Dexamethasone Intravitreal Implant for Pseudophakic Cystoid Macular Edema in Patients With Diabetes

Real-world experience on intravitreal dexamethasone implant in patients with macular edema scheduled to undergo cataract surgery

BACKGROUND

Patients with pre-existing macular edema (ME) due to diabetes and retinal vein occlusions (RVO) make up a growing population receiving cataract surgery. Surgery is associated with an increased risk of worsening existing ME due to post-surgical inflammation that can be further exacerbated by pre-existing diabetic retinopathy (DR) and retinal vein occlusion. This study aimed to examine the pre-operative use of intravitreal dexamethasone (DEX) implants in patients with ME undergoing cataract surgery.

METHODS

A retrospective study was conducted at National Cheng Kung University Hospital in Taiwan involving 19 eyes of 16 patients with DME or ME associated with RVO. All participants received a DEX implant at baseline and underwent phacoemulsification within 3 months after its insertion. Best-corrected visual acuity (BCVA), intraocular pressure (IOP) and central subfield thickness (CST) were evaluated.

RESULTS

DEX implants reduced the CST from baseline (357.8 μm) to pre-surgery (280.8 μm). This reduction below baseline continued to month 6 post-surgery (319.4 μm). From baseline (16.15 mmHg), the mean IOP initially increased pre-surgery (17.78 mmHg) before returning to the baseline value at month 6 post-surgery (16.15 mmHg). All patients improved their BCVA from logMAR 0.943 on average at baseline to logMAR 0.532 at month 6 post-surgery.

CONCLUSIONS

The results of the study suggested that patients with ME could benefit from DEX implants before cataract surgery within 3 months to achieve sufficient postoperative inflammation management and limit ME deterioration. DEX implants did not increase IOP post-surgery and was similar to baseline levels.

Intravitreal Fluocinolone Acetonide Implant (FAc, 0.19 mg, ILUVIEN®) in the Treatment of Patients with Recurrent Cystoid Macular Edema After Pars Plana Vitrectomy

INTRODUCTION

Postoperative cystoid macular edema (PCME) is a complication of several ocular procedures, including pars plana vitrectomy (PPV), due to the activation of the inflammatory cascade. The purpose of this case series is to evaluate the effectiveness and safety of fluocinolone acetonide intravitreal implant (FAc, 0.2 μg/day; ILUVIEN®) in the treatment of refractory PCME after successful PPV.

METHODS

This retrospective observational case series includes consecutive eyes of patients with recurrent PCME after PPV and treated with a single FAc implant at Centro Hospitalar Universitário de São João, Porto, Portugal. Previous treatments, best-corrected visual acuity (BCVA, ETDRS letters), central macular thickness (CMT, μm), intraocular pressure (IOP, mmHg), and IOP-lowering medication needed were recorded at baseline and during follow-up. Total macular edema resolution was defined as CMT less than 300 μm or a reduction of greater than 20%, and partial macular edema resolution was defined as a reduction of greater than 10%.

RESULTS

Nine eyes from nine patients were included. Before FAc implant, all eyes received intravitreal short-action corticosteroids (triamcinolone and dexamethasone implant), with a good response but relapse 1-5 months later. At baseline, BCVA was 55.0 ± 10.6 letters, CMT was 514.9 ± 165.6 μm, and IOP was 15.4 ± 2.4 mmHg with four eyes under IOP-lowering medication. After FAc implant, all eyes achieved edema resolution (eight total and one partial) with a peak gain of 17.2 letters and a maximum decrease of 208.2 μm in CMT. During follow-up (44.0 ± 14.8 months), 66.7% of the eyes kept their macula dry and three showed recurrence after 11, 14, and 28 months, respectively. The maximum IOP registered was 17.0 ± 6.0 mmHg. IOP-lowering regimen was increased in one eye and two additional eyes started hypotensive drops.

CONCLUSION

FAc implant can be considered a therapeutic alternative in PCME refractory to other therapies in vitrectomized eyes, reducing the need for repeated treatments.

Incidence of Pseudophakic Cystoid Macular Oedema Post-Cataract Surgery in Illawarra Shoalhaven Local Health District, Australia

BACKGROUND

Post-operatively, cataract surgery is associated with pseudophakic cystoid macular oedema (PCMO) causing vision disturbances. The presence of comorbidities may increase the incidence of PCMO post-cataract surgery.

OBJECTIVE

This observational study aimed to assess the incidence of PCMO in Australia (Illawarra region) and identify risk factors for developing PCMO.

METHODS

Retrospective analysis was performed on data from patients who underwent uncomplicated phacoemulsification and intraocular lens implantation between 1st March and June 30, 2016. Demographics, comorbidities, central subfield thickness (CST), visual acuity, and intraocular pressure (IOP) were collected preoperatively, day 1, and weeks 2, 4, and 6 post-operatively. Statistical analysis was performed using SPSS v.27.0 and GraphPad Prism v.9.0. The median and 95% confidence intervals were used to describe data. Logistic regression and χ2 tests were used to describe the associations. We followed the Declaration of Helsinki guidelines.

RESULTS

Fifty right and 35 left cataract eyes were operated on (58.8% were females; average age 72.8 ± 8.146 years). Total PCMO incidence was 10.6%, and true PCMO incidence (removing PCMO risk factors) was 4.2% at week 6 post-operatively. CST was slightly increased between pre- and post-cataract surgery at week 4 (p = 0.002) and week 6 (p < 0.0001; median = 259 μm, 264 μm, and 263 μm, respectively). IOP was found to be decreased (p < 0.0001) compared to day 1 (median = 17 mm Hg) and week 6 (median = 13 mm Hg). The probability of developing PCMO (odds ratio [OR] = 3) and vitreomacular traction (OR = 2.9) was higher in diabetic patients compared to non-diabetic patients and in patients >65 years old (OR = 1.5).

CONCLUSION

The true incidence of PCMO was found to be the greatest at 2-4 weeks post-operatively. Patients with diabetes or advanced age (>65 years) are at an elevated risk of developing PCMO after cataract surgery. The treatment regimens for the comorbid populations, especially diabetic patients, remain limited, and future efforts should target pharmaceutical management for these groups.

Case Report: Subconjunctival Bevacizumab for the Treatment of Refractory Pseudophakic Cystoid Macular Edema

SIGNIFICANCE

In this report, the authors present a case of a 63-year-old man with recurrent pseudophakic cystoid macular edema. Macular edema was refractory to the treatments with periocular corticosteroid injection and topical anti-inflammatory medications. It was treated with subconjunctival bevacizumab (2.5 mg) injections.

PURPOSE

The purpose of this report was to demonstrate the efficacy and safety of repeated injections of subconjunctival bevacizumab in pseudophakic cystoid macular edema.

CASE REPORT

A 63-year-old White man presented with ongoing blurred vision in his left eye 4 months after a complicated cataract surgery. Despite the administration of sub-Tenon triamcinolone in the first-month visit because of cystoid macular edema and the use of topical steroid and nonsteroidal anti-inflammatory medications during the 4 months, there was no change in his vision. The first subconjunctival bevacizumab injection was performed 16 weeks after cataract surgery. The best-corrected visual acuity was significantly improved, and central retinal thickness dramatically decreased after the first injection. Macular edema reoccurred 26 and 46 weeks after cataract surgery. At these relapses, repeated subconjunctival injections of bevacizumab were influential in resolving macular edema and restoration of vision, even in the chronic phase. After 6 months, visual acuity (20/20) and central retinal thickness (274 μm) were stable after four total injections. No drug-related adverse events were observed during the follow-up period.

CONCLUSIONS

The repeated subconjunctival injections of bevacizumab were effective and well tolerated in pseudophakic cystoid macular edema. Subconjunctival bevacizumab may be a safe alternative to intravitreal applications in patients with pseudophakic cystoid macular edema.

Dexamethasone intravitreal implant in patients with cataract and naïve diabetic macular edema

PURPOSE

To assess the feasibility and clinical effectiveness of dexamethasone intravitreal implant 0.7 mg (IDI) administered in diabetic patients to prevent the worsening of macular edema.

METHODS

Forty eyes of 40 consecutive patients with naïve macular edema secondary to diabetes mellitus who were treated with IDI administered preoperative (Group A: 20 patients) or IDI administered immediately after cataract surgery (Group B: 20 patients). Best-corrected visual acuity (BCVA) and central macular thickness (CMT) changes were evaluated at baseline and at postoperative time points.

RESULTS

Follow-up study was 20 weeks. In Group A and B, mean BCVA improved significantly at all post-surgery time points (p < 0.05). In Group A and B, mean CMT decreased significantly at 16 weeks (p = 0.02 and p = 0.004, respectively). At week 20, CMT failed to reach statistical significance in both groups (p = 0.5, group A and p = 0.15, group B). No statistical differences were noted between groups in term of BCVA (with the exception of week 4 for the presence of cataract in Group A), CMT and IOP.

CONCLUSIONS

The use of intravitreal dexamethasone implant 1 month prior to scheduled cataract extraction or at the time of phacoemulsification appears to be safe and effective for at least 16 weeks after surgery.

Efficacy of Topical Nepafenac 0.3% in the Management of Postoperative Cystoid Macular Edema

Purpose

To assess the effect of twice-daily nepafenac ophthalmic suspension 0.3% on postoperative cystoid-macular-edema (CME).

Patients and Methods

In this prospective, clinic-based, non-randomized case-series, 21 patients (21 eyes) were enrolled with either acute or chronic postoperative CME after cataract extraction. Patients were treated with twice-daily nepafenac 0.3% drops, and followed for at least a 4-month period. Best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT)-derived central retinal thickness (CRT) were measured.

Results

From 21 patients, eight presented with acute postoperative CME and 13 with chronic CME. Mean follow-up was 4.82±1.24 months. No adverse events were reported during the study. Baseline BCVA was 0.49±0.36 logMAR and improved to 0.36±0.42 logMAR at the last follow-up visit (P<0.005). CRT decreased from 450.40±90.74 μm at baseline to 354.60±81.49 μm (P<0.05), following treatment.

Conclusion

Our outcomes strongly suggest that administrating nepafenac 0.3% drops on a twice-daily regimen could be a promising alternative for the management of postoperative CME. Additional studies are necessary to further validate our results.

Current role of intravitreal injections in Irvine Gass syndrome-CRIIG study

OBJECTIVE

To analyze the role of intravitreal anti-vascular endothelial growth factor (anti-VEGF) or steroid injection for the management of Irvine Gass syndrome.

METHODS

It is an interventional, retrospective, multicenter study. One hundred and thirty-two injections were given in 79 eyes of 72 patients with Irvine Gass syndrome. Patients were treated with at least one intravitreal injection of either anti-VEGF or steroid. Outcomes were measured at 12 months (± 1 week). [Ranibizumab (Lucentis; Genentech, South San Francisco, CA) (Razumab; Intas Pharmaceutical Ltd, Ahmedabad, India) Bevacizumab (Avastin; Genentech, South San Francisco, CA) or Aflibercept (Eylea; Regeneron, Tarrytown, NY)] or steroids [Dexamethasone implant (Ozurdex, Allergan Inc, Irvine, CA) or intravitreal triamcinolone)].

RESULTS

Intravitreal injections were initiated in (67.6%) of eyes within 14 weeks of diagnosis. Intravitreal dexamethasone implant was used as the initial intravitreal therapy in (73.4%) of eyes. More than fifty percent (54.5%) of the patients were switched from anti-VEGF to Intravitreal dexamethasone implant. Reduction in the mean CMT was 336.7 ± 191.7 and 160.1 ± 153.1 microns in eyes treated within four weeks and more than 14 weeks from diagnosis (p = 0.005). Mean ETDRS letter gain was 16.7 ± 12.9 and 5.2 ± 9.2 in eyes treated within 4 weeks and more than 14 weeks from diagnosis (p = 0.004). Three eyes injected with intravitreal dexamethasone implant reported an intraocular pressure spike of > 25 mmHg which was controlled with topical medications. No other ocular or systemic adverse events were observed.

CONCLUSION

Study results suggest that physicians tend to introduce intravitreal therapy within 14 weeks of diagnosis. The most common therapy at initiation and for the switch is intravitreal dexamethasone implant. Patients treated early (within 4 weeks) respond better in terms of structure and function.

Pre-operative intravitreal dexamethasone implant in patients with refractory diabetic macular edema undergoing cataract surgery

To examine preoperative use of intravitreal dexamethasone implant in patients with refractory diabetic macular edema (DME) undergoing cataract surgery. Participants in this study were 17 patients with DME refractory to previous treatment with anti-vascular endothelial growth factor agents or dexamethasone implant, and co-existent cataract. All participants received intravitreal dexamethasone implant at baseline and underwent phacoemulsification within one month after its insertion. Best-corrected visual acuity (BCVA) and central subfield thickness (CST) changes between baseline, time of cataract surgery and postoperative months 1, 2 and 3 were evaluated. At month 1 after surgery, BCVA improved significantly from 42.3 ± 9.6 to 58.7 ± 11.9 letters compared to baseline (p < 0.001) and the improvement was sustained at month 2 and month 3 postoperatively. One month postoperatively, CST improved significantly compared to baseline (p < 0.001) and the improvement was sustained at month 2 (p < 0.001), while at month 3 CST started to increase, but remained significantly lower than baseline (p = 0.003). At month 3 postoperatively, 35.3% of patients presented recurrence of ME. Patients with refractory DME and cataract can safely undergo phacoemulsification when dexamethasone implant is inserted one month prior to surgery to ensure adequate control of postoperative inflammation and prevent deterioration of ME.

Novel Triamcinolone Acetonide-Loaded Liposomal Topical Formulation Improves Contrast Sensitivity Outcome After Femtosecond Laser-Assisted Cataract Surgery

Purpose: To assess visual results, macular modifications, and the incidence of clinically significant macular edema (CSME) in patients using a topical triamcinolone acetonide-loaded liposomal formulation (TA-LF) after femtosecond laser-assisted cataract surgery (FLACS). Methods: Fifty-six eyes after FLACS were selected. Twenty-eight eyes in the combined therapy group (P + N) were treated with prednisolone 1% and nepafenac 0.1% for 21 days postoperatively, whereas 28 eyes in the TA-LF group received a liposomal formulation containing 2 mg/mL of TA (0.2%) for the same period of time. Follow-up visits at 1 day, 6 weeks, and 12 weeks after surgery consisted of visual acuity, contrast sensitivity (CS), central foveal thickness (CFT), total macular volume (TMV) measurements, and the detection of CSME. Results: CS improved in the TA-LF group (basal value: 1.087 ± 0.339 vs. 1.276 ± 0.147 at week 12, P = 0.0346), whereas in the P + N group, CS was not different from the baseline (basal value: 1.130 ± 0.331 vs. 1.274 ± 0.133 at week 12, P = 0.1276). There were similar increases in postoperative CFT and TMV in both groups. CFT and TMV significantly correlate with CS only in the TA-LF group. The r² for CFT and CS was 0.1963 (P = 0.0206), whereas the r² for TMV and CS was 0.3615 (P = 0.0007) at 12 weeks. No difference was observed in the incidence of CSME between the groups. Conclusion: TA-LF is associated with better CS outcomes compared to combined therapy after FLACS.

Novel Triamcinolone Acetonide-Loaded Liposomes Topical Formulation for the Treatment of Cystoid Macular Edema After Cataract Surgery: A Pilot Study

Purpose: To report tolerability, safety, and efficacy of a topical triamcinolone acetonide-loaded liposomes formulation (TA-LF) in targeting the macular area in patients with refractory pseudophakic cystoid macular edema (PCME).

Methods: For tolerability, safety and efficacy evaluation, 12 eyes of 12 patients with refractory PCME were exposed to one drop of TA-LF (TA at 0.2%) every 2 h for 90 days or until best-corrected visual acuity (BCVA) was achieved. Intraocular pressure (IOP), slit lamp examination, and central foveal thickness (CFT) were analyzed at every visit.

Results: Patients with refractory PCME under TA-LF therapy showed a significant improvement in BVCA and CFT without significant IOP modification (P = 0.94). On average CFT decreased to 206.75 ± 135.72 μm and BCVA improved to 20.08 ± 10.35 letters (P < 0.0005). BCVA was achieved at 10.58 ± 6.70 weeks (range 2–18). TA-LF was well tolerated in all cases. Neither ocular surface abnormalities nor adverse events were recorded.

Conclusion: TA-LF was well tolerated and improved BCVA and CFT on patients with refractory PCME.

Dexamethasone protects retinal ganglion cells but not Müller glia against hyperglycemia in vitro

Diabetic retinopathy (DR) is a common complication of diabetes, for which hyperglycemia is a major etiological factor. It is known that retinal glia (Müller cells) and retinal ganglion cells (RGCs) are affected by diabetes, and there is evidence that DR is associated with neural degeneration. Dexamethasone is a glucocorticoid used to treat many inflammatory and autoimmune conditions, including several eye diseases like DR. Thus, our goal was to study the effect of dexamethasone on the survival of RGCs and Müller glial cells isolated from rat retinas and maintained in vitro under hyperglycemic conditions. The behavior of primary RGC cell cultures, and of mixed RGC and Müller cell co-cultures, was studied in hyperglycemic conditions (30 mM glucose), both in the presence and absence of Dexamethasone (1 μM). RGC and Müller cell survival was evaluated, and the conditioned media of these cultures was collected to quantify the inflammatory cytokines secreted by these cells using a multiplex assay. The role of IL-1β, IL-6 and TNFα in RGC death was also evaluated by adding these cytokines to the co-cultures. RGC survival decreased significantly when these cells were grown in high glucose conditions, reaching 54% survival when they were grown alone and only 33% when co-cultured with Müller glia. The analysis of the cytokines in the conditioned media revealed an increase in IL-1β, IL-6 and TNFα under hyperglycemic conditions, which reverted to the basal concentration in co-cultures maintained in the presence of dexamethasone. Finally, when these cytokines were added to co-cultures they appeared to have a direct effect on RGC survival. Hence, these cytokines could be implicated in the death of RGCs when glucose concentrations increase and dexamethasone might protect RGCs from the cell death induced in these conditions.

EFFECT OF AN INTRAVITREAL DEXAMETHASONE IMPLANT ON DIABETIC MACULAR EDEMA AFTER CATARACT SURGERY

PURPOSE

To analyze the effects of a dexamethasone intravitreal implant (DEX; Ozurdex 700 μg; Allergan) administered immediately after cataract surgery in diabetic patients.

METHODS

This prospective, single-arm, open label study (NCT01748487 at ClinicalTrials.gov) involved Type 2 diabetic patients with at least mild diabetic retinopathy (DR) who underwent cataract surgery and DEX insertion after phacoemulsification, and intraocular lens implantation were enrolled. Best-corrected visual acuity and central retinal thickness (CRT) measured by spectral-domain optical coherence tomography were recorded at 1 week preoperatively, and 1 week, 1 month, and 3 months after surgery. Adverse events were also recorded.

RESULTS

Twenty-four eyes of 24 patients (17 [70.8%] men; mean age 63.7 ± 8.7 years) with mild nonproliferative DR (41.7%), moderate nonproliferative DR (33.3%), severe nonproliferative DR (16.7%), or treated proliferative DR (8.3%) were selected. After DEX treatment, mean CRT changed from 241.1 μm (95% confidence interval, 227.5-254.6 μm) at baseline to 236.9 μm (95% confidence interval, 223.9-249.9 μm) at 1 week (P = 0.09), 238.9 μm (95% confidence interval, 225.5-252.3 μm) at 1 month (P = 0.44), and 248 μm (95% confidence interval, 232.4-260.8 μm) at 3 months (P = 0.15). No eyes showed a postoperative increase >50 μm in the CRT at any visit. A 10% increase in CRT was found in 8.3% of eyes. Mean best-corrected visual acuity significantly improved from 0.37 (20/50) at baseline to 0.19 (20/30) at 1 week, 0.12 (20/25) at 1 month, and 0.12 (20/25) at 3 months (P < 0.001 for each comparison). Mean intraocular pressure before surgery was 13.8 mmHg, and none of the patients developed an intraocular pressure ≥22 mmHg at any visit. None of the patients developed any serious adverse events during the follow-up.

CONCLUSION

These short-term results suggest that a single DEX injection intraoperatively after phacoemulsification could avoid an increase in CRT after cataract surgery in diabetic patients.

Evaluation of Predictive Factors for Successful Intravitreal Dexamethasone in Pseudophakic Cystoid Macular Edema

Purpose

To determine the efficacy, safety, and predictive outcome factors for intravitreal dexamethasone implant (DEX) in pseudophakic cystoid macular edema (PCME).

Methods

Retrospective, interventional, controlled study. Patients included had to have clinically significant PCME and have been treated with the DEX between 2012 and 2015. Charts and one-year data were selected consecutively, and efficacy and safety were abstracted. Visual acuity (VA) and central foveal thickness (CFT) were analysed.

Results

Nineteen patient data sets were analysed. After treatment with DEX, mean VA increased significantly by 0.2 logMAR (p = 0.034), while the mean CFT was reduced significantly by 162.79 μm (p < 0.001). Five patients receiving a combination of DEX/bevacizumab have not experienced a higher mean VA gain or CFT reduction compared to fourteen patients receiving DEX alone. Decision rules, when to combine DEX with bevacizumab, have not been defined before the study. Only posttreatment VA gains in the nonhypertensive subgroup (n = 11) were significantly better (p = 0.026). Analysis of data from diabetes patients (n = 4) versus nondiabetics yielded no significant differences in efficacy. There have been no adverse events within follow-up time.

Conclusion

The use of DEX in PCME showed significant improvements in VA and CFT. The VA seems to show greater improvements in patients without hypertension.

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.

Management of macular oedema in diabetic patients undergoing cataract surgery

PURPOSE OF REVIEW

The aim of this study was to describe all the treatment modalities used to prevent and manage macular oedema in diabetic patients undergoing cataract surgery.

RECENT FINDINGS

Topical NSAIDs have been proposed to be an effective strategy to prevent postsurgical macular oedema (PME) in diabetic patients. The prophylactic use of intravitreal antivascular endothelial growth factors (anti-VEGF) drugs and steroids in these patients, even if effective, brings some concerns with regard to possible side effects. By contrast, in patients with a diagnosis of diabetic macular oedema (DME) at the time of cataract surgery, intravitreal therapy, both with anti-VEGF drugs and steroids, appears to be the best approach in order to control PME and achieve a good visual outcome.

CONCLUSION

All diabetic patients undergoing cataract surgery should be treated with topical NSAIDs to prevent PME. Intravitreal anti-VEGF drugs and steroids, combined with cataract surgery, should be reserved for patients with preexisting DME.

Dexamethasone Intravitreal Implant at the Time of Cataract Surgery in Eyes with Diabetic Macular Edema

Purpose

To determine the potential role of intraoperative dexamethasone intravitreal implant (DEX-I) in reducing diabetic macular edema (DME) worsening after phacoemulsification.

Methods

This was a prospective study on 19 eyes of 19 patients with type 2 diabetes mellitus with DME and cataract. Mean preoperative Early Treatment Diabetic Retinopathy Study visual acuity (VA) was 16.7 letters. Mean foveal thickness (FT) was 451 μm. The DME was naive in 11 eyes and refractory in 8 eyes. All eyes underwent a standard phacoemulsification and intraocular lens implantation; DEX-I was injected at the end of surgery. Follow-up was performed at 1 week and then monthly until DME recurrence (up to 8 months).

Results

At 1 week, mean VA improved by 15 letters (range 0-29 letters) and mean FT decreased by 147 μm (range 69-236 μm). Improvement consolidated at month 1, with a mean VA improvement of 18 letters (range 3-32 letters) and a mean improvement in FT of 193 μm (range 76-304 μm), remaining stable at month 2 after surgery in all eyes. The DME recurred in 1 eye at month 3, in 14 eyes (73.8%) between months 4 and 5, and after month 6 in 4 eyes (21%). Refractory DMEs demonstrated the same benefit but recurred earlier than naive ones (4 months versus 5.8 months, p<0.01).

Conclusions

Intraoperative DEX-I prevents DME worsening after phacoemulsification. Its positive effects last for at least 3 months.

Pseudophakic cystoid macular edema: update 2016

Pseudophakic cystoid macular edema (PCME) is the most common complication of cataract surgery, leading in some cases to a decrease in vision. Although the pathogenesis of PCME is not completely understood, the contribution of postsurgical inflammation is generally accepted. Consequently, anti-inflammatory medicines, including steroids and nonsteroidal anti-inflammatory drugs, have been postulated as having a role in both the prophylaxis and treatment of PCME. However, the lack of a uniformly accepted PCME definition, conflicting data on some risk factors, and the scarcity of studies comparing the role of nonsteroidal anti-inflammatory drugs to steroids in PCME prevention make the problem of PCME one of the puzzles of ophthalmology. This paper presents an updated review on the pathogenesis, risk factors, and use of anti-inflammatory drugs in PCME that reflect current research and practice.

Effectiveness and safety of dexamethasone implants for postsurgical macular oedema including Irvine-Gass syndrome: the EPISODIC-2 study

AIM

To assess the effectiveness of intravitreal dexamethasone implants for treating postsurgical macular oedema (PSMO) including Irvine-Gass syndrome and determining the predictive factors of treatment response.

METHODS

Descriptive, observational, retrospective, consecutive, uncontrolled, multicentre, national case series. One hundred patients were included between April 2011 and June 2014, with a minimum of 1-year follow-up. Patients received dexamethasone implant 0.7 mg at baseline. Clinical characteristics, best-corrected visual acuity (BCVA), central subfield macular thickness (CSMT) and intraocular pressure were measured at each visit. The main outcome measure was the change in BCVA (Early Treatment of Diabetic Retinopathy Study (ETDRS) letters: L). An analysis of predictive factors of treatment response is also provided.

RESULTS

Mean improvement in BCVA was 9.6 (±10.6) L at month 6 and 10.3 (±10.7) L at month 12 (p<0.001). The proportion of eyes with gains in BCVA of 15 or more letters was 32.5% and 37.5% at months 6 and 12, respectively. The mean reduction in CSMT was 135.2 and 160.9 µm at months 6 and 12, respectively (p<0.001). Thirty-seven per cent of patients did not need a second injection after the first injection during follow-up. The presence of at least one PSMO risk factor decreases the probability of a gain in visual acuity (VA) ≥10 L (p=0.006). Initial VA ≤50 L at baseline and non-naïve status decrease the probability of having only one injection during follow-up (p=0.044).

CONCLUSIONS

The significant gain in BCVA from baseline achieved at month 6 was maintained at month 12 after intravitreal injection of dexamethasone implant. Naïve status seems to be a good predictive factor of treatment response.

The Association between Intravitreal Steroids and Post-Injection Endophthalmitis Rates

PURPOSE

To determine whether there is a difference in the risk of endophthalmitis after an intravitreal steroid injection compared with an anti-vascular endothelial growth factor (VEGF) agent injection.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A total of 75,249 beneficiaries in a large national US medical claims database representing 406 380 intravitreal injections.

METHODS

Data were searched for all intravitreal injections (Current Procedural Terminology 67028) performed between 2003 and 2012. Cohorts were created on the basis of injections using anti-VEGF agents (bevacizumab, ranibizumab, aflibercept, and pegaptanib) and intraocular steroids (triamcinolone and dexamethasone). Endophthalmitis was defined as having a new endophthalmitis diagnosis (International Classification of Diseases 9th Revision 360.0x) and a "tap-and-inject" procedure (Current Procedural Terminology 67015, 67025), a vitrectomy (67036), or an intravitreal antibiotic injection on the same day, between 1 and 14 days post-injection. Exclusion occurred for any history of endophthalmitis, <6 months in the plan, or <1 month follow-up. The main outcome measure was the odds of endophthalmitis using logistic regression while controlling for injection-associated diagnosis, age, race, and gender.

RESULTS

A total of 387,714 anti-VEGF injections and 18 666 steroid intravitreal injections were performed and followed by 73 (rate=0.019% or 1/5283 anti-VEGF injections) and 24 (rate=0.13% or 1/778 steroid injections) cases of endophthalmitis, respectively. After controlling for diagnosis, age, race, and gender, the odds ratio (OR) for endophthalmitis occurring was 6.92 (95% confidence interval, 3.54-13.52, P<0.001) times higher post-steroid injection compared with anti-VEGF injections.

CONCLUSIONS

The rate of endophthalmitis post-intravitreal steroid injection in a national cohort was 0.13% (1/778 injections). This rate conferred a significantly increased OR of 6.92 for endophthalmitis compared with anti-VEGF agents.