Suprachoroidal CLS-TA with and without Systemic Corticosteroid and/or Steroid-Sparing Therapy: A Post-Hoc Analysis of the Phase 3 PEACHTREE Clinical Trial

SUPRACHOROIDAL SPACE INJECTION TECHNIQUE: Expert Panel Guidance

PURPOSE

To develop professional guidelines for best practices for suprachoroidal space (SCS) injection, an innovative technique for retinal therapeutic delivery, based on current published evidence and clinical experience.

METHODS

A panel of expert ophthalmologists reviewed current published evidence and clinical experience during a live working group meeting to define points of consensus and key clinical considerations to inform the development of guidelines for in-office SCS injection.

RESULTS

Core consensus guidelines for in-office SCS injection were reached and reported by the expert panel. Current clinical evidence and physician experience supported SCS injection as a safe and effective method for delivering retinal and choroidal therapeutics. The panel established consensus on the rationale for SCS injection, including potential benefits relative to other intraocular delivery methods and current best practices in patient preparation, pre- and peri-injection management, SCS-specific injection techniques, and postinjection management and follow-up.

CONCLUSION

These expert panel guidelines may support and promote standardization of SCS injection technique, with the goal of optimizing patient safety and outcomes. Some aspects of the procedure may reasonably be modified based on the clinical setting and physician judgment, as well as additional study.

Optimizing glucocorticoid therapy for Behçet's uveitis: efficacy, adverse effects, and advances in combination approaches

Behçet's uveitis (BU) is a debilitating manifestation of Behçet's disease, often requiring prompt and aggressive treatment to prevent vision loss. Glucocorticoids (GCS) serve as a first-line therapy for BU; however, their long-term, high-dose use can result in significant adverse effects. This review summarizes the efficacy, adverse effects, and advances in combination therapy involving GCS for the management of BU. We discuss the benefits and drawbacks of various GCS administration routes, including periocular and intravitreal injections, intravitreal sustained-release devices, and systemic therapy, highlighting the role of fluocinolone acetonide and dexamethasone as primary sustained-release formulations. Moreover, we underscore the importance of combining GCS with immunosuppressive drugs and biological agents to minimize adverse reactions and optimize therapeutic outcomes. The review concludes that, while GCS remain a crucial component of BU treatment, careful consideration of their administration and combination with other therapies is essential to achieve long-term remission and improved visual outcomes for patients with BU.

Suprachoroidal Injection: A Novel Approach for Targeted Drug Delivery

Treating posterior segment and retinal diseases poses challenges due to the complex structures in the eye that act as robust barriers, limiting medication delivery and bioavailability. This necessitates frequent dosing, typically via eye drops or intravitreal injections, to manage diseases, often leading to side effects with long-term use. Suprachoroidal injection is a novel approach for targeted drug delivery to the posterior segment. The suprachoroidal space is the region between the sclera and the choroid and provides a potential route for minimally invasive medication delivery. Through a more targeted delivery to the posterior segment, this method offers advantages over other routes of administration, such as higher drug concentrations, increased bioavailability, and prolonged duration of action. Additionally, this approach minimizes the risk of corticosteroid-related adverse events such as cataracts and intraocular pressure elevation via compartmentalization. This review focuses on preclinical and clinical studies published between 2019 and 2023, highlighting the potential of suprachoroidal injection in treating a variety of posterior segment diseases. However, to fully harness its potential, more research is needed to address current challenges and limitations, such as the need for technological advancements, refinement of injection techniques, and consideration of cost and accessibility factors. Future studies exploring its use in conjunction with biotech products, gene therapies, and cell-based therapies can lead to personalized treatments that can revolutionize the field of ophthalmology.

Triamcinolone Acetonide Suprachoroidal Injectable Suspension for Uveitic Macular Edema: Integrated Analysis of Two Phase 3 Studies

INTRODUCTION

Macular edema, a common complication of uveitis, may result in vision loss. The aim of this analysis was to report integrated phase 3 trial data for triamcinolone acetonide injectable suspension for suprachoroidal use (SCS-TA) in the treatment of macular edema secondary to noninfectious uveitis using strict inclusion criteria.

METHODS

This analysis included patients with central subfield thickness (CST) ≥ 300 µm and best-corrected visual acuity (BCVA) of ≥ 5 and ≤ 70 Early Treatment Diabetic Retinopathy Study (ETDRS) letters at both screening and baseline who received ≥ 1 study treatment in either PEACHTREE (randomized, double-masked SCS-TA or sham control) or AZALEA (open-label SCS-TA). Patients received SCS-TA 4.0 mg (0.1 ml of 40 mg/ml) or control at baseline and week 12.

RESULTS

In the SCS-TA group (n = 95), 47.4% of patients gained ≥ 15 ETDRS letters from baseline to week 24 versus 16.7% of patients in the control group (n = 60; P < 0.001). Mean change in BCVA in the SCS-TA group was 9.6 letters at week 4 and 13.9 letters at week 24. CST also improved rapidly in the SCS-TA group (mean change: - 158.4 µm at week 4), with sustained reduction throughout the study (mean change: - 163.9 µm at week 24 versus - 19.3 µm in the control group; P < 0.001). No treatment-related serious adverse events (AEs) were reported. Incidence of AEs pertaining to elevated intraocular pressure was 12.6% and 15.0% in the SCS-TA and control groups, respectively; incidence of cataract formation/worsening AEs was 7.4% and 6.7%, respectively.

CONCLUSION

In this integrated analysis utilizing strict inclusion criteria, SCS-TA was found effective in the treatment of patients with macular edema associated with noninfectious uveitis and was generally well tolerated.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02595398, NCT03097315.

Photodynamic Therapy-Induced Acute Exudative Maculopathy (PAEM): Prevalence, Impact and Management Strategies

Photodynamic therapy (PDT) has a niche role in treating various choroidal pathologies. PDT-induced acute exudative maculopathy (PAEM) is an uncommon complication of PDT that results in exudative retinal detachment and mild to severe decrease in vision. Successful management strategies include observation, local or systemic corticosteroids, and intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections. Most cases return to visual acuity near baseline. This review summarizes what is known about PAEM to date including etiology, prevalence, management strategies, and outcomes. We conclude that management of PAEM must take into consideration various patient-specific factors. Treatment with corticosteroids or anti-VEGF agents may expedite time to recovery, though lack of randomized controlled trials preclude firm conclusions regarding a standardized approach to managing this complication of PDT.

Suprachoroidal Space Triamcinolone Acetonide: A Review in Uveitic Macular Edema

Triamcinolone acetonide injectable suspension for suprachoroidal use (Xipere^®; SCS triamcinolone acetonide) is a corticosteroid approved in the USA for the treatment of macular edema associated with uveitis. Suprachoroidal injection of SCS triamcinolone acetonide results in preferential distribution into the posterior segment, which may reduce the risk of corticosteroid-related adverse events, such as cataracts and intraocular pressure (IOP) elevation. In a multicenter phase III trial in patients with non-infectious uveitic macular edema, SCS triamcinolone acetonide significantly and rapidly improved visual acuity and reduced signs of macular edema compared with sham treatment. SCS triamcinolone acetonide was generally well tolerated, with the most common adverse event being eye pain on the day of the procedure. The risk of corticosteroid-related IOP elevation appeared to be reduced in unrescued patients in the SCS triamcinolone acetonide group compared with patients in the sham control group who received rescue therapy. SCS triamcinolone acetonide is a novel and useful treatment option for uveitic macular edema.

Uveitic macular edema is a major cause of blindness in the developed world. Intravitreal and periocular application of corticosteroids (e.g., triamcinolone acetonide) may be effective for uveitis and macular edema, but these routes are often associated with cataracts and corticosteroid-related intraocular pressure (IOP) elevation. Recently, a triamcinolone acetonide suspension for injection into the suprachoroidal space (Xipere^®; SCS triamcinolone acetonide) has been approved for the treatment of uveitic macular edema. The suprachoroidal route preferentially distributes the drug to the back of the eye, resulting in a reduced risk of corticosteroid-related adverse events. In a pivotal clinical trial, SCS triamcinolone acetonide rapidly improved visual acuity and resolved macular edema in patients with non-infectious uveitis. SCS triamcinolone acetonide was generally well tolerated, with the most common ocular adverse event being eye pain on the day of procedure. In unrescued patients in the SCS triamcinolone acetonide group, there appeared to be a reduced risk of corticosteroid-related IOP elevation versus patients who received rescue therapy in the sham control group. SCS triamcinolone acetonide is a novel and useful treatment option for uveitic macular edema.

Triamcinolone acetonide injectable suspension for suprachoroidal use in the treatment of macular edema associated with uveitis

Introduction

Macular edema due to noninfectious uveitis is a sight-threatening complication that is routinely treated with corticosteroids. Triamcinolone acetonide injectable suspension for suprachoroidal use (Xipere™) is an alternative treatment option for patients with non-infectious uveitis associated macular edema.

Areas covered

This review describes the recently FDA approved triamcinolone acetonide injectable suspension that can be injected into the suprachoroidal space. This physiological space is between the sclera and choroid. This allows for therapeutic targeting of the retina and choroid. This review highlights published clinical trials for this novel drug preparation.

Expert opinion

Suprachoroidal administration of triamcinolone acetonide has shown improvement in vision and inflammation in studies with non-infectious uveitis associated macular edema. This unique delivery method suggests the potential to decrease side effects of anterior segment exposure such as glaucoma and cataract, but head-to-head trials are needed for further study of safety and efficacy. Additionally, there are promising prospective studies underway for utilization of the suprachoroidal space for other diseases including macular degeneration, diabetic macular edema, and ocular tumors.