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Kozak I, Gurbaxani A, Pandova M. The effectiveness of the 0.19 mg fluocinolone acetonide implant in treating non-infectious posterior uveitis: a real-world experience. J Ophthalmic Inflamm Infect 2024; 14:24. [PMID: 38833091 DOI: 10.1186/s12348-024-00409-x] [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: 06/28/2023] [Accepted: 05/27/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND The 0.19 mg fluocinolone acetonide (FAc) implant (ILUVIEN) has been approved for prevention of relapse in recurrent non-infectious uveitis affecting the posterior segment of the eye (NIU-PS). There is little data assessing the long-term efficacy and safety of the FAc implant in this indication. Therefore, we conducted a retrospective interventional case review of 18 eyes from 13 patients with NIU-PS treated with the FAc implant at three ophthalmology departments in the Middle East between 2018 and 2021. MAIN TEXT Baseline patient characteristics, including best-corrected visual acuity (BCVA), central retinal thickness (CRT) and intraocular pressure (IOP), were collected at the time of FAc implant administration and at 1-3 months, 6 months and every six months thereafter. The mean time of follow-up was 29.7 ± 14.6 (mean ± SD) months. Over the follow-up, the BCVA significantly increased from month 1 (P = 0.002) until month 36 (P = 0.024) and remained improving throughout the follow-up period (P = 0.004). The CRT significantly decreased from month 1 (P = 0.008) until month 12 (P = 0.003) and was persistently lower during the follow-up period (P = 0.022). Significant improvements in anterior chamber cells (P = 0.004) and vitritis scores (P = 0.001) were observed by Month 6. Similarly, at Month 12, significant improvements were noted in both parameters as well (anterior chamber cells: P = 0.012; vitritis scores: P = 0.004). Mean IOP remained relatively stable throughout (P = 0.205) the follow-up. CONCLUSIONS Our results suggest improvements and long-term maintenance in functional and anatomical outcomes with FAc implant with a manageable safety profile in a real-world clinical setting in patients with NIU-PS.
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Affiliation(s)
- Igor Kozak
- Moorfields Eye Hospitals UAE, Abu Dhabi, UAE.
- Department of Ophthalmology and Vision Science, University of Arizona at Tucson, Tucson, AZ, USA.
| | | | - Maya Pandova
- Department of Ophthalmology, New Ahmadi KOC Hospital, Ahmadi, Kuwait
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Pleyer U, Pavesio C, Miserocchi E, Heinz C, Devonport H, Llorenç V, Burke T, Nogueira V, Kodjikian L, Bodaghi B. Fluocinolone acetonide 0.2 µg/day intravitreal implant in non-infectious uveitis affecting the posterior segment: EU expert user panel consensus-based clinical recommendations. J Ophthalmic Inflamm Infect 2024; 14:22. [PMID: 38814386 PMCID: PMC11139823 DOI: 10.1186/s12348-024-00402-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 05/02/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND Non-infectious uveitis affecting the posterior segment of the eye (NIU-PS) is an inflammatory disease, which can significantly impair visual acuity if not adequately treated. Fluocinolone-acetonide sustained-release-0.2 µg/day intravitreal (FAc) implants are indicated for prevention of relapse in recurrent NIU-PS. The aim here was to provide treating clinicians with some consensus-based-recommendations for the clinical management of patients with NIU-PS with 0.2 µg/day FAc implants. METHODS A European-clinical-expert-group agreed to develop a consensus report on different issues related to the use of FAc implants in patients with NIU-PS. RESULTS The Clinical-expert-panel provided specific recommendations focusing on clinical presentation (unilateral/bilateral) of the NIU-PS; systemic involvement of NIU-PS and the lens status. Treatment algorithms were developed; one that refers to the management of patients with NIU-PS in clinical practice and another that establishes the best clinical scenarios for the use of FAc implants, both as monotherapy and as adjuvant therapy. Additionally, the Clinical-expert-panel has provided recommendations about the use of the FAc implants in a clinical-setting. The Clinical-expert-panel also considered the safety profile of FAc implants and their possible implications in the daily practice. CONCLUSIONS As more clinical experience has been gained using FAc implants, it was necessary to update the clinical recommendations that guide patient management in the clinic. The current consensus document addresses relevant issues related to the use of FAc implants on different types of patients with various etiologies of NIU-PS, and was conducted to standardize approaches to help specialists obtain better clinical outcomes.
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Affiliation(s)
- Uwe Pleyer
- Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Carlos Pavesio
- Department of Ophthalmology at Moorfields Eye Hospital, London, UK
| | - Elisabetta Miserocchi
- Department of Ophthalmology, Ocular Immunology and Uveitis Service, University Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carsten Heinz
- Department of Ophthalmology at St, Franziskus Hospital Muenster, Münster, Germany
- Department of Ophthalmology, University Duisburg-Essen, Essen, Germany
| | - Helen Devonport
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, West Yorkshire, UK
| | - Víctor Llorenç
- Clínic Hospital of Barcelona, Barcelona, Spain
- August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Tomás Burke
- Department of Ophthalmology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Vanda Nogueira
- Instituto de Oftalmologia Dr. Gama Pinto, Lisbon, Portugal
| | - Laurent Kodjikian
- Service d'Ophtalmologie, Hôpital Universitaire de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France
- UMR5510 MATEIS, CNRS, INSA Lyon, Université Lyon 1, 69100, Villeurbanne, France
| | - Bahram Bodaghi
- Department of Ophthalmology, Pitié-Salpêtrière Hospital, Paris, France
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Abu Arif J, Knecht VA, Rübsam A, Lussac V, Jami Z, Pohlmann D, Müller B, Pleyer U. Fluocinolone Acetonide Implant for Uveitis: Dissecting Responder and Non-Responder Outcomes at a Tertiary Center. Biomedicines 2024; 12:1106. [PMID: 38791073 PMCID: PMC11117563 DOI: 10.3390/biomedicines12051106] [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: 04/04/2024] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
Macular edema (ME) remains a primary cause of visual deterioration in uveitis. Visual acuity (VA) can often be maintained using corticosteroid depot systems. This study evaluated the efficacy of a fluocinolone acetonide (FAc) intravitreal implant (ILUVIEN®) in treating non-infectious uveitis using real-world data. This retrospective analysis included 135 eyes subdivided into responders and non-responders. Central retinal thickness (CRT), VA, and intraocular pressure (IOP) were followed over time. A significant decrease in CRT and an increase in VA were observed in all eyes throughout the follow-up period (p < 0.01). An IOP increase (p = 0.028) necessitated treatment in 43% of eyes by Month 6. Non-responders were older (p = 0.004) and had been treated with more dexamethasone (DEX) implants (p = 0.04); 89.3% had a defect in the external limiting membrane (ELM) and inner/outer segment (IS/OS) zone (p < 0.001). Immunomodulatory therapy had no impact on treatment response. Pars plana vitrectomy (PPV) patients had a mean CRT reduction of 47.55 µm and a reduced effect by Month 24 (p = 0.046) versus non-PPV patients. We conclude that the FAc implant achieves long-term control of CRT and improves VA. Increases in IOP were manageable. Eyes with a previous PPV showed milder results. Data showed a correlation between older age, a damaged ELM and IS/OS zone, frequent DEX inserts, and poorer outcome measures.
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Affiliation(s)
- Jasmin Abu Arif
- Department of Ophthalmology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (J.A.A.); (V.A.K.); (A.R.); (Z.J.); (D.P.); (B.M.)
| | - Vitus André Knecht
- Department of Ophthalmology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (J.A.A.); (V.A.K.); (A.R.); (Z.J.); (D.P.); (B.M.)
| | - Anne Rübsam
- Department of Ophthalmology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (J.A.A.); (V.A.K.); (A.R.); (Z.J.); (D.P.); (B.M.)
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Charité Platz 1, 10117 Berlin, Germany
| | - Vanessa Lussac
- Department of Ophthalmology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (J.A.A.); (V.A.K.); (A.R.); (Z.J.); (D.P.); (B.M.)
| | - Zohreh Jami
- Department of Ophthalmology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (J.A.A.); (V.A.K.); (A.R.); (Z.J.); (D.P.); (B.M.)
| | - Dominika Pohlmann
- Department of Ophthalmology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (J.A.A.); (V.A.K.); (A.R.); (Z.J.); (D.P.); (B.M.)
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Charité Platz 1, 10117 Berlin, Germany
| | - Bert Müller
- Department of Ophthalmology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (J.A.A.); (V.A.K.); (A.R.); (Z.J.); (D.P.); (B.M.)
| | - Uwe Pleyer
- Department of Ophthalmology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (J.A.A.); (V.A.K.); (A.R.); (Z.J.); (D.P.); (B.M.)
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Charité Platz 1, 10117 Berlin, Germany
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Samalia PD, Lim LL, Niederer RL. Insights into the diagnosis and management of sarcoid uveitis: A review. Clin Exp Ophthalmol 2024; 52:294-316. [PMID: 38385625 DOI: 10.1111/ceo.14366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 01/08/2024] [Accepted: 01/19/2024] [Indexed: 02/23/2024]
Abstract
Sarcoidosis is a leading cause of non-infectious uveitis that commonly affects middle-aged individuals and has a female preponderance. The disease demonstrates age, sex and ethnic differences in clinical manifestations. A diagnosis of sarcoidosis is made based on a compatible clinical presentation, supporting investigations and histologic evidence of non-caseating granulomas, although biopsy is not always possible. Multimodal imaging with widefield fundus photography, optical coherence tomography and angiography can help in the diagnosis of sarcoid uveitis and in the monitoring of treatment response. Corticosteroid remains the mainstay of treatment; chronic inflammation requires steroid-sparing immunosuppression. Features on multimodal imaging such as vascular leakage may provide prognostic indicators of outcome. Female gender, prolonged and severe uveitis, and posterior involving uveitis are associated with poorer visual outcomes.
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Affiliation(s)
- Priya D Samalia
- Department of Opthalmology, Te Whatu Ora Southern, Dunedin, New Zealand
- Otago School of Medicine, University of Otago, Dunedin, New Zealand
| | - Lyndell L Lim
- The Royal Victorian Eye and Ear Hospital, Melbourne, Australia
- Centre for Eye Research Australia, University of Melbourne, Melbourne, Australia
| | - Rachael L Niederer
- Department of Ophthalmology, Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand
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Mahmud H, Ahmad TR, Gonzales JA, Stewart JM. Efficacy of the Fluocinolone Acetonide (Yutiq) Intravitreal Implant as Monotherapy for Uveitis. Ocul Immunol Inflamm 2023; 31:1603-1607. [PMID: 35793136 DOI: 10.1080/09273948.2022.2076131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 05/04/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE To evaluate the efficacy of the fluocinolone acetonide intravitreal implant (Yutiq) as monotherapy for uveitis. DESIGN Retrospective cohort study. PARTICIPANTS Patients at a single academic health-care institution. METHODS Medical record review of patients with non-infectious uveitis actively suppressed on an alternative anti-inflammatory regimen who received a fluocinolone acetonide implant. The primary outcome was continued control of inflammation based on clinical examination, optical coherence tomography, and fluorescein angiography. RESULTS Thirteen patients (19 eyes) received an implant. Median follow-up was 6 months. Uveitis control was achieved in 14 eyes (74%), though three (21%) required a topical steroid after insertion. The remaining five eyes (26%) required additional intraocular treatments. CONCLUSION The fluocinolone acetonide implant may not suffice as monotherapy for all patients with uveitis, but it may be effective as an adjunctive treatment. We propose a clinical workflow for the selection and treatment of patients who may benefit from it.
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Affiliation(s)
- Hamidah Mahmud
- Department of Ophthalmology, University of California, San Francisco, California, USA
- Zuckerberg San Francisco General Hospital and Trauma Center, Department of Ophthalmology, San Francisco, California, USA
| | - Tessnim R Ahmad
- Department of Ophthalmology, University of California, San Francisco, California, USA
- Zuckerberg San Francisco General Hospital and Trauma Center, Department of Ophthalmology, San Francisco, California, USA
| | - John A Gonzales
- Department of Ophthalmology, University of California, San Francisco, California, USA
- Francis I. Proctor Foundation, University of California, San Francisco,California, USA
| | - Jay M Stewart
- Department of Ophthalmology, University of California, San Francisco, California, USA
- Zuckerberg San Francisco General Hospital and Trauma Center, Department of Ophthalmology, San Francisco, California, USA
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Kessler LJ, Auffarth GU, Khoramnia R. Functional and Morphological Responses to Fluocinolone Acetonide 0.19 mg in Noninfectious Uveitic Macular Edema Evaluated as the Area-Under-the-Curve. J Ocul Pharmacol Ther 2023; 39:449-455. [PMID: 37384926 PMCID: PMC10516239 DOI: 10.1089/jop.2023.0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/04/2023] [Indexed: 07/01/2023] Open
Abstract
Purpose: This study investigated the impact of baseline clinical and optical coherence tomography (OCT) factors on the response to a 0.19-mg fluocinolone acetonide (FAc) implant in patients with noninfectious uveitic macular edema evaluated by the area under the curve over 24 months. Methods: A retrospective study was conducted of eyes of patients with noninfectious uveitic macular edema undergoing FAc treatment, with follow-up from baseline to 24 months. The area under the curve (AUC) of best-corrected visual acuity (BCVA) and the central macular thickness (CMT) were calculated using the trapezoidal rule. Clinical and OCT data at the time of FAc administration were collected, and associations with AUC of BCVA and CMT changes were investigated. Results: Twenty-three patients were enrolled. BCVA and CMT significantly improved after FAc implantation (P < 0.05). AUCBCVA and AUCCMT were 0.41 ± 0.33 logarithm of minimal angle of resolution/6 months and 320.15 ± 321.64 μm/6 months, respectively. Better baseline BCVA (coefficient [coef.] = 0.83, P < 0.001) and macular thickness reduction after FAc administration (coef. = -0.0001, P < 0.05) were associated with better BCVA after FAc treatment. In contrast, baseline OCT biomarkers such as ellipsoid zone reflectivity and choroidal vascularity index, sex, or disease duration before FAc injection showed no correlation with AUCBCVA and AUCCMT (P > 0.05). The younger the patient at the time of FAc injection, the greater the reduction in CMT (coef. = 1.76, P < 0.05). Conclusions: Among all clinical and morphological baseline factors, Baseline BCVA was the strongest predictor for AUCBCVA, while no association with baseline OCT features was observed. Overall, improvement of BCVA and CMT after FAc injection was maintained over 24 months. This study is registered in the German Clinical Trials Register under the DRKS-ID: DRKS00024399.
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Affiliation(s)
| | - Gerd Uwe Auffarth
- Department of Ophthalmology, University of Heidelberg, Heidelberg, Germany
| | - Ramin Khoramnia
- Department of Ophthalmology, University of Heidelberg, Heidelberg, Germany
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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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Mushtaq Y, Mushtaq MM, Gatzioufas Z, Ripa M, Motta L, Panos GD. Intravitreal Fluocinolone Acetonide Implant (ILUVIEN ®) for the Treatment of Retinal Conditions. A Review of Clinical Studies. Drug Des Devel Ther 2023; 17:961-975. [PMID: 37020801 PMCID: PMC10069638 DOI: 10.2147/dddt.s403259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/22/2023] [Indexed: 04/07/2023] Open
Abstract
Fluocinolone acetonide (FAc) intravitreal implant (Iluvien®) is a corticosteroid implant indicated for the treatment of diabetic macular oedema (DMO) in patients who have previously received conventional treatment without good response, non-infectious posterior uveitis, and as an off-label treatment of the macular oedema secondary to retinal vein occlusion. FAc is a non-biodegradable 0.19 mg intravitreal implant which is designed to release FAc over 3 years at a rate of approximately 0.2 mcg per day. The aim of this review is to describe the special pharmacological properties of Iluvien and display the outcomes of the most important clinical trials and real-world studies regarding its efficacy and safety for the management of the above retinal disorders.
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Affiliation(s)
- Yusuf Mushtaq
- Department of Ophthalmology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust & School of Medicine, University of Nottingham, Nottingham, UK
| | - Maryam M Mushtaq
- Department of Acute Medicine, Luton and Dunstable University Hospitals NHS Trust, Luton, UK
| | - Zisis Gatzioufas
- Department of Ophthalmology, Basel University Hospital & University of Basel School of Medicine, Basel, Switzerland
| | - Matteo Ripa
- Ophthalmology Unit, “Fondazione Policlinico Universitario A. Gemelli IRCCS”, Rome, Italy
| | - Lorenzo Motta
- Department of Ophthalmology, William Harvey Hospital, East Kent Hospitals University NHS Foundation Trust, Kent, UK
| | - Georgios D Panos
- Department of Ophthalmology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust & School of Medicine, University of Nottingham, Nottingham, UK
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9
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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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10
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Chang EL, Sobrin L. Local versus Systemic Therapy for Noninfectious Uveitis (NIU). Semin Ophthalmol 2023; 38:15-23. [PMID: 36471661 DOI: 10.1080/08820538.2022.2152707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The mainstay of treatment for noninfectious uveitis (NIU) is immunosuppressant therapy. This may come in a localized form that is administered specifically to the eye or a systemic form that penetrates ocular tissues. Over the last twenty years, both local and systemic treatments have undergone advancements in pharmaceutical development. In this review, we will discuss new therapies and analyze the risks and benefits for all existing NIU therapies. Some of these therapies include topical, intravitreal, periocular, and systemic steroids, as well as systemic antimetabolites, tumor necrosis factor-α inhibitors, T-cell inhibitors, anti-CD 20 agents, interleukin-6 inhibitors, alkylating agents, and intravenous immunoglobulin.
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Affiliation(s)
- Eileen L Chang
- Harvard Medical School, Massachusetts Eye & Ear Infirmary, Boston, USA
| | - Lucia Sobrin
- Harvard Medical School, Massachusetts Eye & Ear Infirmary, Boston, USA
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Single Institution Experience of Intravitreal 0.18-mg Fluocinolone Acetonide Implant for Noninfectious Uveitis. Ophthalmol Retina 2023; 7:67-71. [PMID: 35820567 DOI: 10.1016/j.oret.2022.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/30/2022] [Accepted: 07/05/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE To report the outcomes of the 0.18-mg fluocinolone acetonide implant (FAi) in the treatment of noninfectious uveitis. DESIGN Retrospective cohort study. PARTICIPANTS Patients who received the 0.18-mg FAi for the treatment of noninfectious uveitis affecting the posterior segment (NIU-PS) between July 1, 2019, and August 31, 2021, at the University of Colorado. Patients were excluded if they did not have ≥ 6 months of follow-up after the placement of the implant. METHODS Data including age, race/ethnicity, sex, uveitis diagnosis, history and current use of anti-inflammatory therapy, use of short-acting corticosteroid injections within the 3 months before the 0.18-mg FAi implantation, visual acuity, intraocular pressure (IOP), grading of anterior chamber and vitreous cell, and presence of cystoid macular edema were obtained from the medical charts. Uveitis recurrence was defined as any increased inflammation that required additional anti-inflammatory therapy. MAIN OUTCOME MEASURES Probability of remaining recurrence-free after the placement of the 0.18-mg FAi. RESULTS Sixty-four eyes from 42 patients were included. The overall probability of remaining recurrence-free was 68.8% at 6 months and 52.6% at the 12-month follow-up. Eyes that remained recurrence-free at 12 months had a younger mean age than eyes that had a recurrence within 12 months (P = 0.02). Eyes that received a short-acting corticosteroid injection before the 0.18-mg FAi were more likely to have a recurrence by 6 months of follow-up than eyes that did not receive a pre-FAi corticosteroid injection (P = 0.05). Initiation or addition of IOP-lowering eyedrops was required in 15.6% of eyes, and 4.7% of eyes required IOP-lowering surgery after 0.18-mg FAi placement. CONCLUSIONS The 0.18-mg FAi appears to be an effective option in the management of NIU-PS, with relatively low rates of ocular hypertension requiring intervention. The use of short-acting corticosteroid injections before the placement of the 0.18-mg FAi does not seem to improve the effectiveness of the 0.18-mg FAi, although this may be partially because of selection bias. Additional studies are required to determine patients who are the optimal candidates for this therapy.
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12
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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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13
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Teo AYT, Betzler BK, Hua KLQ, Chen EJ, Gupta V, Agrawal R. Intermediate Uveitis: A Review. Ocul Immunol Inflamm 2022:1-20. [PMID: 35759636 DOI: 10.1080/09273948.2022.2070503] [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: 10/17/2022]
Abstract
PURPOSE This review aims to provide an update on the clinical presentation, etiologies, complications, and treatment options in intermediate uveitis (IU). METHODS Narrative literature review. RESULTS IU affects all age groups with no clear gender predominance and has varied etiologies including systemic illnesses and infectious diseases, or pars planitis. In some instances, IU may be the sole presentation of an underlying associated condition or disease. Management of IU and its complications include administration of corticosteroids, antimetabolites, T-cell inhibitors, and/or biologics, along with surgical interventions, with varying degrees of effectiveness across literature. In particular, increasing evidence of the safety and efficacy of immunomodulatory agents and biologics has seen greater adoption of these therapies in clinical practice. CONCLUSIONS IU is an anatomical description of uveitis, involving intraocular inflammation of the vitreous, peripheral retinal vasculature, and pars plana. Various treatment options for intermediate uveitis are currently used in practice.
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Affiliation(s)
| | | | - Keith Low Qie Hua
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Vishali Gupta
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rupesh Agrawal
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore.,Lee Kong Chian School of Medicine, Singapore.,Singapore Eye Research Institute, Singapore.,Duke NUS Medical School, Singapore
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14
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Kessler LJ, Łabuz G, Auffarth GU, Khoramnia R. Biomarkers to Predict the Success of Treatment with the Intravitreal 0.19 mg Fluocinolone Acetonide Implant in Uveitic Macular Edema. Pharmaceutics 2022; 14:pharmaceutics14040688. [PMID: 35456522 PMCID: PMC9028038 DOI: 10.3390/pharmaceutics14040688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 12/10/2022] Open
Abstract
To predict the need for additional local corticosteroids after receiving the 0.19 mg fluocinolone acetonide (FAc) implant in patients with macular edema secondary to non-infectious uveitis previously treated with local peribulbar corticosteroids. The number of corticosteroids required prior FAc, visual acuity, central retinal thickness, ellipsoid zone reflectivity ratio (EZR), and choroidal vascularity index (CVI) were compared between patients who did and did not require additional corticosteroids after FAc implantation. Pearson’s correlation coefficient (R) between putative predictors and the number of adjunctive corticosteroids after FAc implantation were measured; significant candidates were included in a generalized regression model. Patients who required additional corticosteroids after FAc had higher CVI and central retinal thickness as well as worse EZR at subsequent visits (p < 0.05). The number of corticosteroids required prior to FAc implantation (R: 0.49), CVI change from baseline to 6 months (R: −0.41), and central retinal thickness at baseline (R: −0.36) correlated to the number of additional corticosteroids (all p < 0.05). A higher number of corticosteroids per year before FAc implantation was predictive for an increase in corticosteroids required after FAc (odds ratio = 2.65), while a decrease in CVI from baseline to 6 months was inversely correlated (odds ratio = 0.82). Our results suggest that the more corticosteroids prior to FAc and the greater the short-term CVI reducing effect, the less is the chance to get additional corticosteroids after FAc.
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Affiliation(s)
- Lucy Joanne Kessler
- Department of Ophthalmology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (L.J.K.); (G.Ł.); (G.U.A.)
- HEIKA–Heidelberg Karlsruhe Strategic Partnership, Department of Ophthalmology, Heidelberg University, 69120 Heidelberg, Germany
| | - Grzegorz Łabuz
- Department of Ophthalmology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (L.J.K.); (G.Ł.); (G.U.A.)
| | - Gerd U. Auffarth
- Department of Ophthalmology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (L.J.K.); (G.Ł.); (G.U.A.)
| | - Ramin Khoramnia
- Department of Ophthalmology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (L.J.K.); (G.Ł.); (G.U.A.)
- HEIKA–Heidelberg Karlsruhe Strategic Partnership, Department of Ophthalmology, Heidelberg University, 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-06221-56-4573
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15
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The Use of Sustained Release Intravitreal Steroid Implants in Non-Infectious Uveitis Affecting the Posterior Segment of the Eye. Ophthalmol Ther 2022; 11:479-487. [PMID: 35092605 PMCID: PMC8800436 DOI: 10.1007/s40123-022-00456-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/07/2022] [Indexed: 11/02/2022] Open
Abstract
The treatment of non-infectious uveitis affecting the posterior segment of the eye has been revolutionized by the development of sustained-release corticosteroid implants over the past decade. Their use is now supported by healthcare systems that have licensed and commissioned them on the basis of the high-quality randomised controlled trials that formed part of their development and which have informed clinicians as to their benefits and risks. In particular, they have provided an alternative mode of treatment for patients who do not wish to be systemically immunosuppressed, or in whom such immunosuppression is less desirable, such as those with unilateral disease or those with concurrent illnesses such as diabetes mellitus, renal disease or osteoporosis that are negatively impacted by systemic corticosteroids or other immunosuppressive agents. In this article, we review the evidence for the use of the major licensed corticosteroid implants and assess the advantages and disadvantages of each.
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16
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McHarg M, Young L, Kesav N, Yakin M, Sen HN, Kodati S. Practice patterns regarding regional corticosteroid treatment in noninfectious Uveitis: a survey study. J Ophthalmic Inflamm Infect 2022; 12:3. [PMID: 34982279 PMCID: PMC8727651 DOI: 10.1186/s12348-021-00281-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 12/15/2021] [Indexed: 11/10/2022] Open
Abstract
Background Regional corticosteroid therapy for noninfectious uveitis is well-established but usage patterns have not been studied extensively. This study aims to assess practice patterns of retina and uveitis specialists regarding their preferences on the use of local corticosteroid therapy. Methods A 13-question survey was developed regarding the practice patterns of regional corticosteroid use in specific situations and populations. The survey was distributed to both the American Uveitis Society and Macula Society. Results Responses from 87 ophthalmologists were analyzed. The two most commonly used drugs were the dexamethasone intravitreal implant (Ozurdex®) and posterior sub-tenon’s triamcinolone (also known as posterior sub-Tenon’s Kenalog, or PSTK). Regional corticosteroids were used more frequently as first-line treatment in more than half of posterior uveitis cases when compared to anterior uveitis (39.1–46.0% vs 10.3%, respectively). Respondents were more willing to use regional corticosteroids in more than half of unilateral uveitis cases than in bilateral cases (54.7% vs 18.6%, respectively). A majority of respondents (67.1%) stated that they would avoid using regional corticosteroids in patients under 8 years old. Conclusions Our results demonstrate more frequent regional corticosteroid use in posterior segment uveitis, unilateral cases, and avoidance in younger pediatric patients. Overall, the variability in these responses highlights the need for guidelines regarding regional corticosteroid use. Supplementary Information The online version contains supplementary material available at 10.1186/s12348-021-00281-z.
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Affiliation(s)
- Matthew McHarg
- National Eye Institute, National Institutes of Health, 10 Center Dr, 10/10N109, Bethesda, MD, 20892, USA.,George Washington University School of Medicine, Washington, DC, 20052, USA
| | - LeAnne Young
- National Eye Institute, National Institutes of Health, 10 Center Dr, 10/10N109, Bethesda, MD, 20892, USA.,Cleveland Clinic Lerner College of Medicine, Cleveland, OH, 44195, USA
| | - Natasha Kesav
- National Eye Institute, National Institutes of Health, 10 Center Dr, 10/10N109, Bethesda, MD, 20892, USA.,University Hospitals Eye Institute, Cleveland, OH, 44106, USA
| | - Mehmet Yakin
- National Eye Institute, National Institutes of Health, 10 Center Dr, 10/10N109, Bethesda, MD, 20892, USA
| | - H Nida Sen
- National Eye Institute, National Institutes of Health, 10 Center Dr, 10/10N109, Bethesda, MD, 20892, USA
| | - Shilpa Kodati
- National Eye Institute, National Institutes of Health, 10 Center Dr, 10/10N109, Bethesda, MD, 20892, USA.
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Intravitreal 0.19 mg Fluocinolone Acetonide Implant in Non-Infectious Uveitis. J Clin Med 2021; 10:jcm10173966. [PMID: 34501414 PMCID: PMC8432003 DOI: 10.3390/jcm10173966] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/28/2021] [Accepted: 08/31/2021] [Indexed: 11/24/2022] Open
Abstract
The efficacy of the 0.19-mg fluocinolone acetonide (FAc) intravitreal implant (ILUVIEN) in the treatment of non-infectious uveitic macular edema (UME) was assessed on twenty-six patients (34 eyes) with non-infectious UME between 2013 and 2020, in a mean follow-up of 18 ± 19.3 (mean ± SD) months. Macular edema was resolved in 24 (70.6%) cases. Five of these eyes had a relapse after 23.2 ± 14 months. Three FAc reinjections were performed and a drying of the macula was observed. After FAc implantation, 24 eyes (70.6%) were completely dry; central retinal thickness (CRT) decreased in 6 eyes (17.6%), but residual intraretinal fluid was still evident. In 20 eyes (58.5%), visual acuity (VA) improved (from +1 to +5 lines) and remained stable in 9 eyes (26.5%). Thirty eyes (88.2%) were pseudophakic at baseline and four were phakic. Three of these eyes had a cataract prior to therapy and the other developed a cataract 2.5 years after the FAc implant was administered. There was an overall increase in intraocular pressure (IOP; +4.4 ± 3.7 mmHg) and eye drops were required in three eyes. The FAc implant led to long-term improvements in mean CRT and VA, and that the side-effect profile was manageable in a clinical setting in patients with non-infectious UME.
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19
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Steeples LR, Pockar S, Jones NP, Leal I. Evaluating the Safety, Efficacy and Patient Acceptability of Intravitreal Fluocinolone Acetonide (0.2mcg/Day) Implant in the Treatment of Non-Infectious Uveitis Affecting the Posterior Segment. Clin Ophthalmol 2021; 15:1433-1442. [PMID: 33854297 PMCID: PMC8039205 DOI: 10.2147/opth.s216912] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/18/2021] [Indexed: 11/23/2022] Open
Abstract
Long-acting, slow-release injectable fluocinolone intravitreal implants have been approved for the treatment of non-infectious uveitis affecting the posterior segment. We summarise the development of intravitreal fluocinolone implants and discuss the technology including pharmacokinetics. We conducted a systematic review of evidence for the efficacy, safety and patient acceptability of fluocinolone 0.18 mg and 0.19 mg injectable implants. We summarise evidence from the pivotal phase 3 studies that lead to the approval of these implants and evaluate real-world including disease-specific evidence. Safety including injection-related events and long-term adverse events is presented.
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Affiliation(s)
- Laura R Steeples
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Sasa Pockar
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Nicholas P Jones
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Inês Leal
- Ophthalmology Department, Centro Hospitalar Universitário Lisboa Norte, Hospital de Santa Maria, Lisbon, Portugal.,Centro de Estudos das Ciências da Visão, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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20
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Abstract
The uveitides are a heterogeneous group of diseases characterized by inflammation inside the eye. The uveitides are classified as infectious or non-infectious. The non-infectious uveitides, which are presumed to be immune mediated, can be further divided into those that are associated with a known systemic disease and those that are eye limited,-ie, not associated with a systemic disease. The ophthalmologist identifies the specific uveitic entity by medical history, clinical examination, and ocular imaging, as well as supplemental laboratory testing, if indicated. Treatment of the infectious uveitides is tailored to the particular infectious organism and may include regional and/or systemic medication. First line treatment for non-infectious uveitides is corticosteroids that can be administered topically, as regional injections or surgical implants, or systemically. Systemic immunosuppressive therapy is used in patients with severe disease who cannot tolerate corticosteroids, require chronic corticosteroids at >7.5 mg/day prednisone, or in whom the disease is known to respond better to immunosuppression. Management of many of these diseases is optimized by coordination between the ophthalmologist and rheumatologist or internist.
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Affiliation(s)
- Bryn M Burkholder
- Wilmer Eye Institute, Department of Ophthalmology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Douglas A Jabs
- Wilmer Eye Institute, Department of Ophthalmology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Clinical Trials and Evidence Synthesis, the Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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21
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Li YH, Hsu SL, Sheu SJ. A Review of Local Therapy for the Management of Cystoid Macular Edema in Uveitis. Asia Pac J Ophthalmol (Phila) 2021; 10:87-92. [PMID: 33512830 DOI: 10.1097/apo.0000000000000352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
ABSTRACT Uveitic macular edema is a significant cause of visual impairment in most uveitis types. Treatment options of uveitis have advanced remarkably in recent years. Up to now, corticosteroids remain the mainstay of treatment. Nonsteroidal immunomodulators, and recently the biologic agents, which can reinforce efficacy and enable discontinuation or reduction of steroids to maintenance doses, are becoming increasingly popular in the management of uveitic macular edema. Several medications can be used in intraocular delivery and more and more sustained releasing implants are being developed. This review will briefly focus on the review of local therapy for the management of cystoid macular edema in uveitis, as many of these novel approaches are currently being evaluated in clinical trials.
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Affiliation(s)
- Yi Hsuan Li
- Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shiuh-Liang Hsu
- Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shwu-Jiuan Sheu
- Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Kaohsiung Medical University, Kaohsiung, Taiwan
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22
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Malinowski SM, Wasserman JA. Centrifuged-Concentrated Intravitreal Slurry Triamcinolone Acetonide: An Inexpensive, Easy, and Viable Alternative to Long-Term Steroid Delivery. JOURNAL OF VITREORETINAL DISEASES 2021; 5:15-31. [PMID: 37009586 PMCID: PMC9976047 DOI: 10.1177/2474126420943417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: This work reports the duration, safety, and viability of intravitreal slurry triamcinolone acetonide (TA; 1.0 mL of 40-mg/mL TA centrifuge concentrated into a 0.1-mL pellet) to treat cystoid macular edema (CME). Methods: A retrospective, consecutive review was conducted of patients undergoing intravitreal slurry TA injections, July 2009 to December 2018. Results: In 143 eyes of 120 patients, slurry TA resolved CME for a mean of 327.15 (SD = 213.11) days, or 10.76 (SD = 7.00) months, per intravitreal injection (n = 466). In 100 eyes requiring multiple injections (n = 423), mean duration was 270.95 (SD = 177.14) days, or 8.91 (SD = 5.82) months, between injections. In 43 single-injection eyes, duration was 749.30 (SD = 483.17) days, or 24.63 (SD = 15.88) months. Mean duration decreased from 337.89 (SD = 210.46) days, or 11.11 (SD = 6.92) months, in nonvitrectomized eyes to 279.74 (SD 179.63) days, or 9.20 (SD = 5.91) months, in vitrectomized eyes (n = 74 injections, t = 2.24, P = .014, 1-tailed). Central foveal thickness as shown on optical coherence tomography decreased by 173.89μ (SD = 147.56μ), from 459.16μ (SD = 47.14μ) to 285.27μ (SD = 77.27μ; t = –25.31, P < .001), within 43.41 days (SD = 36.86). Visual acuity improved from 20/100 (logMAR 0.70, SD = 0.33) to 20/74 (logMAR 0.57, SD = 0.31; SD = 0.21; t = –11.01, P < .001), within 33.98 (SD 24.98) days. Fifteen of 31 phakic eyes (48.39%) underwent cataract extraction. Fifty-seven eyes (39.86%) developed a steroid response (> 10 mm Hg increase from baseline) 94.79 days (SD = 85.52 days), or 3.11 (SD = 2.81) months, following injection. Conclusions: A single injection of slurry TA lasted on average 10.76 months with significant improvement of CME and visual acuity. Adverse ocular effects were comparable to currently available, long-term, implantable steroids. Slurry TA appears to be an easily reproducible, safe, and cost-effective alternative to long-term intraocular steroid delivery.
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Affiliation(s)
- Susan M. Malinowski
- Retina Consultants of Michigan, Southfield, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Jason Adam Wasserman
- Department of Foundational Medical Studies and Department of Pediatrics, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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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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Bodaghi B, Nguyen QD, Jaffe G, Khoramnia R, Pavesio C. Preventing relapse in non-infectious uveitis affecting the posterior segment of the eye - evaluating the 0.2 μg/day fluocinolone acetonide intravitreal implant (ILUVIEN ®). J Ophthalmic Inflamm Infect 2020; 10:32. [PMID: 33251553 PMCID: PMC7701203 DOI: 10.1186/s12348-020-00225-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/29/2020] [Indexed: 11/20/2022] Open
Abstract
Background The current article is a short review of an Alimera Sciences-sponsored symposium held during The 15th International Ocular Inflammation Society Congress in Taiwan on the 14th November 2019 entitled, ‘Preventing relapse of non-infectious uveitis effecting the posterior segment of the eye – evaluating the 0.2 μg/day fluocinolone acetonide intravitreal implant.’ Main text The fluocinolone acetonide intravitreal implant was approved in Europe for the prevention of relapse in recurrent non-infectious uveitis affecting the posterior segment of the eye and offers a systemic therapy-sparing treatment option by providing low daily dose of corticosteroid into the vitreous for up to 3 years. In the symposium, the presenters reported clinical outcomes from patients with non-infectious uveitis effecting the posterior segment of the eye to support the effectiveness and safety of the implant for up to 3 years in both randomised controlled trials and real-world practices. Conclusions Data showed that over a 36 month period, treatment with the fluocinolone acetonide intravitreal implant was associated with significantly fewer episodes of uveitic recurrence, a significantly longer time to uveitic recurrence, greater improvement in visual acuity, a lower need for adjunctive therapy, and an acceptable safety profile.
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Affiliation(s)
- Bahram Bodaghi
- Department of Ophthalmology, IHU FOReSIGHT, Sorbonne-APHP, Paris, France
| | - Quan Dong Nguyen
- Byers Eye Institute, Spencer Center for Vision Research, Stanford University of Medicine, Palo Alto, California, USA
| | - Glenn Jaffe
- Department of Ophthalmology, Duke University, Durham, North Carolina, USA
| | - Ramin Khoramnia
- International Vision Correction Research Centre (IVCRC), The David J. Apple International Laboratory for Ocular Pathology, Department of Ophthalmology, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
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Recent advances in the management of non-infectious posterior uveitis. Int Ophthalmol 2020; 40:3187-3207. [PMID: 32617804 DOI: 10.1007/s10792-020-01496-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/23/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To review the current regimens and novel therapeutic modalities in various stages of research and development for the management of non-infectious posterior uveitis (NIPU). METHODS We performed a thorough review of current literature using PubMed, Google Scholar and Clinicaltrials.gov to identify the published literature about the available therapeutics and novel drugs/therapies in different stages of clinical trials. RESULTS The current management regimen for non-infectious posterior uveitis includes corticosteroids, immunomodulatory therapies and anti-metabolites. However, NIPU requires long-term management for efficacious remission of the disease and to prevent disease relapse. Long-term safety issues associated with steroids have led to efforts to develop novel therapeutic agents including biological response modulators and immunosuppressants. The current therapeutic agents in various stages of development include calcineurin inhibitors, biologic response modifiers and a more a comprehensive modalities like ocular gene therapy as well as novel drug delivery mechanisms for higher bioavailability to the target tissues, with minimal systemic effects. CONCLUSION Novel efficacious therapeutic modalities under development will help overcome the challenges associated with the traditional therapeutic agents.
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Local treatment of infectious and noninfectious intermediate, posterior, and panuveitis: current concepts and emerging therapeutics. Curr Opin Ophthalmol 2020; 31:174-184. [DOI: 10.1097/icu.0000000000000651] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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27
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Pavesio CE. Conventional immunosuppression: the search for scientific evidence. Eye (Lond) 2020; 34:1945-1946. [PMID: 32341535 DOI: 10.1038/s41433-020-0875-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 11/09/2022] Open
Affiliation(s)
- Carlos E Pavesio
- Moorfields Eye Hospital NHS Foundation Trust and Biomedical Research Centre, Institute of Ophthalmology, London, UK.
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Effect of a Fluocinolone Acetonide Insert on Recurrence Rates in Noninfectious Intermediate, Posterior, or Panuveitis: Three-Year Results. Ophthalmology 2020; 127:1395-1404. [PMID: 32624244 DOI: 10.1016/j.ophtha.2020.04.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 03/30/2020] [Accepted: 04/02/2020] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To examine the 36-month efficacy and safety of a 0.2 μg/day fluocinolone acetonide insert (FAi) to treat noninfectious uveitis of the posterior segment (NIU-PS). DESIGN Phase 3, prospective, double-masked, multicenter study (clinicaltrials.gov, NCT01694186). PARTICIPANTS Adults (≥18 years old) with a diagnosis of NIU-PS in ≥1 eye for ≥1 year and ≥2 recurrences of uveitis requiring systemic corticosteroid, immunosuppressive treatment, or intraocular corticosteroids. METHODS Participants were randomized 2:1 to FAi or sham (injection plus standard of care) treatment. MAIN OUTCOME MEASURES The primary outcome was the difference between the proportion of FAi-treated and sham-treated patients who had a uveitis recurrence. Secondary outcomes included time to first recurrence, number of recurrences, best-corrected visual acuity (BCVA) change from baseline, resolution of macular edema, and number of adjunctive treatments. RESULTS One hundred twenty-nine participants (n = 87 FAi-treated; n = 42 sham-treated) were enrolled. Over 36 months of treatment, cumulative uveitis recurrences were significantly reduced with FAi compared with sham (65.5% vs. 97.6%, respectively; P < 0.001); time to first recurrence was commensurately longer (median 657.0 and 70.5 days, respectively; P < 0.001). The number of recurrences per eye was significantly lower in the FAi-treated compared with the sham-treated group (mean 1.7 vs. 5.3, respectively, P < 0.001). At 36 months, more FAi-treated eyes had a ≥15-letter increase in BCVA from baseline and fewer FAi-treated eyes had investigator-determined macular edema at month 36 compared with sham-treated eyes (33.3% vs. 14.7% and 13.0% vs. 27.3% for BCVA and macular edema, respectively). Fewer FAi compared with sham-treated participants required adjunctive treatments (57.5% vs. 97.6%, respectively). Intraocular pressure (IOP) was similar for both study groups at month 36 (mean ± standard deviation 14.5±5.1 and 14.8±5.3, respectively), and approximately half as many eyes in the FAi-treated group when compared with the sham-treated group underwent IOP-lowering surgery (5.7% vs. 11.9%). Cataract surgery was required more frequently over 36 months in the FAi-treated compared with the sham-treated group (73.8% vs. 23.8% of eyes, respectively). CONCLUSIONS Fluocinolone acetonide insert-treated eyes had significantly reduced uveitis recurrence rates throughout the study duration, significantly increased recurrence-free durations, fewer recurrence episodes among those with recurrences, less adjunctive therapy, and an acceptable side-effect profile compared with sham-treated eyes.
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Cai CX, Skalak C, Keenan RT, Grewal DS, Jaffe GJ. Time to disease recurrence in noninfectious uveitis following long-acting injectable fluocinolone acetonide implant. Graefes Arch Clin Exp Ophthalmol 2020; 258:1023-1030. [PMID: 32114654 DOI: 10.1007/s00417-020-04614-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 01/22/2020] [Accepted: 01/27/2020] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To determine the time to disease recurrence with long-acting injectable fluocinolone acetonide implant (FAi) for noninfectious intermediate, posterior, and panuveitis. METHODS This was a retrospective study of patients with at least 12 months of follow-up who had completed a 2-year prospective, investigational new drug study with 0.18-mg FAi. Time to uveitis recurrence or cystoid macular edema (CME) occurrence was recorded. RESULTS Twelve eyes from 12 participants (mean age 43 years, range 25-64 years) were included. Patients were followed for a mean of 34.2 months (range, 12.0-56.9 months) after completion of the prospective trial. Five eyes (42%) did not have a documented uveitis recurrence or CME occurrence. Five eyes (42%) had a uveitis recurrence with the mean time to recurrence 36.1 months (range, 22.8-61.1 months) after FAi implantation. Two eyes (16%) had CME alone, the mean time to occurrence 36.9 months (range 36.1-42.1 months). On Kaplan-Meier analysis, the estimated probability of remaining recurrence-free 36 months after FAi implantation was 0.67 (95% confidence interval, 0.34-0.86). CONCLUSIONS Data of study participants after completing a clinical trial suggest that the injectable FAi for noninfectious uveitis can provide control for 3 years on average. These long-term data support the use of FAi to control noninfectious uveitis.
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Affiliation(s)
- Cindy X Cai
- Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA
| | - Cindy Skalak
- Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA
| | - Robert T Keenan
- Department of Rheumatology and Immunology, Duke University Medical Center, Durham, NC, USA
| | - Dilraj S Grewal
- Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA
| | - Glenn J Jaffe
- Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA.
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Callanan D, Nguyen QD, Suhler EB, Paggiarino D, Riedel GE. Withdrawn: Reduced Risk of Recurrence of Noninfectious Posterior Segment Uveitis After 0.18-mg Fluocinolone Acetonide Insert: Randomized Trial. Am J Ophthalmol 2020:S0002-9394(20)30064-7. [PMID: 32087143 DOI: 10.1016/j.ajo.2020.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 01/14/2020] [Accepted: 02/07/2020] [Indexed: 11/30/2022]
Affiliation(s)
- David Callanan
- Texas Retina Associates, Arlington, Texas, USA; University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Quan Dong Nguyen
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Eric B Suhler
- Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon, USA; Department of Public Health, Oregon Health and Science University-Portland State University School of Public Health, Portland, Oregon, USA; Ophthalmology Service, Veterans Affairs Portland Health Care System, Portland, Oregon, USA
| | | | - Gerard E Riedel
- EyePoint Pharmaceuticals, Inc, Watertown, Massachusetts, USA
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Adán A, Moll-Udina A, Alba-Linero C, Figueroa-Vercellino JP, Llorenç V. Recent progress in the treatment of uveitic macular edema. EXPERT REVIEW OF OPHTHALMOLOGY 2019. [DOI: 10.1080/17469899.2019.1644168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Alfredo Adán
- Hospital Clinic de Barcelona, Instituto de Oftalmología, Facultad de Medicina, Universidad de Barcelona, Barcelona, Spain
| | - Aina Moll-Udina
- Hospital Clinic de Barcelona, Instituto de Oftalmología, Facultad de Medicina, Universidad de Barcelona, Barcelona, Spain
| | - Carmen Alba-Linero
- Hospital Clinic de Barcelona, Instituto de Oftalmología, Facultad de Medicina, Universidad de Barcelona, Barcelona, Spain
| | - Juan Pablo Figueroa-Vercellino
- Hospital Clinic de Barcelona, Instituto de Oftalmología, Facultad de Medicina, Universidad de Barcelona, Barcelona, Spain
| | - Victor Llorenç
- Hospital Clinic de Barcelona, Instituto de Oftalmología, Facultad de Medicina, Universidad de Barcelona, Barcelona, Spain
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Biologics for the treatment of noninfectious uveitis: current concepts and emerging therapeutics. Curr Opin Ophthalmol 2019; 30:138-150. [PMID: 30844945 DOI: 10.1097/icu.0000000000000562] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW There is mounting evidence supporting the use of biologic therapeutics for the management of noninfectious uveitis (NIU). This review highlights: biologics with documented efficacy in NIU; agents with ongoing evaluation for efficacy in uveitis; and therapeutics for which investigation for efficacy in NIU is warranted. RECENT FINDINGS The tumor necrosis factor-alpha (TNF-α) inhibitor adalimumab has recently gained approval by the Food and Drug Administration for the treatment of noninfectious intermediate, posterior, and panuveitis. There is mounting evidence supporting the use of tocilizumab and rituximab in NIU. There is developing interest in evaluating the interleukin (IL)-23 inhibitors for efficacy in NIU. SUMMARY The TNF-α inhibitors adalimumab and infliximab have the greatest body of data supporting their use in NIU. These agents are considered second-line therapy for most forms of NIU but may be considered first-line therapy for uveitis associated with Behçet's disease and juvenile idiopathic arthritis. The B-cell inhibitor rituximab and the IL-6 inhibitor tocilizumab also have documented efficacy in NIU. Tocilizumab and interferon therapy may be particularly efficacious in the management of uveitic macular edema. The IL-23 inhibitors and janus kinase inhibitors are agents whose efficacy in NIU will likely be determined in the near future.
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Weber LF, Marx S, Auffarth GU, Scheuerle AF, Tandogan T, Mayer C, Khoramnia R. Injectable 0.19-mg fluocinolone acetonide intravitreal implant for the treatment of non-infectious uveitic macular edema. J Ophthalmic Inflamm Infect 2019; 9:3. [PMID: 30694420 PMCID: PMC6370892 DOI: 10.1186/s12348-019-0168-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/04/2019] [Indexed: 12/14/2022] Open
Abstract
Background A retrospective observational clinical study to evaluate the safety and effectiveness of the injectable 0.19-mg fluocinolone acetonide intravitreal implant (ILUVIEN) in the treatment of non-infectious uveitic macular edema. Results Data are presented from eight patients (11 eyes) with non-infectious uveitic macular edema who were treated with a 0.19-mg fluocinolone acetonide implant. Nine out of 11 eyes were pseudophakic prior to implantation of fluocinolone acetonide implant, and both phakic eyes required cataract surgery during the follow-up period (the median follow-up was 19 months; range, 8–42 months). Effectiveness and safety were assessed from changes in central retinal thickness (measured using spectral domain optical coherence tomography), corrected distance visual acuity, uveitic activity, and intraocular pressure. The main outcome measures were changes in central retinal thickness, corrected distance visual acuity, uveitic activity, and intraocular pressure. In 11/11 eyes, central retinal thickness improved between months 1 and 3. The mean maximum decrease of central retinal thickness throughout the follow-up period was 168 ± 202 μm (± standard deviation). Nine out of 11 eyes showed an improvement in corrected distance visual acuity (between + 1 and + 8 lines), and 2/11 eyes lost corrected distance visual acuity (− 1 and − 3 lines, respectively). Nine out of 11 eyes presented with inactive inflammation during the follow-up period, and in 1/11 eyes, there was a relapse at month 42. Four out of 11 eyes presented with a relapse of macular edema between months 3 and 8. The mean increase in intraocular pressure was 2.1 ± 4.7 mmHg. Nine eyes were pseudophakic prior to implantation of the injectable fluocinolone acetonide intravitreal implant. Both phakic patients developed a cataract that was treated with cataract surgery in the follow-up period. Conclusions In this small case series with long-term follow-up, treatment of non-infectious uveitic macular edema with the injectable fluocinolone acetonide implant was associated with improved central retinal thickness and corrected distance visual acuity and a manageable safety profile. The advantage of this device is the long-term drug release and the fact that it can be injected into the vitreous as a minor surgical procedure, which is in contrast to other treatment options.
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Affiliation(s)
- Lea F Weber
- Department of Ophthalmology, University of Heidelberg, INF 400, 69120, Heidelberg, Germany.,Department of Ophthalmology, University of Tuebingen, Elfriede-Aulhorn-Straße 7, 72076, Tuebingen, Germany
| | - Stefanie Marx
- Department of Ophthalmology, University of Heidelberg, INF 400, 69120, Heidelberg, Germany
| | - Gerd U Auffarth
- Department of Ophthalmology, University of Heidelberg, INF 400, 69120, Heidelberg, Germany
| | - Alexander F Scheuerle
- Department of Ophthalmology, University of Heidelberg, INF 400, 69120, Heidelberg, Germany
| | - Tamer Tandogan
- Department of Ophthalmology, University of Heidelberg, INF 400, 69120, Heidelberg, Germany.,Department of Ophthalmology, HELIOS Clinic Pforzheim, Kanzlerstraße 2-6, 75175, Pforzheim, Germany
| | - Christian Mayer
- Department of Ophthalmology, University of Heidelberg, INF 400, 69120, Heidelberg, Germany
| | - Ramin Khoramnia
- Department of Ophthalmology, University of Heidelberg, INF 400, 69120, Heidelberg, Germany.
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Jaffe GJ, Foster CS, Pavesio CE, Paggiarino DA, Riedel GE. Effect of an Injectable Fluocinolone Acetonide Insert on Recurrence Rates in Chronic Noninfectious Uveitis Affecting the Posterior Segment: Twelve-Month Results. Ophthalmology 2018; 126:601-610. [PMID: 30367884 DOI: 10.1016/j.ophtha.2018.10.033] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/05/2018] [Accepted: 10/15/2018] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To assess the safety and efficacy of an intravitreal fluocinolone acetonide (FA) insert to manage inflammation associated with chronic noninfectious posterior uveitis. DESIGN Multicenter, randomized, prospective, doubled-masked, sham-controlled, 3-year phase 3 clinical trial. PARTICIPANTS One hundred twenty-nine participants with recurrent noninfectious posterior uveitis were assigned randomly to FA insert (n = 87) or sham injection (n = 42). The more severely affected eye in participants with bilateral disease was designated as the study eye. METHODS The insert (FA, 0.18 mg) was injected into the vitreous cavity; sham injection mimicked the insert delivery procedure. Ophthalmic examinations, OCT, and ocular tolerability and discomfort assessments were conducted; study visits were on days 7 and 28 and months 2, 3, 6, 9, and 12. Uveitis recurrence was treated as needed. The 6-month recurrence rate was the primary outcome measure. RESULTS The 6-month (28% and 91%) and 12-month (38% and 98%) uveitis recurrence rates were significantly lower (P < 0.001) with FA insert vs. sham, respectively. Fewer recurrences per study eye (mean, 0.7 vs. 2.5), lower incidence of 15-letter or more decrease in best-corrected visual acuity (14% vs. 31%), and reduced systemic (19% vs. 40%) and local (7% vs. 62%) uveitis adjunctive treatments were observed with FA insert vs. sham, respectively. The FA insert group showed higher rates of cataract. Intraocular pressure-lowering treatment use was similar between groups. No deaths, treatment-related study discontinuations, or unanticipated safety signals were observed through 12 months. CONCLUSIONS Chronic noninfectious posterior uveitis was managed successfully in this study population; FA insert eyes experienced fewer uveitis recurrence episodes, required fewer adjunctive treatments, and demonstrated less visual acuity loss compared with sham eyes. The FA insert treatment group showed higher rates of cataract; delivery by injection was not associated with an increase in ocular adverse events or any other safety measures not typically associated with local steroid use, suggesting the procedure is appropriate for an office setting.
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Affiliation(s)
- Glenn J Jaffe
- Department of Ophthalmology, Duke University, Durham, North Carolina.
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution, Ocular Immunology & Uveitis Foundation, Waltham, Massachusetts
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Zhang Y, Fei S, Yu M, Guo Y, He H, Zhang Y, Yin T, Xu H, Tang X. Injectable sustained release PLA microparticles prepared by solvent evaporation-media milling technology. Drug Dev Ind Pharm 2018; 44:1591-1597. [PMID: 29847181 DOI: 10.1080/03639045.2018.1483382] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
The objective of this study was to develop agomelatine (AGM) intramuscular sustained release PLA microparticles by using solvent evaporation combined with wet milling technology. The final preparation had a regular and homogeneous particle size of approximately 35 µm, as measured by laser diffraction particle size analysis and scanning electron microscopy (SEM). The drug was confirmed to be within the carrier in an amorphous state through differential scanning calorimetry (DSC) and power X-ray diffraction (PXRD) experiments. Additionally, Fourier transform infrared spectroscopy (FT-IR) analysis was applied to confirm that there was hydrogen bonding between the drug and polymer at the molecular level. In vitro release experiments indicated that the drug could achieve long-term sustained release over the period of one month, with only a 3.07% burst release, due to the involvement of the polymer and removal of drug adsorbed on the surface during the wet grinding process. The dominant release mechanism was considered to be diffusion of the drugs in the initial period. Following this, with the hydrolysis of PLA to form a colloidal viscous layer, drug release is due to the combined effect of diffusion and erosion of the polymer matrix. Additionally, drug release behavior is closely related to the degradation mechanism of the polymer carrier. The results suggest that AGM could be developed as a potential delivery system for long-acting intramuscular administration with extensive application prospects.
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Affiliation(s)
- Yan Zhang
- a Department of Pharmaceutics , School of Pharmacy , Shenyang , China
| | - Siyang Fei
- a Department of Pharmaceutics , School of Pharmacy , Shenyang , China
| | - Meiling Yu
- a Department of Pharmaceutics , School of Pharmacy , Shenyang , China
| | - Yuting Guo
- a Department of Pharmaceutics , School of Pharmacy , Shenyang , China
| | - Haibing He
- a Department of Pharmaceutics , School of Pharmacy , Shenyang , China
| | - Yu Zhang
- a Department of Pharmaceutics , School of Pharmacy , Shenyang , China
| | - Tian Yin
- b Department of Functional Food and Wine , Shenyang Pharmaceutical University , Shenyang , China
| | - Hui Xu
- a Department of Pharmaceutics , School of Pharmacy , Shenyang , China
| | - Xing Tang
- a Department of Pharmaceutics , School of Pharmacy , Shenyang , China
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Abstract
Background Sarcoidosis constitutes one of the leading causes of ocular inflammation. Chronic ocular sarcoidosis can affect any segment of the eye and its adnexa, producing a wide range of clinical manifestations and severity. If left untreated, permanent visual impairment or even blindness may ensue. Treatment approaches vary from topical therapy to systemic agents that induce immunosuppression to different levels according to disease severity. Objective To review the published literature on the management options for chronic ocular sarcoidosis and provide a comprehensive list of available treatment strategies, including the newer biologics. Summary Ocular disease remains a challenging aspect of sarcoidosis and may even be the presenting sign of the disease. Prompt and effective therapy may reverse visual damage and prevent permanent loss of vision. Because of the complexity of the disease, a multidisciplinary approach is often required, with a view to addressing both the ocular and other systemic manifestations of sarcoidosis. Recent data suggest that achieving overall optimal systemic control is of paramount importance in controlling eye inflammation as well. Cytotoxic immunosuppressive agents for refractory chronic ocular disease, as well as biologic anti-TNFα therapies, have advanced the management of chronic disease and should be considered corticosteroid-sparing strategies before the onset of significant steroid-induced morbidity.
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Affiliation(s)
- Artemis Matsou
- Second Department of Ophthalmology, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Greece
| | - Konstantinos T Tsaousis
- Ophthalmology Department, Leicester Royal Infirmary, University Hospitals of Leicester, Leicester, UK
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Sharief LAT, Lightman S, Tomkins-Netzer O. Using Local Therapy to Control Noninfectious Uveitis. Ophthalmology 2018; 125:329-331. [DOI: 10.1016/j.ophtha.2017.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 09/18/2017] [Accepted: 09/20/2017] [Indexed: 10/18/2022] Open
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Jaffe GJ. Reply. Ophthalmology 2017; 124:e62-e63. [DOI: 10.1016/j.ophtha.2017.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 03/10/2017] [Indexed: 11/26/2022] Open
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Shrivastav A, Mayor R, Agarwal M, Venkatesh R, Singh S. Re: Jaffe et al.: Injectable fluocinolone acetonide long-acting implant for noninfectious intermediate uveitis, posterior uveitis, and panuveitis: 2-year results ( Ophthalmology . 2016;123:1940-1948). Ophthalmology 2017; 124:e62. [DOI: 10.1016/j.ophtha.2017.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 03/10/2017] [Indexed: 11/29/2022] Open
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Agrawal R. Re: Jaffe et al.: Injectable fluocinolone acetonide long-acting implant for noninfectious intermediate uveitis, posterior uveitis, and panuveitis: two-year results ( Ophthalmology . 2016;123:1940-1948). Ophthalmology 2017; 124:e45. [DOI: 10.1016/j.ophtha.2016.08.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 08/16/2016] [Accepted: 08/29/2016] [Indexed: 11/30/2022] Open
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Jaffe GJ. Reply. Ophthalmology 2017; 124:e45. [DOI: 10.1016/j.ophtha.2016.08.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 08/29/2016] [Indexed: 11/16/2022] Open
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