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Salvetat ML, Pellegrini F, Spadea L, Salati C, Musa M, Gagliano C, Zeppieri M. The Treatment of Diabetic Retinal Edema with Intravitreal Steroids: How and When. J Clin Med 2024; 13:1327. [PMID: 38592149 PMCID: PMC10932454 DOI: 10.3390/jcm13051327] [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: 12/11/2023] [Revised: 02/13/2024] [Accepted: 02/21/2024] [Indexed: 04/10/2024] Open
Abstract
Diabetic macular edema (DME) is a common complication of diabetes mellitus and a leading cause of visual impairment worldwide. It is defined as the diabetes-related accumulation of fluid, proteins, and lipids, with retinal thickening, within the macular area. DME affects a significant proportion of individuals with diabetes, with the prevalence increasing with disease duration and severity. It is estimated that approximately 25-30% of diabetic patients will develop DME during their lifetime. Poor glycemic control, hypertension, hyperlipidemia, diabetes duration, and genetic predisposition are recognized as risk factors for the development and progression of DME. Although the exact pathophysiology is still not completely understood, it has been demonstrated that chronic hyperglycemia triggers a cascade of biochemical processes, including increased oxidative stress, inflammation, activation of vascular endothelial growth factor (VEGF), cellular dysfunction, and apoptosis, with breakdown of the blood-retinal barriers and fluid accumulation within the macular area. Early diagnosis and appropriate management of DME are crucial for improving visual outcomes. Although the control of systemic risk factors still remains the most important strategy in DME treatment, intravitreal pharmacotherapy with anti-VEGF molecules or steroids is currently considered the first-line approach in DME patients, whereas macular laser photocoagulation and pars plana vitrectomy may be useful in selected cases. Available intravitreal steroids, including triamcinolone acetonide injections and dexamethasone and fluocinolone acetonide implants, exert their therapeutic effect by reducing inflammation, inhibiting VEGF expression, stabilizing the blood-retinal barrier and thus reducing vascular permeability. They have been demonstrated to be effective in reducing macular edema and improving visual outcomes in DME patients but are associated with a high risk of intraocular pressure elevation and cataract development, so their use requires an accurate patient selection. This manuscript aims to provide a comprehensive overview of the pathology, epidemiology, risk factors, physiopathology, clinical features, treatment mechanisms of actions, treatment options, prognosis, and ongoing clinical studies related to the treatment of DME, with particular consideration of intravitreal steroids therapy.
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Affiliation(s)
- Maria Letizia Salvetat
- Department of Ophthalmology, Azienda Sanitaria Friuli Occidentale, 33170 Pordenone, Italy; (M.L.S.)
| | - Francesco Pellegrini
- Department of Ophthalmology, Azienda Sanitaria Friuli Occidentale, 33170 Pordenone, Italy; (M.L.S.)
| | - Leopoldo Spadea
- Eye Clinic, Policlinico Umberto I, “Sapienza” University of Rome, 00142 Rome, Italy
| | - Carlo Salati
- Department of Ophthalmology, University Hospital of Udine, 33100 Udine, Italy
| | - Mutali Musa
- Department of Optometry, University of Benin, Benin City 300238, Edo State, Nigeria
| | - Caterina Gagliano
- Faculty of Medicine and Surgery, University of Enna “Kore”, Piazza dell’Università, 94100 Enna, Italy
- Eye Clinic, Catania University, San Marco Hospital, Viale Carlo Azeglio Ciampi, 95121 Catania, Italy
| | - Marco Zeppieri
- Department of Ophthalmology, University Hospital of Udine, 33100 Udine, Italy
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Kour V, Swain J, Singh J, Singh H, Kour H. A Review on Diabetic Retinopathy. Curr Diabetes Rev 2024; 20:e201023222418. [PMID: 37867267 DOI: 10.2174/0115733998253672231011161400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/08/2023] [Accepted: 08/23/2023] [Indexed: 10/24/2023]
Abstract
Diabetic retinopathy is a well-recognised microvascular complication of diabetes and is among the leading cause of blindness all over the world. Over the last decade, there have been advances in the diagnosis of diabetic retinopathy and diabetic macular edema. At the same time, newer therapies for the management of diabetic retinopathy have evolved. As a result of these advances, a decline in severe vision loss due to diabetes has been witnessed in some developing countries. However, there is a steady increase in the number of people affected with diabetes, and is expected to rise further in the coming years. Therefore, it is prudent to identify diabetic retinopathy, and timely intervention is needed to decrease the burden of severe vision loss. An effort has been made to review all the existing knowledge regarding diabetic retinopathy in this article and summarize the present treatment options for diabetic retinopathy.
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Affiliation(s)
- Vijender Kour
- Consultant Ophthalmology, Department of Ophthalmology, Sub District Hospital, Tral, Pulwama, India
| | - Jayshree Swain
- Department of Endocrinology, IMS and Sum Hospital, Siksha O Anusandhan (SOA) University, Bhubaneswar, India
| | - Jaspreet Singh
- Department of Endocrinology, IMS and Sum Hospital, Siksha O Anusandhan (SOA) University, Bhubaneswar, India
| | - Hershdeep Singh
- Consultant Neurosurgeon, Department of Neurosurgery, Fortis Ludhiana, Bhubaneswar, India
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Baillif S, Staccini P, Weber M, Delyfer MN, Le Mer Y, Gualino V, Collot L, Merite PY, Creuzot-Garcher C, Kodjikian L, Massin P. Management of Patients with Diabetic Macular Edema Switched from Dexamethasone Intravitreal Implant to Fluocinolone Acetonide Intravitreal Implant. Pharmaceutics 2022; 14:pharmaceutics14112391. [PMID: 36365209 PMCID: PMC9693281 DOI: 10.3390/pharmaceutics14112391] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/13/2022] [Accepted: 10/20/2022] [Indexed: 11/09/2022] Open
Abstract
To assess anatomical and functional outcomes after switching from dexamethasone implant (DEXi) to fluocinolone acetonide implant (FAci) in 113 diabetic macular edema eyes, a multicentric retrospective observational study was conducted. Seventy-five eyes (73.5%) were switched 1−8 weeks after their last DEXi. The mean best-corrected visual acuity improved to 59.8 letters at month 4 and remained stable during the follow-up. The mean central macular thickness (CMT) significantly decreased during the follow-up, with a minimum of 320.9 μm at month 3. The baseline CMT was higher in eyes that received the last DEXi >8 weeks versus <8 weeks before the first FAci (p < 0.021). After FAci injection, additional treatments were needed in 37 (32.7%) eyes. A longer diabetes duration (p = 0.009), a longer time between the last DEXi and the first FAci (p = 0.035), and a high baseline CMT (p = 0.003) were risk factors for additional treatments. The mean intraocular pressure was <19 mmHg at all timepoints, with no difference between eyes receiving the last DEXi ≤8 weeks or >8 weeks before the switch. Switching from DEXi to FAci in DME is effective and safe. A short time between the last DEXi and the first FAci reduced CMT fluctuations and the need for early additional treatments.
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Affiliation(s)
- Stéphanie Baillif
- Department of Ophthalmology, Hôpital Pasteur 2, Centre Hospitalier Universitaire de Nice, Université Côte d’Azur, 30 Voie Romaine, 06000 Nice, France
- INSERM DR2 U1065, C3M, 151 Avenue Saint-Antoine de Ginestière, 06024 Nice, France
- Correspondence:
| | - Pascal Staccini
- Research Unit RETINES (Risks, Epidemiology, Territories, Information and Education for Health), Université Côte d’Azur, Faculté de Médecine, 28 Avenue de Valombrose, CEDEX 2, 06107 Nice, France
| | - Michel Weber
- Department of Ophthalmology, Centre Hospitalier Universitaire de Nantes, 44000 Nantes, France
| | - Marie-Noëlle Delyfer
- Department of Ophthalmology, Bordeaux University Hospital, 33000 Bordeaux, France
- INSERM, BPH, UMR1219, Bordeaux University, 33000 Bordeaux, France
| | - Yannick Le Mer
- Department of Ophthalmology, A. de Rothschild Ophthalmologic Foundation, 75019 Paris, France
| | - Vincent Gualino
- Clinique Honoré Cave, Department of Ophthalmology, 82000 Montauban, France
- Ophthalmology Department, AP-HP, Hôpital Lariboisière, Université de Paris, 75014 Paris, France
| | - Laurence Collot
- Centre Médico-Chirurgical de Chaumont, 17 Avenue des États-Unis, 52000 Chaumont, France
| | - Pierre-Yves Merite
- Centre D’ophtalmologie, 44 Avenue de Lattre de Tassigny, 13090 Aix-en-Provence, France
| | | | - Laurent Kodjikian
- Department of Ophthalmology, Croix-Rousse University Hospital, Hospices Civils de Lyon, 69002 Lyon, France
- UMR-CNRS 5510 Matéis, University of Lyon, 69622 Villeurbanne, France
| | - Pascale Massin
- Ophthalmic Centre of Breteuil, 14 avenue de Breteuil, 75007 Paris, France
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Elbarky A. Effectiveness and tolerability of the fluocinolone acetonide implant in patients with diabetic macular edema in the UAE: 24 and 36-month outcomes. Eur J Ophthalmol 2022; 33:11206721221128671. [PMID: 36168254 DOI: 10.1177/11206721221128671] [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: 11/15/2022]
Abstract
INTRODUCTION The effectiveness and safety of the fluocinolone acetonide (FAc) implant was evaluated at Month 24 and, in some sustained for up to 36 months, in patients with diabetic macular edema (DME) and a pseudophakic lens treated in the UAE following prior anti-vascular endothelial growth factor and dexamethasone (DEX) implant. METHODS This was a retrospective, observational audit study conducted between September 2017-September 2020 in which 22 patients were treated with the FAc implant and outcomes monitored for up to 36 months. Effectiveness outcomes were: best-corrected visual acuity (BVCA) and central macular thickness (CMT). Safety was assessed by monitoring intraocular pressure (IOP). All outcomes were measured at Months 1, 3, 6, 12, 24, and 36. RESULTS Significant improvements in mean BCVA were observed versus baseline from Month 1, which were maintained up to Month 24 (P < 0.0001 versus baseline). In all five patients completing 36 months follow-up, the improvements in BVCA were maintained through to Month 36 P < 0.005 versus baseline. Similarly, mean CMT improved versus baseline at Month 1 through to Month 24 (P < 0.0001 versus baseline), with significant improvements also noted in the 5 patients completing 36 months follow-up (P < 0.005 versus baseline). An IOP rise to 32 mmHg was observed in one eye, but returned to normal values at next measure. Five eyes required IOP lowering drops and one required IOP-lowering surgical intervention. CONCLUSION The FAc intravitreal implant is effective for 24 months, and sustained for 36 months, in a UAE population previously treated with a DEX implant, with tolerability profile in-line with previous reports.
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Affiliation(s)
- Ahmed Elbarky
- 37532Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
- Ophthalmology, Benha Faculty of Medicine, Benha University, Benha, Egypt
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Extended real-world experience with the ILUVIEN® (fluocinolone acetonide) implant in the United Kingdom: 3-year results from the Medisoft® audit study. Eye (Lond) 2022; 36:1012-1018. [PMID: 33972705 PMCID: PMC8107780 DOI: 10.1038/s41433-021-01542-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/24/2021] [Accepted: 04/06/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND This study aimed to assess the long-term effectiveness of the 0.2 μg/day fluocinolone acetonide (FAc) implant over ≥3 years for patients with diabetic macular oedema. METHODS A retrospective audit of pseudo-anonymised data from patients with chronic diabetic macular oedema (cDMO) and treated with the FAc implant across 14 UK clinical sites. Safety and clinical effectiveness were measured. RESULTS Two-hundred and fifty-six eyes had ≥3 years of follow-up (mean 4.28 years), during which a mean of 1.14 FAc implants were used per eye. Mean best-recorded visual acuity (BRVA) increased from 52.6 to 56.7 letters at month 3 and remained stable thereafter; this trend was also seen in pseudophakic eyes. The proportion of patients attaining a BRVA ≥6/12 increased from 17% at baseline to 27% 1 month after FAc implant and remained stable above 30% from month 12 onwards. Eyes with no prior history of intraocular pressure (IOP)-related events required significantly less treatment-emergent IOP-lowering medication than those with a prior history of IOP events (17.9% vs. 50.0% of eyes; p < 0.001). The incidence of an IOP increase of ≥10 mmHg, use of IOP-lowering medication, laser trabeculoplasty and IOP-lowering surgery was 28.9%, 29.7%, 0.8% and 2.7%, respectively, for the whole cohort. There were significant reductions in mean central foveal thickness and macular volume (p < 0.001). CONCLUSIONS The FAc implant was well tolerated, with predictable and manageable IOP-related events while delivering a continuous microdose of corticosteroid to eyes with cDMO, providing prolonged vision preservation and a reduced number of treatments.
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Updates on the Current Treatments for Diabetic Retinopathy and Possibility of Future Oral Therapy. J Clin Med 2021; 10:jcm10204666. [PMID: 34682788 PMCID: PMC8537579 DOI: 10.3390/jcm10204666] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 10/04/2021] [Accepted: 10/09/2021] [Indexed: 12/23/2022] Open
Abstract
Diabetic retinopathy (DR) is a complication of diabetes and one of the leading causes of vision loss worldwide. Despite extensive efforts to reduce visual impairment, the prevalence of DR is still increasing. The initial pathophysiology of DR includes damage to vascular endothelial cells and loss of pericytes. Ensuing hypoxic responses trigger the expression of vascular endothelial growth factor (VEGF) and other pro-angiogenic factors. At present, the most effective treatment for DR and diabetic macular edema (DME) is the control of blood glucose levels. More advanced cases require laser, anti-VEGF therapy, steroid, and vitrectomy. Pan-retinal photocoagulation for non-proliferative diabetic retinopathy (NPDR) is well established and has demonstrated promising outcomes for preventing the progressive stage of DR. Furthermore, the efficacy of laser therapies such as grid and subthreshold diode laser micropulse photocoagulation (SDM) for DME has been reported. Vitrectomy has been performed for vitreous hemorrhage and tractional retinal detachment for patients with PDR. In addition, anti-VEGF treatment has been widely used for DME, and recently its potential to prevent the progression of PDR has been remarked. Even with these treatments, many patients with DR lose their vision and suffer from potential side effects. Thus, we need alternative treatments to address these limitations. In recent years, the relationship between DR, lipid metabolism, and inflammation has been featured. Research in diabetic animal models points to peroxisome proliferator-activated receptor alpha (PPARα) activation in cellular metabolism and inflammation by oral fenofibrate and/or pemafibrate as a promising target for DR. In this paper, we review the status of existing therapies, summarize PPARα activation therapies for DR, and discuss their potentials as promising DR treatments.
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Wallsh JO, Gallemore RP. Anti-VEGF-Resistant Retinal Diseases: A Review of the Latest Treatment Options. Cells 2021; 10:cells10051049. [PMID: 33946803 PMCID: PMC8145407 DOI: 10.3390/cells10051049] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 02/07/2023] Open
Abstract
Anti-vascular endothelial growth factor (anti-VEGF) therapy currently plays a central role in the treatment of numerous retinal diseases, most notably exudative age-related macular degeneration (eAMD), diabetic retinopathy and retinal vein occlusions. While offering significant functional and anatomic benefits in most patients, there exists a subset of 15–40% of eyes that fail to respond or only partially respond. For these cases, various treatment options have been explored with a range of outcomes. These options include steroid injections, laser treatment (both thermal therapy for retinal vascular diseases and photodynamic therapy for eAMD), abbreviated anti-VEGF treatment intervals, switching anti-VEGF agents and topical medications. In this article, we review the effectiveness of these treatment options along with a discussion of the current research into future directions for anti-VEGF-resistant eyes.
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Affiliation(s)
- Josh O. Wallsh
- Department of Ophthalmology, Albany Medical College, Albany, NY 12208, USA;
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Kodjikian L, Baillif S, Creuzot-Garcher C, Delyfer MN, Matonti F, Weber M, Mathis T. Real-World Efficacy and Safety of Fluocinolone Acetonide Implant for Diabetic Macular Edema: A Systematic Review. Pharmaceutics 2021; 13:pharmaceutics13010072. [PMID: 33430389 PMCID: PMC7827527 DOI: 10.3390/pharmaceutics13010072] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 12/24/2020] [Accepted: 01/04/2021] [Indexed: 12/18/2022] Open
Abstract
To assess real-world outcomes of fluocinolone acetonide (FAc) implant in treating diabetic macular edema (DME), a systematic literature review was conducted on PubMed in order to identify publications assessing the efficacy and safety of the FAc implant in DME in daily practice. Case reports and randomized controlled trials were excluded. Twenty-two observational real-world studies analyzing a total of 1880 eyes were included. Mean peak visual gain was +8.7 letters (11.3 months post-FAc injection) and was greater for lower baseline best corrected visual acuity (BCVA) and for more recent DME. Mean central retinal thickness (CRT) decreased 34.3% from baseline. 77.0% of the analyzed studies reported both BCVA improvement of at least five letters and a CRT decrease by 20% or more. Rescue therapy was needed more frequently when FAc was administered for chronic DME. FAc-induced ocular hypertension was reported in 20.1% of patients but only 0.6% needed surgery. Cataract extraction was performed in 43.2% of phakic patients. Adequate patient selection is essential for optimal FAc response and better safety profile. Currently positioned as second- or third-line treatment in the management algorithm, FAc implant decreases treatment burden and provides better letter gain when administered for more recent DME.
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Affiliation(s)
- Laurent Kodjikian
- Department of Ophthalmology, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon 1, 69004 Lyon, France;
- CNRS-UMR 5510 Mateis, University of Lyon 1, 69100 Villeurbane, France
- Correspondence: ; Tel.: +33-(0)4-26-10-94-31
| | - Stephanie Baillif
- Department of Ophthalmology, Pasteur 2 University Hospital, 06000 Nice, France;
| | - Catherine Creuzot-Garcher
- Department of Ophthalmology, Dijon-Bourgogne University Hospital, 21000 Dijon, France;
- Eye and Nutrition Research Group, CSGA, UMR1324 INRA, 6265 CNRS, Burgundy, 21000 Dijon, France
| | - Marie-Noëlle Delyfer
- Department of Ophthalmology, Bordeaux 2 University Hospital, 33000 Bordeaux, France;
- Bordeaux Population Health Research Center, Team LEHA, 33000 Bordeaux, France
| | - Frédéric Matonti
- Monticelli Paradis Center, 13000 Marseille, France;
- Institut de Neurosciences de la Timone-UMR 7289, University of Aix-Marseille, 13000 Marseille, France
| | - Michel Weber
- Department of Ophthalmology, Nantes University Hospital, 44000 Nantes, France;
- Clinical Investigation Centre CIC1413, INSERM and Nantes University Hospital, 44000 Nantes, France
| | - Thibaud Mathis
- Department of Ophthalmology, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon 1, 69004 Lyon, France;
- CNRS-UMR 5510 Mateis, University of Lyon 1, 69100 Villeurbane, France
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Persistent or Recurrent Diabetic Macular Edema After Fluocinolone Acetonide 0.19 mg Implant: Risk Factors and Management. Am J Ophthalmol 2020; 215:14-24. [PMID: 32209341 DOI: 10.1016/j.ajo.2020.03.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/15/2020] [Accepted: 03/16/2020] [Indexed: 01/12/2023]
Abstract
PURPOSE To investigate baseline characteristics of patients undergoing additional antivascular endothelial growth factor (VEGF) injections for residual or recurrent diabetic macular edema (DME) in the first year after 0.19-mg fluocinolone acetonide (FAc) implant. DESIGN Prospective cohort study. METHODS Ninety-four eyes of 66 patients received an FAc implant. Eyes with persistent or recurrent DME were managed with pro re nata anti-VEGF agents. Demographic data and medical history were collected at baseline. Best-corrected visual acuity and central macular thickness were measured every 2 months. The 3 outcomes explored were 1) the risk factors for administration of additional anti-VEGF agents, 2) the interval from FAc to first anti-VEGF injection; and 3) the number of anti-VEGF doses required to maintain regression of DME. RESULTS Eighteen eyes (19.1%) of 13 patients received 1.3 ± 0.6 anti-VEGF injections. These eyes had significantly thicker central macular thickness at baseline and over the entire follow-up period (P < .001); best-corrected visual acuity was similar at every time point to eyes that were not receiving extra DME treatments. Eyes without preexistent panretinal photocoagulation (PRP) had a higher risk to undergo supplemental treatments (hazard ratio 1.5 [95% confidence interval 1.1-2.5, P = .03). The interval between FAc implant and the first anti-VEGF had a significant linear positive relationship with the number of dexamethasone implants before FAc implant (P = .002, R2 = 0.47). No association was found between baseline factors and the number of injections given. CONCLUSION Anti-VEGF agents are efficient treatment to maintain visual acuity in residual/recurrent DME after FAc. Patients with higher baseline central macular thickness and with no previous central macular thickness are more likely to require additional treatments to control DME.
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Cicinelli MV, Cavalleri M, Lattanzio R, Bandello F. The current role of steroids in diabetic macular edema. EXPERT REVIEW OF OPHTHALMOLOGY 2020. [DOI: 10.1080/17469899.2020.1729743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Maria Vittoria Cicinelli
- Department of Ophthalmology, Scientific Institute San Raffaele, Vita-Salute University, Milan, Italy
| | - Michele Cavalleri
- Department of Ophthalmology, Scientific Institute San Raffaele, Vita-Salute University, Milan, Italy
| | - Rosangela Lattanzio
- Department of Ophthalmology, Scientific Institute San Raffaele, Vita-Salute University, Milan, Italy
| | - Francesco Bandello
- Department of Ophthalmology, Scientific Institute San Raffaele, Vita-Salute University, Milan, Italy
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