Efficacy and Safety of Corticosteroid Implants in Non-infectious Uveitis: A Systematic Review with Network Meta-analysis

INJECTABLE FLUOCINOLONE IMPLANT FOR THE MANAGEMENT OF CHRONIC POSTSURGICAL CYSTOID MACULAR EDEMA IN VITRECTOMIZED EYES

PURPOSE

Long-acting injectable steroids are changing the treatment paradigm for patients with chronic intraocular inflammation and cystoid macular edema (CME). We report the use of the fluocinolone implant 0.18 mg in patients with chronic postsurgical CME after pars plana vitrectomy.

METHODS

This is a retrospective case series of 24 vitrectomized eyes which received fluocinolone implant for the management postsurgical CME. Clinical outcomes and requirement for rescue therapy were studied.

RESULTS

Median length of follow-up was 19.3 months (range 8.3-23.2 months). There was an improvement in median central subfield thickness from 412 µ m (range 167-806 µ m) to 311 µ m (range 157-686 µ m) after fluocinolone implant ( P < 0.001). The injection burden decreased significantly after study treatment ( P < 0.001); however, there was no significant change in visual acuity ( P = 0.334). Eighteen eyes had control of CME that did not require additional intravitreal therapy. Four eyes had initially controlled but recurrent CME requiring intravitreal steroid therapy at median of 7.8 months (range 7.6-15.4 months). One eye never attained sufficient inflammatory control despite rescue therapy.

CONCLUSION

Fluocinolone implant can be an effective treatment in vitrectomized patients with chronic postsurgical CME and can help decrease the overall injection burden.

Efficacy and safety of single-dose intravitreal dexamethasone implant in non-infectious uveitic macular edema: A systematic review and meta-analysis

Purpose

We conducted a systematic review and meta-analysis to investigate the efficacy and safety of single-dose intravitreal dexamethasone (DEX) implant for treating non-infectious uveitic macular edema (UME).

Methods

Studies including clinical outcomes of the DEX implant in UME were comprehensively searched in PubMed, Embase, and Cochrane databases for potential studies from inception to July 2022. The primary outcomes were best corrected visual acuity (BCVA) and central macular thickness (CMT) during the follow-up period. Stata 12.0 was used to perform the statistical analyses.

Results

Six retrospective studies and one prospective investigation involving 201 eyes were ultimately included. Significantly improved BCVA was observed from baseline to 1 month (WMD = -0.15, 95%CI = -0.24, -0.06), 3 months (WMD = -0.22, 95%CI = -0.29, -0.15), and 6 months (WMD = -0.24, 95%CI = -0.35, -0.13), after single-dose DEX implant. When considering CMT, macular thickness of 1 month (WMD = -179.77, 95%CI = -223.45, -136.09), 3 months (WMD = -179.13, 95%CI = -232.63, -125.63), and 6 months (WMD = -140.25, 95%CI = -227.61, -52.88) decreased in comparison with baseline, with statistical significance.

Conclusion

Based on the current results, this meta-analysis confirmed favorable visual prognosis and anatomical improvement in patients with UME, after receiving the single-dose DEX implant. The most common adverse event is increased intraocular pressure, which could be controlled with topical medications.Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022325969.

Comparative Efficacy and Safety of Advanced Intravitreal Therapeutic Agents for Noninfectious Uveitis: A Systematic Review and Network Meta-Analysis

Background: To compare the efficacy and safety of advanced intravitreal therapeutic regimens, including a dexamethasone implant at 350 and 700 μg; a fluocinolone acetonide (FA) implant, 0.2 µg/day, 0.59 and 2.1 mg; intravitreal bevacizumab, 1.25 mg; intravitreal ranibizumab, 0.5 mg; intravitreal triamcinolone acetonide (IVTA), 2 and 4 mg; and standard of care (SOC, systemic therapy) for noninfectious uveitis.

Methods: We searched the Cochrane Library database, EMBASE, Medline, clinicaltrials.gov until April 2021 with 13 RCTs (1806 participants) identified and conducted a pairwise and Bayesian network meta-analysis with random effects.

Results: No specific regimen showed a statistically significant advantage or disadvantage to another treatment regimen with regard to efficacy. However, the FA implant, 0.59 mg was associated with a higher risk of cataract (RR 4.41, 95% CI 1.51–13.13) and raise in intraocular pressure (IOP) (RR 2.53 95% CI 1.14–6.25) compared with SOC at 24 months. IVTA, 4 mg at 6 months was associated with lower risk of IOP rising compared with FA implant, 0.2 µg/day at 36 months (RR 3.43 95% CI 1.12–11.35).

Conclusion: No intravitreal therapeutic regimens showed a significant advantage or disadvantage with regard to efficacy. However, SOC was associated with lower risk of side effects compared with FA implants. IVTA, 4 mg, might be the best choice with lowest risk of IOP rising.

Systematic Review Registration:clinicaltrials.gov, identifier CRD42020172953

Efficacy and safety of intravitreal and periocular injection of corticosteroids in non-infectious uveitis: a systematic review

Uveitis is among the leading causes of visual loss in the working age population. In non-infectious uveitis, corticosteroids are the first line therapy. We sought to review systematically the evidence regarding the regional corticosteroid delivery modalities in the treatment of non-infectious uveitis. A five-database search (Pubmed, ISI Web of Science, Cochrane, ClinicalTrials.gov, and Scopus) was performed from inception to February, 2021. Nineteen studies with a total of 1935 eyes of 1753 patients were selected from 8922 abstracts retrieved by the initial search. The most frequently compared regimens were intravitreal triamcinolone acetonide injection and orbital floor triamcinolone acetonide injection (2 studies), intravitreal triamcinolone acetonide injection and posterior sub-Tenon triamcinolone acetonide injection (2 studies), and posterior sub-Tenon triamcinolone acetonide injection with the intravitreal dexamethasone implant (2 studies). Our results show that the intravitreal injection of corticosteroids is more effective, but is associated with more adverse events, than periocular injection. Some evidence supports the use of subconjunctival triamcinolone acetonide over intravitreal/periocular triamcinolone acetonide. Moreover, the overall results of 0.59 mg dosage of the intravitreal fluocinolone acetonide implant were superior to those from the 2.1 mg dose. The evidence, however, is not robust and further studies with standardized outcomes are warranted.

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

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.