Étude rétrospective du traitement par Ozurdex® dans l’œdème maculaire diabétique : MOZART study

Long-acting ocular drug delivery technologies with clinical precedent

INTRODUCTION

Ocular long-acting injectables and implants (LAIIs) deliver drug at a controlled release rate over weeks to years. A reduced dose frequency eases the treatment burden on patients, minimizes the potential for treatment-related adverse effects, and improves treatment adherence and persistence.

AREAS COVERED

This review provides a comprehensive landscape of ocular LAII drug delivery technologies with clinical precedent, including eight commercial products and 27 clinical programs. Analysis of this landscape, and the specific technologies with the greatest precedent, provides instructive lessons for researchers interested in this space and insights into the direction of the field.

EXPERT OPINION

Further technological advancement is required to create biodegradable LAIIs with extended release durations and LAIIs that are compatible with a broader array of therapeutic modalities. In the future, ocular LAII innovations can be applied to diseases with limited treatment options, prophylactic treatment at earlier stages of disease, and cost-effective treatment of ocular diseases in global health settings.

The effect of pars plana vitrectomy with internal limiting membrane peeling on the durability of the intravitreal dexamethasone implant in the treatment of diabetic macular edema

Purpose

To evaluate the influence of pars plana vitrectomy with internal limiting membrane peeling on recurrence time of diabetic macular edema in eyes under treatment with dexamethasone intravitreal implant injections.

Material and methods

Twelve pseudophakic eyes of 12 patients with non-proliferative diabetic retinopathy and non-tractional diabetic macular edema were included. All eyes had already been treated with two or more dexamethasone intravitreal implant injections evidencing a recurrence time of three months or less (early recurrence). At baseline, they underwent pars plana vitrectomy with internal limiting membrane peeling, ending with dexamethasone intravitreal implant injection. Patients were then followed-up monthly, treated with a second injection at the first recurrence, and followed up to the second recurrence. Measurements of best corrected visual acuity, intraocular pressure, and central foveal thickness by spectral-domain optical coherence tomography were performed at each follow-up examination.

Results

Vitrectomized eyes showed a significant extension of recurrence time of diabetic macular edema, and specifically from 3.4 (3.2–3.7) to 6.5 (5.7–8.2) months after the first injection, and to 7.0 (5.7–8.2) months (p < 0.01) after the second injection (p < 0.01).

Conclusions and importance

Pars plana vitrectomy with internal limiting membrane peeling seems not to influence functional and anatomical results in eyes under treatment with dexamethasone intravitreal implant injections for diabetic macular edema, but appears to significantly extend the benefit of the drug.

CLINICAL FEATURES OF INTRAVITREAL DEXAMETHASONE IMPLANTATION IN VITRECTOMIZED EYES OF PATIENTS WITH DIABETIC MACULAR EDEMA

PURPOSE

To identify the clinical outcomes of intravitreal dexamethasone implantation (IVD) in previously vitrectomized eyes of patients with diabetic macular edema.

METHOD

We performed a retrospective observational study. We recorded central subfield thickness, best-corrected visual acuity, and intraocular pressure up to 12 months after IVD implant placement. We compared the duration of IVD action, intraocular pressure trends, and the prevalence of ocular hypertension after the first IVD treatment of nonvitrectomized and vitrectomized eyes. We also compared the central subfield thickness, best-corrected visual acuity, number of IVD treatments, and prevalence of ocular hypertension between the 2 groups after 12 months.

RESULTS

We found no significant between-group differences in the central subfield thickness, best-corrected visual acuity, or the prevalence of ocular hypertension during treatment. However, the duration of action of the first IVD treatment was significantly shorter in vitrectomized eyes, and these eyes required more IVD treatments during the 12-month follow-up period. The maximal average intraocular pressure was observed at 2 months after the first IVD treatment in the nonvitrectomized group, but 1 month after the first IVD treatment in the vitrectomized group.

CONCLUSION

These findings suggest that the IVD pharmacokinetics and pharmacodynamics differ between vitrectomized and nonvitrectomized eyes. Nevertheless, given the relatively long-lasting effectiveness of the treatment and the good clinical results, consecutive IVD treatments may be beneficial for patients with diabetic macular edema with previously vitrectomized eyes.

Place of intravitreal dexamethasone implant in the treatment armamentarium of diabetic macular edema

Diabetic macular edema (DME) is a very important and well-known cause of visual loss in diabetics. Blood–retina barrier disruption and consequent intraretinal fluid accumulation may lead to retinal thickening at the posterior pole namely DME. Even though it is not clearly understood, current evidence suggests that chronic low-grade inflammation characterized with various cytokines has a major role in the occurrence of DME. Clinical trials are continuously shaping our treatment approaches for the eyes with DME. Today, vascular endothelial growth factor (VEGF) inhibitor and steroid administrations are the main alternatives in DME treatment. Dexamethasone (DEX) implant (Ozurdex^®; Allergan, Inc., Irvine, CA, United States) was approved by the United States Food & Drug Administration in 2014 for DME treatment. The implant is made up of a biodegradable solid copolymer that is broken down by releasing its active ingredient into the vitreous cavity over time. Biphasic release feature of this sustained-release drug delivery system ensures its efficacy for up to 6 mo with an acceptable and manageable safety profile. DEX implant provides a favorable anatomical and functional outcome in DME as shown in several randomized-controlled studies but has a relatively higher ocular side-effect profile such as increased risk of cataract formation and raised intraocular pressure when compared to the gold standard anti-VEGF agents. Thus, DEX implant becomes the second-line treatment option demonstrating inadequate clinical response to anti-VEGF therapy. However, it can be preferred as the first-line treatment in vitrectomized and pseudophakic eyes. Even in some selected conditions DEX implant is favored over anti-VEGF agents where the use of VEGF-inhibitors is either inappropriate or contraindicated such as the patients with a recent history of a major cardiovascular or cerebrovascular event, pregnancy and noncompliant to frequent visits. This mini-review briefly overviews the efficacy, safety profile and complications of DEX implant and summarizes the outcome of DEX implant administration in major clinical studies on DME treatment.

Visual Acuity Gain Profiles and Anatomical Prognosis Factors in Patients with Drug-Naive Diabetic Macular Edema Treated with Dexamethasone Implant: The NAVEDEX Study

Brief Summary Statement

NAVEDEX (NAive diabetic macular Edema treated by DEXamethasone implant) study is a real-life multi-center study on drug-naive diabetic macular edema treated by Dexamethasone-implant. Two different visual acuity gain (VA) profiles were identified, based on baseline visual acuity (VA). Baseline disorganization of retinal inner layers or ellipsoid zone alterations (EZAs) negatively influence final VA but has no impact on VA gain.

Abstract

The purpose of this study is to evaluate the visual acuity (VA) gain profiles between patients with drug-naive diabetic macular edema (DME) treated by dexamethasone implant (DEX-implant) and assess the baseline anatomical and functional factors that could influence the response to the treatment in real-life conditions. A retrospective, multi-center observational study included 129 eyes with drug-naive DME treated by DEX-implant. The Median follow-up was 13 months. Two groups of VA gain trajectories were identified—Group A, with 71% (n = 96) of patients whose average VA gain was less than five letters and Group B, with 29% (n = 33) of patients with an average gain of 20 letters. The probability of belonging to Group B was significantly higher in patients with baseline VA < 37 letters (p = 0.001). Ellipsoid zone alterations (EZAs) or disorganization of retinal inner layers (DRILs) were associated with a lower final VA (53.0 letters versus 66.4, p = 0.002) but without a significant difference in VA gain (4.9 letters versus 6.8, p = 0.582). Despite a low baseline VA, this subgroup of patients tends to have greater visual gain, encouraging treatment with DEX-implant in such advanced-stage disease. However, some baseline anatomic parameters, such as the presence of EZAs or DRILs, negatively influenced final vision.

A Real-World Study of Dexamethasone Implant in Treatment-Naïve Patients with Diabetic Macular Edema: Efficacy and Correlation Between Inflammatory Biomarkers and Treatment Outcome

Purpose

There has been an increasing clinical interest in specific retinal parameters as non-invasive biomarkers of retinal inflammation in diabetic macular edema (DME) that have been shown to have prognostic value, such as hyperreflective retinal fields (HRFs) and subfoveal neuroretinal detachment (SND).

Methods

We conducted a prospective, non-comparative study of treatment-naïve patients with DME to evaluate the efficacy of a Pro Re Nata (PRN) regimen of intravitreal dexamethasone implant 0.7 mg (DexI, Ozurdex™). After administration, patients underwent subsequent injections according to PRN criteria in case of edema relapse, but not earlier than 4 months after the previous treatment. Patients were evaluated at baseline, within 15 days of injection, and every month thereafter. During all visits, best-corrected visual acuity (BCVA) was recorded; central retinal thickness (CRT), type of edema, presence of SND, and presence and number of HRFs were evaluated using swept-source optical coherence tomography (SS-OCT) 3D. Treatment outcome was defined as changes in BCVA, CRT, SND and HRFs at 12 (T12) and 24 (T24) months compared with baseline (T0).

Results

The study enrolled 24 eyes of 18 patients. The mean duration of follow-up was 18±6.6 months; for all eyes, T12 data were available, while follow-up reached T24 for 12 eyes. BCVA improved significantly and CRT decreased significantly during treatment; the edema was no longer detectable in 13/24 eyes at T12 and 8/12 eyes at T24. No patient presented SND at T12 and T24, and the mean number of HRFs decreased significantly during treatment. Results with CRT and HRFs correlated with BCVA at 12 and 24 months. No significant adverse events were observed.

Conclusion

In patients with DME, the intravitreal dexamethasone implant was effective and safe in improving both functional and tomographic parameters. This result is consistent with improvement in biomarkers of inflammation.

Risk factors for ocular hypertension after intravitreal dexamethasone implantation in diabetic macular edema

We designed a retrospective observational study to identify factors associated with ocular hypertension [OHTN, defined as intraocular pressure (IOP) > 25 mmHg] after intravitreal dexamethasone (IVD) implantation in diabetic macular edema (DME) patients. We measured IOP monthly after placement of an IVD implant, and identified the trend of IOP, incidence of OHTN, and its associated systemic or ocular factors. On average, IOP was highest at 2 months after IVD implantation. Of 84 DME patients who received an IVD implant, 3 (3.57%) presented with an IOP ≥ 25 mmHg at 1 month after implantation, 6 (7.14%) at 2 months, and 2 (2.38%) at 3 months. Compared with the non-OHTN group, the OHTN group had significantly shorter axial lengths and were younger. Logistic regression analysis revealed that axial length < 23.00 mm and age < 57 years were associated with OHTN occurrence. Patients whose IOP was elevated > 30% or ≥ 20 mmHg at 1 month post-implantation, subsequently developed OHTN with statistical significance. In conclusion, shorter axial length and younger age were associated with OHTN occurrence after IVD implantation. Additionally, identifying levels or trends in IOP at 1 month after the IVD procedure may be helpful in predicting subsequent OHTN occurrence.

Efficacy and safety of intravitreal dexamethasone implant in treatment naïve eyes with diabetic macular edema: Real world experience

PURPOSE

To evaluate the efficacy and safety of intravitreal dexamethasone implant in treatment naïve eyes with diabetic macular edema (DME).

METHODS

A retrospective analysis of treatment naïve eyes with DME which received intravitreal dexamethasone implant between January 2016 and March 2018 was done. Demographic details of the patients, ocular examination findings at baseline and on follow up visits were noted. Morphological features of DME and central macular thickness were noted on optical coherence tomography at each visit. The details regarding additional treatment for macular edema on follow up were noted.

RESULTS

Sixty five eyes were included in the study. The mean age was 59.14 ± 9.59 years. The follow up ranged from 6 to 48 months. Psuedophakic eyes showed visual improvement whereas the phakic eyes showed stable vision. The central foveal thickness showed significant reduction (p = 0.05) in all the eyes. The best corrected visual acuity at final follow up (+0.65 logMAR) was slightly less as compared to baseline (+0.62 logMAR). Retreatment was needed in 37% eyes and antiglaucoma medications in 8% eyes. Cataract progression was noted in 24 eyes (37%); 17 eyes (26.1%) underwent surgery. Notably, 27 eyes (41.5%) had some degree of macular ischemia at baseline. And five eyes (7.7%) showed progression of retinopathy leading to vitreous hemorrhage.

CONCLUSION

Dexamethasone implant is helpful in reducing the macular thickness and stabilizing the vision in treatment naïve DME; requiring less number of treatment sessions. However, it does not prevent progression of diabetic retinopathy. The visual improvement may be affected by cataract and macular ischemia.

Intravitreal bromfenac liposomal suspension (100 μg / 0.1 ml). A safety study in rabbit eyes

INTRODUCTION

There is a need to find alternative treatments for MEe. Bromfenac has shown promise in inhibiting the COX-2 enzymatic pathway that partially causes the inflammatory cascade which contributes to the precipitation of ME. However, like other NSAID's, its intraocular half-life is limited. We hypothesize that a delayed-release liposome formulation containing bromfenac might provide a similar anti-inflammatory effect as long-lasting steroid release systems without the well-known steroidal side-effects. We introduced a novel formulation with these characteristics into the vitreous cavity of rabbit eyes in order to evaluate its safety profile.

MATERIAL AND METHODS

10 left eyes of rabbits were injected with the liposome-encapsulated bromfenac suspension (100 μg/0.1 ml). Basal ERG's were recorded. Total follow-up time was 3 months, at which point ERG's were repeated and eyes were enucleated for histopathological study. Total amplitude and implicit times were recorded. A difference of 25% in either recording was considered significant. Significance was assessed using the paired-t test and Wilcoxon matched-pairs signed-rank test. A p-value of <0.05 was considered significant.

RESULTS

No significant changes were recorded in ERG measurements after 3 months when compared to basal measurements. Histopathological analysis of retinal specimens found no traces of liposome-induced toxicity.

CONCLUSION

The liposome-encapsulated bromfenac suspension (100 μg/0.1 ml) is not toxic and has been proven safe to use in an animal model. Therefore, this formulation shows promise as a possible future alternative treatment for ME and should be further studied to show its biological effect and efficacy.

[Dexamethasone intravitreal implant (Ozurdex) in patients with diabetic macular edema: Real life safety and efficacy]

PURPOSE

The goal of this study was to investigate the safety and efficacy of the intravitreal dexamethasone implant (DI) for patients with diabetic macular edema (DME) in real life.

METHODS

We conducted a monocentric retrospective analysis of the change in visual acuity and central macular thickness (CMT) after intravitreal injection of the DI at peak efficacy (2 months after injection) as well as the timing of reinjections and complications in patients with a loss of vision due to DME.

RESULTS

Forty eyes of 33 patients were included, with a mean follow-up of 12.6 months. Thirty percent of the eyes experienced an increase in best corrected visual acuity (BCVA)>15 letters at peak efficacy (P<0.05) after each ID injection. Treatment-naive patients had a sustained response after Ozurdex injection, with better visual acuity at 3 months (P=0.02) and 4 months (P=0.04) than non-naïve patients and better visual acuity at 6 months despite identical baseline visual acuity (P<0.05). Anatomical efficacy was good, with approximately 60% of patients with CMT<300 microns at peak efficacy after each injection of ID. Thirty percent of eyes demonstrated ocular hypertension (OHT)>25mmHg at peak efficacy, and 12.5% of eyes required cataract surgery during follow-up.

CONCLUSION

The DI has good functional and anatomic efficacy in these patients, with a good safety profile. Treatment-naïve patients with more recent DME had a more sustained increase in visual acuity after the injections and better visual recovery at 6 months. This encourages us to initiate DI therapy early if there is no response to anti-vascular endothelial growth factor (anti-VEGF) treatment.

Intravitreal dexamethasone implant Ozurdex in the treatment of diabetic macular edema in patients not previously treated with any intravitreal drug: a prospective 12-month follow-up study

Objective: To evaluate the mid-long-term efficacy and safety of the dexamethasone intravitreal (DEX) implant (Ozurdex¹) in naïve patients with diabetic macular edema (DME).Methods: Prospective and single-center study conducted on consecutive patients with a diagnosis of DME, who received a DEX implant and were followed up for at least 12 months. The main outcomes measurements were the mean change in best corrected visual acuity (BCVA) and in foveal thickness (FT) as compared to the baseline values.Results: Of the 84 screened patients 50 were included in the study. The BCVA significantly improved from 52.4 (20.4) letters at baseline to 62.6 (15.6), 61.2 (18.4), 61.6 (18.6), 60.6 (19.0), and 60.6 (18.8) at 2, 4, 6, 12 months and end of follow-up period, respectively (repeated measures ANOVA and the Greenhouse-Geisser correction; p = .0008). At the end of the follow-up period, a gain of BCVA of ≥5, ≥10, and ≥15 letters were observed in 26 (52.0%), 18 (36.0%), and 16 (32.0%) patients, respectively. The mean FT was significantly reduced from 446.0 (139.9) µm at baseline to 327.2 (103.6) at the end of follow-up (repeated measures ANOVA and the Greenhouse-Geisser correction; p = .0008). During the study follow-up, the patients receive a mean of 3.4 (2.9-3.9) implants. Of the 32 phakic eyes at baseline, 17 (53.1%) either developed new lens opacity or progression of an existing opacity.Conclusion: In eyes with DME not previously treated with intravitreal drugs, DEX implants provide meaningful functional and anatomical benefits, and these results are sustained mid-long-term.

A Collaborative Retrospective Study on the Efficacy and Safety of Intravitreal Dexamethasone Implant (Ozurdex) in Patients with Diabetic Macular Edema: The European DME Registry Study

PURPOSE

To evaluate the efficacy, effect profile, and safety of dexamethasone implant on diabetic macular edema (DME) in a real-life setting, further comparing results by DME duration, previous treatment status, and diabetic control.

DESIGN

A multicenter, retrospective cohort of 340 DME eyes of 287 patients from 25 clinical sites from 8 countries.

METHODS

Data were analyzed in 2 perspectives: per injection, in which all measurements were grouped and baseline was defined as the day of injection, and thus the pharmacodynamics of single injections could be assessed; and injection series, defined as 2 or more injections with 3 to 6 months between injections analyzing the outcome 3 to 6 months after the last injection.

MAIN OUTCOME MEASURES

Primary outcome was improvement of 15 or more letters in best-corrected visual acuity (BCVA) from baseline. Secondary outcomes included improvement of 10 letters or more in BCVA, change in central macular thickness (CMT), and time to maximum improvement and safety.

RESULTS

Overall, 762 injections were administered to 340 eyes of 287 patients. Injection series analysis included 171 series in 171 eyes of 150 patients, for a total of 444 injections, with a mean follow-up of 1.7±0.8 years. Of the 762 injections analyzed per injection, 22.7% achieved a 15-letter or more improvement, and 37.8% achieved a 10-letter or more improvement. Mean time to peak improvement was 81.9±39.7 days. Mean maximum change in CMT was -174±171 μm. Overall, 7.6% lost 15 or more letters. More eyes with early DME gained 10 or more letters and fewer eyes lost 10 or more letters compared with eyes with late DME (47.4% vs. 33.9% [P = 0.001] and 8.2% vs. 13.5% [P = 0.029], respectively). Patients with controlled diabetes showed greater CMT reduction (P = 0.0002). A higher percentage of treatment-naive patients gained 10 or 15 letter or more in BCVA (P = 0.001 and P = 0.006, respectively). Intraocular pressure elevation of more than 25 mmHg was found following 7.9% of injections; no endophthalmitis was reported.

CONCLUSIONS

Dexamethasone implant is an effective and safe treatment for DME. Peak improvement was achieved 3 months after injection and dissipated thereafter. Clinicians and providers may consider shortening treatment intervals.

Clinical Decision-Making when Treating Diabetic Macular Edema Patients with Dexamethasone Intravitreal Implants

Diabetes mellitus (DM) is a metabolic disease frequently associated with comorbidities that include diabetic macular edema (DME). The current medical approach to treating DME involves intravitreal injections with either anti-vascular endothelial growth factors or steroids. However, the burden associated with intravitreal injections and DM-derived complications is high, underlining the need to find optimal treatment regimens. In this article we describe the considerations we apply when treating DME patients with dexamethasone intravitreal implants (Ozurdex®), particularly those that influence the clinical decision-making process during the follow-up period. These considerations are based both on the available medical literature and on our clinical experience following the use of these implants in this type of patient, the goal being to optimize the number of injections and the clinical outcome of this therapy. We also provide a general overview of the pathophysiology of DME, highlighting the inflammatory component as a rationale to use steroids in these patients.

Intravitreal dexamethasone implants for diabetic macular edema

AIM

To evaluate the safety and efficacy of a dexamethasone (DEX) intravitreal implant for diabetic macular edema (DME).

METHODS

Totally 113 eyes of 84 patients were divided in three subgroups: naive patients (n=11), pseudophakic patients (n=72) and phakic patients (n=30). Inclusive criterion comprised adult diabetic patients with central fovea thickening and impaired visual acuity resulting from DME for whom previous standard treatments showed no improvement in both central macular thickness (CMT) and best corrected visual acuity (BCVA) after at least 3mo of treatment. Outcome data were obtained from patient visits at baseline and at months 1, 3, 5, 9 and 12 after the first DEX implant injection. At each of these visits, patients underwent measurement of BCVA, a complete eye examination and measurement of CMT and macular volume (MV) carried out with optical coherence tomography (OCT) images.

RESULTS

Seventy-three eyes (64.5%) received a single implant, 30 (26.5%) received two implants and 10 (9%) received three implants. At baseline, average in BCVA, CMT and MV were 43.5±20.8, 462.8±145 and 12.6±2.5 respectively. These values improved significantly at 1mo (BCVA: 47.2±19.5, CMT: 339.6±120, MV: 11.11±1.4) and 3mo (BCVA: 53.2±18.1, CMT: 353.8±141, MV: 11.3±1.3) (P≤0.05). At 5mo (BCVA: 50.9±19.8, CMT: 425±150, MV: 12.27±2.3), 9mo (BCVA: 48.4±17.6, CMT: 445.5±170, MV: 12.5±2.3) and 12mo (BCVA: 47.7±18.8, CMT: 413.2±149, MV: 12.03±2.5), improvements in the three parameters were no longer statistically significant and decreased progressively but did not reach baseline values. There were no clinical differences between subgroups. Ocular complications were minimal.

CONCLUSION

Patients with DEX implants show maximum efficacy at 3mo which then declined progressively, but is still better than baseline values at the end of follow-up.

The Pattern of Recurrence in Diabetic Macular Edema Treated by Dexamethasone Implant: The PREDIAMEX Study

PURPOSE

To assess the time to functional and anatomic recurrence of macular edema (ME) after a first intravitreal dexamethasone implant in eyes with diabetic macular edema (DME).

DESIGN

A 6-month observational, prospective, uncontrolled, multicenter, national case series.

PARTICIPANTS

Thirty-seven patients included between January 2015 and June 2016.

METHODS

Patients were monitored at baseline and then monthly over 6 months after the first treatment.

MAIN OUTCOME MEASURES

Different patterns of recurrence were defined: qualitative and quantitative anatomic recurrences and functional recurrence.

RESULTS

Median ME duration before the first dexamethasone implant was 2.04 months. All patients received a dexamethasone implant for the first time, but 73% of patients had not undergone any form of treatment previously. The mean time from baseline to qualitative anatomic, quantitative anatomic, and functional recurrence was 4.22 months (95% confidence interval [CI], 3.80-4.65 months), 4.73 months (95% CI, 4.34-5.12 months), and 4.89 months (95% CI, 4.53-5.26 months), respectively. Almost all patients (7/8) who demonstrated a qualitative anatomic recurrence showed a subsequent quantitative anatomic and functional recurrence days later. Mean improvement in best-corrected visual acuity was 10.1 letters (95% CI, 6.7-13.4 letters) and 7.3 letters (95% CI, 4.1-10.6 letters) at months 2 and 6, respectively. The mean reduction in central subfield macular thickness was 206 μm (95% CI, 157-255 μm) and 146 μm (95% CI, 98-195 μm) at months 2 and 6, respectively.

CONCLUSIONS

Dexamethasone implant is a functionally and anatomically effective treatment for DME in real-life practice. Qualitative anatomic recurrence seems to be an early sign of quantitative anatomic and functional recurrence. Further studies should demonstrate if early retreatment at the qualitative anatomic recurrence stage could better protect patient visual function.

Outcomes of Intravitreal Dexamethasone Implant in the Treatment of Recalcitrant Diabetic Macular Edema

Objectives:

To investigate the efficacy and safety of intravitreal dexamethasone (OZURDEX®) implantation in patients with recalcitrant diabetic macular edema.

Materials and Methods:

This is a retrospective non-randomized study of patients who underwent intravitreal dexamethasone implantation for recalcitrant diabetic macular edema. Main outcome measures included changes in best corrected visual acuity (BCVA), central macular thickness (CMT), and incidence of ocular side effects.

Results:

Fifty-seven eyes of thirty-eight patients (20 females, 18 males; mean age 65±7 years) were included in the study. The mean hemoglobin A1c level was 7.9±1.7%. Before entering the study, patients had undergone 5.71±3.40 anti-vascular endothelial growth factor (anti-VEGF) and 3.44±2.46 intravitreal triamcinolone acetonide injections. The mean duration of diabetes and diabetic macular edema was 17.2±6.4 years and 60.2±17.6 months, respectively. At baseline, mean CMT was 506.76±166.74 µm, and the mean BCVA was 0.68±0.38 LogMAR. Mean CMT significantly decreased to 341.36±146.26 µm (p<0.001), 324.41±114.58 µm (p<0.001), and 384.82±151 µm (p<0.001) at 1, 3, and 4 months of follow-up and increased again to 462.29±152.87 µm at 5 months. Sixteen eyes (28%) received second injections after mean of 7.4±2.3 months and mean CMT was again significantly decreased at 7, 8, and 9 months. Significant improvement in mean BCVA (0.54±0.41 LogMAR; p<0.001) occurred only at 1 month after implantation. However, subgroup analysis revealed significant BCVA improvement in the pseudophakic group at 1, 3, and 4 months. Among phakic patients, 50% showed cataract progression and 28% had elevated intraocular pressure increase which was managed medically.

Conclusion:

Intravitreal dexamethasone implantation was effective for the first 4 months in eyes with recalcitrant diabetic macular edema. However, it is hard to displace anti-VEGF agents as first-line therapy due to steroid-related complications.

Rapid response to dexamethasone intravitreal implant in diabetic macular edema

PURPOSE

To evaluate the early effects of dexamethasone (DEX) intravitreal implants in patients with diabetic macular edema (DME).

METHODS

This was a prospective, single-arm, interventional clinical series. Eighteen patients (18 eyes) with chronic/recalcitrant or naive DME were included. Patients underwent single DEX intravitreal implant. Clinical assessments, including ophthalmologic examination, central retinal thickness (CRT) measurement by spectral-domain optical coherence tomography (SD-OCT) scan, best-corrected visual acuity (BCVA), and intraocular pressure (IOP) were carried out at baseline, 1-3 hours, and then 3, 7, and 30 days after treatment. The main outcome was change in CRT on SD-OCT, while secondary outcome measures included visual acuity (VA) and changes in IOP following implant.

RESULTS

Mean CRT significantly decreased from 565 ± 171 µm at baseline to 310 ± 89 µm at end of follow-up (p<0.001), with reduction becoming evident 1-3 hours after injection. Mean BCVA also significantly improved 7 days and 30 days after treatment up to 0.14 logMAR (p<0.05). All patients had a controlled IOP after the injection with only 1/18 eyes having a transient increase in IOP during follow-up.

CONCLUSIONS

This is the first study showing very early effects of DEX implants on CRT reduction and VA improvement in DME.

Efficacy of the Intravitreal Sustained-Release Dexamethasone Implant for Diabetic Macular Edema Refractory to Anti-Vascular Endothelial Growth Factor Therapy: Meta-Analysis and Clinical Implications

BACKGROUND AND OBJECTIVE

To assess the effect on best-corrected visual acuity (BCVA) and efficacy of the intravitreal sustained-release 0.7 mg dexamethasone implant (Ozurdex; Allergan, Irvine, CA) in patients with recalcitrant diabetic macular edema (DME).

PATIENTS AND METHODS

Meta-analysis utilizing the MOOSE framework and a random effects model. Studies included adults undergoing treatment with Ozurdex for DME. The methodologic quality of each study was assessed using the MINORS and the Cochrane Collaboration Risk of Bias for randomized studies.

RESULTS

A total of 3,859 patients among 15 studies were included in the final analysis. The mean difference in BCVA was a gain of four lines or 20 Early Treatment of Diabetic Retinopathy Study letters with Ozurdex at a mean follow-up period of 6 months.

CONCLUSIONS

Treatment with Ozurdex is associated with significant mean improvement in visual acuity. Clinicians should have a multimodality approach to treating DME and be aware of this treatment option in those who have a suboptimal response to anti-VEGF therapy. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:160-166.].

Short-term Efficacy of Intravitreal Dexamethasone Implant in Vitrectomized Eyes with Recalcitrant Diabetic Macular Edema and Prior Anti-VEGF Therapy

Purpose:

To determine the efficacy of an intravitreal dexamethasone implant (IDI) for diabetic macular edema (DME) in vitrectomized eyes.

Methods:

This interventional retrospective consecutive case series included vitrectomized eyes undergoing IDI placement for treatment of recalcitrant DME between June 2011 and June 2014. All patients had previously received anti-VEGF therapy (ranibizumab or bevacizumab). Primary endpoints were changes in visual acuity (VA) and central retinal thickness (CRT) from baseline values one month after device implantation. Secondary endpoints were VA and CRT changes at 3 months.

Results:

A total of 8 eyes of 8 patients met the inclusion criteria. One month after IDI placement, there was a significant (p = 0.01) improvement in VA from 0.79 ± 0.52 logMAR (20/123 Snellen equivalent) to 0.64 ± 0.55 logMAR (20/88), meanwhile CRT improved from 455.75 ± 123.19 to 295.00 ± 90.39 μm (p = 0.02). These findings persisted at 3 months.

Conclusion:

In vitrectomized eyes previously treated with anti-VEGF agents for recalcitrant DME, implantation of the IDI appears to be efficacious in improving VA and CRT at 1-month with the observed benefits persisting for at least for 3 months.

Assessment of the Real-Life Usage of Intravitreal Dexamethasone Implant in the Treatment of Chronic Diabetic Macular Edema in France

PURPOSE

Intravitreal steroids, including dexamethasone implant (Ozurdex(®)), are effective for the treatment of diabetic macular edema (DME). However, the dosing regimen for Ozurdex in DME is unclear, and thus, this study was designed to evaluate the dosing regimen for dexamethasone in real-life clinical practice.

METHODS

Results are presented from 3 studies based on a questionnaire that was sent out by e-mail to physicians; the monitoring of drugs dispensing over time through pharmacies; and the French Social Security database for 2011 and 2012. Data are presented as the average number of dexamethasone treatments per year and the time interval between injections.

RESULTS

Study 1 involved 111 ophthalmologists and assessed DME prescriptions. The number of injections per year and the time interval between 2 successive injections were measured as 2.3 and 4.8 months, respectively. In study 2, the survey incorporated 570 prescriptions from retail pharmacies; the mean follow-up period was 13.7 months, and 2.3 injections were administered per year with a time interval between injections of 5.2 months. In study 3, relating to the reimbursements by social security, 114 patients were initially identified and, among these, 15 patients were treated with Ozurdex. Over the course of a 25-month follow-up period, an average of 2.5 Ozurdex implants were injected per year with 4.7 months between injections.

CONCLUSIONS

The average number of dexamethasone implant injections was consistent between studies with an average of 2.4 injections per year and 4.9 months between treatments. This highlights the need for a study to evaluate the optimal treatment frequency in DME.

Perspective on the role of Ozurdex (dexamethasone intravitreal implant) in the management of diabetic macular oedema

Diabetic macular oedema (DMO) is the most common cause of visual loss in the working age population. Intravitreal therapy has superseded macular laser as the first-line treatment for the management of centre-involving DMO in most patients. As well as the proven efficacy of intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents, phase II and III clinical trials of Ozurdex intravitreal dexamethasone implants for DMO have also demonstrated a mean increase in visual acuity and corresponding mean reduction in central macular thickness, particularly in pseudophakic eyes. Because of the risk of visual loss from cataract, glaucoma and intraocular infection with the use of intravitreal steroids, Ozurdex tends to be reserved for use in patients unresponsive to anti-VEGF therapy for centre-involving DMO. Situations where Ozurdex may be considered a first-line treatment option for eyes with centre-involving DMO include pseudophakia, impending cataract surgery, or in the context of a recent arterial thromboembolic event. Because of their stable pharmacokinetics, Ozurdex slow-release implants may also be considered in vitrectomized eyes.

Dexamethasone Implants in Patients with Naïve or Refractory Diffuse Diabetic Macular Edema

PURPOSE

To assess the effect of dexamethasone (DEX) 0.7 mg (Ozurdex™) on refractory and treatment-naïve diffuse diabetic macular edema.

METHODS

A prospective study was conducted in 76 patients (40 refractory and 36 naïve) with visual acuities (VA) of 15-72 ETDRS letters, central macular thickness (CMT) >300 µm and intraocular pressure (IOP) <25 mm Hg. After the DEX implant (±photocoagulation), VA, CMT and total macular volume (TMV) were assessed monthly for 6 months.

RESULTS

At every visit, VA improved significantly from baseline (p < 0.001) in both groups, but values were significantly better in the naïve group, while CMT and TMV decreased significantly (p < 0.001) and similarly in both groups. The naïve group received more photocoagulations (p = 0.001). There were 7.9% transient IOP increases >10 mm Hg.

CONCLUSIONS

Substantial improvements in VA and CMT were achieved in both groups, and a gain of 1 ETDRS line was observed in the treatment-naïve group as compared to the refractory group, with a good safety profile in both.

[Efficacy of intravitreal dexamethasone implants in macular edema excluding venous occlusions: results for a cohort of 80 patients]

INTRODUCTION

The intravitreal dexamethasone implant has shown efficacy in the treatment of macular edema (ME) arising after retinal venous occlusions (central or branch), and in the treatment of non-infectious uveitis. The purpose of this study was to evaluate the efficacy of this implant in the treatment of other diffuse macular edemas with an inflammatory mechanism.

MATERIALS AND METHODS

We carried out a retrospective cohort study over 2 years: from January 2012 to December 2013, including all patients who received at least one injection of intravitreal dexamethasone implant, excluding venous occlusions and non-infectious uveitis. The primary study parameter was the progression of visual acuity. The study protocol had the approval of the institutional review board of the respective clinical ethics committees, and was conducted in accordance to the tenets of the Declaration of Helsinki.

RESULTS

Eighty patients were included. Eighty-eight percent of patients were pseudophakic. The indications for treatment were: diabetic ME when anti-VEGF were ineffective (53%), ME after retinal detachment (RD) (22%), ME of Irvine-Gass syndrome (16%), ME after endophthalmitis (4%), macular telangiectasia (4%), ME secondary to retinitis pigmentosa (1%). The mean ETDRS visual acuity was 53.7 letters prior to injection, improving to 62.3 letters after injection (P<0.001). The average gain in visual acuity was 6.7 letters [4.53;8.84] (P<0.001) in patients treated for diabetic ME, 9.6 letters [6.1;13.1] (P<0.001) in patients with ME after RD, and 15.2 letters [10.25;20.28] (P<0.001) for Irvine-Gass syndrome. The mean duration of efficiency was 4.6 months, with a median of 3.8 months.

CONCLUSION

The intravitreal dexamethasone implant appears to be an effective second-line treatment even in patients with diabetic ME after failure or in the case of contraindication of anti-VEGF. It is also effective and well tolerated in patients with ME after RD, as well as in patients with Irvine-Gass syndrome.

Laser-based strategies to treat diabetic macular edema: history and new promising therapies

Diabetic macular edema (DME) is the main cause of visual impairment in diabetic patients. The management of DME is complex and often various treatment approaches are needed. At the present time, despite the enthusiasm for evaluating several new treatments for DME, including the intravitreal pharmacologic therapies (e.g., corticosteroids and anti-VEGF drugs), laser photocoagulation still remains the current standard in DME. The purpose of this review is to update our knowledge on laser photocoagulation for DME and describe the developments in laser systems. And we will also discuss the new laser techniques and review the latest results including benefits of combined therapy. In this paper, we briefly summarize the major laser therapeutics for the treatment of diabetic macular edema and allude to some future promising laser therapies.

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.