Corticosteroid Treatment in Diabetic Macular Edema

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

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.

Risk factor analysis and clinical decision tree model construction for diabetic retinopathy in Western China

BACKGROUND

Diabetic retinopathy (DR) is the driving force of blindness in patients with type 2 diabetes mellitus (T2DM). DR has a high prevalence and lacks effective therapeutic strategies, underscoring the need for early prevention and treatment. Yunnan province, located in the southwest plateau of China, has a high pre-valence of DR and an underdeveloped economy.

AIM

To build a clinical prediction model that will enable early prevention and treatment of DR.

METHODS

In this cross-sectional study, 1654 Han population with T2DM were divided into groups without (n = 826) and with DR (n = 828) based on fundus photography. The DR group was further subdivided into non-proliferative DR (n = 403) and proliferative DR (n = 425) groups. A univariate analysis and logistic regression analysis were conducted and a clinical decision tree model was constructed.

RESULTS

Diabetes duration ≥ 10 years, female sex, standing- or supine systolic blood pressure (SBP) ≥ 140 mmHg, and cholesterol ≥ 6.22 mmol/L were risk factors for DR in logistic regression analysis (odds ratio = 2.118, 1.520, 1.417, 1.881, and 1.591, respectively). A greater severity of chronic kidney disease (CKD) or hemoglobin A 1c increased the risk of DR in patients with T2DM. In the decision tree model, diabetes duration was the primary risk factor affecting the occurrence of DR in patients with T2DM, followed by CKD stage, supine SBP, standing SBP, and body mass index (BMI). DR classification outcomes were obtained by evaluating standing SBP or BMI according to the CKD stage for diabetes duration < 10 years and by evaluating CKD stage according to the supine SBP for diabetes duration ≥ 10 years.

CONCLUSION

Based on the simple and intuitive decision tree model constructed in this study, DR classification outcomes were easily obtained by evaluating diabetes duration, CKD stage, supine or standing SBP, and BMI.

The Correlation Between MicroRNAs and Diabetic Retinopathy

Micro ribonucleic acids (miRNAs), as a category of post-transcriptional gene inhibitors, have a wide range of biological functions, are involved in many pathological processes, and are attractive therapeutic targets. Considerable evidence in ophthalmology indicates that miRNAs play an important role in diabetic retinopathy (DR), especially in inflammation, oxidative stress, and neurodegeneration. Targeting specific miRNAs for the treatment of DR has attracted much attention. This is a review focusing on the pathophysiological roles of miRNAs in DR, diabetic macular edema, and proliferative DR complex multifactorial retinal diseases, with particular emphasis on how miRNAs regulate complex molecular pathways and underlying pathomechanisms. Moreover, the future development potential and application limitations of therapy that targets specific miRNAs for DR are discussed.

The Role of Intravitreal Corticosteroids in the Treatment of DME: Predictive OCT Biomarkers

This work aims to summarize predictive biomarkers to guide treatment choice in DME. Intravitreal anti-VEGF is considered the gold standard treatment for centers involving DME, while intravitreal steroid treatment has been established as a second-line treatment in DME. However, more than 1/3 of the patients do not adequately respond to anti-VEGF treatment despite up to 4-weekly injections. Not surprisingly, insufficient response to anti-VEGF therapy has been linked to low-normal VEGF levels in the serum and aqueous humor. These patients may well benefit from an early switch to intravitreal steroid treatment. In these patients, morphological biomarkers visible in OCT may predict treatment response and guide treatment decisions. Namely, the presence of a large amount of retinal and choroidal hyperreflective foci, disruption of the outer retinal layers and other signs of chronicity such as intraretinal cysts extending into the outer retina and a lower choroidal vascular index are all signs suggestive of a favorable treatment response of steroids compared to anti-VEGF. This paper summarizes predictive biomarkers in DME in order to assist individual treatment decisions in DME. These markers will help to identify DME patients who may benefit from primary dexamethasone treatment or an early switch.

Diabetic macular edema: Safe and effective treatment with intravitreal triamcinolone acetonide (Taioftal)

Purpose

To suggest the safety and efficacy of preservative-free triamcinolone acetonide intravitreal injectable suspension (Taioftal) for the treatment of diabetic macular edema.

Methods

A prospective clinical study involved 49 patients (49 eyes), that were treated with Taioftal and followed-up for six months. Complete ophthalmic examination, including spectral domain optical coherence tomography, was performed at baseline, and at month 1, 3, 6 after the intravitreal injection. Accurate collection and analysis of best-corrected visual acuity (BCVA), central foveal thickness (CFT), intraocular pressure (IOP), and adverse events (AEs) were carried out in order to evaluate visual function and macular morphology before and after treatment

Results

Median BCVA value chosen as comparing statistics was significantly improved at every follow-up time points (gain of 6 letters at month 1, 12 at month 3 –improvement up to 24% at month 3 with stabilization until month 6) compared to baseline, as certified by Kruskal-Wallis rank sum test (P<0.05). Median CFT significantly waned at each follow-up times (decrease of about 65 μm at month 1, 155 at month 3 –reduction up to 28% at month 3 keeping good outcome until month 6) compared to baseline (P<0.05). IOP elevation, with no severe increases, was the most common among spotted AEs (median of 23 mmHg at month 1, 20 at month 3).

Conclusion

Intravitreal injection of preservative-free triamcinolone (Taioftal) is an effective, safe and inexpensive drug used to improve visual acuity and reduce central foveal thickness in eyes affected by diabetic macular edema during an average time of 6 months. Temporary, never severe, elevation of IOP is totally manageable with topical medications. No serious vision-threatening complications are related to the use of intravitreal triamcinolone injections.

Safety of intravitreal triamcinolone and its impact on optic nerve morphology in patients treated for diabetic macular edema

PURPOSE

To assess the impact of one intravitreal injection (IVT) of Triamcinolone Acetonide (TA) on intraocular pressure (IOP) and optic nerve structural parameters in patients treated for Diabetic Macular Edema (DME).

METHODS

This retrospective study included patients with DME that were naïve to intraocular steroids and underwent one IVT of TA of 4 mg/0.1 mL and age-matched controls with DME without criteria for IVT. Patients records were reviewed for IOP (at baseline and a month after IVT) and optic nerve parameters measured by optical coherence tomography (up to 6 months before and 6 months after IVT). Exclusion criteria included glaucoma and treatment with hypotensive agents.

RESULTS

Twenty-six eyes were included in the Control Group and 29 in the IVT Group, with a mean age of 65.10 ± 10.08 and 67.30 ± 4.71 years, respectively (p = 0.06). At baseline, IOP and optic nerve measurements were equivalent between groups (p > 0.05). One month after IVT, mean IOP measurements in IVT Group were higher than those of controls (17.84 ± 4.50 vs 11.59 ± 3.09 mmHg, p < 0.001). Ocular hypertension (OHT) developed in 17.24% of cases and reversed with topical medication. After one IVT, vertical cup/disc ratio was higher (0.57 ± 0.25 vs 0.60 ± 0.14, p = 0.04) and retinal nerve fiber layer thickness was globally lower (mean: 91.03 ± 4.25 vs 81.33 ± 19.10 µm, p = 0.001) in the IVT Group.

CONCLUSION

Our results confirmed that intravitreal TA results in IOP increase. This seems to negatively affect optic nerve morphology, even in patients without OHT or adequately treated with hypotensive agents.

Targeting RGD-binding integrins as an integrative therapy for diabetic retinopathy and neovascular age-related macular degeneration

Integrins are a class of transmembrane receptors that are involved in a wide range of biological functions. Dysregulation of integrins has been implicated in many pathological processes and consequently, they are attractive therapeutic targets. In the ophthalmology arena, there is extensive evidence suggesting that integrins play an important role in diabetic retinopathy (DR), age-related macular degeneration (AMD), glaucoma, dry eye disease and retinal vein occlusion. For example, there is extensive evidence that arginyl-glycyl-aspartic acid (Arg-Gly-Asp; RGD)-binding integrins are involved in key disease hallmarks of DR and neovascular AMD (nvAMD), specifically inflammation, vascular leakage, angiogenesis and fibrosis. Based on such evidence, drugs that engage integrin-linked pathways have received attention for their potential to block all these vision-threatening pathways. This review focuses on the pathophysiological role that RGD-binding integrins can have in complex multifactorial retinal disorders like DR, diabetic macular edema (DME) and nvAMD, which are leading causes of blindness in developed countries. Special emphasis will be given on how RGD-binding integrins can modulate the intricate molecular pathways and regulate the underlying pathological mechanisms. For instance, the interplay between integrins and key molecular players such as growth factors, cytokines and enzymes will be summarized. In addition, recent clinical advances linked to targeting RGD-binding integrins in the context of DME and nvAMD will be discussed alongside future potential for limiting progression of these diseases.

Diabetic Macular Edema Management in Asian Population: Expert Panel Consensus Guidelines

PURPOSE

The aim of this consensus article was to provide comprehensive recommendations in the management of diabetic macular edema (DME) by reviewing recent clinical evidence.

DESIGN

A questionnaire containing 47 questions was developed which encompassed clinical scenarios such as treatment response to anti-vascular endothelial growth factor and steroid, treatment side effects, as well as cost and compliance/reimbursement in the management of DME using a Dephi questionnaire as guide.

METHODS

An expert panel of 12 retinal specialists from Singapore, Malaysia, Philippines, India and Vietnam responded to this questionnaire on two separate occasions. The first round responses were compiled, analyzed and discussed in a round table discussion where a consensus was sought through voting. Consensus was considered achieved, when 9 of the 12 panellists (75%) agreed on a recommendation.

RESULTS

The DME patients were initially profiled based on their response to treatment, and the terms target response, adequate response, nonresponse, and inadequate response were defined. The panellists arrived at a consensus on various aspects of DME treatment such as need for classification of patients before treatment, first-line treatment options, appropriate time to switch between treatment modalities, and steroid-related side effects based on which recommendations were derived, and a treatment algorithm was developed.

CONCLUSIONS

This consensus article provides comprehensive, evidence-based treatment guidelines in the management of DME in Asian population. In addition, it also provides recommendations on other aspects of DME management such as steroid treatment for stable glaucoma patients, management of intraocular pressure rise, and recommendations for cataract development.

Adherence of patients with diabetic macular oedema to intravitreal injections: A systematic review

The purpose of this study was to review adherence rates to intravitreal injections in the treatment of diabetic macula oedema and to identify factors associated with adherence. A systematic search of Embase, Medline, PsycINFO and CINAHL was conducted up to May 2020. Two authors independently screened, selected and appraised the studies. Seven articles on anti-VEGF treatment were found to meet the inclusion criteria. No studies were found on intravitreal corticosteroids or dexamethasone implants. Attendance rates varied between studies from 35% to 85%. The rate of missed or delayed attendance ranged from 14% to 51%, whereas 25% of patients were lost to follow-up at 12 months. Non-adherence was found to be multifactorial and included patient related reasons, demographic characteristics and clinical factors. Enablers to adherence included patient understanding of the disease and treatment. Further research in this area is warranted in order to better understand adherence in these patients and to improve patient outcomes.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Prognostic role of optical coherence tomography after switch to dexamethasone in diabetic macular edema

AIMS

To analyze the visual outcome after early switch to dexamethasone (DEX) in eyes with diabetic macular edema previously treated with ranibizumab (RNB), based on structural spectral-domain optical coherence tomography (SD-OCT) features.

METHODS

Retrospective study of data from 28 eyes which underwent a loading dose of three monthly RNB injections and were then shifted to DEX implant injection. SD-OCT analysis was performed before switch to DEX (week 12, 12W) according to the presence of integrity of ellipsoid zone (EZ) and external limiting membrane (ELM), disorganization of retinal inner layers (DRIL), and quantity of hyper-reflective spots (HRS). Best-corrected visual acuity (BCVA) changes at different time points after DEX (month 1, 1M; 4 months, 4M; and 12 months, 12M) were compared among groups.

RESULTS

Significantly better BCVA was achieved at 1M in eyes with intact EZ (84.2 ± 12.3 letters; p  =  0.04), with intact ELM (83.2 ± 11.5 letters; p < 0.01), and with fewer HRS (84.6 ± 12.5 letters; p = 0.03). However, the greatest percentage visual increase was achieved in eyes with disrupted EZ (+ 11.4%; p < 0.01), with disrupted ELM (+ 17.2%; p < 0.01), without DRIL (+ 12.5%; p < 0.01), and with more HRS (+ 14.3%; p = 0.04). After 12 months, a significant BCVA gain was observed only in eyes with intact retinal inner layers (+ 14.2%; p = 0.03).

CONCLUSIONS

Greater percentage BCVA improvement at 1M after switch to DEX was associated with EZ disruption, ELM disruption, intact retinal inner layers, and higher quantity of HRS. A switch to DEX therapy would be useful in patients with these SD-OCT features.

Effectiveness of Intravitreal Dexamethasone Implant Treatment for Diabetic Macular Edema in Vitrectomized Eyes

Objectives:

To report the effectiveness and long-term outcomes of intravitreal dexamethasone implantation for diabetic macular edema (DME) in vitrectomized eyes

Materials and Methods:

Medical records of patients were retrospectively reviewed. Time of pars plana vitrectomy (PPV), PPV indications, interval between DEX injection and PPV, other intravitreal treatment prior to DEX application, best corrected visual acuity (BCVA), intraocular pressure (IOP), and central retinal thickness (CRT) measured by optical coherence tomography were recorded.

Results:

Seventeen eyes of 17 patients were included in the study. The mean follow-up after DEX injection was 21±2.4 months (12-43 months). The female/male ratio was 11/6. Mean age was 60.7 years (46-70 years). Sixteen eyes (94.1%) were pseudophakic at the time of DEX treatment. The most common indication for PPV was tractional retinal detachment (8 eyes, 47.1%). Ten eyes (58.8%) received a single injection and a total of 30 DEX implantations were performed. Mean BCVA was 0.77 logarithm of the minimum angle of resolution (logMAR) units before the first injection and improved to 0.64, 0.68 and 0.66 logMAR after 1, 3 and 6 months, respectively (p<0.01). CRT decreased significantly from 452 µm at baseline to 310, 368±34 and 375 µm after 1, 3 and 6 months, respectively (p<0.04). Mean IOP was 16±1.2 mmHg at baseline and 18.2, 18.8 and 18.5 mmHg after 1, 3, and 6 months (p>0.05). Two eyes (%8) received topical anti-glaucoma medication (IOP≥25 mmHg). Similar results were observed in eyes receiving repeated DEX injections.

Conclusion:

Intravitreal DEX injection treatment seems to be effective for improving BCVA and decreasing CRT in vitrectomized eyes with DME. This effect seemed to last for 6 months in most eyes, but maximized at 3 months. Patients with repeated injections often require injection before 6 months.

Real-world retrospective comparison of 0.19 mg fluocinolone acetonide and 0.7 mg dexamethasone intravitreal implants for the treatment of diabetic macular edema in vitrectomized eyes

Purpose

The aim of this study was to evaluate the long-term real-world effectiveness of FAc and DEX implants in vitrectomized DME eyes in a real-world setting.

Methods

This was a non-interventional, retrospective, comparative study of 46 vitrectomized eyes in 33 patients with persistent or recurrent DME quantified best-corrected visual acuity (BCVA), central foveal thickness (CFT) and intraocular pressure (IOP) over up to 37 months.

Results

Both FAc and DEX treatment led to statistically and clinically significant improvements in BCVA and CFT. FAc >10-letter improvement on the Early Treatment Diabetic Retinopathy Study [ETDRS] chart over months 3–24 and a sustained ~200 µm CFT reduction over months 1–24; DEX: >5-letter improvement on the ETDRS chart at months 1 and 3 and >100 µm CFT reduction at month 1. FAc demonstrated sustained, stable and predictable effects on BCVA and CFT over 24 months and also improved BCVA and decreased CFT in a cohort of DME eyes that was refractory to DEX over 6 months.

Conclusion

This real-world study demonstrates long-term effectiveness of FAc in vitrectomized DME eyes and sustained effectiveness in DME eyes that did not respond to DEX therapy.

Vascular endothelial growth factors and placenta growth factor in retinal vasculopathies: Current research and future perspectives

Vision loss due to disease or degeneration of the eye (retina, choroid, retinal veins, or macula) is a leading cause of blindness worldwide. In most cases, vision-threatening ocular diseases are accompanied by abnormal changes in the vasculature of the eye, especially the retina, and these conditions are collectively referred to as retinal vasculopathies. Impaired blood supply or hypoxia stimulates angiogenesis in the vascular and non-vascular sections of the eye, which results in neovascularization, leading to conditions such as diabetic retinopathy or age-related macular degeneration. Studies show that vascular endothelial growth factors: VEGF-A, VEGF-B, and placental growth factor (PlGF) are elevated in these diseases, and hence, these factors could be used as markers for disease prognosis and therapy. In this review, we discuss the function of these growth factors in normal development and disease, with focus on ocular disorders and emphasize the importance of accurately determining their levels in the vitreous and serum of patients for correct diagnosis and therapy.