Treatment of Non-infectious Uveitic Macular Edema with the Intravitreal Dexamethasone Implant

Purpose: To describe the clinical outcome of phakic eyes with macular edema (ME) due to non-infectious uveitis treated with a dexamethasone intravitreal implant.

Methods: A retrospective analysis of 41 eyes treated with a total of 58 dexamethasone intravitreal implants was conducted. Best corrected visual acuity (BCVA), central retinal thickness (CRT) and complications data were collected.

Results: One month after the first implant, even as CRT improved significantly in most eyes (p<0.001), 31.7% showed no improvement in BCVA. At 6 months post-implantation, CRT and BCVA had deteriorated in up to 70% of patients. Thirteen eyes were re-implanted, with a similar effect to that of the first implant. Ocular hypertension developed in 36.2% of eyes, and three eyes had cataract surgery, all in eyes with repeated implants.

Conclusions: The dexamethasone intravitreal implant can be safely used to treat ME due to non-infectious uveitis, but with a limited and short effect on BCVA.     

Intravitreal Dexamethasone Implant for the Treatment of Macular Edema in Chronic Non-infectious Uveitis

Purpose: To report observations on the single and repeat use of the dexamethasone (DEX) intravitreal implant (Ozurdex; Allergan, Inc, Irvine, CA) for the treatment of macular edema in patients with non-infectious posterior segment uveitis.

Methods: A chart review of 15 consecutive patients (25 eyes) was conducted. The primary outcome measure of the first and subsequent implants was central retinal thickness (CRT) on spectral-domain optical coherence tomography (sdOCT). Secondary outcomes were best-corrected visual acuity (BCVA), time to repeat implant, and adverse events. Multilevel mixed-effects linear regression was used to determine the effect of the DEX implant compared with baseline. The Kaplan–Meier estimator was used to examine survival from relapse.

Results: A total of 35 implants on 25 eyes of 15 patients were included in the analysis. Of these, 91.4% (32 of 35 eyes) had a reduction in CRT and 80% (20 of 25 eyes) had improved BCVA. After the first DEX implant, CRT decreased from 590 µm (SE: 28 µm) at baseline to 370 µm (SE: 31 µm) at 3 months (p < 0.001). The logMAR VA was 0.614 (SE: 0.089) at baseline and improved to 0.35 (SE: 0.10, p = 0.002), reaching a statistically significant difference at 3 months. A repeat implant led to VA improvement of –0.184 logMAR (SE: 0.171 logMAR) and CRT reduction of –291 µm (SE: 74 µm). There was no significant difference in effect between the first repeat implant and the initial implant. Kaplan–Meier estimates of treatment success were 72% between 3 and 6 months.

Conclusions: The DEX implant is an effective adjunct treatment to systemic corticosteroid or immunomodulatory therapy. Additional research is required to determine the efficacy of DEX implant as monotherapy for controlling chronic uveitic macular edema.     

Intravitreal Triamcinolone Injection for Uveitic Macular Edema: A Randomized Clinical Study

Abstract

Purpose: To evaluate the additive effect of intravitrial triamcinolone (TA) injection in uveitic macular edema compared to systemic anti-inflammatory treatment only.

Methods: Patients were randomized into the intravitreal TA injection group and the sham group. All patients received systemic anti-inflammatory treatment with follow-up monthly to 6 months, with additional treatment as needed.

Results: Fifty eyes of 50 patients were enrolled. Central foveal thickness decreased significantly from month 1 in the TA group, and from month 3 in the sham group. Parafoveal area thickness significantly decreased in both groups from month 1, with greater decrease in the TA group at months 2 and 3. Leakage area on fluorescein angiography was significantly smaller in the TA group at months 1 to 3. Intraocular pressure increased in the TA group at months 1 and 2.

Conclusions: Intravitreal TA injection showed earlier reduction of leakage and retinal edema compared to systemic anti-inflammatory treatment alone.     

Long-Term Intravitreal Dexamethasone Implant Outcomes in Uveitis

ABSTRACT

Purpose: To describe the long-term clinical outcomes in a cohort of uveitic eyes treated with the intravitreal dexamethasone implant (Ozurdex; Allergan, Inc).

Methods: Seventy-nine (63 patients) receiving 134 implant injections over 82 months were included. Indication, visual acuity (VA), intraocular pressure (IOP), vitreous haze score (VHS), central retinal thickness (CRT), time to reinjection, systemic treatments, and complications data were recorded.

Results: The cumulative probability of VA improvement was 80% at 1 month and 90% at 12 months, and it was maintained until 60 months. Eyes with baseline vitritis (VHS >0.5; 68%) had a probability of VHS improvement of 33% at 1 month, 75% at 12 months, and 85% at 60 months. The probability of CRT improvement was 33% at 1 month, 75% at 12 months, and 85% at 60 months. The most frequent adverse event was moderate IOP elevation (≥25 mmHg) in 30.3%, no cases of retinal detachment or endophthalmitis were observed.

Conclusions: The dexamethasone implant provides favorable VA, CRT, and VHS long-term outcomes in uveitis with a reduced rate of severe adverse events.     

Short-term Results of a Single Intravitreal Bevacizumab (Avastin) Injection versus a Single Intravitreal Triamcinolone Acetonide (Kenacort) Injection for the Management of Refractory Noninfectious Uveitic Cystoid Macular Edema

Purpose: To report the short-term results of a single intravitreal injection of bevacizumab (IVB) versus a single intravitreal injection of triamcinolone acetonide (IVT) to treat refractory noninfectious uveitic cystoid macular edema (CME).

Methods: Twenty-eight consecutive patients (36 eyes) were retrospectively included. Patients received either 2.5?mg of IVB (16 eyes) or 4?mg of IVT (20 eyes).

Results: In the IVT group, baseline best-corrected visual acuity (BCVA) was logMAR 1.1?±?0.2, and improved to 0.7?±?0.3 (p?<?.001) at 6 months. In the IVB group, baseline BCVA was logMAR of 1.2?±?0.4 and improved to 0.8?±?0.4 at 6 months (p?=?.031). At 6 months, central macular thickness (CMT) in the IVT group improved from 454.8?±?238.9?μm to 296?±?134.4?μm (p?<?.0001).

Conclusion: A single IVT injection improves BCVA and reduces CMT more effectively than IVB in refractory noninfectious uveitic CME at 6 months.     

Tocilizumab in Uveitic Macular Edema Refractory to Previous Immunomodulatory Treatment

Purpose: To analyze the efficacy of tocilizumab in uveitic macular edema (ME) resistant to various immunomodulatory drugs.

Methods: Patients received tocilizumab every 4 weeks intravenously. Central foveal thickness (CFT) was assessed by optical coherence tomography (OCT).

Results: Five patients (8 eyes) who were ineffectively pretreated with systemic prednisolone, at least one immunosuppressive drug, and at least one biologic drug for uveitic macular edema were included in the study. At 3 months, a response of ME (≥25% reduction in CFT) was observed in 6 eyes (75.0%) of 5 patients. During follow-up, complete resolution of ME was achieved in 5 eyes (62.5%) of 4 patients. Improvement of BCVA was observed in 3 eyes of 3 patients, and stabilization in 3 eyes of 3 patients. Tocilizumab was well tolerated, and no severe side effects occurred.

Conclusions: Treatment with tocilizumab can be considered in chronic uveitic macular edema even if previous immunomodulatory therapy has failed.     

地塞米松玻璃体内植入剂治疗顽固性糖尿病性黄斑水肿

目的：观察地塞米松玻璃体内植入剂(DEX)治疗顽固性糖尿病性黄斑水肿(DME)的疗效。

方法：回顾性研究。收集2019-06/2020-01于郑州市第二人民医院确诊为顽固性DME并行玻璃体腔内注射DEX患者30例30眼的临床资料。观察治疗前后最佳矫正视力(BCVA)、眼压、黄斑中心凹厚度(CMT)变化及并发症。

结果：治疗后1、2、3、4、6mo BCVA(LogMAR)(0.57±0.53、0.42±0.48、0.43±0.26、0.45±0.66、0.51±0.37)较治疗前(0.86±0.47)显著提高(均P<0.05); 治疗后1、2、3、4、6mo CMT(412.57±74.55、370.21±23.83、371.53±52.66、373.28±68.49、389.35±95.61μm)较治疗前(495.64±107.23μm)有差异(均P<0.05)。用药后2mo BCVA和CMT临床效果达到最佳,部分患者病情反复,再次出现视力下降及黄斑水肿加重,4眼于术后3mo、5眼于术后4mo及2眼于术后6mo,再次注射DEX。所有患者中4眼出现高眼压(≥22mmHg),应用降眼压药物后,眼压均控制在正常范围内。1眼出现白内障加重。随访6mo中未发生眼内炎、视网膜脱离等并发症。

结论：玻璃体腔注射DEX可以有效提高顽固性DME患者BCVA,减轻黄斑水肿。     

Safety and Efficacy of Intravitreal Triamcinolone Acetonide for Uveitic Macular Edema

Background: To evaluate the safety and efficacy of intravitreal triamcinolone acetonide (TA) for treating macular edema secondary to non-infectious uveitis. Methods: Retrospective review of sixteen patients (20 eyes) with chronic cystoid macular edema (CME) as a consequence of controlled intermediate uveitis, posterior uveitis, or panuveitis who received at least one intravitreal injection of TA. Main outcome measures were visual acuity (VA), intraocular pressure (IOP), formation or progression of an existing cataract, and CME resolution during the follow-up period. Results: At last follow-up, VA showed improvement (compared to baseline) in 11 eyes (55%), deterioration in three eyes (15%), remained completely unchanged in one eye (5%), and showed improvement initially but returned to baseline levels in five eyes (25%). At last follow-up, CME had relapsed or was still present in 10 of the eyes (50%). The remaining eyes showed complete resolution of the CME, without evidence of recurrence during the follow-up time. Mean VA at last follow-up showed statistically significant improvement (p = 0.02) in nonvitrectomized eyes (mean baseline VA: 1.14 ± 0.58; mean final VA: 0.96 ± 0.66) compared to the almost unaltered mean visual acuity for vitrectomized eyes (mean baseline VA: 0.76 ± 0.41; mean final VA: 0.71 ± 0.48)(p = 0.40, paired samples t-test). Elevation of IOP was transient in all cases and responded well to topical medications, except for one patient who required placement of an Ahmed valve. Preexisting cataract progressed in three of the 15 phakic eyes (20%). One patient developed a retinal detachment and required additional surgery to reattach it. Patients were followed for a mean of 34 weeks (median: 32 weeks; range: 19–56 weeks). Conclusions: Intravitreal TA may play a role in the treatment of uveitis-related CME. Further controlled studies are necessary to test this hypothesis.     

Somatostatin for Uveitic Cystoid Macular Edema (CME)

Purpose: To report the favorable response of bilateral recalcitrant uveitic cystoid macular edema (CME) to treatment with a somatostatin analog. Methods: Medical ophthalmic history and the results of ophthalmic examinations were recorded. Fluorescein angiography (FA) studies were reviewed. Results: A 52-year-old white female with intermediate uveitis developed bilateral recalcitrant CME. Treatment with subcutaneous injections of the somatostatin analog octreotide resulted in partial resolution of the CME and improvement of visual acuity. Conclusions: Somatostatin may play a role in the treatment of CME secondary to uveitis.     

INFLIXIMAB and ADALIMUMAB in Uveitic Macular Edema

Purpose: To compare the efficacy of infliximab and adalimumab in patients with refractory uveitis-related macular edema (ME).

Methods: A retrospective study was conducted in all patients with refractory uveitis-related ME treated with infliximab or adalimumab in Pitié-Salpêtrière hospital between January 1, 2006 and January 1, 2016. All patients underwent a complete ophthalmologic examination, OCT and retinal angiography at baseline, and 6 (M6) and 24 months (M24) after treatment initiation. Main outcome was a decrease in central foveal thickness (CFT) on OCT.

Results: Twenty-five patients were included: 12 treated with adalimumab and 13 treated with infliximab. The median baseline CFT was 381 μm (Q1 = 254; Q3 = 470) in the adalimumab group and 469 μm (307; 539) in the infliximab group. At M6, 6/12 adalimumab-treated patients (50%) and 8/13 infliximab-treated patients (61%) were responders. The median CFT decrease from baseline was 61 μm (17–136) and 66 μm (?59–119) respectively at M6 and M24 in the adalimumab group versus 92 μm (9–165) and 52 μm (33–130) respectively at M6 and M24 in the infliximab group (all p > 0.05).

Conclusion: No significant difference in efficacy was observed between infliximab and adalimumab at M6 and M24.     

地塞米松玻璃体内植入剂治疗非感染性葡萄膜炎顽固性黄斑水肿

目的：观察地塞米松玻璃体内植入剂(IDI)治疗非感染性葡萄膜炎(NIU)顽固性黄斑水肿的有效性及安全性。

方法：选取2018-04/2020-06在新疆军区总医院北京路医疗区眼科确诊的NIU患者25例30眼,均进行玻璃体腔注射IDI治疗,观察治疗前后最佳矫正视力(BCVA)、黄斑中心凹视网膜厚度(CMT)、玻璃体混浊程度评分及并发症等情况。

结果：首次玻璃体腔注射IDI治疗前,纳入患者BCVA(LogMAR)为0.76±0.37,CMT为480.03±96.72μm,玻璃体混浊程度评分为3.06±0.78分; 治疗后1、3、6mo,BCVA分别为0.61±0.24、0.53±0.10、0.40±0.13,均较治疗前明显改善(P<0.05),CMT分别为324.54±79.88、245.16±67.87、185.52±36.05μm,较治疗前明显降低(P<0.05),玻璃体混浊程度评分分别为2.31±0.64、1.37±0.76、0.82±0.42分,均较治疗前明显降低(P<0.05)。平均随访8.2±2.1mo,6眼眼压升高,经降眼压治疗后末次随访时处于正常范围; 3眼玻璃体腔重复注射IDI; 所有患者均无感染性眼内炎等并发症发生。

结论：玻璃体腔注射IDI治疗NIU继发的顽固性黄斑水肿具有良好的安全性及有效性,可有效降低CMT,减轻玻璃体炎症,改善视力。     

Triamcinolone Intravitreal Injection and Intraocular Pressure in Macular Edema Associated with Retinal Vein Occlusion

 Purpose: To study the risk factors of increased intraocular pressure (IOP) response to triamcinolone acetonide intravitreal (IVTA) injection in eyes with macular edema associated with retinal vein occlusion. Methods: Eighty-nine eyes with macular edema associated with retinal vein occlusion first received periocular injection of 40 mg triamcinolone acetonide (TA) and were followed for one month. According to the diversity of IOP after periocular TA (PTA) injection, they were divided into the elevation IOP group (group A, 26 eyes) and the normal IOP group (group B, 63 eyes). They then received 4 mg TA intravitreal injection. IOP measurements were recorded after PTA and IVTA injections, and were followed for six months. Results: Both PTA and IVTA injections caused a rise in IOP, but it was higher in the IVTA injection (40.45%) than in the PTA injection (29.21%). The mean rise in IOP was more significant in eyes with IVTA injection (28.08 ± 8.24 mmHg) than in eyes with PTA injection (20.87 ± 4.07 mmHg). Patients with an elevation IOP above 6 mmHg after PTA injection had a 73.08% chance of developing a pressure of 24 mmHg or higher, whereas only 12.70% of those with an elevation IOP below 6 mmHg after PTA injection experienced pressure elevation. Conclusion: IOP response to PTA injection is a good way to judge IOP response to IVTA. If the patient is highly sensitive to corticosteroid, treatments other than IVTA injection are used to avoid the increased risks associated with intravitreal corticosteroid injection.     

地塞米松玻璃体内植入剂治疗非感染性葡萄膜炎继发黄斑水肿的研究进展

葡萄膜炎继发的黄斑水肿(macular edema,ME)是一种葡萄膜炎常见的并发症,可导致非感染性葡萄膜炎(noninfectious uveitis,NIU)患者的视功能障碍。临床上,葡萄膜炎继发ME的治疗仍然非常棘手。目前有多种药物用于治疗葡萄膜炎继发ME,例如皮质类固醇、抗血管内皮生长因子和免疫调节剂等。但是,临床效果报告不一致。近些年来,地塞米松玻璃体内植入剂(intravitreal dexamethasone implant,IDI)是一种广泛应用的皮质类固醇药物。最近的研究表明,IDI有效地改善了葡萄膜炎相关的ME,根据需要通过密切监测和再治疗,这种效应可持续至少6mo。本文就目前国内外关于IDI治疗NIU继发ME进行汇总,并概述相关结果,以期为未来NIU继发ME的诊治提供依据。     

Different Dosages of Intravitreal Triamcinolone Acetonide Injections for Macular Edema Secondary to Central Retinal Vein Occlusion

Purpose:.To study the effect of intravitreal injections of triamcinolone acetonide (TA) for the treatment of macular edema secondary to central retinal vein occlusion.(CRVO).in a sample of Chinese patients from Shaanxi province. Methods:.The 50 eyes from 50 patients were separated into three TA treatment groups:.17 patients were given 4 mg/0.1 ml,.19 patients were given 8 mg/0.2 ml,.and 14 patients were given 16 mg/0.4 ml. Patients were followed up for 12 months. Foveal thickness, intraocular pressure (IOP), and best-corrected visual acuity (BCVA) were measured. Results:.Macular edema responded well both anatomically and functionally to the TA injections. After the initial intravitreal injection,.macular edema recurred at 2-4 months in the low-dose group.(4 mg),.at 3-5 months in the medium-dose group (8 mg), and at 6-9 months in the high-dose group (16 mg)..No significant difference in BCVA or in foveal thickness were observed between the first intravitreal injection and the re-injection. There was no increase in IOP after re-injection of 16 mg TA,.if the patient did not have an elevated IOP after the initial intravitreal injection of 4/8 mg TA. Conclusion: A low dosage of TA (4 mg) administered via intravitreal injection might be useful as an initial treatment for macular edema secondary to CRVO..A higher dosage of TA (16mg) can be used if there is no IOP elevation with the initial TA injection.     

Interferon alpha 2b in the Treatment of Uveitic Cystoid Macular Edema

Purpose: To determine the efficacy of interferon alpha 2b in the treatment of refractory, uveitic cystoid macular edema (CME).

Methods: Retrospective chart review of 4 patients attending the uveitis clinic at the Casey Eye Institute, Oregon Health & Science University.

Results: All 4 patients had uveitis and refractory CME, resistant to a variety of immunosuppressants. All patients, except one with severe scleral thinning, had tried and failed therapy with locally injected corticosteroids. Treatment with systemic interferon alpha 2b produced dramatic improvement in CME (central macular thickness: 563 to 267?µm, p?=?.002) and visual acuity (logMAR: +0.81 to +0.45, p?=?.0004) in all 4 cases. All patients have been able to reduce the interferon dosage, but none has discontinued it completely. All patients had some mild adverse response that did not necessitate stopping therapy.

Conclusions: Interferon alpha 2b is an effective option to treat refractory CME secondary to uveitis.     

Management of Anterior Chamber Dislocation of Dexamethasone Implant

Purpose: To report dislocation of dexamethasone implant (Ozurdex®) into the anterior chamber and to discuss intervention options.

Design: Interventional case report.

Methods: An 89-year-old woman presented after Ozurdex® implant injection for chronic cystoid macular edema secondary to idiopathic intermediate uveitis. The dexamethasone implant dislocated into the anterior chamber. Pharmacologic dilation was administered and the patient was placed in a reclined supine position.

Results: Successful repositioning of the implant into the vitreous cavity.

Conclusions: Although it is a rare complication, anterior dislocation of a dexamethasone implant may have serious consequences. Early recognition and appropriate management is advisable.     

地塞米松玻璃体内植入剂在非感染性葡萄膜炎继发黄斑水肿患者治疗中的作用

目的　观察地塞米松玻璃体内植入剂在治疗非感染性葡萄膜炎继发黄斑水肿中的安全性和临床疗效。方法　回顾性分析我院2019年12月至2021年12月临床确诊的非感染性葡萄膜炎继发黄斑水肿患者30例（30眼）,给予玻璃体内注射地塞米松玻璃体内植入剂治疗。所有患眼均行最佳矫正视力(BCVA)及眼压测量,并采用OCT测量黄斑中心视网膜厚度(CMT)。术后随访6个月,所有患者均于术前,术后1个月、3个月及6个月重复检测并比较BCVA、CMT。随访期间观察患者眼压变化,监测白内障进展、结膜下出血等眼部不良反应。结果　患者术前及术后1个月、3个月及6个月BCVA(logMAR)分别为0.74±0.37、0.47±0.29、0.28±0.14、0.37±0.17。患者术前,术后1个月、3个月及6个月CMT分别为(372.12± 99.42)μm、(298.14±82.44)μm、(278.45±62.43)μm、(289.31±56.34)μm。患者各时间点BCVA、CMT差异均有统计学意义（均为P<0.05)。与术前相比,患者术后1个月、3个月及6个月BCVA和CMT差异均有统计学意义（均为P<0.05）。术后各时间点两两比较结果显示,患者BCVA和CMT差异均无统计学意义（均为P>0.05)。随访期间有6例患者出现眼压升高（≥25 mmHg,1 kPa=7.5 mmHg）,经局部降眼压药物应用后降至正常水平。4例患者出现白内障进展,均无需手术治疗。结论　玻璃体内注射地塞米松玻璃体内植入剂能够提高患者视力及降低CMT,有效治疗非感染性葡萄膜炎继发黄斑水肿。     

The Use of Topical Non-steroidal Anti-inflammatory Drugs for Uveitic Cystoid Macular Edema

The use of topical non-steroidal anti-inflammatory drugs in the management of uveitic cystoid macular edema is controversial. In this letter, we review the literature and report our results from a retrospective case series of 281 patients taking topical nepafenac 0.1% for uveitic cystoid macular edema between 2010 and 2016. Over a 4-month period, there was a modest improvement in best-corrected visual acuity (0.66 ± 3.7 logMAR) and central macular thickness (69.8 ± 132.5 μm). Patients with idiopathic anterior uveitis and HLA-B*27-associated anterior uveitis recovered more vision while taking topical nepafenac 0.1%, than those with other uveitides, however, this was not statistically significant. There is a need for controlled prospective studies to evaluate the efficacy of topical non-steroidal anti-inflammatory drugs in the management of uveitic cystoid macular edema. At present, clinicians have little evidence on which to base practice.