Use of flucinolone acetonide for patients with diabetic macular oedema: patient selection criteria and early outcomes in real world setting

Intravitreal Fluocinolone Acetonide Implant (ILUVIEN®) for the Treatment of Retinal Conditions. A Review of Clinical Studies

Fluocinolone acetonide (FAc) intravitreal implant (Iluvien®) is a corticosteroid implant indicated for the treatment of diabetic macular oedema (DMO) in patients who have previously received conventional treatment without good response, non-infectious posterior uveitis, and as an off-label treatment of the macular oedema secondary to retinal vein occlusion. FAc is a non-biodegradable 0.19 mg intravitreal implant which is designed to release FAc over 3 years at a rate of approximately 0.2 mcg per day. The aim of this review is to describe the special pharmacological properties of Iluvien and display the outcomes of the most important clinical trials and real-world studies regarding its efficacy and safety for the management of the above retinal disorders.

Diabetic Macular Oedema Guidelines: An Australian Perspective

The number of people living with diabetes is expected to rise to 578 million by 2030 and to 700 million by 2045, exacting a severe socioeconomic burden on healthcare systems around the globe. This is also reflected in the increasing numbers of people with ocular complications of diabetes (namely, diabetic macular oedema (DMO) and diabetic retinopathy (DR)). In one study examining the global prevalence of DR, 35% of people with diabetes had some form of DR, 7% had PDR, 7% had DMO, and 10% were affected by these vision-threatening stages. In many regions of the world (Australia included), DR is one of the top three leading causes of vision loss amongst working age adults (20-74 years). In the management of DMO, the landmark ETDRS study demonstrated that moderate visual loss, defined as doubling of the visual angle, can be reduced by 50% or more by focal/grid laser photocoagulation. However, over the last 20 years, antivascular endothelial growth factor (VEGF) and corticosteroid therapies have emerged as alternative options for the management of DMO and provided patients with choices that have higher chances of improving vision than laser alone. In Australia, since the 2008 NHMRC guidelines, there have been significant developments in both the treatment options and treatment schedules for DMO. This working group was therefore assembled to review and address the current management options available in Australia.

Comparison of Icare HOME and non-contact tonometer in intraocular pressure measurement in the early stage after ICL V4c implantation

Purpose

To investigate the characteristics of intraocular pressure (IOP) measurements using the Icare HOME rebound tonometer (RBT) and non-contact tonometer (NCT) during the early stage after implantable collamer lens (ICL) V4c implantation, and to assess the agreement between the two methods.

Methods

This prospective case series study included 104 eyes of 53 patients (mean age 28.77  ±  5.34 years), who underwent ICL V4c implantation. IOP was measured preoperatively, and at 0.5, 1, 2, 4, and 24 h postoperatively by Icare HOME and NCT, respectively.

Results

All surgeries were uneventful. IOP measurements by Icare and NCT preoperatively were 14.03  ±  2.90 mmHg and 14.09  ±  2.87 mmHg, respectively.The corresponding values were 12.56  ±  8.09 mmHg and 14.12  ±  6.52 mmHg (P > 0.05) at postoperative 0.5 h, 19.21  ±  8.74 mmHg and 19.60  ±  7.66 mmHg at postoperative 1 h (P > 0.05), 21.21  ±  8.10 mmHg and 20.31  ±  6.93 mmHg at postoperative 2 h (P > 0.05), 16.11  ±  5.89 mmHg and 17.04  ±  4.84 mmHg at postoperative 4 h (P > 0.05), and 14.04  ±  3.88 mmHg and 14.78  ±  2.80 mmHg at postoperative 24 h, respectively (P > 0.05). There was good agreement based on intraclass correlation coefficients (ICCs) between NCT and Icare HOME (all ICCs > 0.6 at different time points [range, 0.6986–0.956]). The Bland-Altman plot showed a mean percentage of over 95.81% of the points falling within the limits of agreement. There was a significant difference in the low IOP measurements (<10 mmHg) between Icare HOME and NCT (7.28  ±  2.55 vs. 10.65  ±  2.48, P < 0.001).

Conclusion

Icare HOME can be used for IOP measurement after ICL V4c implantation and demonstrated good agreement with NCT, except in cases with low intraocular pressure (<10 mmHg).

Foveal Eversion: A Possible Biomarker of Persistent Diabetic Macular Edema

Introduction

We aimed to evaluate the impact of foveal eversion on treatment response and persistent diabetic macular edema (DME).

Methods

The study was designed as interventional and prospective. DME eyes were treated with ranibizumab and/or dexamethasone (DEX) implants, or with fluocinolone acetonide (FAc) implants. FAc-treated eyes were eventually retreated by additional ranibizumab injections. Main outcome measure was the relationship between foveal eversion and both clinical outcome and persistent DME.

Results

Sixty-eight DME eyes (68 patients) treated by anti-VEGF/DEX and 50 FAc-treated eyes (50 patients) were recruited. The follow-up was 16 ± 3 months. The anti-VEGF/DEX group and FAc-treated group were statistically matched for age, sex, DME duration and previous number of injections (p > 0.05). Both groups experienced statistically significant improvements of both BCVA and central macular thickness (p < 0.01) at the end of the follow-up. Persistent DME was shown by 46% of anti-VEGF/DEX eyes and 42% of FAc-treated eyes. Foveal eversion was found in 50% of anti-VEGF/DEX eyes and in 44% of FAc-treated eyes. Its presence was associated with worse anatomical and visual outcome and higher persistence of DME in both groups (p < 0.01) and with higher retreatment percentages in FAc-treated eyes (p < 0.01).

Conclusion

Foveal eversion is associated with worse clinical and morphological outcomes in DME.

Retinal thickness fluctuations in patients receiving fluocinolone acetonide implant for diabetic macular edema

Objectives: To evaluate central foveal thickness (CFT) variability and accompanying changes in visual acuity (VA) 12 months before and after treatment with the 190 mcg fluocinolone acetonide (FAc) intravitreal implant for diabetic macular edema (DME).Methods: The Iluvien Clinical Evidence cohort study in the United Kingdom (ICE-UK) investigated the effectiveness of the FAc implant in people treated at 13 hospitals from April 2013 to April 2015. The following parameters were calculated for CFT for each patient: mean, standard deviation (SD), retinal thickness amplitude (RTA, the difference between maximum and minimum values), and coefficient of variation (CV).Results: In 149 eyes with ≥2 CFT observations both before and after FAc implantation, the median VA was 50 ETDRS letters at implantation. Mean CFT was 487 µm at implantation and 135 µm at 12 months post-implant. Before implantation, the mean CV and mean SD for CFT were 24.6% and 112 µm, respectively; the mean RTA was 254 µm. A statistically significant (p < .001) decrease in all three parameters was observed after implantation (18.3%, 68.2 μm and 146 μm, respectively). There was an association between CFT change between extremes and the corresponding change in VA (Pearson's correlation coefficient, r = -0.292, p < .001, prior to the implant; r = -0.379, p < .001, post-implant).Conclusions: After accounting for the reduction in CFT, retinal thickness stabilized following FAc implantation. There might be VA benefits in reducing variability in CFT over time. This merits further exploration but would require more frequent CFT observations in order to properly determine patterns of retinal thickness variability.

A New Approach for Diabetic Macular Edema Treatment: review of clinical practice results with 0.19 mg fluocinolone acetonide intravitreal implant including vitrectomized eyes

PURPOSE OF REVIEW

Fluocinolone acetonide is a synthetic fluorinated glucocorticoid. It has selective and potent agonist properties by binding to the cytosolic glucocorticoid receptor with high affinity; it is devoid of mineralocorticoid activity. Two extended-release (i.e. lasting up to 3 years) drug delivery systems containing fluocinolone acetonide (FAc) have been approved by the FDA for intravitreal use: Retisert ® (Bausch&Lomb, New Jersey, USA) and Iluvien ® (Alimera Sciences, Atlanta, USA). The former contains 0.59 mg of FAc, which is approved for the treatment of chronic noninfectious posterior segment uveitis. The latter contains a dose of 0.19 mg of FAc and is approved for the treatment of diabetic macular edema and here we review the results published in the clinical literature relating to its use in the treatment of diabetic macular edema (DME).

RECENT FINDINGS

The 0.19 mg FAc implant (Iluvien®) is a new approved treatment approach for DME. It is a non-biodegradable implant that continuously releases a microdose of FAc into the vitreous cavity for up to three years. It is effective in chronic DME with the added value of decreasing the treatment burden of multiple intravitreal injections. Recently, clinical practice studies are reporting its efficacy and safety profile (intra-ocular pressure rise and cataract), as well as its use in clinical setting not included in clinical trial such as vitrectomized eyes.

SUMMARY

The FAc implant has demonstrated in clinical practice results that mirror the results of the clinical trials efficacy wise. Regarding its safety profile, cataract is a common complication, however, intra-ocular pressure rises may be lower than the ones reported in trials. The implant has shown effectiveness in vitrectomized eyes. An increasing evidence of real-world studies have supported utility of the implant in DME patients. It's extended-release format for up to 3 years benefits to the patient and carer as it means fewer injections and visits to the clinic.

Advanced implantable drug delivery technologies: transforming the clinical landscape of therapeutics for chronic diseases

Chronic diseases account for the majority of all deaths worldwide, and their prevalence is expected to escalate in the next 10 years. Because chronic disorders require long-term therapy, the healthcare system must address the needs of an increasing number of patients. The use of new drug administration routes, specifically implantable drug delivery devices, has the potential to reduce treatment-monitoring clinical visits and follow-ups with healthcare providers. Also, implantable drug delivery devices can be designed to maintain drug concentrations in the therapeutic window to achieve controlled, continuous release of therapeutics over extended periods, eliminating the risk of patient non-compliance to oral treatment. A higher local drug concentration can be achieved if the device is implanted in the affected tissue, reducing systemic adverse side effects and decreasing the challenges and discomfort of parenteral treatment. Although implantable drug delivery devices have existed for some time, interest in their therapeutic potential is growing, with a global market expected to reach over $12 billion USD by 2018. This review discusses implantable drug delivery technologies in an advanced stage of development or in clinical use and focuses on the state-of-the-art of reservoir-based implants including pumps, electromechanical systems, and polymers, sites of implantation and side effects, and deployment in developing countries.

Intravitreal fluocinolone acetonide implant (ILUVIEN®) for diabetic macular oedema: a literature review

Diabetic macular oedema (DMO) is a common complication of diabetic retinopathy and may lead to severe visual loss. In this review, we describe the pathophysiology of DMO and review current therapeutic options such as macular laser photocoagulation, anti-vascular endothelial growth factor agents, and steroid implants with a focus on the new fluocinolone acetonide implant, ILUVIEN®. The results of the Fluocinolone Acetonide in Diabetic Macular Edema (FAME) studies are also presented together with the results of real-world studies to support the clinical use of ILUVIEN® in achieving efficient resolution of DMO and improving vision and macular anatomy in this challenging group of patients.

Changes in intraocular pressure after intravitreal fluocinolone acetonide (ILUVIEN): real-world experience in three European countries

Aims

The ILUVIEN Registry Safety Study is an ongoing, multicentre, open-label, observational study collecting real-world data on the safety and effectiveness of the 0.2 µg/day fluocinolone acetonide (FAc) implant in patients treated according to the European label requirements.

Methods

Patients included in this analysis were treated for the licensed indication of chronic diabetic macular oedema (cDMO; that is, DMO that persists or recurs despite treatment). Data presented in the current analysis were collected from patient records up to 6 March 2017. Visual acuity (VA) data, including mean change in VA over time and at last observation, intraocular pressure (IOP) over the course of the study, IOP events, use of IOP-lowering therapy and cup:disc ratio were analysed. Information on additional DMO treatments post-FAc implant was also captured.

Results

Five hundred and sixty-three patients (593 eyes) were enrolled on the study. Mean IOP for the overall population remained within the normal range throughout follow-up and 76.7% of patients did not require IOP-lowering therapy following treatment with the FAc implant. Sixty-nine per cent of eyes did not require additional DMO treatments. Mean VA in the overall population increased from 51.9 letters at baseline to 55.6 letters at month 12, with a significant increase of 2.9 letters at last observation. Patients with short-term cDMO experienced greater VA gains than those with long-term cDMO.

Conclusions

The results of this analysis are comparable with those of other studies, including the Fluocinolone Acetate for Macular Edema study. The study reinforces the good safety and effectiveness profile of FAc, and demonstrates the benefit of early FAc treatment.

Iluvien™ (Fluocinolone Acetonide 0.19 mg Intravitreal Implant) in the Treatment of Diabetic Macular Edema: A Review

Diabetic macular edema (DMO) is a leading cause of blindness in the working age population. Although anti-vascular endothelial growth factor (VEGF) therapy provided a major advance in treatment of DMO for many patients, there is a significant proportion of patients who maintain persistent DMO and have minimal response to anti-VEGF treatment. Iluvien (fluocinolone acetonide 0.19 mg [FAc]) is an important additional treatment option for DMO. In this review we describe the clinical context and the evidence for the use of the FAc implant in treating DMO, from pilot to randomized controlled studies, to later phase real world data. These studies indicate that the FAc implant is effective, well tolerated and a cost-effective option in the treatment of insufficiently responsive DMO.

CLINICAL EVIDENCE OF THE MULTIFACTORIAL NATURE OF DIABETIC MACULAR EDEMA

As the disease duration increases, the multifactorial nature of diabetic macular edema becomes more prominent, and corticosteroid therapy represents an important treatment option for patients whose disease is multifactorial.

Purpose:

To report functional and morphologic outcomes, based on diabetic macular edema (DME) chronicity and baseline best-corrected visual acuity (BCVA), from a subanalysis of the fluocinolone acetonide for macular edema (FAME) trials.

Methods:

Patients were categorized by DME duration (nonchronic [ncDME] or chronic [cDME] DME) and three nonexclusive baseline vision strata. Anatomic and visual acuity VA outcomes of these cohorts were compared with treatment assignment.

Results:

For all patients with ncDME and cDME who received sham control, 27.8% and 13.4%, respectively, gained ≥15 BCVA letters, whereas 22.3% and 34.0% of 0.2 μg/day fluocinolone acetonide (FAc)-treated patients, respectively, gained ≥15 BCVA letters. Among patients with ncDME who received sham control, as baseline vision decreased, the percentage gaining ≥15 BCVA letters increased; however, among those with cDME, the percentage gaining ≥15 BCVA letters did not change as baseline vision decreased. Conversely, among 0.2 μg/day FAc-treated patients, the percentage gaining ≥15 BCVA letters increased with decreasing baseline vision, regardless of DME chronicity. Anatomical outcomes were similar within treatment arms, regardless of the DME duration.

Conclusion:

Patients with cDME and poor baseline vision who were exposed to low-dose FAc experienced BCVA improvements that were not observed in a similar group from the sham-control arm. These data support the multifactorial pathogenesis of cDME.

Patterns of retinal thickness prior to and following treatment with fluocinolone acetonide 190 µg intravitreal implant for diabetic macular edema

OBJECTIVES

To compare retinal thickness before and after treatment with the fluocinolone acetonide (FAc) 190 µg intravitreal implant in people with diabetic macular edema (DME) using data from the Iluvien Clinical Evidence study in the UK (ICE-UK).

METHODS

For this retrospective cohort study, data on people attending any one of 13 participating ophthalmology departments and treated with FAc intravitreal implant between April 1, 2013 and April 15, 2015 were collected for 12 months prior to and at least 12 months after implantation. Cross-sectional and longitudinal patterns of central foveal thickness (CFT) were compared before and after FAc implant.

RESULTS

There were 208 people who contributed data from 233 individual eyes treated with the FAc implant. Mean age was 68.1 years and 62% were male. Median (interquartile range) CFT decreased from 462 µm (354-603 µm) at time of implant to 309 µm (222-433 µm) at 12 months post-implant (p < .001). Over the same period, a reduction of ≥10%, ≥25%, and ≥50% in CFT was observed in 113 (65%), 87 (50%), and 37 (21%) treated eyes, respectively. Eyes with a CFT of ≥400 µm at the time of implant were significantly more likely to achieve a reduction in CFT of ≥10%, ≥25%, and ≥50% at 12 months (all p < .001) compared with eyes with a CFT of <400 µm at implant. Both retinal thickness and changes in retinal thickness were loosely correlated with visual acuity.

CONCLUSION

A marked reduction in retinal thickness was observed in people following FAc intravitreal implant for DME. The response was related to the degree of retinal thickness prior to treatment.

Evaluation of the clinical effectiveness of fluocinolone acetonide 190 µg intravitreal implant in diabetic macular edema: a comparison between study and fellow eyes

OBJECTIVES

To compare visual and anatomical outcomes between eyes treated with fluocinolone acetonide (FAc) 190 µg intravitreal implant for clinically significant chronic diabetic macular edema (DME) and fellow eyes not treated with FAc implant using data from the Iluvien Clinical Evidence study in the UK (ICE-UK) study.

METHODS

In this retrospective cohort study, data on people attending hospital eye services and treated with the FAc implant between April 1, 2013 and April 15, 2015 were collected. Changes in visual acuity (VA), central foveal thickness (CFT) and intraocular pressure (IOP) were compared between study eyes (intervention) and fellow eyes.

RESULTS

A total of 208 people were selected. Mean age was 68.1 years and 62% were male. Mean change in VA was -0.09 LogMAR units for study eyes and 0.04 LogMAR units for fellow eyes at 12 months post-implant (p < .001). Over the same period, ≥5 letter, ≥10 letter and ≥15 letter improvements in Early Treatment Diabetic Retinopathy Study (ETDRS) score were achieved by more FAc treated eyes than by fellow eyes (41% versus 23%, p < .001; 28% versus 11%, p < .001; and 18% versus 4%, p < .001 at 12 months, respectively). Differences in the mean change in CFT (-113 µm versus -13 µm, p < .001) and IOP (3.2 mmHg versus -0.2 mmHg, p < .001) were also observed between study and fellow eyes at 12 months.

CONCLUSION

Visual acuity improved in study eyes over the 12 months following FAc implant and worsened in fellow eyes. Over the same period, study eyes showed a larger improvement in central foveal thickness. Intraocular pressure worsened in study eyes only. Change in visual acuity, central foveal thickness and intraocular pressure between FAc implant and the end of the 12-month follow-up period differed significantly between study and fellow eyes.

Evaluation of the clinical effectiveness in routine practice of fluocinolone acetonide 190 µg intravitreal implant in people with diabetic macular edema

OBJECTIVE

The aim of the Iluvien Clinical Evidence study in the UK (ICE-UK) was to assess the real-world effectiveness of fluocinolone acetonide (FAc) 190 µg intravitreal implant for the treatment of clinically significant chronic diabetic macular edema (DME) in routine clinical practice.

METHODS

This retrospective study collected data from patient medical records in 13 ophthalmology centers for people with DME prescribed FAc intravitreal implant between April 1, 2013 and April 15, 2015. Visual acuity (VA) and intraocular pressure (IOP) measurements were collected for 12 months prior to and after implant.

RESULTS

Two hundred and eight people, contributing 233 eyes, treated with FAc implant were included. Mean age was 68.1 years and 62% were male. In the 12 months prior to FAc implant, VA declined. Median (interquartile range, IQR) VA was 0.66 (0.48-1.00) LogMAR units (equivalent to 52.0 ETDRS letters) at implant, improving to 0.60 (0.38-0.90) LogMAR units (55.0 letters) at 12 months post-implant (p < 0.001). In total, 44%, 30%, and 18% of people achieved an improvement in ETDRS score of ≥5, ≥10, and ≥15 letters, respectively, over the same period. A small but significant (p < .001) increase in median IOP was observed (median = 15.0, IQR = 13.0-18.0 mmHg at implant to 18.0, 15.0-21.0 mmHg at 12 months). In the 12 months following implant, additional IOP-lowering therapy was prescribed in 15% of subjects previously not requiring such therapy.

CONCLUSION

Following FAc implant, an overall significant improvement in VA was observed over a period of 12 months, accompanied by a significant but small increase in IOP.

Fluocinolone acetonide for the treatment of diabetic macular edema

INTRODUCTION

Fluocinolone acetonide intravitreal implant is a non-erodible implant approved for the treatment of diabetic macular edema (DME) insufficiently responsive to available therapies. Areas covered: The injectable intravitreal implant releases fluocinolone acetonide at an average rate of 0.2 µg/day for at least 36 months. The two pooled pivotal FAME trials showed that, in patients with DME previously treated with laser photocoagulation, fluocinolone acetonide intravitreal implant was more beneficial than sham injection when looking at the proportion of patients with an improvement from baseline in visual acuity of more than 15 letters at 24 months and at 36 months. Cataract (82%) and intraocular pressure (IOP) elevation (37%) were the most common adverse events. Raised IOP was mostly treated with IOP-lowering medications, with <5% of eyes requiring incisional IOP-lowering surgery. FAME trial program results are confirmed by a series of real-world studies in eyes with chronic/recalcitrant DME. Expert opinion: data indicate that fluocinolone acetonide intravitreal implant is a useful second-line option for the treatment of DME.

Real-world experience with 0.2 μg/day fluocinolone acetonide intravitreal implant (ILUVIEN) in the United Kingdom

Aims

To compare safety outcomes and visual function data acquired in the real-world setting with FAME study results in eyes treated with 0.2 μg/day fluocinolone acetonide (FAc).

Methods

Fourteen UK clinical sites contributed to pseudoanonymised data collected using the same electronic medical record system. Data pertaining to eyes treated with FAc implant for diabetic macular oedema (DMO) was extracted. Intraocular pressure (IOP)-related adverse events were defined as use of IOP-lowering medication, any rise in IOP>30 mm Hg, or glaucoma surgery. Other measured outcomes included visual acuity, central subfield thickness (CSFT) changes and use of concomitant medications.

Results

In total, 345 eyes had a mean follow-up of 428 days. Overall, 13.9% of patients required IOP-lowering drops (included initiation, addition and switching of current drops), 7.2% had IOP elevation >30 mm Hg and 0.3% required glaucoma surgery. In patients with prior steroid exposure and no prior IOP-related event, there were no new IOP-related events. In patients without prior steroid use and without prior IOP-related events, 10.3% of eyes required IOP-lowering medication and 4.3% exhibited IOP >30 mm Hg at some point during follow-up. At 24 months, mean best-recorded visual acuity increased from 51.9 to 57.2 letters and 20.8% achieved ≥15-letter improvement. Mean CSFT reduced from 451.2 to 355.5 μm.

Conclusions

While overall IOP-related emergent events were observed in similar frequency to FAME, no adverse events were seen in the subgroup with prior steroid exposure and no prior IOP events. Efficacy findings confirm that the FAc implant is a useful treatment option for chronic DMO.

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

Purpose:

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

Patients and Methods:

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

Results:

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

Conclusion:

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

Identification of time point to best define 'sub-optimal response' following intravitreal ranibizumab therapy for diabetic macular edema based on real-life data

PurposeTo determine the average time-point at which it is best to define 'sub-optimal response' after ranibizumab treatment for diabetic macular edema (DME) based on the data obtained from real-life clinical practice.MethodsIn this retrospective observational study, 322 consecutive treatment naïve eyes with DME were treated with three loading doses of intravitreal ranibizumab followed by re-treatment based on decision of the treating physician on a case-by-case basis. The demographic data, clinic-based visual acuity measurements and central subfield thickness (CST) assessed on spectral domain optical coherence tomography (OCT) were evaluated at baseline (month 0), 1, 2, 3, 6, and 12 months.ResultsOn an average, the improvement in visual acuity and CST was first seen after the loading dose. However, the maximal response in terms of proportion of patients with improvement in visual acuity and/ or CST in this cohort was observed at 12 months. Patients who presented with low visual acuity at baseline (<37 ETDRS letters) were unlikely to attain driving vision with ranibizumab therapy.ConclusionsOn an average, a 'sub-optimal response' after ranibizumab therapy is best defined at month 12 as patients may continue to improve with treatment.

Fluocinolone Acetonide Intravitreal Implant 0.19 mg (ILUVIEN®): A Review in Diabetic Macular Edema

Fluocinolone acetonide intravitreal implant 0.19 mg (ILUVIEN^®) is a nonbiodegradable, injectable, corticosteroid implant that is approved in several countries, including the USA, for the treatment of diabetic macular edema (DME). ILUVIEN^® releases fluocinolone acetonide at an initial rate of 0.25 µg/day (average rate 0.2 µg/day) and lasts 36 months. In the two pooled pivotal FAME trials in patients with DME previously treated with macular laser photocoagulation, fluocinolone acetonide intravitreal implant 0.2 µg/day was significantly more effective than sham injection with respect to the proportion of patients with an improvement from baseline in best-corrected visual acuity of ≥15 letters at 24 months (primary endpoint). This therapeutic effect was maintained at 36 months. The implant also significantly decreased foveal thickness at 24 months. FAME study results are broadly supported by real-world studies in patients with chronic DME considered insufficiently responsive to available therapies. Consistent with corticosteroid class-specific adverse events, cataract and elevated intraocular pressure (IOP) were the most common adverse events with the fluocinolone acetonide intravitreal implant. Raised IOP was treated with medications in most patients, with <5% requiring incisional IOP-lowering surgery. In the USA, fluocinolone acetonide intravitreal implant should be used only in patients who have been previously treated with a course of corticosteroids and did not have a clinically significant increase in IOP. Available data indicate that fluocinolone acetonide intravitreal implant 0.19 mg is a useful option for the treatment of DME in these patients.

Clinical utility of intravitreal fluocinolone acetonide (Iluvien®) implant in the management of patients with chronic diabetic macular edema: a review of the current literature

The first-line therapy for patients with center-involving diabetic macular edema (DME) is with intravitreal anti-vascular endothelial growth factor (VEGF) agents, with or without adjunctive macular laser treatment. However, a significant proportion of patients have persistent and recurrent edema despite repeated anti-VEGF injections. The fluocinolone acetonide (FA) 190 μg intravitreal implant has been shown in pivotal clinical trials to be efficacious for the treatment of DME and has been approved in many countries for use in patients who have not responded to first-line therapy. In this report, we have collated the latest data from the increasing number of studies to illustrate the pattern of usage of the Iluvien FA implant for DME during the current anti-VEGF era. We have shown that there is now a wealth of published evidence from real-world studies to support the clinical utility of the FA implant in achieving further resolution of edema and improving visual acuity outcomes in this challenging group of patients.

Diabetic macular edema outcomes in eyes treated with fluocinolone acetonide 0.2 µg/d intravitreal implant: real-world UK experience

PURPOSE

To conduct an observational, multicenter study to evaluate real-world clinical efficacy and safety of the 0.2 µg/day fluocinolone acetonide (FAc) implant in the treatment of patients with chronic diabetic macular edema (DME) in 3 large hospital ophthalmology departments in the United Kingdom.

METHODS

Fluocinolone acetonide implants were inserted into the study eyes following a suitable washout period; phakic eyes received FAc implant following cataract surgery. Follow-up visits took place 2-4 weeks postinjection and then at 3, 6, and 12 months; change in central macular thickness (CMT) from baseline was measured by optical coherence tomography and best-corrected visual acuity (BCVA) was also assessed. Adverse events and changes in intraocular pressure (IOP) were recorded in order to evaluate the safety profile for the FAc implant.

RESULTS

Improvements in BCVA and CMT were observed from 3 months and sustained for the duration of observation. At 12 months, the overall mean change from baseline CMT was -126 μm and mean increase in BCVA from baseline was 5.1 letters. Increases in IOP following FAc implant were easily managed with IOP-lowering medication. Implant migration into the anterior chamber occurred in 2 eyes where prior vitrectomy had resulted in a posterior capsule defect; this was rectified and resolved.

CONCLUSIONS

The results of this study provide further efficacy and safety profile data for FAc implant treatment of chronic DME in a real-world clinical setting; the FAc implant appears to be a valuable therapeutic approach for patients with chronic DME who have suboptimal response to other treatment options.

Efficacy of 0.2 μg/day fluocinolone acetonide implant (ILUVIEN) in eyes with diabetic macular edema and prior vitrectomy

Purpose

Limited data are available on the efficacy of the 0.2 μg/day fluocinolone acetonide (FAc) implant in eyes with prior vitrectomy. Here, we present a collection of 26 vitrectomized eyes treated with the 0.2 μg/day FAc implant.

Methods

Retrospective study involving six centers from four European countries analyzing the safety and efficacy data from patients (26 eyes from 25 patients) with DME and a prior vitrectomy that had been treated with one 0.2 μg/day FAc implant.

Results

Prior intravitreal therapies included anti-VEGF (mean, 3.8 injections) and steroids (mean, 1.9 injections). Pars plana vitrectomy (PPV) was performed in these eyes primarily for abnormalities of vitreoretinal interface, followed by proliferative diabetic retinopathy and vitreous hemorrhage. The 0.2 μg/day FAc implant was injected 24.2 months, on average, after PPV and the mean duration of follow-up after injection was 255 days (range, 90 to 759 days). The mean change in BCVA was +11.7 ETDRS letters (range, −19 to +40 letters; P<0.0004) and the mean change in central foveal thickness (CFT) was −233.5 μm (range, −678 to 274 μm; P<0.0001). The mean change in IOP from baseline at the last visit was +1.4 mm Hg (range, −9 to +8 mm Hg; P=0.0090). Eight eyes initiated or continued IOP lowering medications.

Conclusions

These data suggest the 0.2 μg/day FAc implant is effective in vitrectomized patients with an acceptable safety profile. Further studies are still required to confirm the current findings and to assess the effect of the 0.2 μg/day FAc implant over a longer period of follow-up.