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Hanson J, Hsu D, Pillar S, Tsui E, Tsui I. Resolution of Postoperative Cystoid Macular Edema with a Suprachoroidal Triamcinolone Acetonide Injectable Suspension. Ocul Immunol Inflamm 2024:1-4. [PMID: 38781576 DOI: 10.1080/09273948.2024.2356723] [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: 04/03/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
AIM To report a case of significant postoperative cystoid macular edema (CME) in a patient with no prior history of uveitis or systemic inflammatory disease, in which a suprachoroidal (SC) triamcinolone acetonide injectable suspension resulted in complete resolution of CME. DESIGN Case report. METHODS An 81-year-old man presented with a complex, dense brunescent cataract, floppy iris, and miotic pupil in the left eye. Six weeks following cataract extraction, the intraocular lens (IOL) was dislocated completely from the visual axis. He underwent a pars plana vitrectomy and IOL exchange with an anterior chamber IOL due to a three-piece IOL dislocation. Following the operation, the patient began treatment with prednisolone acetate and ketorolac. However, 2 weeks later, he was noted to be a steroid responder and glaucoma suspect. Therefore, the decision was made to taper and discontinue topical steroids. At 6 months postoperatively, ranibizumab was injected for persistent CME. However, following injection, there was intraocular pressure (IOP) elevation and increased CME. IOP improved 1 month later with dorzolamide hydrochloride and timolol maleate. At 8 months post-operation, there was persistent CME. The patient was then treated with an SC triamcinolone acetonide injection. There was complete resolution of CME by 14 weeks later, with improvement in visual acuity. Despite the patient's known steroid response with topical steroids, IOP remained within normal limits during the entire follow-up period after injection. CONCLUSION SC triamcinolone acetonide injection is indicated for macular edema associated with uveitis; however, treatment for postoperative macular edema with this novel suprachoroidal injection may be considered.
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Affiliation(s)
- Justin Hanson
- UCLA Department of Ophthalmology, Jules Stein Eye Institute, Los Angeles, California, USA
| | - David Hsu
- UCLA Department of Ophthalmology, Jules Stein Eye Institute, Los Angeles, California, USA
| | - Shani Pillar
- UCLA Department of Ophthalmology, Jules Stein Eye Institute, Los Angeles, California, USA
| | - Edmund Tsui
- UCLA Department of Ophthalmology, Jules Stein Eye Institute, Los Angeles, California, USA
| | - Irena Tsui
- UCLA Department of Ophthalmology, Jules Stein Eye Institute, Los Angeles, California, USA
- Division of Ophthalmology, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
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Thng ZX, Bromeo AJ, Mohammadi SS, Khatri A, Tran ANT, Akhavanrezayat A, T T Than N, Nguyen KS, Yoo WS, Mobasserian A, Or CCM, Nguyen QD. Recent advances in uveitis therapy: focus on selected phase 2 and 3 clinical trials. Expert Opin Emerg Drugs 2023; 28:297-309. [PMID: 38129984 DOI: 10.1080/14728214.2023.2293049] [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: 09/19/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Uveitis is a heterogeneous group of ocular conditions characterized by inflammation of the uveal tract. It is a leading cause of blindness in developed countries and exerts significant psychological, social, and economic impact on both patients and the larger society. While there are numerous pharmacotherapy options, posterior segment noninfectious uveitis remains a significant challenge to treat due to its severity, chronicity, and high recurrence rates. AREAS COVERED The index review highlights the unmet needs of uveitis pharmacotherapy and its research and the shortcomings of existing ocular and systemic therapeutic options for noninfectious uveitis. The more promising novel ocular drug delivery methods and therapeutic targets/drugs are discussed, and evidence from the clinical trials is evaluated. EXPERT OPINION There has been incredible growth in the number of treatment options available to uveitis patients today, especially with the new generation of biologic drugs. Available evidence suggests that these newer options may be superior to conventional immunosuppressive therapies in terms of efficacy and side effect profiles. Further high-quality research and additional clinical trials will be needed to clarify their roles in the stepladder treatment approach of noninfectious uveitis.
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Affiliation(s)
- Zheng Xian Thng
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
| | - Albert John Bromeo
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
- Asian Eye Institute, Makati, Philippines
| | - S Saeed Mohammadi
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Anadi Khatri
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
- Birat Aankha Aspatal, Biratnagar, Nepal
- Department of Ophthalmology, Birat Medical College and Teaching Hospital, Kathmandu University, Biratnagar, Nepal
| | - Anh N T Tran
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | | | - Ngoc T T Than
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Khiem S Nguyen
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Woong-Sun Yoo
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
- Department of Ophthalmology, Gyeongsang National University College of Medicine, and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | | | | | - Quan Dong Nguyen
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
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de Smet MD, Goncerut M, Asmus F, Yamamoto R. Refractory post-surgical cystoid macular edema managed following suprachoroidal microcatheterization and delivery of triamcinolone. BMC Ophthalmol 2023; 23:367. [PMID: 37670276 PMCID: PMC10478372 DOI: 10.1186/s12886-023-03110-0] [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: 06/13/2023] [Accepted: 08/22/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Post-surgical macular edema (ME) is a common cause of prolonged visual impairment. Here we report on the feasibility and clinical outcomes from the use of a novel suprachoroidal microcatheter to treat post-surgical chronic ME by the posterior suprachoroidal placement of a triamcinolone acetonide (TA) suspension. METHODS Two patients were catheterized with the Oxulumis suprachoroidal delivery system on two separate occasions starting 5 and 10 mm posterior to the limbus. The catheter only remains in the suprachoroidal space for the time of the drug administration. Visual acuity and spectral domain optical coherence tomography (SD-OCT) changes were followed over several weeks to months to determine the duration of ME resolution. RESULTS Suprachoroidal microcatheterization for posterior delivery of triamcinolone was possible in all attempts using the illuminated Oxulumis catheter. No reflux, scleral or choroidal trauma was observed. There was no intraocular pressure rise during the follow-up period. The triamcinolone deposit was visible on infrared imaging and on SD-OCT a choroidal elevation was visible. Both progressively disappeared over time. A rapid resolution of ME associated with improved vision was observed following each injection for 3 to 7 months with a TA dose of 2.4 mg or 4 mg. CONCLUSIONS In these patients with poorly responsive ME, posterior suprachoroidal TA led to a visible suprachoroidal drug deposit and prolonged visual improvement. The Oxulumis microcatheterization device performed as expected and was not associated with any complications.
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Affiliation(s)
- Marc D de Smet
- Helvetia Retina Associates, Lausanne, Switzerland.
- New York Eye and Ear Infirmary of Mt Sinai, Icahn School of Medicine, New York City, NY, USA.
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Rujkorakarn P, Zhou A, Babiker F, Chang PY. Suprachoroidal Triamcinolone Injection in Posterior Scleritis: A Case Report. Ocul Immunol Inflamm 2023:1-4. [PMID: 37450640 DOI: 10.1080/09273948.2023.2232447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/28/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023]
Abstract
Suprachoroidal triamcinolone acetonide (SCS-TA) injections were recently approved to treat macular edema secondary to noninfectious uveitis. However, its use in managing posterior scleritis has not been reported. We report the first case of SCS-TA used in the treatment of posterior scleritis. A 67-year-old woman with posterior scleritis complicated by exudative retinal detachment, diagnosed by spectral-domain optical coherence tomography scan (OCT), presented with pain, decreased vision, and redness in the left eye for 8 months. She was previously prescribed topical prednisolone and oral prednisone with minimal improvement. She also had a history of rheumatoid arthritis treated with multiple systemic immunosuppressive agents. After SCS-TA, the patient's pain resolved and visual acuity improved. OCT demonstrated significant reduction in sclerochoroidal thickening. Via its novel delivery method, SCS-TA may be an effective treatment for posterior scleritis. Further studies are needed to establish long-term efficacy and safety of this treatment modality.
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Affiliation(s)
- Ploysai Rujkorakarn
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA
- Department of Ophthalmology, Suddhavej Hospital, Faculty of Medicine, Mahasarakham University, Maha Sarakham, Thailand
| | - Avery Zhou
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA
| | - Fatima Babiker
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA
| | - Peter Y Chang
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA
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Rotenstreich Y, Sher I, Lawrence M, Mangelus M, Ingerman A, Barak Y. A Novel Device for Suprachoroidal Drug Delivery to Retina: Evaluation in Nonhuman Primates. Transl Vis Sci Technol 2023; 12:3. [PMID: 37289173 PMCID: PMC10257339 DOI: 10.1167/tvst.12.6.3] [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: 12/12/2022] [Accepted: 04/04/2023] [Indexed: 06/09/2023] Open
Abstract
Purpose Evaluation of distribution and tolerance of suprachoroidal injection of indocyanine green (ICG) in nonhuman primates (NHPs) using a novel suprachoroidal (SC) delivery technology. Methods Three live and three euthanized African green monkeys were injected with 150 or 200 µL ICG/eye into the SC space of both eyes, 2.5 mm posterior to the limbus in the inferior quadrant, utilizing a novel SC injector. Eyes were analyzed by imaging of scleral flatmounts. Live animals were observed for 24 hours for general health. Ophthalmic evaluation included slit-lamp biomicroscopy, tonometry, fundus imaging, confocal laser ophthalmoscopy, and spectral-domain optical coherence tomography (SD-OCT) before and at 10 minutes and 1, 3, and 24 hours post-injection. Results SC dosing was successfully performed in all eyes. Infrared fundus imaging demonstrated ICG distribution throughout the posterior segment, reaching the macula within 24 hours post-injection. No inflammation, intravitreal penetration, SC blebs, retinal detachment, or hemorrhages were detected. No significant changes were observed in retinal thickness by SD-OCT (P = 0.267, ANOVA). A mild, statistically insignificant elevation in intraocular pressure was observed within 10 minutes post-injection (mean ± standard error: 7.28 ± 5.09 mmHg; P = 0.061) and was spontaneously resolved within the first hour after dosing. Conclusions Suprachoroidal injection of 150 to 200 µL ICG dye was successfully performed and well tolerated in NHP eyes, with rapid distribution into the macular region and throughout the posterior pole. Translational Relevance This novel SC drug delivery system may potentially provide safe and effective delivery of therapeutics to the posterior pole region in humans.
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Affiliation(s)
- Ygal Rotenstreich
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Ifat Sher
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- TELEM Rubin Excellence in Biomedical Research Program, Sheba Medical Center, Tel Hashomer, Israel
| | | | | | | | - Yoreh Barak
- Department of Ophthalmology, Rambam Health Care Campus, Haifa, Israel
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Wang L, Zhang H. Ocular barriers as a double-edged sword: preventing and facilitating drug delivery to the retina. Drug Deliv Transl Res 2023; 13:547-567. [PMID: 36129668 DOI: 10.1007/s13346-022-01231-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2022] [Indexed: 12/30/2022]
Abstract
In recent decades, the growing of the aging population in the world brings increasingly heavy burden of vision-threatening retinal diseases. One of the biggest challenges in the treatment of retinal diseases is the effective drug delivery to the diseased area. Due to the existence of multiple anatomical and physiological barriers of the eye, commonly used oral drugs or topical eye drops cannot effectively reach the retinal lesions. Innovations in new drug formulations and delivery routes have been continuously applied to improve current drug delivery to the back of the eye. Unique ocular anatomical structures or physiological activities on these ocular barriers, in turn, can facilitate drug delivery to the retina if compatible formulations or delivery routes are properly designed or selected. This paper focuses on key barrier structures of the eye and summarizes advances of corresponding drug delivery means to the retina, including various local drug delivery routes by invasive approaches, as well as systemic eye drug delivery by non-invasive approaches.
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Affiliation(s)
- Lixiang Wang
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China
| | - Hui Zhang
- Triapex Laboratories Co., Ltd No. 9 Xinglong Road, Jiangbei New Area, Jiangsu, Nanjing, China.
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Sumnicht AJ, Chalam KV, Sierpina DI. Photodynamic Therapy-Induced Acute Exudative Maculopathy (PAEM): Prevalence, Impact and Management Strategies. Clin Ophthalmol 2022; 16:3145-3154. [PMID: 36193512 PMCID: PMC9526441 DOI: 10.2147/opth.s359302] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/31/2022] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Andrew J Sumnicht
- Loma Linda University Eye Institute, Loma Linda University, Loma Linda, CA, USA
| | - Kakarla V Chalam
- Loma Linda University Eye Institute, Loma Linda University, Loma Linda, CA, USA
| | - David I Sierpina
- Loma Linda University Eye Institute, Loma Linda University, Loma Linda, CA, USA
- Correspondence: David I Sierpina, 11370 Anderson St., Suite #2900, Loma Linda, CA, 92354, USA, Tel +1 909-558-2182, Fax +1 909-558-2506, Email
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An Update on Suprachoroidal Corticosteroid Injections in the Management of Macular Edema. CURRENT OPHTHALMOLOGY REPORTS 2022. [DOI: 10.1007/s40135-022-00291-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Suprachoroidal Space Triamcinolone Acetonide: A Review in Uveitic Macular Edema. Drugs 2022; 82:1403-1410. [PMID: 36018461 PMCID: PMC9512860 DOI: 10.1007/s40265-022-01763-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 11/20/2022]
Abstract
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.
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Ciulla T, Yeh S, Hariprasad SM. Suprachoroidal Drug Delivery for Clinicians: Anatomic Principles, Clinical Data in Uveitis, and Future Directions. Ophthalmic Surg Lasers Imaging Retina 2022; 53:361-366. [PMID: 35858236 DOI: 10.3928/23258160-20220617-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Conrady CD, Yeh S. A Review of Ocular Drug Delivery Platforms and Drugs for Infectious and Noninfectious Uveitis: The Past, Present, and Future. Pharmaceutics 2021; 13:1224. [PMID: 34452185 PMCID: PMC8399730 DOI: 10.3390/pharmaceutics13081224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/03/2021] [Accepted: 08/05/2021] [Indexed: 12/11/2022] Open
Abstract
Uveitis refers to a broad group of inflammatory disorders of the eye that often require medical and surgical management to improve or stabilize vision and prevent vision-threatening pathological changes to the eye. Drug delivery to the eye to combat inflammation and subsequent complications from uveitic conditions is complex as there are multiple barriers to absorption limiting availability of the needed drug in the affected tissues. As such, there has been substantial interest in developing new drugs and drug delivery platforms to help reduce intraocular inflammation and its complications. In this review, we discuss the challenges of drug delivery, novel technologies recently approved for uveitis patient care and promising drug delivery platforms for uveitis and sequelae of ocular inflammation.
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Affiliation(s)
- Christopher D. Conrady
- Department of Ophthalmology and Visual Sciences, Truhlsen Eye Center, University of Nebraska Medical Center, Omaha, NE 68105, USA
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, MI 48105, USA
| | - Steven Yeh
- Department of Ophthalmology and Visual Sciences, Truhlsen Eye Center, University of Nebraska Medical Center, Omaha, NE 68105, USA
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Naftali Ben Haim L, Moisseiev E. Drug Delivery via the Suprachoroidal Space for the Treatment of Retinal Diseases. Pharmaceutics 2021; 13:pharmaceutics13070967. [PMID: 34206925 PMCID: PMC8309112 DOI: 10.3390/pharmaceutics13070967] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 06/18/2021] [Accepted: 06/22/2021] [Indexed: 02/06/2023] Open
Abstract
The suprachoroidal space (SCS), a potential space between the sclera and choroid, is becoming an applicable method to deliver therapeutics to the back of the eye. In recent years, a vast amount of research in the field has been carried out, with new discoveries in different areas of interest, such as imaging, drug delivery methods, pharmacokinetics, pharmacotherapies in preclinical and clinical trials and advanced therapies. The SCS can be visualized via advanced techniques of optical coherence tomography (OCT) in eyes with different pathologies, and even in healthy eyes. Drugs can be delivered easily and safely via hollow microneedles fitted to the length of the approximate thickness of the sclera. SCS injections were found to reach greater baseline concentrations in the target layers compared to intravitreal (IVT) injection, while agent clearance was faster with highly aqueous soluble molecules. Clinical trials with SCS injection of triamcinolone acetonide (TA) were executed with promising findings for patients with noninfectious uveitis (NIU), NIU implicated with macular edema and diabetic macular edema (DME). Gene therapy is evolving rapidly with viral and non-viral vectors that were found to be safe and efficient in preclinical trials. Here, we review these novel different aspects and new developments in clinical treatment of the posterior segment of the eye.
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Affiliation(s)
- Liron Naftali Ben Haim
- Department of Ophthalmology, Meir Medical Center, Kfar Saba, 59 Tshernichovsky St., Kfar Saba 4428164, Israel;
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Correspondence: ; Tel.: +972-97471527; Fax: +972-97472427
| | - Elad Moisseiev
- Department of Ophthalmology, Meir Medical Center, Kfar Saba, 59 Tshernichovsky St., Kfar Saba 4428164, Israel;
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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