Decreasing efficacy of repeated intravitreal triamcinolone injections in diabetic macular oedema

Cost-effectiveness of dexamethasone and triamcinolone for the treatment of diabetic macular oedema in Finland: A Markov-model

PURPOSE

Diabetic macular oedema (DMO), a complication of diabetes, causes vision loss and blindness. Corticosteroids are usually used as a second-line treatment. The aim of this study was to analyse the cost-effectiveness of dexamethasone implants compared to cheaper and more frequently applied triamcinolone injections.

METHODS

Markov-modelling, which incorporated both eyes, was used for economic evaluation. The model consisted of five health states based on visual acuity, illustrating the progression of DMO. A cycle length of five months was chosen for dexamethasone and four months for triamcinolone. Time horizons of two and five years were applied. Transition probabilities and health state utilities were sourced from previous studies. The perspective used in this analysis was the hospital perspective. The health care costs were acquired from Kuopio University Hospital in Finland.

RESULTS

In this cost-effectiveness analysis, the incremental cost-effectiveness ratio ICER with 3% discount rate was €56 591/QALY for a two-year follow-up and -€1 110 942/QALY for a five-year follow-up. In order to consider dexamethasone as cost-effective over a 2-year time horizon, the WTP needs to be around €55 000/QALY. Over the five-year follow-up, triamcinolone is clearly a dominant treatment. Sensitivity analyses support the cost-effectiveness of dexamethasone over a 2-year time horizon.

CONCLUSIONS

Since the sensitivity analyses support the results, dexamethasone would be a cost-effective treatment during the first two years with WTP threshold around €55 000/QALY, and triamcinolone would be a convenient treatment after that. This recommendation is in line with the guidelines of EURETINA.

High-Dose Decanted Triamcinolone for Treatment-Resistant Persistent Macular Edema

BACKGROUND AND OBJECTIVE

To report the outcomes of decanted high-dose intravitreal triamcinolone acetonide (HD-IVTA) injection for treatment-resistant persistent macular edema (ME).

PATIENTS AND METHODS

Seventy-seven eyes of 70 consecutive patients who failed prior treatments for persistent ME received as-needed HD-IVTA injections. Best-corrected visual acuity and central macular thickness (CMT) were assessed at all follow-up visits.

RESULTS

Thirty-three eyes (42.8%) had ME following pars plana vitrectomy. The mean ETDRS letter score from baseline improved by 6.3 letters ± 11.5 letters at 3 months (P < .001) and 4.8 letters ± 11.4 letters at 12 months (P = .016). The mean change in CMT from baseline was significant at all follow-up visits (P < .001). During 1-year follow-up, 49 eyes (63.6%) required only one HD-IVTA injection. The mean time for reinjection was 6 months ± 2.4 months (range: 1.6 months to 10.5 months) after the first injection of HD-IVTA. The incidence of elevated intraocular pressure was 40.2% (31 of 77 eyes). Of these, one eye required glaucoma surgery. Among 14 phakic eyes, 21.4% (three eyes) developed cataract formation requiring surgery.

CONCLUSION

A single HD-IVTA injection can provide a long duration of effect on ME of up to 6 months. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:717-726.].

Efficacy of Intravitreal Triamcinolone Acetonide for Diabetic Macular Edema After Vitrectomy

PURPOSE

To compare the efficacy of intravitreal injection of triamcinolone acetonide (IVTA) for diabetic macular edema (DME) in vitrectomized eyes with DME without vitrectomy eyes.

METHODS

This retrospective comparative study evaluated the efficacy of IVTA treatment of DME in 26 consecutive eyes (23 patients). Changes in mean best-corrected visual acuity (VA) and mean central retinal thickness (CRT) were retrospectively evaluated before IVTA and during the 6-month period after IVTA.

RESULTS

Subjects were divided into 2 groups: 13 consecutive eyes (11 patients) with proliferative diabetic retinopathy or DME that underwent vitrectomy (vitrectomized group), and 13 consecutive eyes (12 patients) with DME who received IVTA, but did not undergo vitrectomy (nonvitrectomized group). In the vitrectomized group, there was a significantly decreased CRT for up to 4 months as compared to the thicknesses before IVTA. In the nonvitrectomized group, there was a significantly decreased CRT for up to 5 months after IVTA. In both groups, there was significant improvement in the VA for up to 4 months after IVTA.

CONCLUSION

IVTA may represent a valid treatment option for DME, even in vitrectomized eyes.

Clinical trials on corticosteroids for diabetic macular edema

Diabetic macular edema (DME) is a common cause of visual impairment in diabetic patients. It is caused by an increase in the permeability of the perifoveal capillaries and a disruption of the blood retinal-barrier. The pathogenesis of DME is multifactorial. Several therapeutic modalities have been proposed for the treatment of DME. Corticosteroid treatments have emerged as an alternative therapy for persistent DME or refractory to conventional laser photocoagulation and other modalities, due to anti-inflammatory, anti-vascular endothelial growth factor and anti-proliferative effects. Many studies have demonstrated the beneficial therapeutic effect of corticosteroids with improvement to both retinal thickness and visual acuity in short-term on the treatment of DME. Peribulbar and intravitreal injections have been used to deliver steroids for DME with frequent injections due to the chronic and recurrent nature of the disease. Steroid-related side effects include elevated intraocular pressure, cataract, and injection related complications such as endophthalmitis, vitreous hemorrhage, and retinal detachment particularly with intravitreal steroid injections. In order to reduce the risks, complications and frequent dosing of intravitreal steroids, intravitreal implants have been developed recently to provide sustained release of corticosteroids and reduce repeated intravitreal injections for the management of DME.

Treatment options for diffuse diabetic macular edema

PURPOSE

To describe the current management of diffuse diabetic macular edema (DDME).

METHODS

Review and discussion of the literature regarding DDME.

RESULTS

Diffuse diabetic macular edema is a condition that can be managed by means of several treatment options, including focal/grid laser photocoagulation, intravitreal or periocular corticosteroids, intravitreal anti-vascular endothelial growth factor (VEGF), and vitrectomy with or without internal limiting membrane peeling.

CONCLUSIONS

Even though there is no randomized clinical trial specifically designed to assess the best treatment approach for DDME, new therapeutic approaches based on intravitreal injections of corticosteroid and anti-VEGF molecules offer new hope for its management.

Clinical development of new treatments for diabetic macular oedema

The benchmark treatment for diabetic macular oedema, the major cause of visual impairment in patients with diabetes mellitus, has traditionally been laser photocoagulation; however, as laser treatment does not always improve vision or even prevent further loss in many cases, several new pharmacotherapies that are injected into the vitreous for diabetic macular oedema have been successfully trialled over the past decade. Others are currently being evaluated. The two major classes of these drugs are steroids and vascular endothelial growth factor antagonists. In this article we briefly review the major clinical studies recently conducted in this field.

Comparison of the short-term effects of intravitreal triamcinolone acetonide and bevacizumab injection for diabetic macular edema

Purpose

To compare the short-term effects of intravitreal triamcinolone acetonide (IVTA) with those of intravitreal bevacizumab (IVB) injection for diabetic macular edema (DME).

Methods

The present retrospective, comparative case study included 58 eyes of 35 consecutive patients (IVTA group, 20 eyes; IVB group, 38 eyes) with DME. IVTA (4 mg) or IVB (1.25 mg) injection was performed under local anesthesia. The effects of injection for DME were evaluated using best-corrected visual acuity (BCVA), central macular thickness (CMT) by optical coherence tomography and intraocular pressure (IOP) by applanation tonometer. Patients underwent eye examinations, including BCVA, CMT, and IOP at pre-injection, 2, 4, and 8 weeks after injection.

Results

BCVA (logarithm of the minimum angle of resolution) ± SD at pre-injection, 2, 4, and 8 weeks after injection was 0.67 ± 0.40, 0.56 ± 0.35 (p = 0.033), 0.55 ± 0.33 (p = 0.041), and 0.43 ± 0.31 (p = 0.001) in the IVTA group and 0.51 ± 0.31, 0.42 ± 0.26 (p = 0.003), 0.43 ± 0.32 (p = 0.001), and 0.43 ± 0.27 (p = 0.015) in the IVB group, respectively. CMT (µm) ± SD at pre-injection, 2, 4, and 8 weeks after injection was 400.4 ± 94.9, 332.8 ± 47.4 (p = 0.002), 287.5 ± 49.1 (p = 0.007), and 282.5 ± 49.6 (p = 0.043) in the IVTA group and 372.6 ± 99.5, 323.2 ± 72.4 (p = 0.077), 360.9 ± 50.3 (p = 0.668), 368.2 ± 88.6 (p = 0.830) in the IVB group, respectively.

Conclusions

The effects of IVTA for BCVA were more favorable than were those of IVB and were consistent throughout the eight weeks after injection. IVTA significantly reduced CMT during the eight weeks after injection, while IVB did not.

Development of novel drugs for ocular diseases: possibilities for individualized therapy

In clinical ophthalmology, new and old drug regimens are available for the treatment of major eye diseases, including potentially blinding conditions, such as glaucoma, and various macular diseases. In glaucoma, therapeutic treatment mainly deals with control of intraocular pressure at low levels but the clinical courses of patients can be very variable. Very often, specific drug combinations and dosages have to be formulated for individual glaucoma patients. In neovascular age-related macular degeneration, choroidal neovascularization can lead to progressive and irreversible visual impairment if not treated early. In recent years, clinical trials using photodynamic therapy with verteporfin and various anti-VEGF antibodies, such as ranibizumab and bevacizumab, have enhanced the treatment outcomes of neovascular age-related macular degeneration. In diabetic macular edema, intravitreal triamcinolone acetonide and anti-VEGF therapy are effective in some patients. Again, responses to treatment are not uniform in all macular patients. Traditional herbal medicine has long been known to play a role in the practice of personalized formulations in Asia. Potential preventive and therapeutic effects have been claimed in individual eye patients. Meanwhile, advanced technologies in molecular biology have led to identification of genes associated with many eye diseases and development of the concept of individual medicine, in which the genotype of a person can be used as a basis for disease prediction or prophylactic treatments. Moreover, pharmacogenomic studies have demonstrated the association of various genotypes or haplotypes with responses to drug therapies, providing hope for tailormade personalized treatments. The combination of genotypic information with clinical features for the prescription of treatment modes in eye diseases is under vigorous research.

Factors associated with variability in response of diabetic macular oedema after intravitreal triamcinolone

PURPOSE

To identify factors associated with variability in anatomical and functional response of diabetic macular oedema (DMO) after 4 mg of intravitreal triamcinolone acetonide (ivTA), and for recurrence of macular oedema.

DESIGN

Pooled analysis of individual data from two randomized controlled trials.

METHODS

This was a multicentre study involving 107 eyes with DMO administered 4 mg ivTA. Predictive factors for response to treatment were evaluated with linear regression analysis. Factors associated with time to recurrence of oedema were studied with Cox proportional hazards modelling. Main outcome measures were maximum improvement in optical coherence tomography (OCT)-measured central foveal thickness (CFT) and best-corrected visual acuity (BCVA), final CFT and BCVA at 12 months and time to oedema recurrence.

RESULTS

Greater reduction of retinal thickening occurred in eyes with worse baseline thickening (P < 0.001). There was also greater improvement of visual acuity in eyes with poorer preoperative BCVA levels (P < 0.001). Age, duration of oedema and previous macular laser treatment had no significant effect on maximal BCVA or CFT improvement. Eyes given 4 mg triamcinolone alone were more likely to develop recurrence of oedema at 12 months than those given a combination of 4 mg triamcinolone plus sequential laser (hazard ratio 2.60 [95% confidence interval: 1.45-4.67]).

CONCLUSION

Baseline OCT-measured retinal thickening and BCVA are important predictors of maximal anatomical and functional response of DMO to ivTA, respectively. Combination treatment strategy using sequential laser therapy may have a role in delaying recurrence of oedema after triamcinolone.

Efficacy of intravitreal triamcinolone after or concomitant with laser photocoagulation in nonproliferative diabetic retinopathy with macular edema

PURPOSE

To investigate the clinical effects and outcomes of intravitreal injection of 4 mg of triamcinolone acetonide (IVTA) after or concomitant with macular laser photocoagulation (MP) for clinically significant macular edema (CSME).

METHODS

Forty-nine eyes of 49 patients with nonproliferative diabetic retinopathy and CSME were randomized into three groups. The eyes in the laser group (n=17), group 1, were subjected to MP 3 weeks after IVTA; the eyes in the IVTA group (n=13), group 2, were subjected to MP, concomitant with IVTA; the eyes in the control group (n=19), group 3, underwent only IVTA application. Visual acuity (VA), fundus fluorescein angiography, and photography were performed in each group.

RESULTS

In the first group, the mean VA improved from 0.17-/+0.09 at baseline to 0.28-/+0.15 (p=0.114) and in the second group, deteriorated from 0.19-/+0.08 at baseline to 0.14-/+0.08 at the sixth month (p=0.141), respectively. In Group 3, the mean VA improved from 0.16-/+0.08 at baseline to 0.28-/+0.18 (p=0.118) at the end of the follow-up. When VA was compared between the control and study groups, significant difference was detected at the sixth month (p=0.038).

CONCLUSIONS

MP after IVTA improved VA, rather than MP concomitant with IVTA, and only IVTA application for CSME. MP after IVTA may reduce the recurrence of CSME and needs further investigations in a longer period.

Efficacy of 1.25 MG versus 2.5 MG intravitreal bevacizumab for diabetic macular edema: six-month results of a randomized controlled trial. Retina. 2009;29:292-299. [PMID: 19287286 DOI: 10.1097/iae.0b013e31819a2d61]

PURPOSE

To evaluate the efficacy of intravitreal injections of two different dosages of bevacizumab (Avastin) for treating diffuse diabetic macular edema.

METHODS

Fifty-two eyes of 52 patients with diabetic macular edema were randomized to receive three monthly intravitreal injections of 1.25 mg or 2.5 mg bevacizumab. Patients were observed for 6 months and optical coherence tomography central foveal thickness, logMAR best-corrected visual acuity (BCVA), and adverse events were assessed.

RESULTS

Forty-eight eyes of 48 patients completed the 6-month follow-up and were analyzed. Significant mean central foveal thickness reductions were observed in both groups at all follow-up visits (P < 0.013). Significant improvements between baseline and 6-month mean logMAR BCVAs were seen, with the mean logMAR BCVA improved from 0.63 to 0.52 in the 1.25 mg group and 0.60 to 0.47 in the 2.5 mg group. No significant difference in BCVA was observed between the two groups at any time point (P > 0.56). Subgroup analysis showed that intravitreal bevacizumab seemed to be more effective in eyes without any previous diabetic macular edema treatment.

CONCLUSIONS

Three monthly intravitreal bevacizumab injections resulted in significant reduction in central foveal thickness and improvements in BCVA in diabetic macular edema patients. Both 1.25 mg and 2.5 mg seemed to have similar treatment efficacy.

Effects of repeated injection of intravitreal triamcinolone on macular oedema in central retinal vein occlusion

PURPOSE

To investigate the effectiveness of repeated injections of intravitreal triamcinolone acetonide (IVTA) in the treatment of macular oedema caused by central retinal vein occlusion (CRVO).

METHODS

Seventeen pseudophakic or aphakic eyes of 17 patients (10 male, seven female) with macular oedema caused by CRVO received a repeat injection of 4 mg IVTA, 16 weeks after the first injection of the same dose. The examination included measurements of best-corrected visual acuity (BCVA) for distance and central foveal thickness (CFT) by optical coherence tomography (OCT), preoperatively and 1, 2, 3 and 4 months postoperatively. The values were compared by paired-t test. Side-effects were monitored.

RESULTS

BCVA and CFT were not significantly different before initial and repeat injections. Transient improvements of BCVA and CFT were achieved after both injections. At the end of follow-up, BCVA and CFT were significantly different compared to pre-injection values in the same group (P = 0.032, 0.049 in the initial-injection group and P = 0.001, 0.008 in the repeat-injection group, respectively). However, compared to the initial injection, BCVA measurements were significantly worse at each time-point (P = 0.043, 0.011, 0.010 and 0.012, respectively) after the repeat injection, as were CFT at 1, 2 and 3 months post-injection (P = 0.040, 0.015 and 0.025, respectively). The achieved maximum mean intraocular pressures were 20.00 [standard deviation (SD) 2.06] mmHg and 18.56 (SD 3.65) mmHg after the first and repeat injections, respectively. These values were not significantly different (P = 0.467). No other significant adverse events were noted during the study.

CONCLUSION

A repeat injection of 4 mg IVTA may not be as effective as an initial injection for the treatment of macular oedema caused by CRVO.

Pars plana vitrectomy with internal limiting membrane peeling for diabetic macular edema

PURPOSE

To evaluate anatomic and visual acuity (VA) results of pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling for diffuse diabetic macular edema (DME), and to review the literature on the topic.

METHODS

Retrospective noncomparative case series of patients who underwent PPV with ILM peeling for diffuse DME between January 1, 2000, and December 1, 2005, performed by three surgeons at Bascom Palmer Eye Institute. Main outcome measures included pre- and postoperative optical coherence tomography (OCT) and visual acuity. Mean follow-up period was 8 months (range, 43 days-2 years).

RESULTS

Twenty-four eyes of 23 patients meeting the criteria were evaluated. Duration of DME ranged from 1 to 93 months. Mean preoperative logMAR vision was 0.782 (range, 0.30-1.82). Mean logMAR visual acuity at final follow-up was 0.771 (range, 0.10-2.00). At last follow-up, 25% of eyes had > or =2 line increase in VA from baseline, 54% of eyes had no improvement in VA, and 21% of eyes had > or =2 line decrease in VA. Of 9 eyes with pre- and postoperative OCT, there was an overall reduction in central macular thickness of 141 microm at postoperative month 3 and 120 microm at last follow-up. Postoperative complications included progression of cataract in 6 (60%) of 10 phakic eyes, postoperative intraocular pressure > or =30 mmHg in 6 (24%) eyes, and postoperative vitreous hemorrhage in 2 (8%) eyes.

CONCLUSIONS

Pars plana vitrectomy with ILM peeling was associated with a reduction in DME when measured by OCT in the majority of eyes, but visual acuity outcomes showed minimal improvement compared to baseline. These results suggest the efficacy of PPV with ILM peeling for eyes with DME has not been well established and should be reserved for therapy with selected cases.

Efficacy and safety of multiple intravitreal triamcinolone injections for refractory diabetic macular oedema

AIM

The efficacy and safety of repeated injections of intravitreal triamcinolone (IVTA) for diabetic macular oedema is unclear, with results of previous reports conflicting.

METHODS

This is a prospective, observational case series of 27 eyes receiving IVTA for diabetic macular oedema. LogMAR visual acuity (VA) and central macular thickness (CMT) were measured at baseline and in 3 to 6 monthly intervals for up to 24 months, then correlated with the number of IVTA injections given.

RESULTS

One IVTA injection was required in 6 (18%) eyes, 2 in 8 (24%) eyes, 3 in 13 (39%) eyes and 4-5 in 6 (18%) eyes. VA improved in all patients, but neither the final improvement in VA nor the absolute improvement in CMT from baseline to 24 months correlated with the number of injections received (p = 0.44 and 0.84, respectively). Cataract surgery was more frequent in eyes receiving more injections (p = 0.01).

CONCLUSIONS

This study suggests that repeated injections of IVTA continue to be as effective as the first over a 2-year period. The probability of cataract surgery increases with an increasing number of injections.