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Pimple P, Sawant A, Nair S, Sawarkar SP. Current Insights into Targeting Strategies for the Effective Therapy of Diseases of the Posterior Eye Segment. Crit Rev Ther Drug Carrier Syst 2024; 41:1-50. [PMID: 37938189 DOI: 10.1615/critrevtherdrugcarriersyst.2023044057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
The eye is one a unique sophisticated human sense organ with a complex anatomical structure. It is encased by variety of protective barriers as responsible for vision. There has been a paradigm shift in the prevalence of several major vision threatening ocular conditions with enhanced reliance on computer-based technologies in our workaday life and work-from-home modalities although aging, pollution, injury, harmful chemicals, lifestyle changes will always remain the root cause. Treating posterior eye diseases is a challenge faced by clinicians worldwide. The clinical use of conventional drug delivery systems for posterior eye targeting is restricted by the ocular barriers. Indeed, for overcoming various ocular barriers for efficient delivery of the therapeutic moiety and prolonged therapeutic effect requires prudent and target-specific approaches. Therefore, for efficient drug delivery to the posterior ocular segment, advancements in the development of sustained release and nanotechnology-based ocular drug delivery systems have gained immense importance. Therapeutic efficacy and patient compliance are of paramount importance in clinical translation of these investigative drug delivery systems. This review provides an insight into the various strategies employed for improving the treatment efficacies of the posterior eye diseases. Various drug delivery systems such as systemic and intraocular injections, implants have demonstrated promising outcomes, along with that they have also exhibited side-effects, limitations and strategies employed to overcome them are discussed in this review. The application of artificial intelligence-based technologies along with an appreciation of disease, delivery systems, and patient-specific outcomes will likely enable more effective therapy for targeting the posterior eye segment.
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Affiliation(s)
- Prachi Pimple
- Department of Pharmaceutics, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, University of Mumbai, V.L. Mehta Road, Vile Parle (West), Mumbai 400 056, India
| | - Apurva Sawant
- Department of Pharmaceutics, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, University of Mumbai, V.L. Mehta Road, Vile Parle (West), Mumbai 400 056, India
| | - Sujit Nair
- Department of Pharmaceutics, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, University of Mumbai, V.L. Mehta Road, Vile Parle (West), Mumbai 400 056, India
| | - Sujata P Sawarkar
- Department of Pharmaceutics, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, University of Mumbai, V.L. Mehta Road, Vile Parle (West), Mumbai 400 056, India
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Buhl L, Schmelter V, Schworm B, Thurau S, Kern C. Long-Term Results of 0.19mg Fluocinolone Acetonide Insert for Treatment of Non-Infectious Uveitis in Clinical Practice. Ocul Immunol Inflamm 2023:1-5. [PMID: 37656834 DOI: 10.1080/09273948.2023.2250431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/16/2023] [Accepted: 08/16/2023] [Indexed: 09/03/2023]
Abstract
PURPOSE To evaluate the long-term outcomes of patients with non-infectious uveitis treated with 0.19 mg fluocinolone acetonide insert (FAi) for up to 36 months in clinical practice. METHODS A retrospective study conducted at a single uveitis center. RESULTS Fifty eyes of 39 patients were included. Mean best corrected visual acuity (BCVA) and central retinal thickness (CRT) remained stable until month 36 after FAi implantation (61.04 vs. 70.25 letters and 370.8 vs. 332.5 µm, respectively). The recurrence rate was 34% (17 eyes) after 36 months, of which 82% (14 eyes) received high-dose corticosteroids before FAi. Mean intraocular pressure (IOP) remained unchanged (13.38 vs. 15.74 mmHg), while most phakic eyes (13 of 14 eyes) required cataract surgery. CONCLUSIONS We show that FAi effectively prevents recurrences of non-infectious uveitis for up to three years in clinical practice, comparable with randomized clinical trials. Patients who received high-dose corticosteroids before FAi have an increased risk for early recurrence and should be considered for scheduled re-treatment.
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Affiliation(s)
- Lara Buhl
- Department of Ophthalmology, University Hospital, LMU Munich, Munich, Germany
| | - Valerie Schmelter
- Department of Ophthalmology, University Hospital, LMU Munich, Munich, Germany
| | - Benedikt Schworm
- Department of Ophthalmology, University Hospital, LMU Munich, Munich, Germany
| | - Stephan Thurau
- Department of Ophthalmology, University Hospital, LMU Munich, Munich, Germany
| | - Christoph Kern
- Department of Ophthalmology, University Hospital, LMU Munich, Munich, Germany
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3
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Reddy A, Liu SH, Brady CJ, Sieving PC, Palestine AG. Corticosteroid implants for chronic non-infectious uveitis. Cochrane Database Syst Rev 2023; 8:CD010469. [PMID: 37642198 PMCID: PMC10464657 DOI: 10.1002/14651858.cd010469.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND Uveitis is a term used to describe a group of intraocular inflammatory diseases. Uveitis is the fifth most common cause of vision loss in high-income countries, with the highest incidence of disease in the working-age population. Corticosteroids are the mainstay of treatment for all subtypes of non-infectious uveitis. They can be administered orally, topically with drops, by periocular (around the eye) or intravitreal (inside the eye) injection, or by surgical implantation. OBJECTIVES To determine the efficacy and safety of steroid implants in people with chronic non-infectious posterior uveitis, intermediate uveitis, and panuveitis. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register), MEDLINE Ovid, Embase, PubMed, LILACS, and three trials registries to November 2021. SELECTION CRITERIA We included randomized controlled trials comparing either fluocinolone acetonide (FA) or dexamethasone (DEX) intravitreal implants with standard-of-care therapy or sham procedures, with at least six months of follow-up after treatment. We included studies that enrolled participants of all ages, who had chronic non-infectious posterior uveitis, intermediate uveitis, or panuveitis with vision that was better than hand-motion. DATA COLLECTION AND ANALYSIS We applied standard Cochrane methodology. MAIN RESULTS We included data from four trials (683 participants, 907 eyes) that compared corticosteroid implants with either sham or standard-of-care therapy. Study characteristics and risk of bias Of the two trials that compared corticosteroid implants with sham procedure, one examined a 0.18 mg FA implant, and the other, a 0.7 mg DEX implant. The other two trials compared a 0.59 mg FA implant with standard-of-care therapy, which included systemic corticosteroids and immunosuppressive medications, if needed. Considering improvement in visual acuity, we assessed the four trials to be at either low risk, or with some concerns of risk of bias across all domains. Findings Using sham procedure as control, combined results at the six-month primary time point suggested that corticosteroid implants may decrease the risk of uveitis recurrence by 60% (relative risk [RR] 0.40, 95% confidence interval [CI] 0.30 to 0.54; 2 trials, 282 participants; low-certainty evidence); and lead to a greater improvement in best-corrected visual acuity (BCVA; mean difference [MD] 0.15 logMAR, 95% CI 0.06 to 0.24; 1 trial, 153 participants; low-certainty evidence). Evidence based on a single-study report (146 participants) suggested that steroid implants may have no effects on visual functioning quality of life, measured on the National Eye Institute 25-Item Visual Function Questionnaire (MD 2.85, 95%CI -3.64 to 9.34; 1 trial, 146 participants; moderate-certainty evidence). Using standard-of care therapy as control, combined estimates at the 24-month primary time point suggested that corticosteroid implants were likely to decrease the risk of recurrence of uveitis by 54% (RR 0.46, 95% CI 0.35 to 0.60; 2 trials, 619 eyes). Combined estimates at 24 months also suggested that steroid implants may have little to no effects on improving BCVA (MD 0.05 logMAR, 95% CI -0.02 to 0.12; 2 trials, 619 eyes; low-certainty evidence). Evidence based on a single-study report (232 participants) suggested that steroid implants may have minimal clinical effects on visual functioning (MD 4.64, 95% CI 0.13 to 9.15; 1 trial, 232 participants; moderate-certainty evidence); physical functioning (SF-36 physical subscale MD 2.95, 95% CI 0.55 to 5.35; 1 trial, 232 participants; moderate-certainty evidence); or mental health (SF-36 mental subscale MD 3.65, 95% CI 0.52 to 6.78; 1 trial, 232 participants; moderate-certainty evidence); but not on EuroQoL (MD 6.17, 95% CI 1.87 to 10.47; 1 trial, 232 participants; moderate-certainty evidence); or EuroQoL-5D scale (MD 0.02, 95% CI -0.04 to 0.08; 1 trial, 232 participants; moderate-certainty evidence). Adverse effects Compared with sham procedures, corticosteroid implants may slightly increase the risk of cataract formation (RR 2.69, 95% CI 1.17 to 6.18; 1 trial, 90 eyes; low-certainty evidence), but not the risk of cataract progression (RR 2.00, 95% CI 0.65 to 6.12; 1 trial, 117 eyes; low-certainty evidence); or the need for surgery (RR 2.98, 95% CI 0.82 to 10.81; 1 trial, 180 eyes; low-certainty evidence), during up to 12 months of follow-up. These implants may increase the risk of elevated intraocular pressure ([IOP] RR 2.81, 95% CI 1.42 to 5.56; 2 trials, 282 participants; moderate-certainty evidence); and the need for IOP-lowering eyedrops (RR 1.85, 95% CI 1.05 to 3.25; 2 trials, 282 participants; moderate-certainty evidence); but not the need for IOP-lowering surgery (RR 0.72, 95% CI 0.13 to 4.17; 2 trials, 282 participants; moderate-certainty evidence). Evidence comparing the 0.59 mg FA implant with standard-of-care suggested that the implant may increase the risk of cataract progression (RR 2.71, 95% CI 2.06 to 3.56; 2 trials, 210 eyes; low-certainty evidence); and the need for surgery (RR 2.98, 95% CI 2.33 to 3.79; 2 trials, 371 eyes; low-certainty evidence); along with the risk of elevated IOP (RR 3.64, 95% CI 2.71 to 4.87; 2 trials, 605 eyes; moderate-certainty evidence); and the need for medical (RR 3.04, 95% CI 2.36 to 3.91; 2 trials, 544 eyes; moderate-certainty evidence); or surgical interventions (RR 5.43, 95% CI 3.12 to 9.45; 2 trials, 599 eyes; moderate-certainty evidence). In either comparison, these implants did not increase the risk for endophthalmitis, retinal tear, or retinal detachment (moderate-certainty evidence). AUTHORS' CONCLUSIONS Our confidence is limited that local corticosteroid implants are superior to sham therapy or standard-of-care therapy in reducing the risk of uveitis recurrence. We demonstrated different effectiveness on BCVA relative to comparators in people with non-infectious uveitis. Nevertheless, the evidence suggests that these implants may increase the risk of cataract progression and IOP elevation, which will require interventions over time. To better understand the efficacy and safety profiles of corticosteroid implants, we need future trials that examine implants of different doses, used for different durations. The trials should measure core standard outcomes that are universally defined, and measured at comparable follow-up time points.
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Affiliation(s)
- Amit Reddy
- Department of Ophthalmology, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
| | - Su-Hsun Liu
- Department of Ophthalmology, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, School of Public Health, Aurora, Colorado, USA
| | - Christopher J Brady
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Surgery, Division of Ophthalmology, University of Vermont, Burlington, Vermont, USA
| | - Pamela C Sieving
- Special Volunteer, National Eye Institute, Sacramento, California, USA
| | - Alan G Palestine
- Department of Ophthalmology, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
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Menia NK, Mohan S, Agarwal A. Intravitreal immunotherapy in non-infectious uveitis: an update. Expert Rev Clin Pharmacol 2023; 16:959-976. [PMID: 37674332 DOI: 10.1080/17512433.2023.2256660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/24/2023] [Accepted: 09/05/2023] [Indexed: 09/08/2023]
Abstract
INTRODUCTION In the past several years, there have been numerous advances in pharmacotherapeutics for the management of uveitis and other ocular inflammatory diseases, including newer therapeutic agents and ocular drug delivery systems. One of the most attractive modes of drug delivery is the intravitreal route since it has proven to be safe and efficacious and prevents unwanted systemic adverse events related to the agent. AREAS COVERED In this review, intravitreal delivery of various pharmacotherapeutic agents for noninfectious uveitis has been described. An extensive review of the literature was performed using specific keywords on the PubMed database to identify clinical studies employing various pharmacotherapeutic agents with intravitreal drug delivery for noninfectious uveitis. The mode of action, safety, efficacy, and tolerability of these drugs have also been elucidated. EXPERT OPINION Several agents, including biologic response modifier agents, have been found to be safe and efficacious for various indications of uveitis, such as cystoid macular edema, active uveitis, and other conditions such as retinal vasculitis and vitreous haze. The use of intravitreal biological therapies, especially infliximab, has been fraught with potential safety signals such as photoreceptor toxicity. However, pharmacotherapeutic agents such as corticosteroids and anti-vascular endothelial growth factor agents are now widely used in the clinical management of uveitis and its complications.
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Affiliation(s)
- Nitin Kumar Menia
- Department of Ophthalmology, All India Institute of Medical Sciences (AIIMS), Jammu, India
| | - Sashwanthi Mohan
- Department of Ophthalmology, Medcare Eye Center, Dubai, United Arab Emirates
| | - Aniruddha Agarwal
- Eye Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
- Department of Ophthalmology, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
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Rafael D, Guerrero M, Marican A, Arango D, Sarmento B, Ferrer R, Durán-Lara EF, Clark SJ, Schwartz S. Delivery Systems in Ocular Retinopathies: The Promising Future of Intravitreal Hydrogels as Sustained-Release Scaffolds. Pharmaceutics 2023; 15:pharmaceutics15051484. [PMID: 37242726 DOI: 10.3390/pharmaceutics15051484] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
Slow-release delivery systems are needed to ensure long-term sustained treatments for retinal diseases such as age-related macular degeneration and diabetic retinopathy, which are currently treated with anti-angiogenic agents that require frequent intraocular injections. These can cause serious co-morbidities for the patients and are far from providing the adequate drug/protein release rates and required pharmacokinetics to sustain prolonged efficacy. This review focuses on the use of hydrogels, particularly on temperature-responsive hydrogels as delivery vehicles for the intravitreal injection of retinal therapies, their advantages and disadvantages for intraocular administration, and the current advances in their use to treat retinal diseases.
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Affiliation(s)
- Diana Rafael
- Drug Delivery & Targeting, Vall d'Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona (UAB), 08035 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Functional Validation & Preclinical Research (FVPR), 20 ICTS Nanbiosis, Vall d'Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona (UAB), 08035 Barcelona, Spain
| | - Marcelo Guerrero
- Bio & Nano Materials Lab, Drug Delivery and Controlled Release, Departamento de Microbiología, Facultad de Ciencias de la Salud, Universidad de Talca, Talca 3460000, Chile
- Center for Nanomedicine, Diagnostic & Drug Development (ND3), Universidad de Talca, Talca 3460000, Chile
| | - Adolfo Marican
- Bio & Nano Materials Lab, Drug Delivery and Controlled Release, Departamento de Microbiología, Facultad de Ciencias de la Salud, Universidad de Talca, Talca 3460000, Chile
- Center for Nanomedicine, Diagnostic & Drug Development (ND3), Universidad de Talca, Talca 3460000, Chile
- Instituto de Química de Recursos Naturales, Universidad de Talca, Talca 3460000, Chile
| | - Diego Arango
- Group of Biomedical Research in Digestive Tract Tumors, Vall d'Hebron University Hospital Research Institute (VHIR), Universitat Autònoma de Barcelona, 08035 Barcelona, Spain
- Group of Molecular Oncology, Biomedical Research Institute of Lleida (IRBLleida), 25198 Lleida, Spain
| | - Bruno Sarmento
- i3S-Instituto de Investigação e Inovação, Saúde Universidade do Porto, Rua Alfredo Allen 208, 4200-135 Porto, Portugal
| | - Roser Ferrer
- Clinical Biochemistry Group, Vall d'Hebron Hospital, 08035 Barcelona, Spain
| | - Esteban F Durán-Lara
- Bio & Nano Materials Lab, Drug Delivery and Controlled Release, Departamento de Microbiología, Facultad de Ciencias de la Salud, Universidad de Talca, Talca 3460000, Chile
- Center for Nanomedicine, Diagnostic & Drug Development (ND3), Universidad de Talca, Talca 3460000, Chile
| | - Simon J Clark
- Department for Ophthalmology, University Eye Clinic, Eberhard Karls University of Tübingen, 72076 Tübingen, Germany
- Institute for Ophthalmic Research, Eberhard Karls University of Tübingen, 72076 Tübingen, Germany
- Lydia Becker Institute of Immunology and Inflammation, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Simo Schwartz
- Drug Delivery & Targeting, Vall d'Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona (UAB), 08035 Barcelona, Spain
- Clinical Biochemistry Group, Vall d'Hebron Hospital, 08035 Barcelona, Spain
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Reddy A, Liu SH, Brady CJ, Sieving PC, Palestine AG. Corticosteroid implants for chronic non-infectious uveitis. Cochrane Database Syst Rev 2023; 1:CD010469. [PMID: 36645716 PMCID: PMC9841887 DOI: 10.1002/14651858.cd010469.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Uveitis is a term used to describe a group of intraocular inflammatory diseases. Uveitis is the fifth most common cause of vision loss in high-income countries, with the highest incidence of disease in the working-age population. Corticosteroids are the mainstay of treatment for all subtypes of non-infectious uveitis. They can be administered orally, topically with drops, by periocular (around the eye) or intravitreal (inside the eye) injection, or by surgical implantation. OBJECTIVES To determine the efficacy and safety of steroid implants in people with chronic non-infectious posterior uveitis, intermediate uveitis, and panuveitis. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register), MEDLINE Ovid, Embase, PubMed, LILACS, and three trials registries to November 2021. SELECTION CRITERIA: We included randomized controlled trials comparing either fluocinolone acetonide (FA) or dexamethasone (DEX) intravitreal implants with standard-of-care therapy or sham procedures, with at least six months of follow-up after treatment. We included studies that enrolled participants of all ages, who had chronic non-infectious posterior uveitis, intermediate uveitis, or panuveitis with vision that was better than hand-motion. DATA COLLECTION AND ANALYSIS We applied standard Cochrane methodology. MAIN RESULTS We included data from four trials (683 participants, 907 eyes) that compared corticosteroid implants with either sham or standard-of-care therapy. Study characteristics and risk of bias Of the two trials that compared corticosteroid implants with sham procedure, one examined a 0.18 mg FA implant, and the other, a 0.7 mg DEX implant. The other two trials compared a 0.59 mg FA implant with standard-of-care therapy, which included systemic corticosteroids and immunosuppressive medications, if needed. We assessed the four trials to be at either low risk, or with some concerns of risk of bias across all domains. Findings Using sham procedure as control, combined results at the six-month primary time point suggested that corticosteroid implants may decrease the risk of uveitis recurrence by 60% (relative risk [RR] 0.40, 95% confidence interval [CI] 0.30 to 0.54; 2 trials, 282 participants; low-certainty evidence); and lead to a greater improvement in best-corrected visual acuity (BCVA; mean difference [MD] 0.22 logMAR, 95% CI 0.13 to 0.31; 1 trial, 153 participants; low-certainty evidence). Evidence based on a single-study report (146 participants) suggested that steroid implants may have no effects on visual functioning quality of life, measured on the National Eye Institute 25-Item Visual Function Questionnaire (MD 2.85, 95%CI -3.64 to 9.34; 1 trial, 146 participants; moderate-certainty evidence). Using standard-of care therapy as control, combined estimates at the 24-month primary time point suggested that corticosteroid implants were likely to decrease the risk of recurrence of uveitis by 54% (RR 0.46, 95% CI 0.35 to 0.60; 2 trials, 619 eyes). Combined estimates at 24 months also suggested that steroid implants may have little to no effects on BCVA (MD 0.05 logMAR, 95% CI -0.02 to 0.12; 2 trials, 619 eyes; low-certainty evidence). Evidence based on a single-study report (232 participants) suggested that steroid implants may have minimal clinical effects on visual functioning (MD 4.64, 95% CI 0.13 to 9.15; 1 trial, 232 participants; moderate-certainty evidence); physical functioning (SF-36 physical subscale MD 2.95, 95% CI 0.55 to 5.35; 1 trial, 232 participants; moderate-certainty evidence); or mental health (SF-36 mental subscale MD 3.65, 95% CI 0.52 to 6.78; 1 trial, 232 participants; moderate-certainty evidence); but not on EuroQoL (MD 6.17, 95% CI 1.87 to 10.47; 1 trial, 232 participants; moderate-certainty evidence); or EuroQoL-5D scale (MD 0.02, 95% CI -0.04 to 0.08; 1 trial, 232 participants; moderate-certainty evidence). Adverse effects Compared with sham procedures, corticosteroid implants may slightly increase the risk of cataract formation (RR 2.69, 95% CI 1.17 to 6.18; 1 trial, 90 eyes; low-certainty evidence), but not the risk of cataract progression (RR 2.00, 95% CI 0.65 to 6.12; 1 trial, 117 eyes; low-certainty evidence); or the need for surgery (RR 2.98, 95% CI 0.82 to 10.81; 1 trial, 180 eyes; low-certainty evidence), during up to 12 months of follow-up. These implants may increase the risk of elevated intraocular pressure ([IOP] RR 2.81, 95% CI 1.42 to 5.56; 2 trials, 282 participants; moderate-certainty evidence); and the need for IOP-lowering eyedrops (RR 1.85, 95% CI 1.05 to 3.25; 2 trials, 282 participants; moderate-certainty evidence); but not the need for IOP-lowering surgery (RR 0.72, 95% CI 0.13 to 4.17; 2 trials, 282 participants; moderate-certainty evidence). Evidence comparing the 0.59 mg FA implant with standard-of-care suggested that the implant may increase the risk of cataract progression (RR 2.71, 95% CI 2.06 to 3.56; 2 trials, 210 eyes; low-certainty evidence); and the need for surgery (RR 2.98, 95% CI 2.33 to 3.79; 2 trials, 371 eyes; low-certainty evidence); along with the risk of elevated IOP (RR 3.64, 95% CI 2.71 to 4.87; 2 trials, 605 eyes; moderate-certainty evidence); and the need for medical (RR 3.04, 95% CI 2.36 to 3.91; 2 trials, 544 eyes; moderate-certainty evidence); or surgical interventions (RR 5.43, 95% CI 3.12 to 9.45; 2 trials, 599 eyes; moderate-certainty evidence). In either comparison, these implants did not increase the risk for endophthalmitis, retinal tear, or retinal detachment (moderate-certainty evidence). AUTHORS' CONCLUSIONS: Our confidence is limited that local corticosteroid implants are superior to sham therapy or standard-of-care therapy in reducing the risk of uveitis recurrence. We demonstrated different effectiveness on BCVA relative to comparators in people with non-infectious uveitis. Nevertheless, the evidence suggests that these implants may increase the risk of cataract progression and IOP elevation, which will require interventions over time. To better understand the efficacy and safety profiles of corticosteroid implants, we need future trials that examine implants of different doses, used for different durations. The trials should measure core standard outcomes that are universally defined, and measured at comparable follow-up time points.
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Affiliation(s)
- Amit Reddy
- Department of Ophthalmology, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
| | - Su-Hsun Liu
- Department of Ophthalmology, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, School of Public Health, Aurora, Colorado, USA
| | - Christopher J Brady
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Surgery, Division of Ophthalmology, University of Vermont, Burlington, Vermont, USA
| | - Pamela C Sieving
- Special Volunteer, National Eye Institute, Sacramento, California, USA
| | - Alan G Palestine
- Department of Ophthalmology, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
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Buhl L, Thurau S, Kern C. Fluocinolone acetonide 0.19-mg implant for the treatment of noninfectious uveitis with involvement of the posterior segment: a real-world study. Graefes Arch Clin Exp Ophthalmol 2022; 261:1101-1108. [PMID: 36399176 PMCID: PMC10050064 DOI: 10.1007/s00417-022-05893-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/31/2022] [Accepted: 11/03/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Purpose
To evaluate the effectiveness of 0.19-mg fluocinolone acetonide implant (FAi) for preventing inflammatory relapses in noninfectious uveitis with posterior segment involvement in standard clinical practice. Further, to assess the value of remission induction therapy with intraocular and periorbital administered high-dose corticosteroids before FAi.
Methods
A retrospective cohort study in a tertiary referral center specialized in uveitis management. The primary study outcomes were the best-corrected visual acuity (BVCA) and central retinal thickness (CRT) within a 12-month observation period. The secondary outcomes were intraocular pressure (IOP) and intraocular inflammation. The main safety measures were IOP increase and cataract formation.
Results
In total, 76 eyes of 57 patients received FAi. Locally administered high-dose corticosteroids were applied in 68.4% of all eyes before FAi. BCVA remained stable within the 12-month observation period (63.21 vs. 62.95, difference 0.26 letters; 95% CI: − 6.31 to 6.84; p > 0.9). Significant CRT reduction upon FAi was sustained after 12 months (362.7 vs. 309.1 μm, difference 53.57 μm; 95% CI: 1.55 to 105.6; p = 0.04). Intraocular inflammation was reduced until 9 months of follow-up (0.82 vs. 0.3, difference 0.53; 95% CI: 0.11 to 0.95; p = 0.007). A mean IOP increase (13.68 vs. 15.6; difference − 1.92; 95% CI: − 3.85 to 0.004; p = 0.0507) and cataract development (20% of all phakic eyes) were noted.
Conclusion
We observed similar levels of FAi effectiveness for the treatment of noninfectious uveitis in standard clinical practice compared to previous randomized clinical trials. Moreover, remission induction therapy before FAi can benefit patients with increased baseline uveitis activity.
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Affiliation(s)
- Lara Buhl
- Department of Ophthalmology, Ludwig-Maximilians-University, Mathildenstrasse 8, 80336, Munich, Germany.
| | - Stephan Thurau
- Department of Ophthalmology, Ludwig-Maximilians-University, Mathildenstrasse 8, 80336, Munich, Germany
| | - Christoph Kern
- Department of Ophthalmology, Ludwig-Maximilians-University, Mathildenstrasse 8, 80336, Munich, Germany
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8
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O'Brien Laramy MN, Nagapudi K. Long-acting ocular drug delivery technologies with clinical precedent. Expert Opin Drug Deliv 2022; 19:1285-1301. [PMID: 35912841 DOI: 10.1080/17425247.2022.2108397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Matthew N O'Brien Laramy
- Small Molecule Pharmaceutical Sciences, Genentech Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Karthik Nagapudi
- Small Molecule Pharmaceutical Sciences, Genentech Inc., 1 DNA Way, South San Francisco, CA 94080, USA
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EVALUATION OF SURGICAL FACTORS AFFECTING VITREOUS HEMORRHAGE FOLLOWING PORT DELIVERY SYSTEM WITH RANIBIZUMAB IMPLANT INSERTION IN A MINIPIG MODEL. Retina 2021; 40:1520-1528. [PMID: 31436674 PMCID: PMC7392584 DOI: 10.1097/iae.0000000000002614] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To develop an animal model of vitreous hemorrhage (VH) to explore the impact of surgical parameters on VH associated with insertion of the Port Delivery System with ranibizumab (PDS) implant. METHODS Ninety eyes from 45 treatment-naive male Yucatan minipigs received PDS implant insertion or a sham procedure. The effect of prophylactic pars plana hemostasis, scleral incision length, scleral cauterization, surgical blade type/size, and viscoelastic usage on postsurgical VH was investigated. RESULTS Postsurgical VH was detected in 60.0% (54/90) of implanted eyes. A systematic effect on VH was only detected for pars plana hemostasis before the pars plana incision. The percentage of eyes with VH was 96.6% (28/29) among eyes that did not receive prophylactic pars plana hemostasis and 42.4% (24/58) among eyes that did. There was no VH in eyes that received laser ablation of the pars plana using overlapping 1,000-ms spots; pars plana cautery or diathermy was less effective. The majority of all VH cases (83.3% [45/54]) were of mild to moderate severity (involving ≤25% of the fundus). CONCLUSION In this minipig surgical model of VH, scleral dissection followed by pars plana laser ablation before pars plana incision most effectively mitigated VH secondary to PDS implant insertion.
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García-Estrada P, García-Bon MA, López-Naranjo EJ, Basaldúa-Pérez DN, Santos A, Navarro-Partida J. Polymeric Implants for the Treatment of Intraocular Eye Diseases: Trends in Biodegradable and Non-Biodegradable Materials. Pharmaceutics 2021; 13:701. [PMID: 34065798 PMCID: PMC8151640 DOI: 10.3390/pharmaceutics13050701] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 12/15/2022] Open
Abstract
Intraocular/Intravitreal implants constitute a relatively new method to treat eye diseases successfully due to the possibility of releasing drugs in a controlled and prolonged way. This particularity has made this kind of method preferred over other methods such as intravitreal injections or eye drops. However, there are some risks and complications associated with the use of eye implants, the body response being the most important. Therefore, material selection is a crucial factor to be considered for patient care since implant acceptance is closely related to the physical and chemical properties of the material from which the device is made. In this regard, there are two major categories of materials used in the development of eye implants: non-biodegradables and biodegradables. Although non-biodegradable implants are able to work as drug reservoirs, their surgical requirements make them uncomfortable and invasive for the patient and may put the eyeball at risk. Therefore, it would be expected that the human body responds better when treated with biodegradable implants due to their inherent nature and fewer surgical concerns. Thus, this review provides a summary and discussion of the most common non-biodegradable and biodegradable materials employed for the development of experimental and commercially available ocular delivery implants.
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Affiliation(s)
- Paulina García-Estrada
- Departamento de Ingenieria de Proyectos-CUCEI, Universidad de Guadalajara, C.P. 45157 Zapopan, Mexico; (P.G.-E.); (M.A.G.-B.); (E.J.L.-N.); (D.N.B.-P.)
| | - Miguel A. García-Bon
- Departamento de Ingenieria de Proyectos-CUCEI, Universidad de Guadalajara, C.P. 45157 Zapopan, Mexico; (P.G.-E.); (M.A.G.-B.); (E.J.L.-N.); (D.N.B.-P.)
| | - Edgar J. López-Naranjo
- Departamento de Ingenieria de Proyectos-CUCEI, Universidad de Guadalajara, C.P. 45157 Zapopan, Mexico; (P.G.-E.); (M.A.G.-B.); (E.J.L.-N.); (D.N.B.-P.)
| | - Dulce N. Basaldúa-Pérez
- Departamento de Ingenieria de Proyectos-CUCEI, Universidad de Guadalajara, C.P. 45157 Zapopan, Mexico; (P.G.-E.); (M.A.G.-B.); (E.J.L.-N.); (D.N.B.-P.)
| | - Arturo Santos
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Campus Guadalajara, C.P. 45138 Zapopan, Mexico;
| | - Jose Navarro-Partida
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Campus Guadalajara, C.P. 45138 Zapopan, Mexico;
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11
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Ocular Drug Delivery to the Retina: Current Innovations and Future Perspectives. Pharmaceutics 2021; 13:pharmaceutics13010108. [PMID: 33467779 PMCID: PMC7830424 DOI: 10.3390/pharmaceutics13010108] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 01/13/2021] [Accepted: 01/13/2021] [Indexed: 12/12/2022] Open
Abstract
Treatment options for retinal diseases, such as neovascular age-related macular degeneration, diabetic retinopathy, and retinal vascular disorders, have markedly expanded following the development of anti-vascular endothelial growth factor intravitreal injection methods. However, because intravitreal treatment requires monthly or bimonthly repeat injections to achieve optimal efficacy, recent investigations have focused on extended drug delivery systems to lengthen the treatment intervals in the long term. Dose escalation and increasing molecular weight of drugs, intravitreal implants and nanoparticles, hydrogels, combined systems, and port delivery systems are presently under preclinical and clinical investigations. In addition, less invasive techniques rather than intravitreal administration routes, such as topical, subconjunctival, suprachoroidal, subretinal, and trans-scleral, have been evaluated to reduce the treatment burden. Despite the latest advancements in the field of ophthalmic pharmacology, enhancing drug efficacy with high ocular bioavailability while avoiding systemic and local adverse effects is quite challenging. Consequently, despite the performance of numerous in vitro studies, only a few techniques have translated to clinical trials. This review discusses the recent developments in ocular drug delivery to the retina, the pharmacokinetics of intravitreal drugs, efforts to extend drug efficacy in the intraocular space, minimally invasive techniques for drug delivery to the retina, and future perspectives in this field.
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12
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Abstract
Uveitis is characterized by intraocular inflammation involving the uveal tract; its etiologies generally fall into two broad categories: autoimmune/inflammatory or infectious. Corticosteroids are a powerful and important class of medications ubiquitous in the treatment of uveitis. They may be given systemically or locally, in the form of topical drops, periocular injection, intravitreal suspension, or intravitreal implant. This review describes each of the currently available corticosteroid treatment options for uveitis, including favorable and unfavorable characteristics of each as well as applicable clinical trials. The main advantage of corticosteroids as a whole is their ability to quickly and effectively control inflammation early on in the course of uveitis. However, they can have serious side effects, whether localized to the eye (such as cataract and elevated intraocular pressure) or systemic (such as osteonecrosis and adrenal insufficiency) and in the majority of cases of uveitis are not an appropriate option for long-term therapy.
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13
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Ajamil-Rodanes S, Testi I, Luis J, Robson AG, Westcott M, Pavesio C. Evaluation of fluocinolone acetonide 0.19 mg intravitreal implant in the management of birdshot retinochoroiditis. Br J Ophthalmol 2020; 106:234-240. [PMID: 33243833 DOI: 10.1136/bjophthalmol-2020-317372] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE To report treatment outcomes and efficacy of the fluocinolone acetonide 0.19 mg intravitreal implant (Iluvien) in controlling retinal and choroidal inflammation in 11 patients with birdshot retinochoroiditis. METHODS A single-centre, retrospective, interventional case series. The primary efficacy end point was improvement in vascular leakage on fluorescein angiography (FA), effect on cystoid macular oedema (CMO) and resolution of hypofluorescent lesions on indocyanine green angiography (ICGA); secondary measures were improvements on pattern and full-field electroretinogram (PERG; ERG) parameters. Safety outcome measures were intraocular elevation and cataractogenesis. RESULTS Fifteen eyes received Iluvien implant with an average follow-up of 31 months (range 12-36 months). Prior to the implant, 5 (33.3%) eyes had received dexamethasone intravitreal implant 0.7 mg (Ozurdex). FA showed evidence of vascular leakage in all eyes at baseline. Between month 6 and 12, FA showed that 73.4% of eyes had no leakage, this increased to 84.6% by month 24. Three eyes in our study had CMO at baseline. 6 months after Iluvien implant, all eyes achieved complete CMO resolution. One year after insertion of the implant, the characteristic hypofluorescent lesions on ICGA were unchanged in all cases. There was baseline ERG evidence indicating a high incidence of peripheral cone system dysfunction and most showed PERG evidence of macular dysfunction. Retinal function improved and macular function improved or was stable in the majority following treatment. CONCLUSIONS The results show the possible therapeutic effect of Iluvien in the management of Birdshot-related vascular leakage, CMO and retinal dysfunction. However, choroidal lesions seem to persist with no detectable response to treatment.
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Affiliation(s)
- Sofia Ajamil-Rodanes
- Medical Retina and Uveitis Department, Ophthalmology Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Ilaria Testi
- Medical Retina and Uveitis Department, Ophthalmology Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Joshua Luis
- Medical Retina and Uveitis Department, Ophthalmology Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Anthony G Robson
- Electrophysiology Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, London
| | - Mark Westcott
- Medical Retina and Uveitis Department, Ophthalmology Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, London
| | - Carlos Pavesio
- Medical Retina and Uveitis Department, Ophthalmology Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, London
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14
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Sadowsky AJ, Pecen PE, Feinstein E, Palestine AG. Indicators of Post-Operative Intraocular Pressure Elevation after Naïve Fluocinolone Acetonide Surgical Implantation. Ocul Immunol Inflamm 2020; 28:828-832. [PMID: 31408390 DOI: 10.1080/09273948.2019.1624778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To determine factors conferring an increased risk of developing ocular hypertension secondary to the fluocinolone acetonide (FA) sustained-release surgical implant (Retisert). DESIGN Retrospective, observational case series. METHODS Patients with a history of chronic noninfectious posterior uveitis undergoing naïve surgical FA implantation from 2007 to 2018 at the University of Colorado were studied. Patient demographics and multiple clinical measures were noted one year before and after FA implantation. RESULTS Twenty-nine eyes of 21 patients were studied. The median age experiencing an IOP rise vs median age experiencing no IOP rise post-FA implantation was 27.0 and 54.0 years old, respectively (p = .01). A pre-FA implant risk factor of needing future glaucoma surgery after FA implantation is prior to maximum IOP (p = .02). CONCLUSIONS A risk factor of elevated post-FA implantation IOP includes younger age. A potential risk factor for glaucoma surgery after FA implantation was higher maximum IOP before FA implantation.
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Affiliation(s)
- Aaron J Sadowsky
- Department of Ophthalmology, University of Colorado School of Medicine , Aurora, CO, USA
| | - Paula E Pecen
- Department of Ophthalmology, University of Colorado School of Medicine , Aurora, CO, USA
| | - Eric Feinstein
- Department of Ophthalmology, University of Colorado School of Medicine , Aurora, CO, USA
| | - Alan G Palestine
- Department of Ophthalmology, University of Colorado School of Medicine , Aurora, CO, USA
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15
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Kang-Mieler JJ, Rudeen KM, Liu W, Mieler WF. Advances in ocular drug delivery systems. Eye (Lond) 2020; 34:1371-1379. [PMID: 32071402 DOI: 10.1038/s41433-020-0809-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/21/2020] [Accepted: 02/04/2020] [Indexed: 12/26/2022] Open
Abstract
Recent advances in pharmacological agents have led to successful treatment of a variety of retinal diseases such as neovascular age-related macular degeneration (AMD), diabetic macular oedema (DMO), and retinal vascular occlusions (RVO). These treatments often require repeated drug injections for an extended period of time. To reduce these repeated treatment burdens, minimally invasive drug delivery systems are needed. An ideal therapy should maintain effective levels of drug for the intended duration of treatment following a single application, recognising that a significant number of months of therapy may be required. There are numerous approaches under investigation to improve treatment options. This review will highlight the advantages and limitations of selected drug delivery systems of novel biomaterial implants and depots. The main emphasis will be placed on less invasive, longer acting, sustained release formulations for the treatment of retinal disorders.
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Affiliation(s)
- Jennifer J Kang-Mieler
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL, 60616, USA.
| | - Kayla M Rudeen
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL, 60616, USA
| | - Wenqiang Liu
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL, 60616, USA
| | - William F Mieler
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA.
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16
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Preliminary evaluation of YUTIQ™ (fluocinolone acetonide intravitreal implant 0.18 mg) in posterior uveitis. Ther Deliv 2019; 10:621-625. [PMID: 31663454 DOI: 10.4155/tde-2019-0051] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Uveitis is a major cause of ocular morbidity, potentially leading to significant visual impairment. The recent adoption of alternative drug delivery options has led to the development of new sustained-delivery corticosteroid systems, able to manage successfully chronic noninfectious posterior uveitis. The treatment goal is to target the site of inflammation with low dose of corticosteroids, delivered over an extended period of time, to minimize the cumulative damage resulting from repeated recurrences, reducing both injections frequency and ocular side effects. This article will review the pharmacology and preliminary clinical data of the 0.18 mg fluocinolone acetonide intravitreal implant (YUTIQ™), to show its efficacy and safety in the treatment of noninfectious posterior uveitis.
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17
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Pierstorff E, Yang WW, Chen YJA, Cheung S, Kalinec F, Slattery WH. Prevention of cisplatin-induced hearing loss by extended release fluticasone propionate intracochlear implants. Int J Pediatr Otorhinolaryngol 2019; 121:157-163. [PMID: 30913504 PMCID: PMC6502669 DOI: 10.1016/j.ijporl.2019.03.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 02/27/2019] [Accepted: 03/17/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Cisplatin is a chemotherapeutic drug known to induce hearing loss. Although corticosteroids may help to mitigate the ototoxic side effects of cisplatin, there are complications associated with their systemic and prolonged use. The goal of this study is to test the efficacy of extended-release fluticasone propionate intracochlear implant particles to protect against cisplatin-induced hearing loss. METHODS We used guinea pigs (n = 9) injected with cisplatin (IP, 12 mg/kg weight). Fluticasone particles were delivered to the cochlear scala tympani through the round window membrane into the right ears of the guinea pigs (left ears being used as a control) two weeks prior to cisplatin administration, and hearing function was evaluated by ABR and DPOAE before implantation, immediately before cisplatin administration, and 2 weeks after the challenge with cisplatin. Data was statistically evaluated using paired t-test analysis. RESULTS No significant differences were observed in ABR threshold between control and implanted ears on day 14 (23.9 ± 2.3 dB vs. 25.6 ± 1.3 dB, P = 0.524), whereas the significant cisplatin-induced hearing loss in control animals (23.9 ± 2.3 dB at day 14 vs. 40.7 ± 2.5 dB at day 28, P ≤ 0.0001) was prevented in implanted animals (25.6 ± 1.3 dB at day 14 vs. 25.0 ± 3.1 at day 28, P ≥ 0.85). A similar, though not statistically significant, trend was observed in DPOAE responses in untreated ears (7.9 ± 5.8 dB at day14 vs. -0.5 ± 5.3 dB at day 28, P = 0.654) as compared to treatment (11.1 ± 3.4 dB at day 14 vs. 13.6 ± 4.8 dB at day 28, P = 0.733). CONCLUSION These results suggest that fluticasone intracochlear implants are safe and able to provide effective otoprotection against cisplatin-induced hearing loss in the guinea pig model.
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Affiliation(s)
- Erik Pierstorff
- O-Ray Pharma, Inc., 2285 E. Foothill Blvd, Pasadena, CA, 91107, USA.
| | - Wan-Wan Yang
- O-Ray Pharma, Inc., 2285 E. Foothill Blvd, Pasadena, CA 91107
| | - Yen-Jung Angel Chen
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA. 10833 Le Conte Ave., Los Angeles, CA 90095
| | - Shirley Cheung
- O-Ray Pharma, Inc., 2285 E. Foothill Blvd, Pasadena, CA 91107
| | - Federico Kalinec
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA. 10833 Le Conte Ave., Los Angeles, CA 90095
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19
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Shah KK, Majumder PD, Biswas J. Intravitreal therapeutic agents in noninfectious uveitic macular edema. Indian J Ophthalmol 2018; 66:1060-1073. [PMID: 30038143 PMCID: PMC6080427 DOI: 10.4103/ijo.ijo_35_18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The management of uveitis is challenging for most treating ophthalmologists. The treatment of uveitis often requires the use of high dose of systemic corticosteroid and immunosuppressive agents, which are almost always associated with potential side effects. Intravitreal medications have become a popular mode of drug administration in uveitis patients as they provide high volume of drug to the target tissues, eliminating the risk of systemic toxicity. There has been tremendous development in the intravitreal therapeutics over the last few years. With the advent of sustained-release technique, increasing patient compliance, biodegradable nature of the implant, and introduction of newer agents with better safety profile, the intravitreal medications have become more popular in recent years. This review presents evidence in the scientific literature supporting the use of intravitreal medications for the management of uveitis and its complications.
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Affiliation(s)
- Kunal Kaushik Shah
- Shri Bhagwan Mahavir VitreoRetinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | | | - Jyotirmay Biswas
- Department of Uvea, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India
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20
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Intravitreal Steroid Implants in the Management of Retinal Disease and Uveitis. Int Ophthalmol Clin 2018; 56:127-49. [PMID: 27575764 DOI: 10.1097/iio.0000000000000132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Abstract
The relationship between the eye and psoriasis has been recognized for decades, but the precise eye manifestations in patients with psoriasis and psoriatic arthritis are only recently coming to light. Psoriatic eye findings may include conjunctivitis, dry eye, episcleritis, and uveitis, all of which may precede articular changes. Uveitis, seen in 7% to 25% of psoriatic arthritis patients, may be recognized by the presence of conjunctival injection, photophobia, pain, lid swelling, or otherwise unexplained visual changes. Early recognition is paramount because its natural course may lead to vision loss. Immunopathogenesis has shown evidence for T-helper cell (Th) type 1 (Th1) and Th17 involvement in the pathogenesis of uveitis according to the murine experimental autoimmune uveitis model. Corticosteroids are the primary treatment modality; however, increasing emphasis has been placed on immunomodulators and biologics for more intractable cases. Referral to an ophthalmologist is essential for definitive diagnosis and treatment.
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Affiliation(s)
- Shiu-chung Au
- Department of Dermatology, Tufts Medical Center, Boston, Massachusetts
| | - Shimrat Yaniv
- Albert Einstein College of Medicine, New York, New York
| | - Alice B. Gottlieb
- Department of Dermatology, Tufts Medical Center, Boston, Massachusetts
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22
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Jonas JB, Spandau UH, Kamppeter BA, Vossmerbaeumer U, Harder B. Follow-Up after Intravitreal Triamcinolone Acetonide for Diabetic Macular Edema. Eur J Ophthalmol 2018; 16:566-72. [PMID: 16952096 DOI: 10.1177/112067210601600411] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To report on the follow-up of patients who received an intravitreal high-dosage injection of triamcinolone acetonide (IVTA) as treatment of diffuse diabetic macular edema. METHODS The clinical interventional case-series study included 109 eyes (90 patients) with diffuse diabetic macular edema who consecutively received an IVTA of about 20 mg. Mean follow-up was 11.2 +/- 6.2 months. RESULTS Visual acuity improved significantly (p<0.001) from 0.89 +/- 0.33 logMAR to a best minimum of 0.65 +/- 0.35 logMAR. An increase in best visual acuity by at least 1 Snellen line, 2 lines, and 3 lines was found in 91 (83%) eyes, 68 (62%) eyes, and 45 (41%) eyes, respectively. Differences in visual acuity between baseline and follow-up examinations were significant for measurements performed at 1 month (p<0.001), 2 months (p<0.001), 3 months (p<0.001), and at 6 months (p=0.001) after the injection. At 9 months after the injection, mean visual acuity regressed significantly so that visual acuity at 9 months (p=0.83) and at 12 months after the injection (p=0.58) compared with baseline values did not differ significantly. Forty-seven (43%) eyes developed a rise in intraocular pressure (pressure >21 mmHg) for 6 to 8 months after the injection. No other severe complications were detected. CONCLUSIONS The duration of a visual acuity increase and intraocular pressure rise after high-dosage IVTA in diffuse diabetic macular edema is about 6 to 8 months. Compared with data in the literature, the high-dosage IVTA may not have a markedly higher profile of side effects than low-dosage IVTA.
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Affiliation(s)
- J B Jonas
- Department of Ophthalmology, Faculty of Clinical Medicine Mannheim, Universitäts-Augenklinik, Ruprecht-Karls-University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
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Ratay ML, Bellotti E, Gottardi R, Little SR. Modern Therapeutic Approaches for Noninfectious Ocular Diseases Involving Inflammation. Adv Healthc Mater 2017; 6:10.1002/adhm.201700733. [PMID: 29034584 PMCID: PMC5915344 DOI: 10.1002/adhm.201700733] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 07/25/2017] [Indexed: 12/12/2022]
Abstract
Dry eye disease, age-related macular degeneration, and uveitis are ocular diseases that significantly affect the quality of life of millions of people each year. In these diseases, the action of chemokines, proinflammatory cytokines, and immune cells drives a local inflammatory response that results in ocular tissue damage. Multiple therapeutic strategies are developed to either address the symptoms or abate the underlying cause of these diseases. Herein, the challenges to deliver drugs to the relevant location in the eye for each of these diseases are reviewed along with current and innovative therapeutic approaches that attempt to restore homeostasis within the ocular microenvironment.
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Affiliation(s)
- Michelle L. Ratay
- Department of Bioengineering, University of Pittsburgh, 427 Benedum Hall 3700 O’Hara Street Pittsburgh, Pa 15261
| | - Elena Bellotti
- Department of Chemical Engineering, University of Pittsburgh, 427 Benedum Hall 3700 O’Hara Street Pittsburgh, Pa 15261
| | - Riccardo Gottardi
- Department of Chemical Engineering, Department of Orthopedic Surgery, Ri.MED Foundation, 427 Benedum Hall 3700 O’Hara Street Pittsburgh, Pa 15261
| | - Steven R. Little
- Department of Chemical Engineering, Department of Bioengineering, Department of Ophthalmology, Department of Immunology, Department of Pharmaceutical Sciences, The McGowan Institute for Regenerative Medicine, 940 Benedum Hall 3700 O’Hara Street Pittsburgh Pa 15261
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Kempen JH, Altaweel MM, Holbrook JT, Sugar EA, Thorne JE, Jabs DA. Association Between Long-Lasting Intravitreous Fluocinolone Acetonide Implant vs Systemic Anti-inflammatory Therapy and Visual Acuity at 7 Years Among Patients With Intermediate, Posterior, or Panuveitis. JAMA 2017; 317:1993-2005. [PMID: 28477440 PMCID: PMC5540027 DOI: 10.1001/jama.2017.5103] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE A randomized clinical trial comparing fluocinolone acetonide implant vs systemic corticosteroids and immunosuppression for treatment of severe noninfectious intermediate, posterior, and panuveitides did not result in a significant difference in visual acuity at 2 and 4.5 years; longer-term outcomes are not known. OBJECTIVE To compare the association between intravitreous fluocinolone acetonide implant vs systemic therapy and long-term visual and other outcomes in patients with uveitis. DESIGN, SETTING, AND PARTICIPANTS Nonprespecified 7-year observational follow-up of the Multicenter Uveitis Steroid Treatment (MUST) randomized clinical trial comparing the alternative treatments. Follow-up was conducted in tertiary uveitis subspecialty practices in the United States (21), the United Kingdom (1), and Australia (1). Of 255 patients 13 years or older with intermediate, posterior, or panuveitis (active within ≤60 days) enrolled in the MUST trial between December 6, 2005, and December 9, 2008, 215 consented to ongoing follow-up through at least 7 years postrandomization (last visit, February 10, 2016). INTERVENTIONS Participants had been randomized to receive a surgically placed intravitreous fluocinolone acetonide implant or systemic corticosteroids supplemented by immunosuppression. When both eyes required treatment, both eyes were treated. MAIN OUTCOMES AND MEASURES Primary outcome was change from baseline in best-corrected visual acuity in uveitic eyes (5 letters = 1 visual acuity chart line; potential range of change in letters read, -121 to +101; minimal clinically important difference, 7 letters), analyzed by treatment assignment accounting for nonindependence of eyes when patients had 2 uveitic eyes. Secondary outcomes included potential systemic toxicities of corticosteroid and immunosuppressive therapy and death. RESULTS Seven-year data were obtained for 161 uveitic eyes (70% of 90 patients assigned to implant) and 167 uveitic eyes (71% of 90 patients assigned to systemic therapy) (77% female; median age at enrollment, 48 [interquartile range, 36-56] years). Change in mean visual acuity from baseline (implant, 61.7; systemic therapy, 65.0) through 7 years (implant, 55.8; systemic therapy, 66.2) favored systemic therapy by 7.2 (95% CI, 2.1-12) letters. Among protocol-specified, prospectively collected systemic adverse outcomes, the cumulative 7-year incidence in the implant and systemic therapy groups, respectively, was less than 10%, with the exceptions of hyperlipidemia (6.1% vs 11.2%), hypertension (9.8% vs 18.4%), osteopenia (41.5% vs 43.1%), fractures (11.3% vs 18.6%), hospitalization (47.6% vs 42.3%), and antibiotic-treated infection (57.4% vs 72.3%). CONCLUSIONS AND RELEVANCE In 7-year extended follow-up of a randomized trial of patients with severe intermediate, posterior, or panuveitis, those randomized to receive systemic therapy had better visual acuity than those randomized to receive intravitreous fluocinolone acetonide implants. Study interpretation is limited by loss to follow-up. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00132691.
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Affiliation(s)
| | - John H Kempen
- Department of Ophthalmology, Massachusetts Eye and Ear, Boston3The Discovery Eye Center, MyungSung Christian Medical Center and MyungSung Medical School, Addis Ababa, Ethiopia
| | - Michael M Altaweel
- Fundus Photograph Reading Center, Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison
| | - Janet T Holbrook
- Center for Clinical Trials and Evidence Synthesis, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland6Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth A Sugar
- Center for Clinical Trials and Evidence Synthesis, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland7Department Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jennifer E Thorne
- Center for Clinical Trials and Evidence Synthesis, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland6Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland8Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Douglas A Jabs
- Center for Clinical Trials and Evidence Synthesis, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland6Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland9Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York10Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Kinoshita S, Ohguchi T, Noda K, Murata M, Yasueda SI, Obata H, Matsunaga T, Fukushima T, Kanda A, Ishida S. Evaluation of the Safety and Tolerability of Conjunctival Ring for Posterior Segment of the Eye. Curr Eye Res 2017; 42:1149-1154. [PMID: 28358216 DOI: 10.1080/02713683.2017.1287277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate the safety and tolerability of conjunctival rings (CRs), a novel device for drug delivery to the posterior segment of the eye. METHODS In animal studies, CRs containing 5% dexamethasone sodium phosphate (DSP) or vehicle solution were placed on the right and left eyes of C57BL/6J mice, respectively. Contact lenses (CLs) containing vehicle solution were used as a control. Twenty-four hours after placement of the CRs, corneal fluorescein staining was graded based on the McDonald-Shadduck scoring system, ranging from 0 to 4. In humans, CRs containing vehicle solution were placed on the right eye of healthy volunteers for 9 hours. The corneal curvature, corneal thickness, intraocular pressure, visual acuity, tear production (Schirmer I test), tear film break-up time and fluorescein staining scores of the cornea (scores ranging from 0 to 3) and conjunctiva (scores ranging from 0 to 6) were assessed before and after wearing the CRs. The release characteristics of DSP from CRs were also evaluated. RESULTS In animal experiments, corneal fluorescein staining scores were 1 or less in all the groups, and there was no significant difference between the CR group and the CL group. In the preclinical safety evaluation of CR for humans, ophthalmic examination revealed that CR caused no significant changes in all the parameters investigated including corneal curvature (p = 0.77), corneal thickness (p = 0.96), intraocular pressure (p = 0.59), visual acuity (p = 0.14), Schirmer I test results (p = 0.76), tear film break-up time (p = 0.68), corneal fluorescein staining scores (p = 0.64), and conjunctival fluorescein staining scores (p = 0.52). The DSP release from CRs occurs within a few hours, which is similar to the drug-release property of medicated CL, as reported previously. CONCLUSIONS The current data showed the safety and tolerability of CR as a drug delivery device for the treatment of posterior segment diseases.
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Affiliation(s)
- Satoshi Kinoshita
- a Laboratory of Ocular Cell Biology and Visual Science , Hokkaido University Graduate School of Medicine , Sapporo , Japan.,b Department of Ophthalmology , Hokkaido University Graduate School of Medicine , Sapporo , Japan
| | - Takeshi Ohguchi
- a Laboratory of Ocular Cell Biology and Visual Science , Hokkaido University Graduate School of Medicine , Sapporo , Japan.,b Department of Ophthalmology , Hokkaido University Graduate School of Medicine , Sapporo , Japan
| | - Kousuke Noda
- a Laboratory of Ocular Cell Biology and Visual Science , Hokkaido University Graduate School of Medicine , Sapporo , Japan.,b Department of Ophthalmology , Hokkaido University Graduate School of Medicine , Sapporo , Japan
| | - Miyuki Murata
- a Laboratory of Ocular Cell Biology and Visual Science , Hokkaido University Graduate School of Medicine , Sapporo , Japan.,b Department of Ophthalmology , Hokkaido University Graduate School of Medicine , Sapporo , Japan
| | - Shin-Ichi Yasueda
- c Research Laboratories, Senju Pharmaceutical Co., Ltd. , Kobe , Japan
| | - Haruka Obata
- d Research Laboratories, SEED Co., Ltd. , Saitama , Japan
| | - Toru Matsunaga
- d Research Laboratories, SEED Co., Ltd. , Saitama , Japan
| | | | - Atsuhiro Kanda
- a Laboratory of Ocular Cell Biology and Visual Science , Hokkaido University Graduate School of Medicine , Sapporo , Japan.,b Department of Ophthalmology , Hokkaido University Graduate School of Medicine , Sapporo , Japan
| | - Susumu Ishida
- a Laboratory of Ocular Cell Biology and Visual Science , Hokkaido University Graduate School of Medicine , Sapporo , Japan.,b Department of Ophthalmology , Hokkaido University Graduate School of Medicine , Sapporo , Japan
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Jaffe GJ, Lin P, Keenan RT, Ashton P, Skalak C, Stinnett SS. Injectable Fluocinolone Acetonide Long-Acting Implant for Noninfectious Intermediate Uveitis, Posterior Uveitis, and Panuveitis: Two-Year Results. Ophthalmology 2016; 123:1940-8. [PMID: 27421623 DOI: 10.1016/j.ophtha.2016.05.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 05/19/2016] [Accepted: 05/19/2016] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To determine the effect of an injectable fluocinolone acetonide implant (FAi) in eyes with noninfectious intermediate uveitis, posterior uveitis, or panuveitis. DESIGN Noncomparative, interventional, dose-randomized, dose-masked, prospective, individual, investigator-sponsored investigational new drug study. PARTICIPANTS Eleven eyes of 11 participants with a history of recurrent noninfectious intermediate uveitis, posterior, or panuveitis. METHODS Participants were randomized to receive either a low- or a high-dose FAi. Eyes were observed on day 0 (day the implant was injected) and then at regular intervals through 2 years. MAIN OUTCOME MEASURES Ocular inflammation, visual acuity, anti-inflammatory medication use, and safety parameters before and after FAi implantation. RESULTS All participants were followed up for 2 years. At baseline, mean study eye visual acuity was 0.56 logarithm of the minimum angle of resolution (logMAR; standard deviation [SD], 0.43 logMAR). These values improved significantly to +0.25 logMAR (SD, 0.14 logMAR) and +0.17 logMAR (SD, 0.14 logMAR) at 12 and 24 months after implantation, respectively (P = 0.041 and P = 0.016, respectively). The average number of inflammation recurrences in the 12 months before implantation was 1.54 episodes per eye. None of the study eyes experienced a recurrence during the follow-up period. Of the 6 participants who continued receiving systemic medication after implantation, the dosage was reduced in 4 participants. Five of 11 eyes received an average of 1.6 posterior sub-Tenon triamcinolone acetonide (PSTA) injections in the 12 months preceding implantation. None required a PSTA injection after FAi implantation. The most common adverse event was intraocular pressure (IOP) rise. At baseline, 1 study eye (9%) required pressure-lowering drops; 2 additional study eyes (18%) required them during the follow-up period. Filtering procedures were performed in 2 of these eyes (18.1%). No FAi explantations were required, nor were any participants lost to follow-up during the investigation. CONCLUSIONS It is feasible to place a long-acting FAi in an outpatient setting, without prolonged adverse events attributed to the implant injection procedure. The FAi effectively controlled intraocular inflammation in all eyes in the study, and at the last follow-up, all implanted eyes demonstrated an improvement in visual acuity. Elevated IOP that occurred in 18% of FAi-implanted eyes was managed by standard means. The FAi implant is a promising approach for patients with noninfectious intermediate uveitis, posterior uveitis, or panuveitis who do not respond to, or are intolerant to, conventional therapy.
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Affiliation(s)
- Glenn J Jaffe
- Division of Rheumatology, Department of Ophthalmology, Duke University, Durham, North Carolina.
| | - Phoebe Lin
- Division of Rheumatology, Department of Ophthalmology, Duke University, Durham, North Carolina
| | - Robert T Keenan
- Division of Rheumatology, Duke University, Durham, North Carolina
| | | | - Cindy Skalak
- Division of Rheumatology, Department of Ophthalmology, Duke University, Durham, North Carolina
| | - Sandra S Stinnett
- Division of Rheumatology, Department of Ophthalmology, Duke University, Durham, North Carolina
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Comparison of In Vivo Gene Expression Profiling of RPE/Choroid following Intravitreal Injection of Dexamethasone and Triamcinolone Acetonide. J Ophthalmol 2016; 2016:9856736. [PMID: 27429799 PMCID: PMC4939337 DOI: 10.1155/2016/9856736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 04/29/2016] [Accepted: 05/03/2016] [Indexed: 11/17/2022] Open
Abstract
Purpose. To identify retinal pigment epithelium (RPE)/choroid genes and their relevant expression pathways affected by intravitreal injections of dexamethasone and triamcinolone acetonide in mice at clinically relevant time points for patient care. Methods. Differential gene expression of over 34,000 well-characterized mouse genes in the RPE/choroid of 6-week-old C57BL/6J mice was analyzed after intravitreal steroid injections at 1 week and 1 month postinjection, using Affymetrix Mouse Genome 430 2.0 microarrays. The data were analyzed using GeneSpring GX 12.5 and Ingenuity Pathway Analysis (IPA) microarray analysis software for biologically relevant changes. Results. Both triamcinolone and dexamethasone caused differential activation of genes involved in “Circadian Rhythm Signaling” pathway at both time points tested. Triamcinolone (TAA) uniquely induced significant changes in gene expression in “Calcium Signaling” (1 week) and “Glutamate Receptor Signaling” pathways (1 month). In contrast, dexamethasone (Dex) affected the “GABA Receptor Signaling” (1 week) and “Serotonin Receptor Signaling” (1 month) pathways. Understanding how intraocular steroids affect the gene expression of RPE/choroid is clinically relevant. Conclusions. This in vivo study has elucidated several genes and pathways that are potentially altering the circadian rhythms and several other neurotransmitter pathways in RPE/choroid during intravitreal steroid injections, which likely has consequences in the dysregulation of RPE function and neurodegeneration of the retina.
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Abstract
The aim of this review is to summarize recent developments in the treatment of uveitic macular edema (ME). ME represent a major cause of visual loss in uveitis and adequate management is crucial for the maintenance of useful vision in patients with chronic uveitis.
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Affiliation(s)
- Raquel Goldhardt
- Assistant Professor of Clinical Ophthalmology, University of Miami Miller School of Medicine, Bascom Palmer Eye Institute
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Brady CJ, Villanti AC, Law HA, Rahimy E, Reddy R, Sieving PC, Garg SJ, Tang J. Corticosteroid implants for chronic non-infectious uveitis. Cochrane Database Syst Rev 2016; 2:CD010469. [PMID: 26866343 PMCID: PMC5038923 DOI: 10.1002/14651858.cd010469.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Uveitis is a term used to describe a heterogeneous group of intraocular inflammatory diseases of the anterior, intermediate, and posterior uveal tract (iris, ciliary body, choroid). Uveitis is the fifth most common cause of vision loss in high-income countries, accounting for 5% to 20% of legal blindness, with the highest incidence of disease in the working-age population.Corticosteroids are the mainstay of acute treatment for all anatomical subtypes of non-infectious uveitis and can be administered orally, topically with drops or ointments, by periocular (around the eye) or intravitreal (inside the eye) injection, or by surgical implantation. OBJECTIVES To determine the efficacy and safety of steroid implants in people with chronic non-infectious posterior uveitis, intermediate uveitis, and panuveitis. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (Issue 10, 2015), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to November 2015), EMBASE (January 1980 to November 2015), PubMed (1948 to November 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to November 2015), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) (last searched 15 April 2013), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic search for studies. We last searched the electronic databases on 6 November 2015.We also searched reference lists of included study reports, citation databases, and abstracts and clinical study presentations from professional meetings. SELECTION CRITERIA We included randomized controlled trials comparing either fluocinolone acetonide (FA) or dexamethasone intravitreal implants with standard-of-care therapy with at least six months of follow-up after treatment. We included studies that enrolled participants of all ages who had chronic non-infectious posterior uveitis, intermediate uveitis, or panuveitis with vision that was better than hand-motion. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed studies for inclusion. Two review authors independently extracted data and assessed the risk of bias for each study. MAIN RESULTS We included data from two studies (619 eyes of 401 participants) that compared FA implants with standard-of-care therapy. Both studies used similar standard-of-care therapy that included administration of prednisolone and, if needed, immunosuppressive agents. The studies included participants from Australia, France, Germany, Israel, Italy, Portugal, Saudi Arabia, Spain, Switzerland, Turkey, the United Kingdom, and the United States. We assessed both studies at high risk of performance and detection bias.Only one study reported our primary outcome, recurrence of uveitis at any point during the study through 24 months. The evidence, judged as moderate-quality, showed that a FA implant probably prevents recurrence of uveitis compared with standard-of-care therapy (risk ratio (RR) 0.29, 95% confidence interval (CI) 0.14 to 0.59; 132 eyes). Both studies reported safety outcomes, and moderate-quality evidence showed increased risks of needing cataract surgery (RR 2.98, 95% CI 2.33 to 3.79; 371 eyes) and surgery to lower intraocular pressure (RR 7.48, 95% CI 3.94 to 14.19; 599 eyes) in the implant group compared with standard-of-care therapy through two years of follow-up. No studies compared dexamethasone implants with standard-of-care therapy. AUTHORS' CONCLUSIONS After considering both benefits and harms reported from two studies in which corticosteroids implants were compared with standard-of-care therapy, we are unable to conclude that the implants are superior to traditional systemic therapy for the treatment of non-infectious uveitis. These studies exhibited heterogeneity in design and outcomes that measured efficacy. Pooled findings regarding safety outcomes suggest increased risks of post-implant surgery for cataract and high intraocular pressure compared with standard-of-care therapy.
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Affiliation(s)
- Christopher J Brady
- Johns Hopkins University School of MedicineWilmer Eye InstituteBaltimoreMarylandUSA
| | - Andrea C Villanti
- Johns Hopkins Bloomberg School of Public HealthDepartment of Health, Behavior and SocietyBaltimoreMarylandUSA
| | - Hua Andrew Law
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 N. Wolfe StreetBaltimoreMarylandUSA21205
| | - Ehsan Rahimy
- Thomas Jefferson UniversityMidAtlantic Retina, The Retina Service of Wills Eye HospitalPhiladelphiaPennsylvaniaUSA
| | - Rahul Reddy
- Associated Retinal ConsultantsPhoenixArizonaUSA
| | - Pamela C Sieving
- National Institutes of Health Library10 Center DriveRoom 1L09G MSC 1150BethesdaMarylandUSA20892
| | - Sunir J Garg
- Thomas Jefferson UniversityMidAtlantic Retina, The Retina Service of Wills Eye HospitalPhiladelphiaPennsylvaniaUSA
| | - Johnny Tang
- University Hospitals Eye Institute/Case Western Reserve UniversityUniversity Hospitals Eye Institute11100 Euclid Avenue, Lakeside 4107ClevelandOhioUSA44106
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Yi Y, Buttner U, Foulds IG. A cyclically actuated electrolytic drug delivery device. LAB ON A CHIP 2015; 15:3540-3548. [PMID: 26198777 DOI: 10.1039/c5lc00703h] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
This work, focusing on an implantable drug delivery system, presents the first prototype electrolytic pump that combines a catalytic reformer and a cyclically actuated mode. These features improve the release performance and extend the lifetime of the device. Using our platinum (Pt)-coated carbon fiber mesh that acts as a catalytic reforming element, the cyclical mode is improved because the faster recombination rate allows for a shorter cycling time for drug delivery. Another feature of our device is that it uses a solid-drug-in-reservoir (SDR) approach, which allows small amounts of a solid drug to be dissolved in human fluid, forming a reproducible drug solution for long-term therapies. We have conducted proof-of-principle drug delivery studies using such an electrolytic pump and solvent blue 38 as the drug substitute. These tests demonstrate power-controlled and pulsatile release profiles of the chemical substance, as well as the feasibility of this device. A drug delivery rate of 11.44 ± 0.56 μg min(-1) was achieved by using an input power of 4 mW for multiple pulses, which indicates the stability of our system.
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Affiliation(s)
- Ying Yi
- School of Engineering, University of British Columbia, Kelowna, British Columbia, Canada.
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Asmus LR, Grimshaw JP, Richle P, Eicher B, Urech DM, Gurny R, Möller M. Injectable formulations for an intravitreal sustained-release application of a novel single-chain VEGF antibody fragment. Eur J Pharm Biopharm 2015; 95:250-60. [DOI: 10.1016/j.ejpb.2015.02.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 02/05/2015] [Accepted: 02/09/2015] [Indexed: 10/23/2022]
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Lee DJ. Intraocular Implants for the Treatment of Autoimmune Uveitis. J Funct Biomater 2015; 6:650-66. [PMID: 26264035 PMCID: PMC4598676 DOI: 10.3390/jfb6030650] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 07/21/2015] [Accepted: 07/27/2015] [Indexed: 12/15/2022] Open
Abstract
Uveitis is the third leading cause of blindness in developed countries. Currently, the most widely used treatment of non-infectious uveitis is corticosteroids. Posterior uveitis and macular edema can be treated with intraocular injection of corticosteroids, however, this is problematic in chronic cases because of the need for repeat injections. Another option is systemic immunosuppressive therapies that have their own undesirable side effects. These systemic therapies result in a widespread suppression of the entire immune system, leaving the patient susceptible to infection. Therefore, an effective localized treatment option is preferred. With the recent advances in bioengineering, biodegradable polymers that allow for a slow sustained-release of a medication. These advances have culminated in drug delivery implants that are food and drug administration (FDA) approved for the treatment of non-infectious uveitis. In this review, we discuss the types of ocular implants available and some of the polymers used, implants used for the treatment of non-infectious uveitis, and bioengineered alternatives that are on the horizon.
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Affiliation(s)
- Darren J Lee
- Department of Ophthalmology/Dean McGee Eye Institute, University of Oklahoma Health Sciences Center, 608 Stanton L. Young Blvd, DMEI PA404, Oklahoma City, OK 73104, USA.
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Safety and efficacy of fluocinolone acetonide intravitreal implant (0.59 mg) in birdshot retinochoroidopathy. Retina 2015; 34:2259-68. [PMID: 24999722 DOI: 10.1097/iae.0000000000000239] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To report the treatment outcomes of the fluocinolone acetonide intravitreal implant (0.59 mg) in patients with birdshot retinochoroidopathy whose disease is refractory or intolerant to conventional immunomodulatory therapy. METHODS A retrospective case series involving 11 birdshot retinochoroidopathy patients (11 eyes). Eleven patients (11 eyes) underwent surgery for fluocinolone acetonide implant (0.59 mg). Treatment outcomes of interest were noted at baseline, before fluocinolone acetonide implant, and then at 6 months, 1 year, 2 years, 3 years, and beyond 3 years. Disease activity markers, including signs of ocular inflammation, evidence of retinal vasculitis, Swedish interactive threshold algorithm-short wavelength automated perimetry Humphrey visual field analysis, electroretinographic parameters, and optical coherence tomography were recorded. Data on occurrence of cataract and raised intraocular pressure were collected in all eyes. RESULTS Intraocular inflammation was present in 54.5, 9.9, 11.1, and 0% of patients at baseline, 6 months, 1 year, 2 years, 3 years, and beyond 3 years after receiving the implant, respectively. Active vasculitis was noted in 36.3% patients at baseline and 0% at 3 years of follow-up. More than 20% (47.61-67.2%) reduction in central retinal thickness was noted in all patients with cystoid macular edema at 6 months, 1 year, 2 years, and 3 years postimplant. At baseline, 54.5% patients were on immunomodulatory agents. This percentage decreased to 45.45, 44.4, and 14.28% at 1 year, 2 years, and 3 years postimplant, respectively. Adverse events included increased intraocular pressure (54.5%) and cataract formation (100%). CONCLUSION The data suggest that fluocinolone acetonide implant (0.59 mg) helps to control inflammation in otherwise treatment-refractory cases of birdshot retinochoroidopathy. It is associated with significant side effects of cataract and ocular hypertension requiring treatment.
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Transplantation of PEDF-transfected pigment epithelial cells inhibits corneal neovascularization in a rabbit model. Graefes Arch Clin Exp Ophthalmol 2015; 253:1061-9. [DOI: 10.1007/s00417-015-2954-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 01/19/2015] [Accepted: 01/26/2015] [Indexed: 02/05/2023] Open
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Abstract
Different types of cationic clay minerals and their applications in various biological systems.
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Affiliation(s)
- M. Ghadiri
- University of Sydney
- Faculty of Pharmacy
- Sydney
- Australia
| | - W. Chrzanowski
- University of Sydney
- Faculty of Pharmacy
- Sydney
- Australia
- Department of Nanobiomedical Science & BK21 PLUS NBM Global Research Centre for Regenerative Medicine
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Freitas-Neto CA, Maghsoudlou A, Dhanireddy S, Payal A, Boonsopon S, Ratwatte MD, Foster CS. Outcome of Multiple Implants and Dissociation of Fluocinolone Acetonide Intravitreal Implant (Retisert) in a Series of 187 Consecutive Implants. Ocul Immunol Inflamm 2014; 23:425-9. [PMID: 25541739 DOI: 10.3109/09273948.2014.986583] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To evaluate outcomes of long-term follow-up of Retisert multiple implantation and dissociation in eyes with chronic noninfectious uveitis. METHODS Review of 187 consecutive Retisert implants. Outcomes of multiple implantation and spontaneous medication pellet-strut dissociation were evaluated. RESULTS A total of 187 consecutive Retisert implants were reviewed. Eight implants were removed. The prevalence of spontaneous dissociation was 2.6% (5/187). The rate of dissociation increased to 11.11% (2/18) in cases of multiple implants. The mean period between Retisert implantation and spontaneous dissociation was 65.05 months. The mean period between implants in the same eye was 55.25 months. In cases of multiple implantations the old implant was not removed and 17.64% (3/17) of eyes required glaucoma filtering surgery. CONCLUSION The rate of spontaneous dissociation of Retisert medication pellet-strut in eyes with single implant for noninfectious uveitis is low, which tends to increase in eyes with multiple implants.
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Affiliation(s)
- Clovis Arcoverde Freitas-Neto
- a Massachusetts Eye Research and Surgery Institution , Cambridge , Massachusetts , USA .,b Ocular Immunology and Uveitis Foundation , Cambridge , Massachusets , USA .,c Hospital de Olhos Santa Luzia , Recife-PE , Brazil , and
| | - Armin Maghsoudlou
- a Massachusetts Eye Research and Surgery Institution , Cambridge , Massachusetts , USA .,b Ocular Immunology and Uveitis Foundation , Cambridge , Massachusets , USA
| | - Swetha Dhanireddy
- a Massachusetts Eye Research and Surgery Institution , Cambridge , Massachusetts , USA .,b Ocular Immunology and Uveitis Foundation , Cambridge , Massachusets , USA
| | - Abhishek Payal
- a Massachusetts Eye Research and Surgery Institution , Cambridge , Massachusetts , USA .,b Ocular Immunology and Uveitis Foundation , Cambridge , Massachusets , USA
| | - Sutasinee Boonsopon
- a Massachusetts Eye Research and Surgery Institution , Cambridge , Massachusetts , USA .,b Ocular Immunology and Uveitis Foundation , Cambridge , Massachusets , USA
| | - Malinga D Ratwatte
- a Massachusetts Eye Research and Surgery Institution , Cambridge , Massachusetts , USA .,b Ocular Immunology and Uveitis Foundation , Cambridge , Massachusets , USA
| | - C Stephen Foster
- a Massachusetts Eye Research and Surgery Institution , Cambridge , Massachusetts , USA .,b Ocular Immunology and Uveitis Foundation , Cambridge , Massachusets , USA .,d Harvard Medical School , Cambridge , Massachusetts , USA
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Use of the Fluocinolone Acetonide Intravitreal Implant for the Treatment of Noninfectious Posterior Uveitis: 3-Year Results of a Randomized Clinical Trial in a Predominantly Asian Population. Ophthalmol Ther 2014; 4:1-19. [PMID: 25502122 PMCID: PMC4470982 DOI: 10.1007/s40123-014-0027-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Indexed: 12/20/2022] Open
Abstract
Introduction The fluocinolone acetonide (FA) intravitreal implant 0.59 mg (Retisert®, Bausch + Lomb, Rochester, NY, USA) provides sustained release of FA directly to the vitreous cavity over a prolonged period of time. The purpose of this study was to evaluate the safety and efficacy of a 0.59- and 2.1-mg FA intravitreal implant in patients with noninfectious posterior uveitis. Methods A prospective, multicenter, randomized, double-masked, dose-controlled study was performed. Patients were randomized to the 0.59- or 2.1-mg FA implant surgically placed in the vitreous cavity through a pars plana incision and were evaluated at visits through 3 years. Patients with bilateral disease had the more severely affected eye implanted. Outcomes included uveitis recurrence rate, best-corrected visual acuity (BCVA), use of adjunctive therapy, and safety. Results A total of 239 patients, predominantly Asian, were implanted (n = 117, 0.59-mg implant; n = 122, 2.1-mg implant). Approximately 80% of patients had bilateral disease. Recurrence rates for implanted eyes decreased from 42.3% during the 1-year pre-implantation period to 25.9% during the 3-year post-implantation period (P = 0.0003) and increased for nonimplanted fellow eyes from 19.8 to 59.7% (P < 0.0001). More implanted eyes gained ≥3 lines of BCVA compared to nonimplanted fellow eyes (P ≤ 0.0046); and implanted eyes required less adjunctive systemic therapy and fewer periocular injections (P < 0.0001). Elevations of intraocular pressure (≥10 mm Hg) were frequent in implanted eyes (67.8%, 0.59-mg implant; 71.3%, 2.1-mg implant); nearly all (94.9%) phakic implanted eyes required cataract surgery. Conclusion The FA intravitreal implant significantly reduced uveitis recurrence rates and led to improvements in visual acuity and reductions in adjunctive therapy. Lens clarity and intraocular pressure require monitoring. Electronic supplementary material The online version of this article (doi:10.1007/s40123-014-0027-6) contains supplementary material, which is available to authorized users.
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Stewart MW. Review of the latest treatments for retinal vein occlusions: emphasis on pharmacologic therapy. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.2014.948423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kang-Mieler JJ, Osswald CR, Mieler WF. Advances in ocular drug delivery: emphasis on the posterior segment. Expert Opin Drug Deliv 2014; 11:1647-60. [PMID: 24975820 DOI: 10.1517/17425247.2014.935338] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Recent advances in pharmacological therapies to treat ocular diseases such as glaucoma, age-related macular degeneration, diabetic macular edema and retinal vascular occlusions have greatly improved the prognosis for these diseases. Due to these advances in pharmacological therapy, there is a great deal of interest in minimally invasive delivery methods, which has generated rapid developments in the field of ocular drug delivery. AREAS COVERED This review will summarize currently available and recent developments for ocular drug delivery to both the anterior and posterior segments. Modes of delivery, including topical, systemic, transcleral/periocular and intravitreal, will be discussed and corresponding examples will be given. This review will highlight the advantages and disadvantages of each mode of delivery and discuss strategies to address these issues. EXPERT OPINION An ideal therapy should maintain effective levels of drug for the intended duration of treatment following a single application, yet a significant number of months of therapy may be required. There are numerous approaches under investigation to improve treatment options. From the use of novel biomaterial implants and depots for sustained release, to prodrug formations, to iontophoresis to improve drug delivery, the main emphasis will continue to be placed on less invasive, longer acting, sustained release formulations in the treatment of numerous ocular disorders.
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Affiliation(s)
- Jennifer J Kang-Mieler
- Illinois Institute of Technology, Department of Biomedical Engineering , Chicago, IL 60616 , USA
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Callanan DG. Novel intravitreal fluocinolone acetonide implant in the treatment of chronic noninfectious posterior uveitis. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.2.1.33] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Shah SS, Denham LV, Elison JR, Bhattacharjee PS, Clement C, Huq T, Hill JM. Drug delivery to the posterior segment of the eye for pharmacologic therapy. EXPERT REVIEW OF OPHTHALMOLOGY 2014; 5:75-93. [PMID: 20305803 DOI: 10.1586/eop.09.70] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Treatment of diseases of the posterior segment of the eye, such as age-related macular degeneration, cytomegalovirus retinitis, diabetic retinopathy, posterior uveitis and retinitis pigmentosa, requires novel drug delivery systems that can overcome the many barriers for efficacious delivery of therapeutic drug concentrations. This challenge has prompted the development of biodegradable and nonbiodegradable sustained-release systems for injection or transplantation into the vitreous as well as drug-loaded nanoparticles, microspheres and liposomes. These drug delivery systems utilize topical, systemic, subconjunctival, intravitreal, transscleral and iontophoretic routes of administration. The focus of research has been the development of methods that will increase the efficacy of spatiotemporal drug application, resulting in more successful therapy for patients with posterior segment diseases. This article summarizes recent advances in the research and development of drug delivery methods of the posterior chamber of the eye, with an emphasis on the use of implantable devices as well as micro- and nanoparticles.
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Affiliation(s)
- Shalin S Shah
- Department of Ophthalmology, Louisiana State University Health Sciences Center (LSUHSC), 2020 Gravier St. Suite B, Room 3E6, New Orleans, LA 70112-2234, USA, Tel.: +1 678 296 2334, ,
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Lu C, Zahedi P, Forman A, Allen C. Multi-arm PEG/silica hydrogel for sustained ocular drug delivery. J Pharm Sci 2013; 103:216-26. [PMID: 24285503 DOI: 10.1002/jps.23777] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Revised: 09/20/2013] [Accepted: 10/18/2013] [Indexed: 11/12/2022]
Abstract
In the present study, a series of sustained drug delivery multiarm poly(ethylene glycol) (PEG)/silica hydrogels were prepared and characterized. The hydrogels were formed by hydrolysis and condensation of poly(4-arm PEG silicate) using the sol-gel method. The relationships between water content in the PEG/silica hydrogel and stability as well as rheological properties were evaluated. Scanning electron microscopy analysis of the PEG/silica hydrogels revealed water content-dependent changes in microstructure. An increase in water content resulted in larger pores within the hydrogel, longer gelation time and higher viscosity. The PEG/silica hydrogels were loaded with dexamethasone (DMS) or dexamethasone sodium phosphate (DMSP), drugs that are hydrophobic and hydrophilic in nature, respectively. Evaluation of in vitro release revealed a zero-order release profile for DMS over the first 6 days, suggesting that degradation of the silica hydrogel matrix was the primary mechanism of drug release. It was also found that the drug-release profile could be tailored by varying the water content used during hydrogel preparation. In contrast, more than 90% of DMSP was released within 1 h, suggesting that DMSP release was only controlled by diffusion. Overall, results from this study indicate that PEG/silica hydrogels may be promising drug-eluting depot materials for the sustained delivery of hydrophobic, ophthalmic drugs.
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Affiliation(s)
- Changhai Lu
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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Emerging therapies for the treatment of uveitis: clinical trial observations. ACTA ACUST UNITED AC 2013. [DOI: 10.4155/cli.13.87] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Intraocular Pressure Monitoring Post Intravitreal Steroids: A Systematic Review. Surv Ophthalmol 2013; 58:291-310. [DOI: 10.1016/j.survophthal.2012.08.003] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 08/04/2012] [Accepted: 08/07/2012] [Indexed: 12/29/2022]
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Karim R, Sykakis E, Lightman S, Fraser-Bell S. Interventions for the treatment of uveitic macular edema: a systematic review and meta-analysis. Clin Ophthalmol 2013; 7:1109-44. [PMID: 23807831 PMCID: PMC3685443 DOI: 10.2147/opth.s40268] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Uveitic macular edema is the major cause of reduced vision in eyes with uveitis. Objectives To assess the effectiveness of interventions in the treatment of uveitic macular edema. Search strategy Cochrane Central Register of Controlled Trials, Medline, and Embase. There were no language or data restrictions in the search for trials. The databases were last searched on December 1, 2011. Reference lists of included trials were searched. Archives of Ophthalmology, Ophthalmology, Retina, the British Journal of Ophthalmology, and the New England Journal of Medicine were searched for clinical trials and reviews. Selection criteria Participants of any age and sex with any type of uveitic macular edema were included. Early, chronic, refractory, or secondary uveitic macular edema were included. We included trials that compared any interventions of any dose and duration, including comparison with another treatment, sham treatment, or no treatment. Data collection and analysis Best-corrected visual acuity and central macular thickness were the primary outcome measures. Secondary outcome data including adverse effects were collected. Conclusion More results from randomized controlled trials with long follow-up periods are needed for interventions for uveitic macular edema to assist in determining the overall long-term benefit of different treatments. The only intervention with sufficiently robust randomized controlled trials for a meta-analysis was acetazolamide, which was shown to be ineffective in improving vision in eyes with uveitic macular edema, and is clinically now rarely used. Interventions showing promise in this disease include dexamethasone implants, immunomodulatory drugs and anti-vascular endothelial growth-factor agents. When macular edema has become refractory after multiple interventions, pars plana vitrectomy could be considered. The disease pathophysiology is uncertain and the course of disease unpredictable. As there are no clear guidelines from the literature, interventions should be tailored to the individual patient.
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Affiliation(s)
- Rushmia Karim
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia
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Tlucek PS, Folk JC, Sobol WM, Mahajan VB. Surgical management of fibrotic encapsulation of the fluocinolone acetonide implant in CAPN5-associated proliferative vitreoretinopathy. Clin Ophthalmol 2013; 7:1093-8. [PMID: 23785231 PMCID: PMC3682853 DOI: 10.2147/opth.s43939] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Objective To review fibrosis of fluocinolone acetonide (FA) implants in subjects with CAPN5 autosomal dominant neovascular inflammatory vitreoretinopathy (ADNIV). Methods A retrospective case series was assembled from ADNIV patients in which there was fibrotic encapsulation of a fluocinolone acetonide implant. CAPN5 genotypes and surgical repair techniques were reviewed. Results Two eyes of two ADNIV patients developed a fibrotic capsule over the fluocinolone acetonide implant. Both patients had Stage IV disease. Patient A had a c.731T > C mutation in the CAPN5 gene and patient B had a c.728G > T mutation. The fibrotic membrane was surgically excised and the implant function was restored. Conclusion The exuberant fibrotic response in later stages of ADNIV may be resistant to local immunosuppression with steroids. Surgical excision of fibrotic membranes over FA implants can reestablish local steroid delivery in cases of severe proliferative vitreoretinopathy.
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Affiliation(s)
- Paul S Tlucek
- Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, IA, USA
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Patel A, Cholkar K, Agrahari V, Mitra AK. Ocular drug delivery systems: An overview. World J Pharmacol 2013; 2:47-64. [PMID: 25590022 PMCID: PMC4289909 DOI: 10.5497/wjp.v2.i2.47] [Citation(s) in RCA: 458] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2012] [Revised: 03/21/2013] [Accepted: 04/04/2013] [Indexed: 02/06/2023] Open
Abstract
The major challenge faced by today’s pharmacologist and formulation scientist is ocular drug delivery. Topical eye drop is the most convenient and patient compliant route of drug administration, especially for the treatment of anterior segment diseases. Delivery of drugs to the targeted ocular tissues is restricted by various precorneal, dynamic and static ocular barriers. Also, therapeutic drug levels are not maintained for longer duration in target tissues. In the past two decades, ocular drug delivery research acceleratedly advanced towards developing a novel, safe and patient compliant formulation and drug delivery devices/techniques, which may surpass these barriers and maintain drug levels in tissues. Anterior segment drug delivery advances are witnessed by modulation of conventional topical solutions with permeation and viscosity enhancers. Also, it includes development of conventional topical formulations such as suspensions, emulsions and ointments. Various nanoformulations have also been introduced for anterior segment ocular drug delivery. On the other hand, for posterior ocular delivery, research has been immensely focused towards development of drug releasing devices and nanoformulations for treating chronic vitreo-retinal diseases. These novel devices and/or formulations may help to surpass ocular barriers and associated side effects with conventional topical drops. Also, these novel devices and/or formulations are easy to formulate, no/negligibly irritating, possess high precorneal residence time, sustain the drug release, and enhance ocular bioavailability of therapeutics. An update of current research advancement in ocular drug delivery necessitates and helps drug delivery scientists to modulate their think process and develop novel and safe drug delivery strategies. Current review intends to summarize the existing conventional formulations for ocular delivery and their advancements followed by current nanotechnology based formulation developments. Also, recent developments with other ocular drug delivery strategies employing in situ gels, implants, contact lens and microneedles have been discussed.
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Tlucek PS, Folk JC, Orien JA, Stone EM, Mahajan VB. Inhibition of neovascularization but not fibrosis with the fluocinolone acetonide implant in autosomal dominant neovascular inflammatory vitreoretinopathy. ACTA ACUST UNITED AC 2013; 130:1395-401. [PMID: 22777573 DOI: 10.1001/archophthalmol.2012.1971] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To review the effect of the fluocinolone acetonide implant in subjects with autosomal dominant neovascular inflammatory vitreoretinopathy (ADNIV), an inherited autoimmune uveitis. METHODS A retrospective case series was assembled from patients with ADNIV who received fluocinolone acetonide implants. Visual acuity and features of ADNIV, including inflammatory cells, neovascularization, fibrosis, and cystoid macular edema, were reviewed. RESULTS Nine eyes of 5 related patients with ADNIV with uncontrolled inflammation were reviewed. Follow-up ranged from 21.7 to 56.7 months. Visual acuity at implantation ranged from 20/40 to hand motion. Preoperatively, 8 eyes had vitreous cells (a ninth had diffuse vitreous hemorrhage). Eight eyes had cystoid macular edema, 7 had an epiretinal membrane, and 3 had retinal neovascularization. Following implantation, vitreous cells resolved in all eyes and neovascularization regressed or failed to develop. Central macular thickness improved in 4 eyes. During the postoperative course, however, visual acuity continued to deteriorate, with visual acuity at the most recent examination ranging from 20/60 to no light perception. There was also progressive intraocular fibrosis and phthisis in 1 case. Four eyes underwent cataract surgery. Six of the 7 eyes without previous glaucoma surgery had elevated intraocular pressure at some point, and 3 of these required glaucoma surgery. CONCLUSIONS The fluocinolone acetonide implant may inhibit specific features of ADNIV such as inflammatory cells and neovascularization but does not stabilize long-term vision, retinal thickening, or fibrosis. All eyes in this series required cataract extraction, and more than half required surgical intervention for glaucoma. Further studies may identify additional therapies and any benefit of earlier implantation.
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Kiernan DF, Mieler WF. Intraocular corticosteroids for posterior segment disease: 2012 update. Expert Opin Pharmacother 2012; 13:1679-94. [PMID: 22783878 DOI: 10.1517/14656566.2012.690736] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Diabetic macular edema (DME), cystoid macular edema (CME), age-related macular degeneration (AMD), retinal vascular occlusion (RVO) and uveitis are responsible for severe visual impairment worldwide. In some patients with these conditions, treatment with intraocular corticosteroids may be beneficial. Although off-label use of these agents has occurred for many years, novel agents including preservative-free and sustained-release intravitreal implants are currently being studied in clinical trials (CTs). AREAS COVERED This paper reviews the use of CTs for vitreoretinal (VR) diseases including choroidal neovascularization, CME, DME, RVO and posterior uveitis. It also discusses the use of corticosteroids for treating VR disease, including dexamethasone, fluocinolone acetonide, intravitreal implants and triamcinolone acetonide. EXPERT OPINION Used alone, intravitreal corticosteroids may benefit disorders such as DME, RVO and uveitis compared with standard therapy. Cases of exudative AMD non-responsive to standard treatment may benefit from combination therapy, including usage of intravitreal corticosteroid injections. Intraoperative use of these agents may aid visualization of retinal structures. Sustained-release intraocular implants have been approved for posterior uveitis and RVO associated with macular edema. In spite of this, most intraocular corticosteroids have a limited duration of action along with significant side effects, including cataract and glaucoma. Currently, intravitreal corticosteroid usage for DME is considered off-label.
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Affiliation(s)
- Daniel F Kiernan
- Ophthalmic Consultants of Long Island, Rockville Centre, NY, USA
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