Steroid implants

Intravitreal steroid implants can provide significant improvements in patients with diabetic macular oedema (DME) in the long-term, Anat Loewenstein MD, Tel Aviv Medical Center, Israel, told the 15th EURETINA Congress in Nice, France.

Noting that steroids address the multifactorial nature of DME via inhibition of various signalling pathways within the eye, she reviewed the literature on intravitreal steroid implants for DME, with particular emphasis on the Illuvien® intravitreal fluocinolone implant and the Ozurdex® intravitreal dexamethasone implant.

“Both of these sustained-release devices have recently been approved by regulatory bodies for the treatment of DME. The implants’ sustained release of the active molecule over many months also allows for a decreased number of intravitreal injections, with a lower burden on both patients and the healthcare system,” Dr Loewenstein told the delegates.

Another feature of these agents it that patients also often respond after failure of anti-VEGF treatment regimens. Dr Loewenstein highlighted the strong correlation between ETDRS retinopathy severity and intraocular concentrations of cytokines, a correlation that is lacking for
VEGF concentrations.

Dr Loewenstein also addressed the well-known side effects of intravitreal steroids. “Although the incidence of cataract in phakic patients is very high, from 60 to 80 per cent, patients who underwent cataract surgery eventually gained the same visual benefit as pseudophakic patients. Approximately 40 per cent of eyes experienced increased intraocular pressure (IOP), and depending on the duration of the study, between one and five per cent of patients require a filtering procedure to control this increased IOP.”

But what can physicians expect in daily practice, outside the highly organised confines of clinical trials? “Studies such as the MOZART trial suggest six to nine letter gains after two to three injections of Ozurdex®. Best corrected visual acuity improvement of at least 15 letters was greatest in patients with chronic DME,” she said.

What differentiates the longer-lasting Illuvien® from Ozurdex®? “Illuvien® is primarily intended for patients with DME that has been present for 1.7 or three years at least (according to different analysis), and has been insufficiently responsive to Ozurdex®, anti-VEGF or other available therapies,” reported Dr Loewenstein.

Compliance issues also come into play, as a subset of patients are unable to attend even the relatively infrequent hospital appointments required for monitoring of the retinal response to Ozurdex®, let alone anti-VEGF agents.

And what about long-term use? “The Fluocinolone Acetonide for Diabetic Macular Edema (FAME) study, the first report of a five-year follow-up, indicated that 90 per cent of patients no longer need DME treatment two years after the end of a three-year clinical study treatment regimen,” said Dr Loewenstein.

Anat Loewenstein: anatlow@tasmc.health.gov.il