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Soares RM, Ferreira CC, Fernandes JDS, Madeira C, Silva LMA, Saraiva E, Ribeiro L, Fonseca S. Real-World Evidence of the Long-Term Effectiveness of 0.2 μg/Day Fluocinolone Acetonide Implant in Persistent and Recurrent Diabetic Macular Edema - A Single Center Study. Clin Ophthalmol 2024; 18:1057-1066. [PMID: 38646183 PMCID: PMC11032137 DOI: 10.2147/opth.s382920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/15/2024] [Indexed: 04/23/2024] Open
Abstract
Purpose To report the long-term functional, anatomical and safety outcomes of 0.2 μg/day fluocinolone acetonide 0.19mg in patients with persistent or recurrent diabetic macular edema (DME). Methods Retrospective, observational, single-center study of patients with recurrent or persistent DME. All patients received 0.2 μg/day of fluocinolone acetonide 0.19mg, and data were collected at baseline and months 1, 3, 6, 12, 24 and 36 after implantation. Outcomes measured included best-corrected visual acuity (BCVA), central macular thickness (CMT), intraocular pressure (IOP), and safety outcomes. Results A total of 28 eyes from 28 patients were included. The mean age was 66.5 years (95% CI 62.8-70.2) with a mean duration of DME of 8.8 years (95% CI 7.7-10.0). Only two eyes were phakic. Mean follow-up was 25.4 months (95% CI 21.2-29.6). Mean BCVA at baseline was 48.6 ETDRS letters (95% CI 41.3-55.8) and improved as early as month 1 of follow-up with a mean gain in BCVA of 7.8 (95% CI 4.3-11.3) ETDRS letters (p<0.001). Statistically significant improvements in BCVA were also observed at months 6, 12 and 24. At baseline, patients had a mean CMT of 530.5µm (95% CI 463.0-598.0), and a decrease in CMT was observed, starting at the first month of follow-up (mean CMT reduction of -170.5µm, 95% CI -223.8- -117.1; p<0.001). Statistically significant decreases in CMT were also observed at months 6, 12, 24, and 36, with the maximum decrease observed at month 12 (p<0.001). Mean IOP at baseline was 16.4mmHg (95% CI 15.3-17.5) and nine eyes (32.1%) had an IOP ≥21mmHg during follow-up. Conclusion Our results support the effectiveness and safety profile of fluocinolone acetonide. Although additional long-term real-world evidence is required, fluocinolone acetonide may represent a safe strategy for daily, low-dose, sustained and localized release to the posterior segment of the eye, providing both functional and anatomical benefits in DME.
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Affiliation(s)
- Ricardo Machado Soares
- Department of Ophthalmology - Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal
| | - Catarina Cunha Ferreira
- Department of Ophthalmology - Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal
| | | | - Carolina Madeira
- Department of Ophthalmology - Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal
| | - Luís M A Silva
- Department of Ophthalmology - Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal
| | - Eduardo Saraiva
- Department of Ophthalmology - Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal
| | - Lígia Ribeiro
- Department of Ophthalmology - Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal
| | - Sofia Fonseca
- Department of Ophthalmology - Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal
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Taloni A, Coco G, Rastelli D, Buffon G, Scorcia V, Giannaccare G. Safety and Efficacy of Dexamethasone Intravitreal Implant Given Either First-Line or Second-Line in Diabetic Macular Edema. Patient Prefer Adherence 2023; 17:3307-3329. [PMID: 38106365 PMCID: PMC10725633 DOI: 10.2147/ppa.s427209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/06/2023] [Indexed: 12/19/2023] Open
Abstract
Diabetic macular edema (DME) is a common sight-threatening complication of diabetic retinopathy (DR) and the leading cause of severe visual impairment among the working-age population. Several therapeutic options are available for the management of DME, including intravitreal corticosteroids. They have been traditionally used as second-line treatment, due to the risk of intraocular pressure increase and cataract-related adverse events. However, attention has recently been focused on the primary or early use of intravitreal corticosteroids, due to growing evidence of the crucial role of inflammation in the pathogenesis of DME. Furthermore, intravitreal steroid implants offer the additional advantage of a longer duration of action compared to anti-vascular endothelial growth factor agents (anti-VEGF). This review aims to summarize the available evidence on the efficacy and safety profile of dexamethasone (DEX) intravitreal implant, with a specific focus on clinical scenarios in which it might be considered or even preferred as first-line treatment option by adequate selection of patients, considering both advantages and possible adverse events. Patients with contraindications to anti-VEGF, DME with high inflammatory OCT biomarkers, pseudophakic patients and phakic patients' candidates to cataract surgery as well as vitrectomized eyes may all benefit from first-line DEX implant. Additionally, DME not responders to anti-VEGF should be considered for a switch to DEX implant and a combination therapy of DEX implant and anti-VEGF could be a valid option in severe and persistent DME.
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Affiliation(s)
- Andrea Taloni
- Department of Ophthalmology, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Giulia Coco
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Davide Rastelli
- Department of Ophthalmology, Policlinico Casilino, Rome, Italy
| | - Giacinta Buffon
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Vincenzo Scorcia
- Department of Ophthalmology, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Giuseppe Giannaccare
- Eye Clinic, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
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Sorour OA, Levine ES, Baumal CR, Elnahry AG, Braun P, Girgis J, Waheed NK. Persistent diabetic macular edema: Definition, incidence, biomarkers, and treatment methods. Surv Ophthalmol 2023; 68:147-174. [PMID: 36436614 DOI: 10.1016/j.survophthal.2022.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
Intravitreal antivascular endothelial growth factor (anti-VEGF) treatment has drastically improved the visual and anatomical outcomes in patients with diabetic macular edema (DME); however, success is not always guaranteed, and a proportion of these eyes demonstrate persistent DME (pDME) despite intensive treatment. While standardized criteria to define these treatment-resistant eyes have not yet been established, many studies refer to eyes with no clinical response or an unsatisfactory partial response as having pDME. A patient is considered to have pDME if the retinal thickness improves less than 10-25% after 6 months of treatment. A range of treatment options have been recommended for eyes with pDME, including switching anti-VEGF agents, using corticosteroids and/or antioxidant drugs in adjunct with anti-VEGF therapy, and vitrectomy. In addition, multimodal imaging of DME eyes may be advantageous in predicting the responsiveness to treatment; this is beneficial when initiating alternative therapies. We explore the literature on persistent DME regarding its defining criteria, incidence, the baseline biological markers that may be useful in anticipating the response to treatment, and the available treatment options.
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Affiliation(s)
- Osama A Sorour
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA; Department of Ophthalmology, Tanta University, Tanta, Egypt
| | - Emily S Levine
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA; Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Caroline R Baumal
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Phillip Braun
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jessica Girgis
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Nadia K Waheed
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA.
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Elbarky A. Effectiveness and tolerability of the fluocinolone acetonide implant in patients with diabetic macular edema in the UAE: 24 and 36-month outcomes. Eur J Ophthalmol 2022; 33:11206721221128671. [PMID: 36168254 DOI: 10.1177/11206721221128671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The effectiveness and safety of the fluocinolone acetonide (FAc) implant was evaluated at Month 24 and, in some sustained for up to 36 months, in patients with diabetic macular edema (DME) and a pseudophakic lens treated in the UAE following prior anti-vascular endothelial growth factor and dexamethasone (DEX) implant. METHODS This was a retrospective, observational audit study conducted between September 2017-September 2020 in which 22 patients were treated with the FAc implant and outcomes monitored for up to 36 months. Effectiveness outcomes were: best-corrected visual acuity (BVCA) and central macular thickness (CMT). Safety was assessed by monitoring intraocular pressure (IOP). All outcomes were measured at Months 1, 3, 6, 12, 24, and 36. RESULTS Significant improvements in mean BCVA were observed versus baseline from Month 1, which were maintained up to Month 24 (P < 0.0001 versus baseline). In all five patients completing 36 months follow-up, the improvements in BVCA were maintained through to Month 36 P < 0.005 versus baseline. Similarly, mean CMT improved versus baseline at Month 1 through to Month 24 (P < 0.0001 versus baseline), with significant improvements also noted in the 5 patients completing 36 months follow-up (P < 0.005 versus baseline). An IOP rise to 32 mmHg was observed in one eye, but returned to normal values at next measure. Five eyes required IOP lowering drops and one required IOP-lowering surgical intervention. CONCLUSION The FAc intravitreal implant is effective for 24 months, and sustained for 36 months, in a UAE population previously treated with a DEX implant, with tolerability profile in-line with previous reports.
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Affiliation(s)
- Ahmed Elbarky
- 37532Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
- Ophthalmology, Benha Faculty of Medicine, Benha University, Benha, Egypt
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Grzybowski A, Markeviciute A, Zemaitiene R. Treatment of Macular Edema in Vascular Retinal Diseases: A 2021 Update. J Clin Med 2021; 10:5300. [PMID: 34830582 PMCID: PMC8619917 DOI: 10.3390/jcm10225300] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/02/2021] [Accepted: 11/11/2021] [Indexed: 01/14/2023] Open
Abstract
Macular edema (ME) is associated with various conditions; however, the main causes of ME are retinal vein occlusion (RVO) and diabetes. Laser photocoagulation, formerly the gold standard for the treatment of ME, has been replaced by anti-vascular endothelial growth factor (anti-VEGF) intravitreal injections. Despite its efficiency, this treatment requires frequent injections to preserve the outcomes of anti-VEGF therapy, and as many patients do not sufficiently respond to the treatment, ME is typically a chronic condition that can lead to permanent visual impairment. Generalized recommendations for the treatment of ME are lacking, which highlights the importance of reviewing treatment approaches, including recent anti-VEGFs, intravitreal steroid implants, and subthreshold micropulse lasers. We reviewed relevant studies, emphasizing the articles published between 2019 and 2021 and using the following keywords: macular edema, diabetic macular edema, retinal vein occlusion, laser photocoagulation, anti-VEGF, and intravitreal injections. Our results revealed that a combination of different treatment methods may be beneficial in resistant cases. Additionally, artificial intelligence (AI) is likely to help select the best treatment option for patients in the near future.
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Affiliation(s)
- Andrzej Grzybowski
- Department of Ophthalmology, University of Warmia and Mazury, 10-561 Olsztyn, Poland;
- Institute for Research in Ophthalmology, 60-836 Poznan, Poland
| | - Agne Markeviciute
- Department of Ophthalmology, Medical Academy, Lithuanian University of Health Sciences, 50161 Kaunas, Lithuania;
| | - Reda Zemaitiene
- Department of Ophthalmology, Medical Academy, Lithuanian University of Health Sciences, 50161 Kaunas, Lithuania;
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Lopes BO, Brizido MS, Aerts F, Pina SM, Simoes PS, Miranda MI. Prognostic biomarkers of chronic diabetic macular edema treated with a fiuocinolone acetonide intravitreal implant. MEDICAL HYPOTHESIS, DISCOVERY & INNOVATION OPHTHALMOLOGY JOURNAL 2021; 10:50-58. [PMID: 37641614 PMCID: PMC10460228 DOI: 10.51329/mehdioph-thal1421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Background This study aimed to investigate retinal imaging biomarkers, such as disorganization of the retinal inner layers (DRIL) and/or ellipsoid zone (EZ) disruption by spectral domain optical coherence tomography (SD-OCT), and functional outcomes in eyes treated with 0.2 µg/day of a fluocinolone acetonide intravitreal implant (FAc) after an insufficient response to previous treatments. Methods This was a retrospective comparative study of 18 eyes (15 patients) with persistent and/or recurrent diabetic macular edema (DME) treated with FAc. Eyes were divided according to the number of prior intravitreal treatments: group 1 (n = 8) with ≤ 6 injections (early switch) and group 2 (n = 10) with > 6 injections (late switch). Outcomes included percentage of eyes with DRIL and/or EZ disruption at baseline and analysis of the best corrected visual acuity (BCVA) using ETDRS letters, central macular thickness (CMT), DRIL, and EZ disruption at the last observation. Results Group 2 revealed a significantly higher percentage of DRIL and/or EZ disruption than group 1 (P < 0.05). At the last observation, group 1 revealed a higher percentage of eyes achieving vision stability/ improvement, gaining ≥ 15 letters, and achieving ≥70 letters (P > 0.05 for all comparisons). The mean BCVA gain was 8.8 and 0.7 letters for groups 1 and 2 (P = 0.397). Both groups revealed a significant mean CMT reduction (> 20% reduction from the baseline value), without a significant statistical difference between them (P = 0.749). After treatment, most eyes from both groups showed resolution of DRIL and EZ disruption. Conclusions Patients with DME presenting with a lower percentage of DRIL and/or EZ disruption at baseline had better functional outcomes, supporting the possible benefit of an early switch to FAc after insufficient response to previous treatments. Future randomized studies with a larger patient cohort are warranted to confirm our conclusions.
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Affiliation(s)
| | | | - Florence Aerts
- Department of Ophthalmology, Beatriz Angelo Hospital, Loures, Portugal
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Matonti F, Conrath J, Devin F, Morin BR, Morel C. [Intraoperative photo of fluocinolone acetonide and dexamethasone implants]. J Fr Ophtalmol 2021; 44:1100-1101. [PMID: 34016475 DOI: 10.1016/j.jfo.2020.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/02/2020] [Accepted: 11/05/2020] [Indexed: 11/25/2022]
Affiliation(s)
- F Matonti
- Centre Monticelli Paradis, 433bis, rue Paradis, 13008 Marseille, France; Université Aix-Marseille, CNRS, INT, Institut de Neurosciences de la Timone, Marseille, France.
| | - J Conrath
- Centre Monticelli Paradis, 433bis, rue Paradis, 13008 Marseille, France
| | - F Devin
- Centre Monticelli Paradis, 433bis, rue Paradis, 13008 Marseille, France
| | - B R Morin
- Centre Monticelli Paradis, 433bis, rue Paradis, 13008 Marseille, France
| | - C Morel
- Centre Monticelli Paradis, 433bis, rue Paradis, 13008 Marseille, France
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Augustin AJ, Bopp S, Fechner M, Holz FG, Sandner D, Winkgen AM, Khoramnia R, Neuhann T, Warscher M, Spitzer MS, Sekundo W, Seitz B, Duncker T, Ksinsik C, Höh H. The impact of vitrectomy on outcomes achieved with 0.19 mg fluocinolone acetonide implant in patients with diabetic macular edema. Eur J Ophthalmol 2021; 32:11206721211014728. [PMID: 33947233 DOI: 10.1177/11206721211014728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is a lack of consensus on the use of intravitreal corticosteroid therapies in patients with diabetic macular edema (DME) and prior vitrectomized eyes in clinical practice. METHODS Retro-IDEAL was a 3-year retrospective, multicenter study in patients with chronic DME (i.e. DME that persists or recurs despite treatment) treated with ILUVIEN® (0.2 µg daily fluocinolone acetonide intravitreal implant), who had suboptimal outcomes with first-line vascular endothelial growth-factor inhibitors and other DME therapies. RESULTS A total of 81 eyes (63 patients) were included of which 39 eyes had undergone prior vitrectomy (PV group) while 42 eyes had not undergone prior vitrectomy (NPV). Baseline characteristics were balanced; however, more patients had proliferative diabetic retinopathy in the PV group vs. the NPV group (21.62% vs 9.38%, respectively). Over 36 months, mean visual acuity (VA) increased in both groups with a tendency for more ETDRS letters being gained in the NPV group (+5.33) vs. the PV group (+2.42). By month 36, central retinal thickness was reduced to ⩽300 µm in two-thirds of the eyes in both groups and the mean change from baseline in intraocular pressure was similar in both groups (+0.50 mmHg -0.75 mmHg; NPV and PV group). CONCLUSIONS These long-term data suggest that the 0.2 μg/day FAc implant is effective in both vitrectomized and non-vitrectomized patients, with a manageable safety profile, and improved VA and reduced supplemental therapies for patients with a suboptimal response to first-line DME therapies. Clinicians may consider utilizing the FAc implant earlier in the DME disease process.
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Affiliation(s)
| | - Silvia Bopp
- Augenklinik Universitätsallee, Bremen, Germany
| | | | - Frank G Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Dirk Sandner
- Universitäts-Augenklinik Dresden, Dresden, Germany
| | | | | | | | - Markus Warscher
- Klinik für Augenheilkunde, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | | | | | - Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Tobias Duncker
- Makula Zentrum, Institut für Augenheilkunde Halle, Halle, Germany
| | | | - Helmut Höh
- Augenklinik, Dietrich-Bonhoeffer-Klinikum, Neubrandenburg, Germany
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Intravitreal Therapy for Diabetic Macular Edema: An Update. J Ophthalmol 2021; 2021:6654168. [PMID: 33688431 PMCID: PMC7925023 DOI: 10.1155/2021/6654168] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 02/11/2021] [Accepted: 02/16/2021] [Indexed: 02/07/2023] Open
Abstract
Diabetic macular edema (DME) represents a prevalent and disabling eye condition. Despite that DME represents a sight-threatening condition, it is also among the most accessible to treatment. Many different treatment options including photocoagulation, intravitreal medical treatment (either vascular endothelial growth factor inhibitors or corticosteroids therapies), and surgical removal are currently available. Although laser has been considered as the gold standard for many years, over the past several years vascular endothelial growth factor inhibitors (anti-VEGFs) have become first-line therapy. However, many patients do not adequately respond to them. With the development of sustained-release corticosteroid devices, steroids have gained a presence in the management of the DME. We review and update the role of anti-VEGF and intravitreal sustained-release corticosteroid management of DME. According to the currently available scientific evidence, the choice of one anti-VEGF over another critically depends on the baseline best-corrected visual acuity (BCVA). While aflibercept may be the drug of choice in low baseline BCVA, the three anti-VEGFs (bevacizumab, ranibizumab, and aflibercept) provided similar functional outcomes when the baseline BCVA was higher. DEX implants are a valuable option for treating DME, although they are usually seen as a second choice, particularly in those eyes that have an insufficient response to anti-VEGF. The new evidence suggested that, in eyes that did not adequately respond to anti-VEGF, switching to a DEX implant at the time to 3 monthly anti-VEGF injections provided better functional outcomes.
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Chronopoulos A, Chronopoulos P, Ashurov A, Korb C, Pfeiffer N, Hattenbach LO. Switching to intravitreal fluocinolone acetonide implant for refractory diabetic macular edema: 12- and 24-month results. Eur J Ophthalmol 2021; 32:443-449. [PMID: 33601897 DOI: 10.1177/1120672121992982] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE To report visual and anatomical outcomes of chronic/refractory diabetic macular edema (DME) treated with intravitreal fluocinolone acetonide implant. SETTING Retrospective, one arm, multicentric study. METHOD Between 2013 and 2018, 27 consecutive eyes of 25 patients with chronic/refractory DME were treated with a fluocinolone acetonide intravitreal implant. Best registered visual acuity (BRVA), central retinal thickness (CRT), and Goldmann tonometry intraocular pressure (IOP) were assessed at 12 and 24 months. The need for IOP lowering treatment as well as top-up therapy during the follow-up were also assessed. RESULTS The duration of DME prior to treatment in our study was 54 ± 24 months. The baseline mean BRVA of 0.7 ± 0.34 logMAR improved to 0.5 ± 0.3 (p = 0.01) at 12 months and 0.46 ± 0.3 (p = 0.04) at 24 months. At 12 months, BRVA improved in 14 eyes (52%), stabilized in 5 eyes (20%), and decreased in 3 eyes (11%). At 24 months, BRVA improved further in 6 eyes (24%), stabilized in 3 eyes (12%), and decreased in 6 eyes (24 %). Mean CRT decreased from 497 ± 176 to 349 ± 186 μm at 12 months (p = 0.0005) and to 267 ± 104 μm at 24 months (p = 0.001). Only five eyes required additional treatment for DME and only three eyes required treatment for raised IOP. DISCUSSION Our results show that the visual and the anatomical improvements achieved by a single injection of a fluocinolone acetonide implant were maintained up to 24 months with minimal additional therapy even in eyes with a long and heavy history; however, IOP monitoring remains essential.
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Affiliation(s)
| | - Panagiotis Chronopoulos
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Agharza Ashurov
- Department of Ophthalmology, Ludwigshafen Hospital, Ludwigshafen am Rhein, Germany
| | - Christina Korb
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Norbert Pfeiffer
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Lars-Olof Hattenbach
- Department of Ophthalmology, Ludwigshafen Hospital, Ludwigshafen am Rhein, Germany
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Cicinelli MV, Rosenblatt A, Grosso D, Zollet P, Capone L, Rabiolo A, Lattanzio R, Loewenstein A, Bandello F. The outcome of fluocinolone acetonide intravitreal implant is predicted by the response to dexamethasone implant in diabetic macular oedema. Eye (Lond) 2021; 35:3232-3242. [PMID: 33479485 DOI: 10.1038/s41433-020-01373-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 11/15/2020] [Accepted: 12/09/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND/OBJECTIVES To investigate if the visual and anatomic response to the first dexamethasone implant (DEX) predicts the 12-month clinical outcome after shifting to fluocinolone acetonide (FAc) implant in patients with diabetic macular oedema (DMO). METHODS Retrospective cohort study including pseudophakic patients with previously treated DMO, undergone one or more DEX injections before FAc. Functional and morphologic response to DEX was defined based on the best-corrected visual acuity (BCVA) and central macular thickness (CMT) changes after the first DEX, respectively. Steroid-response was defined as intraocular pressure (IOP) elevation ≥5 mmHg or IOP > 21 mmHg after any previous DEX exposure. Pairwise comparisons for BCVA, CMT, and IOP after FAc were performed with linear mixed models and a repeated-measure design. RESULTS Forty-four eyes of 33 patients were included. Patients were shifted to FAc after a mean ± standard deviation of 4.6 ± 3.2 DEX injections. Overall, BCVA and CMT improved during the first 12 months after switching to FAc (p = 0.04 and p < 0.001, respectively). Only eyes with a good morphologic response to DEX had a significant CMT reduction after FAc (p < 0.001), while no significant relationship was found between BCVA improvement after DEX and after FAc. IOP elevation occurred in 9 eyes (20%) following DEX implant. These eyes carried a 20-fold increased risk of having an IOP rise after FAc (p < 0.001), with a non-linear relationship between the IOP increase after DEX and the one after FAc. CONCLUSION The response to previous DEX may anticipate the morphologic response to subsequent FAc. Eyes with steroid-induced IOP elevation after DEX are at a high risk of IOP increase after FAc. The visual response after FAc was not associated with the visual response to previous steroids, indicating that FAc may have a role also in patients refractory to DEX implant.
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Affiliation(s)
- Maria Vittoria Cicinelli
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy. .,Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Amir Rosenblatt
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Domenico Grosso
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Piero Zollet
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Capone
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Rabiolo
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Department of Ophthalmology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, United Kingdom
| | - Rosangela Lattanzio
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anat Loewenstein
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Francesco Bandello
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.,Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Elbarky AM. Effectiveness and tolerability of the fluocinolone acetonide implant in patients with diabetic macular edema in UAE: 12-Month results. Eur J Ophthalmol 2021; 31:3196-3202. [PMID: 33426902 DOI: 10.1177/1120672120982948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION To evaluate 12-month outcomes following fluocinolone acetonide (FAc 0.2 μg/day) implant in pseudophakic patients with diabetic macular edema (DME) that persists or recurs despite previous treatment with anti-vascular endothelial growth factors (anti-VEGF) and dexamethasone implant (DEX) in a UAE population. METHODS A retrospective, observational, single-center, 12-month audit study, where 22 pseudophakic eyes (22 patients) with DME were treated with the FAc intravitreal implant according to licensed UAE indications. Outcome measurements at baseline and at months 1, 3, 6, and 12 included best-corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP). RESULTS Post-FAc implantation, mean BCVA significantly improved at 1, 3, and 12 months (+10.4 ± 16.1, +22.8 ± 13.6, and +25.5 ± 13.0 letters, respectively; p < 0.0001), with 86% of eyes gaining ⩾15 letters at month 12. Similarly, CMT reduced significantly at month 1, and stabilized thereafter at months 3-12 (-171.5 ± 72.5 µm, -240.9 ± 74.2 µm, and -246.2 ± 93.4 µm, respectively; p < 0.0001). By month 12, 64% (n = 14/22) of eyes had a CMT below 300 µm. Only 1 eye had an IOP ⩾ 21 mmHg at baseline and month 12. Five eyes required IOP lowering drops and 1 required IOP-lowering surgical intervention. CONCLUSION In pseudophakic patients with DME FAc implant provide a substantial functional and anatomical benefits for up to 12 months.
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Affiliation(s)
- Ahmed Mohammed Elbarky
- Faculty of Medicine, Benha University, Benha, Egypt.,Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
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Kodjikian L, Baillif S, Creuzot-Garcher C, Delyfer MN, Matonti F, Weber M, Mathis T. Real-World Efficacy and Safety of Fluocinolone Acetonide Implant for Diabetic Macular Edema: A Systematic Review. Pharmaceutics 2021; 13:pharmaceutics13010072. [PMID: 33430389 PMCID: PMC7827527 DOI: 10.3390/pharmaceutics13010072] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 12/24/2020] [Accepted: 01/04/2021] [Indexed: 12/18/2022] Open
Abstract
To assess real-world outcomes of fluocinolone acetonide (FAc) implant in treating diabetic macular edema (DME), a systematic literature review was conducted on PubMed in order to identify publications assessing the efficacy and safety of the FAc implant in DME in daily practice. Case reports and randomized controlled trials were excluded. Twenty-two observational real-world studies analyzing a total of 1880 eyes were included. Mean peak visual gain was +8.7 letters (11.3 months post-FAc injection) and was greater for lower baseline best corrected visual acuity (BCVA) and for more recent DME. Mean central retinal thickness (CRT) decreased 34.3% from baseline. 77.0% of the analyzed studies reported both BCVA improvement of at least five letters and a CRT decrease by 20% or more. Rescue therapy was needed more frequently when FAc was administered for chronic DME. FAc-induced ocular hypertension was reported in 20.1% of patients but only 0.6% needed surgery. Cataract extraction was performed in 43.2% of phakic patients. Adequate patient selection is essential for optimal FAc response and better safety profile. Currently positioned as second- or third-line treatment in the management algorithm, FAc implant decreases treatment burden and provides better letter gain when administered for more recent DME.
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Affiliation(s)
- Laurent Kodjikian
- Department of Ophthalmology, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon 1, 69004 Lyon, France;
- CNRS-UMR 5510 Mateis, University of Lyon 1, 69100 Villeurbane, France
- Correspondence: ; Tel.: +33-(0)4-26-10-94-31
| | - Stephanie Baillif
- Department of Ophthalmology, Pasteur 2 University Hospital, 06000 Nice, France;
| | - Catherine Creuzot-Garcher
- Department of Ophthalmology, Dijon-Bourgogne University Hospital, 21000 Dijon, France;
- Eye and Nutrition Research Group, CSGA, UMR1324 INRA, 6265 CNRS, Burgundy, 21000 Dijon, France
| | - Marie-Noëlle Delyfer
- Department of Ophthalmology, Bordeaux 2 University Hospital, 33000 Bordeaux, France;
- Bordeaux Population Health Research Center, Team LEHA, 33000 Bordeaux, France
| | - Frédéric Matonti
- Monticelli Paradis Center, 13000 Marseille, France;
- Institut de Neurosciences de la Timone-UMR 7289, University of Aix-Marseille, 13000 Marseille, France
| | - Michel Weber
- Department of Ophthalmology, Nantes University Hospital, 44000 Nantes, France;
- Clinical Investigation Centre CIC1413, INSERM and Nantes University Hospital, 44000 Nantes, France
| | - Thibaud Mathis
- Department of Ophthalmology, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon 1, 69004 Lyon, France;
- CNRS-UMR 5510 Mateis, University of Lyon 1, 69100 Villeurbane, France
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Adán A, Cabrera F, Figueroa MS, Cervera E, Ascaso FJ, Udaondo P, Abraldes M, Reyes MÁ, Pazos M, Pessoa B, Armadá F. Clinical-Decision Criteria to Identify Recurrent Diabetic Macular Edema Patients Suitable for Fluocinolone Acetonide Implant Therapy (ILUVIEN ®) and Follow-Up Considerations/Recommendations. Clin Ophthalmol 2020; 14:2091-2107. [PMID: 32801618 PMCID: PMC7398681 DOI: 10.2147/opth.s252359] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/21/2020] [Indexed: 12/26/2022] Open
Abstract
Current management of diabetic macular edema (DME) predominantly involves treatment with short-acting intravitreal injections of anti-vascular endothelial growth factors (anti-VEGFs) and/or corticosteroids; however, short-acting therapies (lasting between 1 and 6 months) require frequent injections to maintain efficacy, meaning a considerable treatment burden for diabetic patients with multiple comorbidities. Continuous injections needed in some cases are an economic burden for patients/healthcare system, so real-life clinical practice tends to adopt a reactive approach, ie, watch and wait for worsening symptoms, which consequently increases the risk of undertreatment and edema recurrence. On March 7th 2019, a group of experts in retinal medicine and surgery held a roundtable meeting in Madrid, Spain to discuss how to (1) optimize clinical outcomes through earlier use of fluocinolone acetonide (FAc) implant (ILUVIEN®) in patients with persistent or recurrent DME despite therapy; and, (2) to provide guidance to assist physicians in deciding which patients should be treated with ILUVIEN. In this regard, a 36-month follow-up consensus protocol is presented. In conclusion, patients that achieve a complete or partial anatomical, and preferably functional, response following one or two intravitreal dexamethasone implants, but with recurrence of edema after 3-4 months, are deemed by the authors most likely to benefit from ILUVIEN, and the switch to FAc implant should not be delayed more than 12 months after the initiation of at least the first dexamethasone implant.
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Affiliation(s)
| | - Francisco Cabrera
- Complejo Hospitalario Universitario Insular Materno-Lnfantil de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | | | | | - Francisco J Ascaso
- Hospital Clínico Universitario Lozano Blesa de Zaragoza, Aragon Health Research Institute (IIS Aragon), Zaragoza, Spain
| | - Patricia Udaondo
- Hospital Universitario y Politécnico la Fe de Valencia, Valencia, Spain
| | - Maximino Abraldes
- Complexo Hospitalario Universitario de Santiago de Compostela, Universidad de Santiago de Compostela, Instituto Oftalmológico Gómez-Ulla, Santiago de Compostela, Spain
| | - Miguel Ángel Reyes
- Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - Marta Pazos
- Hospital Clínic de Barcelona, Barcelona, Spain
| | - Bernardete Pessoa
- Centro Hospitalar e Universitário do Porto, Hospital Geral de Santo António, Porto, Portugal
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Zarranz-Ventura J, Mali JO. Effectiveness of 190 µg Fluocinolone Acetonide and 700 µg Dexamethasone Intravitreal Implants in Diabetic Macular Edema Using the Area-Under-the-Curve Method: The CONSTANT Analysis. Clin Ophthalmol 2020; 14:1697-1704. [PMID: 32606585 PMCID: PMC7319506 DOI: 10.2147/opth.s253370] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/08/2020] [Indexed: 12/14/2022] Open
Abstract
Purpose Calculations of area-under-the-curve (AUC) provide the average letters gained across the entire treatment period, which may be a better estimate of long-term effectiveness than single time-point outcomes, particularly when it comes to sustained-release therapies. Materials and Methods The AUC method was used to compare the efficacy of the 0.2 µg/day fluocinolone acetonide (total dose of 0.19 mg; FAc) and dexamethasone (DEX) 700 µg implants based on published data from their respective Phase 3 FAME (Fluocinolone Acetonide for Macular Edema) and MEAD pivotal clinical trials in diabetic macular edema (DME). Best-corrected visual acuity (BCVA) letter scores were collated from the FAME trial and compared with those reported in MEAD. The trapezoidal rule was then used to calculate AUC, based on BCVA letter score, from baseline to Month 36 (FAME)/Month 39 (MEAD) and presented as an overall mean visual acuity change per day. Results Treatment with either the FAc or DEX implant resulted in an improved BCVA over the treatment period compared with sham. This effect was statistically greater (p=0.029) for the FAc implant than the DEX implant (5.2 vs 3.5 letters/day, respectively) and even greater in the recurrent DME subgroup (p<0.001; 6.9 vs 3.5 letters/day, respectively). Conclusion Although direct comparisons between trial cohorts cannot be performed, this analysis indicated that, in their respective pivotal clinical trial cohorts, treatment with the FAc implant provides better long-term visual acuity outcomes and a lower treatment burden than achieved with the DEX implant.
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Affiliation(s)
- Javier Zarranz-Ventura
- Clinical Institute of Ophthalmology (ICOF), Hospital Clinic, Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
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Preoperative, Intraoperative and Postoperative Corticosteroid Use as an Adjunctive Treatment for Rhegmatogenous Retinal Detachment. J Clin Med 2020; 9:jcm9051556. [PMID: 32455658 PMCID: PMC7290919 DOI: 10.3390/jcm9051556] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 12/19/2022] Open
Abstract
The treatment for rhegmatogenous retinal detachment (RRD) is surgery, including pars plana vitrectomy (PPV) and scleral buckling (SB). Despite surgical advances, degeneration of the photoreceptors and post-operative complications, such as proliferative vitreoretinopathy (PVR), often occurs as the result of inflammation, preventing complete visual recovery or causing RRD recurrence. There is increasing evidence that in the presence of RRD, the activation of inflammatory processes occurs and the surgery itself induces an inflammatory response. This comprehensive review focuses on the use of different formulations of corticosteroids (CCS), as an adjunctive treatment to surgery, either PPV or SB, for RRD repair. The purpose was to review the efficacy and safety of CCS in improving functional and anatomical outcomes and in preventing postoperative complications. This review is organized according to the timing of CCS administration: preoperative, intraoperative, and postoperative. The evidence reviewed supported the role of the pre-operative use of CCS in the treatment of combined RRD and choroidal detachment (CD), reducing CD height. No solid consensus exists on intraoperative and postoperative use of CCS to treat and prevent postoperative complications. However, a large randomized clinical trial including more than 200 eyes suggested that oral prednisone after surgery decreases the rate of postoperative grade B PVR.
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