INTRAVITREAL DEXAMETHASONE FOR THE TREATMENT OF MACULAR EDEMA SECONDARY TO HYDROXYCHLOROQUINE TOXICITY

PURPOSE

Cystoid macular edema is a vision-threatening complication infrequently associated with hydroxychloroquine retinal toxicity. There are limited data on the best treatment for this pathology.

METHODS

A retrospective case series is presented.

RESULTS

In this series, we present three cases of cystoid macular edema in patients with diagnosed hydroxychloroquine maculopathy successfully treated with intravitreal dexamethasone implantation.

CONCLUSION

Minimal literature has been published regarding the best management of cystoid macular edema related to hydroxychloroquine toxicity. Our case series suggests a possible new agent in the treatment of this rare occurrence.

Evolving Treatment Patterns in Diabetic Macular Edema Between 2015 and 2020

Purpose: To explore the recent evolution of diabetic macular edema (DME) treatment practice patterns over 5 years among retina specialists in the United States. Methods: This retrospective analysis assessed 306 700 eyes with newly diagnosed DME from the Vestrum Health database between January 2015 and October 2020. The year-over-year and cumulative 5-year distributions of eyes treated with antivascular endothelial growth factor (anti-VEGF) agents, steroids, focal laser, or any combination and those of untreated eyes were calculated. Changes from baseline visual acuity were assessed. Results: Yearly treatment patterns changed significantly from 2015 (n = 18056) to 2020 (n = 11042). The proportion of untreated patients declined over time (32.7% vs 27.7%; P < .001), the use of anti-VEGF monotherapy increased (43.5% vs 61.8%; P < .001), the use of focal laser monotherapy declined (9.7% vs 3.0%; P < .001), and the use of steroid monotherapy remained stable (0.9% vs 0.7%; P = 1.000). Of eyes that maintained follow-up for 5 years (from 2015 to 2020), 16.3% were untreated while 77.5% were treated with anti-VEGF agents (as monotherapy or combination therapy). Vision gains in treated patients remained approximately stable from 2015 (3.6 letters) to 2020 (3.5 letters). Conclusions: From 2015 to 2020, treatment patterns for DME evolved toward greater anti-VEGF monotherapy, stable steroid monotherapy, less laser monotherapy, and fewer untreated eyes.

Comparing the Efficacy of Intravitreal Dexamethasone and Time-displaced Fluocinolone Acetonide on Central Retinal Thickness in Patients with Uveitis

BACKGROUND

To compare the efficacy of intravitreally administered dexamethasone (Dex) and subsequent time-displaced fluocinolone acetonide (FA) on central subfield thickness (CST) in eyes with noninfectious uveitis.

METHODS

Retrospective analysis of twenty-three eyes (18 patients) subsequently receiving intravitreal Dex and FA implants. The main outcome measures were CST, best-corrected visual acuity (BCVA), intraocular pressure (IOP), and status of inflammation.

RESULTS

CST (Dex: p < .0001; FA: p = .0008) and BCVA (Dex: p = .0009; FA: p = .0005) improved significantly with both implants. Significantly better effects were noted with Dex for absolute and relative CST reduction (p = .0089 and p = .0051, respectively). Final BCVA did not differ between groups (p = .1893). Dex significantly increased IOP, whereas FA did not. One eye was actively inflamed after Dex and FA injection at follow-up (inflamed eyes before injection: [Dex: 2; FA: 6]).

CONCLUSION

Both implants significantly reduced CST and induced a significant gain in visual acuity. Dex might be more effective in reducing CST.

Resolution of Pseudophakic Cystoid Macular Edema: 2 mg Intravitreal Triamcinolone Acetonide versus 40 mg Posterior Sub-Tenon Triamcinolone Acetonide

PURPOSE

To compare 2 mg intravitreal triamcinolone (IVT) versus 40 mg posterior sub-Tenon triamcinolone acetonide (STT) for the treatment of eyes with pseudophakic cystoid macular edema.

METHODS

A retrospective, single-center review of eyes receiving 2 mg IVT between 3/1/2012-3/1/2017 and 40 mg STT between 1/1/2015-3/1/2017. Visual acuity (VA) and central macular thickness (CMT) were recorded at baseline, 1-, 3-, and 6-month follow-up visits.

RESULTS

Forty-five eyes were included in the IVT group and 50 eyes in the STT group. Change in VA from baseline to 1, 3, and 6 months was not significantly different between IVT and STT (6 months: 2.3 lines vs. 2.4 lines, p = .10). The IVT group achieved significantly better CMT improvement from baseline compared to STT at 1 month (255 μm vs. 187 μm; p = .03), but this difference was not present at month 3 (214 μm vs. 212 μm; p = .79) or month 6 (176 μm vs. 207 μm; p = .29). During the 6-month follow-up period, approximately 7% of eyes in the IVT group and 12% of eyes in the STT group developed ocular hypertension (p = .43), and all cases were successfully managed with topical anti-ocular hypertensive therapy or observation.

CONCLUSIONS

2 mg IVT and 40 mg STT both achieved significant improvement in vision and CMT with no significant difference between interventions at 3- and 6-month follow-up.

Triamcinolone acetonide induces sterile endophthalmitis in patients with intermediate uveitis: A case report series

Due to their anti-inflammatory, antiangiogenic and antiedematous properties, corticosteroids have been commonly used in the treatment of retinal diseases. Intravitreal administration of steroids offers the maximal drug efficacy and the lowest risk of systemic side effects. The authors report three cases of presumed sterile endophthalmitis induced by triamcinolone acetonide (TA) in three eyes with intermediate non-infectious uveitis. Each patient received a single intravitreal injection of TA of 4 mg. Because of the intense vitreous inflammatory reaction, retina examination and the optical coherence tomography could not be performed, although vitreous opacities were observed on the ocular ultrasound. The dense vitreous opacity is a defining factor, the anterior segment inflammation is mild to moderate and a hypopyon is present, which may be a sterile inflammatory reaction or the triamcinolone material itself. In cases of sterile endophthalmitis, the visual acuity increases progressively as the intraocular inflammation diminishes. Local treatment with topical antibiotics, prednisolone acetate and cycloplegic eyedrops is recommended to control the inflammatory reaction.

Emerging drugs for the treatment of diabetic retinopathy

INTRODUCTION

Diabetic retinopathy (DR) is one of the main pathological features of the diabetes mellitus spectrum. It is estimated that in 2020 about 4 million people worldwide suffered from blindness or visual impairment caused by DR. Many patients cannot access treatment, mostly because of high costs, while others discontinue it prematurely due to the high number of intravitreal administrations required, or the occurrence of ocular complications, or discomfort in quality of life.

AREAS COVERED

The aims of this paper are to summarize the current understanding of the pathogenesis and treatment of diabetic retinopathy, focus on the most promising new approaches to treatment that are being evaluated in clinical trials, and outline the potential financial impact of new drugs in future markets.

EXPERT OPINION

Slow-release systems with steroids, anti-VEGF or sunitinib are promising. Oral imatinib would avoid the ocular complications of intravitreal drugs. Brolucizumab and abicipar pegol may be superior to aflibercept and ranibizumab with the advantage of less frequent administrations. Faricimab, active on Tie-2 receptors, is being evaluated in two phase 3 clinical trials. Further knowledge of the efficacy and safety of these drugs is necessary before their final approval for the treatment of diabetic retinopathy.

The Role of Steroids and NSAIDs in Prevention and Treatment of Postsurgical Cystoid Macular Edema

BACKGROUND

Pseudophakic cystoid macular edema (PCME) remains one of the most common visionthreatening complication of phacoemulsification cataract surgery (PCS). Pharmacological therapy is the current mainstay of both prophylaxis, and treatment of PCME in patients undergoing PCS. We aimed to review pharmacological treatment options for PCME, which primarily include topical steroids, topical nonsteroidal antiinflammatory drugs (NSAIDS), periocular and intravitreal steroids, as well as anti-vascular endothelial growth factor therapy.

METHODS

The PubMed and Web Of Science web platforms were used to find relevant studies using the following keywords: cataract surgery, phacoemulsification, cystoid macular edema, and pseudophakic cystoid macular edema. Of articles retrieved by this method, all publications in English and abstracts of non-English publications were reviewed. Other studies were also considered as a potential source of information when referenced in relevant articles. The search revealed 193 publications. Finally 82 articles dated from 1974 to 2018 were assessed as significant and analyzed.

RESULTS

Based on the current literature, we found that corticosteroids remain the mainstay of PCME prophylaxis in uncomplicated cataract surgery, while it is still unclear if NSAID can offer additional benefits. In patients at risk for PCME development, periocular subconjunctival injection of triamcinolone acetonide may prevent PCME development. For PCME treatment the authors recommend a stepwise therapy: initial topical steroids and adjuvant NSAIDs, followed by additional posterior sub-Tenon or retrobulbar corticosteroids in moderate PCME, and intravitreal corticosteroids in recalcitrant PCME. Intravitreal anti-vascular endothelial growth factor agents may be considered in patients unresponsive to steroid therapy at risk of elevated intraocular pressure, and with comorbid macular disease.

CONCLUSION

Therapy with topical corticosteroids and NSAIDs is the mainstay of PCME prophylaxis and treatment, however, periocular and intravitreal steroids should be considered in refractory cases.

A Review of the Role of Intravitreal Corticosteroids as an Adjuvant to Antibiotics in Infectious Endophthalmitis

Infectious endophthalmitis is an important cause of vision loss worldwide. This entity most often occurs as a complication of intraocular surgery especially following cataract surgery or intravitreal injection. Endophthalmitis is regarded as a serious complication following ocular surgery and the final visual outcome is fundamentally contingent on timely recognition and intervention. Intravitreal and oral antibiotics in combination with pars plana vitrectomy or vitreous aspiration remain the mainstay in the management of endophthalmitis. However, significant inflammation may persist even after sterilization of the intraocular cavities with appropriate antibiotics resulting in failure of treatment. This forms the basis for the use of intravitreal corticosteroids as an adjuvant to antibiotics in the management of infectious endophthalmitis. In the index manuscript, we review the existing literature to determine the role of intravitreal corticosteroids as an adjuvant to antibiotics in treating infectious endophthalmitis, and discuss their beneficial effects and controversial concerns.

Management of noninfectious posterior uveitis with intravitreal drug therapy

Uveitis is an important cause of vision loss worldwide due to its sight-threatening complications, especially cystoid macular edema, as well as choroidal neovascularization, macular ischemia, cataract, and glaucoma. Systemic corticosteroids are the mainstay of therapy for noninfectious posterior uveitis; however, various systemic side effects can occur. Intravitreal medication achieves a therapeutic level in the vitreous while minimizing systemic complications and is thus used as an exciting alternative. Corticosteroids, antivascular endothelial growth factors, immunomodulators such as methotrexate and sirolimus, and nonsteroidal anti-inflammatory drugs are currently available for intravitreal therapy. This article reviews the existing literature for efficacy and safety of these various options for intravitreal drug therapy for the management of noninfectious uveitis (mainly intermediate, posterior, and panuveitis).

Investigational drugs for retinal vein occlusion

INTRODUCTION

Retinal vein occlusion (RVO) is the second most common retinal vascular disorder. This multifactorial disease frequently leads to visual impairment. Some risk factors for RVO can be managed prophylactically. Given the complex physiopathology of RVO, most of the latest therapeutic strategies focus on secondary clinical features (such as macular oedema and neovascularization).

AREAS COVERED

This author reviews ongoing, prospective, open-label Phase I and Phase II clinical trials of novels treatments for RVO (primarily intravitreal steroids and anti-VEGF agents). Specifically, they review the pharmacokinetics, safety profile, study design and adverse events associated with innovative drugs in clinical development.

EXPERT OPINION

A number of innovative, early-phase clinical trials are based on combination therapy with an anti-VEGF agent and steroids. There is good evidence that early treatment of RVO has clinical benefits. Larger, randomized studies are now required for a better understanding of patient selection, treatment timing and dosing, and thus the optimized use of novel drugs and medical devices.

Advances in diabetic retinopathy

Diabetic retinopathy (DR) is a complication of long-term diabetes mellitus (DM). Over the last 2 decades lot of work has been on early diagnosis of DR and screening programs have been designed to help the masses. Large numbers of clinical studies have been done for patients of diabetes and DR wherein the role of blood sugar control, metabolic control, role of oral medicines for DR, role of imaging, fluorescein angiography, and retinal photocoagulation has been studied. Newer treatment modalities are being devised and studied for better patient care. We discuss these issues in our review highlight and newer advances over the last few years.