune noninfectious and nontumoral uveitis complicated by macular edema in at least 1 eye.

INTERVENTION

Patients received either subcutaneous IFN-α2a, systemic corticosteroids, or no treatment for 4 months. The efficacy and safety were assessed for up to 4 months.

MAIN OUTCOME MEASURES

The main endpoint was the change of the central foveal thickness (CFT) obtained by optical coherence tomography.

RESULTS

Forty-eight patients were included. In intention-to-treat analysis, the median CFT change showed no significant difference. However, the per-protocol analysis showed a significant difference between groups for both eyes (OD and OS), and for the worse and better eyes. Statistically significant difference was found between the control and corticosteroid groups for the OD (P = .0285), and between the control and IFN-α groups for the OD (P = .0424) and worse eye (P = .0354). Serious adverse events occurred in 2 patients in the IFN group, in 1 patient in the corticosteroid group, and in 2 patients in the control group and were completely resolved after switch.

CONCLUSIONS

IFN-α and systemic corticosteroids, compared with no treatment, were associated with significant anatomic and visual improvement shown in the per-protocol study.

Anterior segment migration of dexamethasone implant: risk factors, complications, and management

PURPOSE OF REVIEW

To describe the risk factors, clinical course, and complications related to anterior segment migration of a dexamethasone (DEX) intravitreal implant, and review over potential management strategies.

RECENT FINDINGS

Recent reports have demonstrated that migration of a DEX implant into the anterior chamber may occur in patients with higher risk ocular characteristics. Although a relatively rare occurrence, DEX implant migration carries the possibility of inducing potentially vision-threatening corneal endothelial decompensation and edema.

SUMMARY

Any combination of previous pars plana vitrectomy, an open/defective lens capsule, and/or iris defects may increase the risk of DEX implant migration into the anterior chamber. In the setting of a DEX implant that has moved into the anterior segment with corneal edema already present, urgent removal of the implant is warranted to reduce the risk of permanent visual compromise.

SAFETY AND EFFICACY OF INTRAVITREAL DEXAMETHASONE IMPLANTS IN THE MANAGEMENT OF MACULAR EDEMA SECONDARY TO INFECTIOUS UVEITIS

PURPOSE

To assess the safety and efficacy of intravitreal dexamethasone implants in the treatment of macular edema secondary to infectious uveitis.

METHODS

We retrospectively reviewed clinical records from three uveitis referral units in Spain. The main outcome measures were rate of reactivation of infection, improvements in visual acuity and resolution of macular edema, as measured by optical coherence tomography.

RESULTS

We included eight eyes from seven patients with a median age of 64 years (30-75). Etiologies of the infections were Herpes simplex virus-type 1, Varicela-Zoster virus, Treponema pallidum, Brucella mellitensis, Borrelia burgdorferi, Toxoplasma gondii, and cytomegalovirus. Median visual acuity was 20/160 (20/30-20/400) at baseline and 20/70 (20/25-20/200) at the last follow-up visit. Mean macular thickness was 516 μm (115) at baseline and 266.3 μm (40) at the last follow-up visit. Visual acuity improved in 100% of the eyes and none of the eyes showed macular edema at the last follow-up visit. Five patients required reinjections of the implant. Only one patient required antiglaucoma drops for a temporary increase in ocular pressure. There were no cases of reactivation of the infectious ocular disease. Median follow-up time was 18 months.

CONCLUSION

In this small case series of eyes with macular edema secondary to infectious uveitis, treatment with dexamethasone intravitreal implants was not associated with reactivation of the infectious ocular disease. Furthermore, significant improvements in visual acuity and macular thickness were observed in our patients.

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

PURPOSE

To assess the outcomes of intravitreal benzyl alcohol-free triamcinolone acetonide suspension in uveitis-related macular oedema.

METHODS

Single-center retrospective cohort study of 66 injections to 44 eyes of 40 patients. Uveitis diagnosis, systemic and local therapy, intraocular pressure (IOP), central retinal thickness (CRT), number of injections, time to re-injection and side-effects were noted during 6-months minimum follow-up.

RESULTS

Sixty eight percent of eyes received a single injection. 18% required 2 injections, and 13% received ≥3 injections with mean time to second and third injections of 25.5 and 52.7 weeks, respectively. 90% of injections were unilateral. Mean CRT reduced, and by 12-weeks visual acuity improvement >0.3logMar was achieved in 46%. Cataract progression (47%) and IOP>21 mmHg (45%) were the commonest adverse events.

CONCLUSION

Preservative-free triamcinolone is an additional option for uveitis-related macular oedema, particularly in unilateral cases, with favorable CRT and visual outcomes. Repeat injections may be necessary, and the period of efficacy varies between eyes.

Slow-Release Dexamethasone in Proliferative Vitreoretinopathy: A Prospective, Randomized Controlled Clinical Trial

PURPOSE

To test the hypothesis that adjunctive slow-release dexamethasone implant (Ozurdex; Allergan Inc, Irvine, CA) can improve the outcomes of vitreoretinal surgery for established proliferative vitreoretinopathy (PVR).

DESIGN

A 2-year, single-center, prospective, participant- and surgeon-masked randomized controlled clinical trial (EudraCT No. 2011-004498-96).

PARTICIPANTS

A total of 140 patients requiring vitrectomy surgery with silicone oil for retinal detachment with established PVR (Grade C) were randomized to standard (control) or study treatment (adjunct) in a 1:1 allocation ratio.

METHODS

Intraoperatively, the adjunct group received an injection of 0.7 mg of slow-release dexamethasone (Ozurdex) at the time of (1) vitrectomy surgery and (2) silicone oil removal. The control group received standard care.

MAIN OUTCOME MEASURES

Primary outcome measure was the proportion of patients with a stable retinal reattachment with removal of silicone oil without additional vitreoretinal surgical intervention at 6 months. Secondary outcomes included (1) final visual acuity (VA) (median and Early Treatment Diabetic Retinopathy Study [ETDRS] of 55 letters or better); (2) cystoid macular edema (CMO), foveal thickness, and macular volume; (3) development of overt PVR recurrence; (4) complete and posterior retinal reattachment; (5) tractional retinal detachment; (6) hypotony/increased intraocular pressure (IOP); (7) macula pucker/epiretinal membrane; (8) cataract; and (9) quality of life.

RESULTS

All 140 patients were recruited within 25 months of study commencement; 138 patients had primary outcome data. Primary outcome assessment showed similar results in anatomic success between the 2 groups (49.3% vs. 46.3%, adjunct vs. control; odds ratio, 0.89; 95% confidence interval, 0.46-1.74; P = 0.733). Mean VA at 6 months was 38.3 ETDRS letters and 40.2 letters in the adjunct and control groups, respectively. Secondary anatomic outcomes (complete/posterior reattachment rates and PVR recurrence) were comparable between the 2 groups. At 6 months, fewer adjunct patients had CMO (42.7%) or a foveal thickness of >300 μm (47.6%) compared with controls (67.2% and 67.7%, respectively, P = 0.004, P = 0.023).

CONCLUSIONS

A slow-release dexamethasone implant did not improve the primary anatomic success rate in eyes undergoing vitrectomy surgery with silicone oil for PVR. Further clinical trials are indicated to improve anatomic and visual outcomes in these eyes, but this study suggests that there is a greater reduction in CMO observed at 6 months in vitrectomized eyes treated with slow-release dexamethasone.

Efficacy of Ozurdex implant in treatment of noninfectious intermediate uveitis

Aims:

To report our experiences using Ozurdex, a biodegradable implant, containing 0.7 mg of dexamethasone in the treatment of noninfectious intermediate uveitis.

Settings and Design:

Retrospective study design.

Methods:

We conducted a retrospective study of medical records of patients with noninfectious intermediate uveitis having either cystoid macular edema (CME) or vitritis who were not responsive to standard treatment and subsequently received Ozurdex implant from March 2011 to April 2013. The outcomes measured were best-corrected visual acuity, central retinal thickness (CRT), and vitreous haze score.

Statistical Analysis Used:

Paired t-test was used to test the significance of difference between quantitative variables. A P < 0.05 is taken to denote significant relationship.

Results:

Twenty eyes of 15 patients with mean age of 39.8 years who received Ozurdex implant were included in the study. The mean baseline visual acuity improved from 0. 666 logarithm of the minimum angle of resolution (logMAR) units to 0.479 logMAR units at 6 weeks after the implant. The mean CRT improved from 536.1 to 361.4 microns at 6 weeks postimplant both parameters were statistically significant. The ocular inflammation was controlled in almost all the patients. Cataract and raised intraocular pressure were documented complications.

Conclusion:

Ozurdex implant is a promising treatment option and efficient in controlling the inflammation and CME in cases of noninfectious intermediate uveitis not responding to standard treatment.

Uveitic macular edema

Macular edema (ME) may complicate anterior, intermediate, and posterior uveitis, which may be because of various infectious, neoplastic or autoimmune etiologies. BRB breakdown is involved in the pathogenesis of Uveitic ME (UME). Optical coherence tomography has become a standard tool to confirm the diagnosis of macular thickening, due to its non-invasive, reproducible, and sensitive features. Retinal fluorescein and indocyanine green angiography is helpful to study the macula and screen for associated vasculitis, detect ischemic areas and preretinal, prepapillary or choroidal neovascular complications, and it may provide information about the etiology and be needed to assess the therapeutic response. UME due to an infection or neoplastic infiltration may require a specific treatment. If it remains persistent or occurs in other etiologies, immunomodulatory treatments may be needed. Intravitreal, subconjunctival, or subtenon corticosteroids are widely used. Their local use is contraindicated in glaucoma patients and limited by their short-lasting action. In case of bilateral sight-threatening chronic posterior uveitis, systemic treatments are usually needed, and corticosteroids are used as the standard first-line therapy. In order to reduce the daily steroid dose, immunosuppressive or immunomodulatory agents may be added, some of them being now available intravitreally. Ongoing prospective studies are assessing biotherapies and immunomodulators to determine their safety and efficacy in this indication.

Treatment of Non-infectious Uveitic Macular Edema with the Intravitreal Dexamethasone Implant

PURPOSE

To describe the clinical outcome of phakic eyes with macular edema (ME) due to non-infectious uveitis treated with a dexamethasone intravitreal implant.

METHODS

A retrospective analysis of 41 eyes treated with a total of 58 dexamethasone intravitreal implants was conducted. Best corrected visual acuity (BCVA), central retinal thickness (CRT) and complications data were collected.

RESULTS

One month after the first implant, even as CRT improved significantly in most eyes (p<0.001), 31.7% showed no improvement in BCVA. At 6 months post-implantation, CRT and BCVA had deteriorated in up to 70% of patients. Thirteen eyes were re-implanted, with a similar effect to that of the first implant. Ocular hypertension developed in 36.2% of eyes, and three eyes had cataract surgery, all in eyes with repeated implants.

CONCLUSIONS

The dexamethasone intravitreal implant can be safely used to treat ME due to non-infectious uveitis, but with a limited and short effect on BCVA.

Dexamethasone intravitreal implant for treatment of persistent macular oedema in Birdshot retinochoroidopathy

CLINICAL CASE

The case is reported of a 32 year-old man with a bilateral cystoid macular oedema and serous macular detachment due to birdshot retinochoroidopathy. An intravitreal implant of 0.7 mg dexamethasone (Ozurdex®, Allergan) was performed on both eyes, after a partial response of the macular oedema to oral and subtenon corticosteroids. Anatomical and visual improvements were observed and maintained after six months of follow up.

DISCUSSION

Intravitreal dexamethasone implant may be a good therapeutic option in patients with macular oedema due to Birdshot retinochoroidopathy, and who were refractory or had intolerance to previous therapies.