The Role of Steroids in the Management of Uveitic Macular Edema

Bromfenac 0.09% for the Treatment of Macular Edema Secondary to Noninfectious Uveitis

PURPOSE

The topical nonsteroidal anti-inflammatory drug bromfenac 0.09% has a potential benefit in uveitic macular edema (UME) with a safe side effect profile. The aim of the study is to assess the efficacy of bromfenac sodium solution in the treatment of UME.

METHODS

The charts of 10 patients with macular edema due to noninfectious uveitis treated with bromfenac 0.09% were reviewed retrospectively. The main outcomes studied were the best-corrected visual acuity (BCVA) and the central retinal thickness (CRT) compared 4 months before bromfenac initiation, at the time of its initiation, and 4 months later.

RESULTS

Twelve eyes of 10 patients were included. BCVA and CRT were unchanged 4 months befoew bromfenac compared to the time of bromfenac initiation (P = 1.0 and P = 0.2, respectively). There were a significant improvement in BCVA after 4 months of bromfenac treatment (P = 0.043) and a significant decrease in CRT (P = 0.002). Subretinal fluid resolved completely in 8/9 eyes, and 4/9 eyes had a complete resolution of cystoid macular edema at 4 months.

CONCLUSION

Bromfenac may be a useful addition to the treatment of UME.

Anti-tumour necrosis factor biological therapies for the treatment of uveitic macular oedema (UMO) for non-infectious uveitis

BACKGROUND

Non-infectious uveitis describes a heterogenous group of ocular disorders characterised by intraocular inflammation in the absence of infection. Uveitis is a leading cause of visual loss, most commonly due to uveitic macular oedema (UMO). Treatment is aimed at reducing disease activity by suppression of the intraocular inflammatory response. In the case of macular oedema, the aim is to restore macular architecture as quickly as possible, in order to prevent irreversible photoreceptor damage in this area. Acute exacerbations are typically managed with corticosteroids, which may be administered topically, locally or systemically. Whilst these are often rapidly effective in achieving disease control, long-term use is associated with significant local and systemic side effects, and 'steroid sparing agents' are typically used to achieve prolonged control in severe or recalcitrant disease. Anti-tumour necrosis factor (TNF) drugs block a critical cytokine in the inflammatory signalling process, and have emerged as effective steroid-sparing immunomodulatory agents in a wide range of non-ocular conditions. There is mechanistic data to suggest that they may provide a more targeted approach to disease control in UMO than other agents, but to date, these agents have predominantly been used 'off label' as the majority are not licensed for ocular use. This review aims to summarise the available literature reporting the use of anti-TNF therapy in UMO, thus developing the evidence-base on which to make future treatment decisions and develop clinical guidelines in this area.

OBJECTIVES

To assess the efficacy of anti-TNF therapy in treatment of UMO.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 2), which contains the Cochrane Eyes and Vision Trials Register; Ovid MEDLINE; Ovid Embase; LILACS; Web of Science Conference Proceedings Citation Index- Science (CPCI-S); System for Information on Grey Literature in Europe (OpenGrey); the ISRCTN registry; ClinicalTrials.gov and the WHO ICTRP. The date of the search was 29 March 2018.

SELECTION CRITERIA

We planned to include all relevant randomised controlled trials assessing the use of anti-TNF agents in treatment of UMO. No limits were applied to participant age, gender or ethnicity. The primary comparisons of this review were: anti-TNF versus no treatment or placebo; anti-TNF versus another pharmacological agent; comparison of different anti-TNF drugs; comparison of different doses and routes of administration of the same anti-TNF drug. The primary outcome measure that we assessed for this review was best-corrected visual acuity (BCVA) in the treated eye. Secondary outcome measures were anatomical macular change, clinical estimation of vitreous haze and health-related quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts retrieved through the database searches. We retrieved full-text reports of studies categorised as 'unsure' or 'include' after we had reviewed the abstracts. Two review authors independently reviewed each full-text report for eligibility. We resolved discrepancies through discussion.

MAIN RESULTS

We identified no completed or ongoing trial that was eligible for this Cochrane Review.

AUTHORS' CONCLUSIONS

Our review did not identify any evidence from randomised controlled trials for or against the role of anti-TNF agents in the management of UMO. Although there are a number of high-quality randomised controlled trials that demonstrate the efficacy of anti-TNF agents in preventing recurrence of inflammation in uveitis, the reported study outcomes do not include changes in UMO. As a result, there were insufficient data to conclude whether there was a significant treatment effect specifically for UMO. Future trials should be designed to include quantitative measures of UMO as primary study outcomes, for example by reporting the presence or absence of UMO, or by measuring central macular thickness for study participants. Furthermore, whilst UMO is an important complication of uveitis, we acknowledge that uveitis is associated with many significant structural and functional complications. It is not possible to determine treatment efficacy based on a single outcome measure. We recommend that future reviews of therapeutic interventions in uveitis should use composite measures of treatment response comprising a range of potential complications of disease.

Results of intravitreal dexamethasone implant 0.7 mg (Ozurdex®) in non-infectious posterior uveitis

AIM

To evaluate the safety and efficacy of dexamethasone implant in patients with non-infectious posterior uveitis with cystoid macular edema (CME).

METHODS

Retrospective analysis of patients reports with CME secondary to non-infectious uveitis treated with dexamethasone implant. Data included type of posterior uveitis, any systemic immunosuppressive therapy, Early Treatment Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity (BCVA), central macular thickness (CMT) on optical coherence tomography (OCT) and signs of intraocular inflammation at baseline and then at 2wk postoperatively and monthly thereafter. Follow-up is up to 10mo. Any per-operative and post-operative complications were recorded.

RESULTS

Six eyes of 4 patients with CME due to non-infectious posterior uveitis treated with dexamethasone implant. Diagnosis included idiopathic panuveitis, birdshot chorioretinopathy and idiopathic intermediate uveitis. At baseline mean ETDRS BCVA was 63 letters and mean CMT 556 µm at 2wk postoperatively mean ETDRS BCVA improved to 70 letters and mean CMT decreased to 329 µm. All eyes showed clinical evidence of decreased inflammation. The duration of effect of the implant was 5 to 6mo and retreatment was required in 2 eyes. Two patients required antiglaucoma therapy for increased intraocular pressures.

CONCLUSION

In patients with non-infectious posterior uveitis dexamethasone implant can be a short-term effective treatment option for controlling intraocular inflammation.

Effect of interferon α2a in cystoid macular edema due to intraocular infection

PURPOSE

Cystoid macular edema (CME) is a severe complication and a major cause of visual loss in patients with intraocular infection. In this type of CME, therapeutic strategies remain controversial. We aimed to investigate the efficacy and tolerability of interferon (IFN)-α2a in cystoid macular edema caused by intraocular infection.

METHODS

In this retrospective, noncomparative, interventional case series, 5 patients (6 eyes) who were diagnosed with intraocular infection with chronic CME were included. Interferon-α2a (3 million units 3 times a week) was administered subcutaneously. Clinical observations were recorded before and after treatment.

RESULTS

The average duration of CME before treatment with IFN-α was 26 months. According to the preset criteria, IFN-α2a therapy was shown to be effective in 2 patients (3 eyes), effective dose-dependent in 2 patients, and partly effective in 1 patient, and was well-tolerated in 4 patients. The most common side effect was flu-like symptoms.

CONCLUSIONS

Interferon α-2a may be an effective alternative treatment for CME due to intraocular infection that is resistant to other treatment. Studies with larger sample sizes are required to confirm this conclusion.

Effectiveness of the Dexamethasone Intravitreal Implant for Treatment of Patients with Diabetic Macular Oedema

Diabetic macular oedema (DMO) is a leading cause of vision loss in the working-age population worldwide. Corticosteroid drugs have been demonstrated to inhibit the expression of both the vascular endothelial growth factor (VEGF) gene and other anti-inflammatory mediators, such as prostaglandins. Triamcinolone, fluocinolone and dexamethasone are the main steroids that have been studied for the treatment of macular oedema. Over the last few years, several studies have suggested an important role for dexamethasone in the management of DMO. The dexamethasone intravitreal implant (DEX implant) (Ozurdex®; Allergan, Inc., Irvine, CA) is a novel approach approved by the US Food and Drug Administration (FDA) and by the EU for the intravitreal treatment of macular oedema after branch or central retinal vein occlusion, and for the treatment of non-infectious uveitis affecting the posterior segment of the eye. We reviewed manuscripts that had investigated the pharmacokinetics, efficacy and safety of the DEX implant regarding DMO treatment.