Intravitreal Corticosteroid Injections Research Articles

Complications of Subconjunctival, Subtenon and Intravitreal Injections During the Procedure, Early and Late Post-procedure period

Intravitreal and periocular injections are increasingly applied for the treatment of a wide variety of retinal and uveal diseases, including age-related macular degeneration, diabetic retinopathy, retinal vascular occlusions, and uveitis. Despite promising results in stopping or slowing disease progression and improving visual acuity, intravitreal injection of anti-VEGF agents and corticosteroids may be associated with systemic side effects and serious ocular complications. In this review, we aim to provide an overview of the complications of intravitreal, subconjunctival and subtenon injection applications.

Use of Adjunctive Corticosteroid With Antivascular Endothelial Growth Factor Agents in the Treatment of Choroidal Neovascular Membrane Associated With Presumed Ocular Histoplasmosis

Purpose: To evaluate the impact of combination treatment of antivascular endothelial growth factor (anti-VEGF) intravitreal injections and corticosteroids in patients with choroidal neovascularization (CNV) secondary to presumed ocular histoplasmosis syndrome (POHS). Methods: A retrospective multicenter study was conducted in a cohort from Illinois and Missouri. Patients were identified over an 8-year period, and data were evaluated over a 1-year study window commencing with treatment initiation. Group 1 included patients treated with intravitreal injections of anti-VEGF, and group 2 included those who received intravitreal injections of anti-VEGF and adjuvant corticosteroids. Optical coherence tomography (OCT) measurements and increases in Early Treatment Diabetic Retinopathy Study (ETDRS) letter score were compared between each group. Results: Using the method of last visit carried forward, the visual acuity (VA) in group 2 was 6.42 ETDRS letters better than the VA in group 1 at the final assessment. Patients in group 2 had a mean ETDRS letter gain of 21.50 ( P = .06) from the initial baseline vision. The average amount of decrease in OCT central subfield thickness compared with baseline was lower in group 1 (80.9 ± 129.8 µm) vs group 2 (102.8 ± 90.40 µm) at the 1-year follow-up visit ( P = .25). Conclusions: Approved treatment of CNV secondary to POHS is limited. Adjuvant corticosteroid treatment in patients with CNV secondary to POHS may provide better long-term vision and OCT outcomes than anti-VEGF alone and may offer an additional therapy option for these patients.

Surgical Treatment for Diabetic Macular Edema

Diabetic macular edema (DME) is defined as excess fluid accumulation within the retina in the macular area, and when it is centered on the fovea it is the most common cause of decreased visual acuity in patients with diabetic retinopathy. The development of diabetic macular edema is closely related to the duration of diabetes, poor glycemic control, and type 2 diabetes on insulin therapy. The first-line therapy in diabetic macular edema has been the intravitreal injection of anti-vascular endothelial growth factors (VEGF). Other treatment modalities are intravitreal corticosteroid injection and focal laser photocoagulation. However, the efficacy of intravitreal therapy may decrease significantly over time, especially in the presence of vitreomacular traction, tight posterior hyaloid, or epiretinal membrane (ERM). At this stage, pars plana vitrectomy (PPV) is preferred as an alternative treatment method in eyes with chronic DME resistant to intravitreal injections. The vitreous of diabetic patients contains high amounts of VEGF and Angiotensin 2, which cause DME, and cytokines such as interleukin-6 and ICAM-1. In addition, due to the enzymes, it contains, the vitreous causes cross-linking and thickening of the collagen fibers in its structure, causing tight adhesion and traction on the macula. The mechanism of action of pars plana vitrectomy in macular edema can be explained by removing the vitreous and vitreomacular tractions. Vitrectomy may also increase retinal oxygenation. Selection of the appropriate case is important. The undisturbed integrity of the outer retinal layers including the external limiting membrane(ELM) and the ellipsoid zone, no preoperative foveal ischemia, and performing surgery early before ELM is damaged, have been found to be related to better postoperative visual acuity gain. Further, prospective, randomized, controlled studies with large series including detailed parameters and long follow-up evaluating the efficacy of surgical treatment in diabetic macular edema are warranted.

The role and efficacy of vitrectomy for the management of refractory diabetic macular edema: Systematic review and meta-analysis

This study aimed to evaluate the role and efficacy of vitrectomy in the management of chronic diabetic macular edema (DME) refractory to intravitreal anti-vascular endothelial growth factor (anti-VEGF) and corticosteroid treatments. A systematic review and meta-analysis were performed by searching the Embase, Medline, and gray literature. Eight hundred and thirty-nine studies were retrieved and eight were selected (three for quantitative synthesis and five for qualitative synthesis). Visual acuity (VA) and central macular thickness (CMT) were compared between the vitrectomy-treated and control groups (treated with anti-VEGF and intravitreal corticosteroid injection) using the standardized mean difference (SMD) with 95% confidence intervals (CIs) and P-values. There was no significant difference in post-operative VA between the vitrectomy-treated and control groups (SMD = −0.31, 95% CI: −0.76, 0.14, P = 0.18). However, CMT was significantly lower in the vitrectomy group than in the control group (SMD = −0.31, 95% CI: −0.76, 0.14, P = 0.18). In addition, the incidence of postoperative complications was higher in the control groups than that in the vitrectomy group.This systematic review and meta-analysis suggest that vitrectomy may be viable for the management of chronic DME refractory to anti-VEGF and corticosteroid agents. Although there was no significant difference in VA, the CMT was significantly reduced in the vitrectomy group. Moreover, the incidence of post-operative complications was lower in the vitrectomy group than that in the control group. Further studies are needed to confirm these findings and identify patient subgroups that may benefit from vitrectomy.

Frequency and Treatment Regimens of Macular Edema in 1946 Consecutive Patients with Noninfectious Uveitis at a Tertiary Ophthalmic Center in Shaanxi, China.

We investigated the frequency of uveitic macular edema (UME) in patients with different types of noninfectious uveitis and present the primary treatment methods for UME at a specialized eye center in Shaanxi Province, China. We conducted a retrospective, noninterventional, observational survey involving 1946 patients with noninfectious uveitis (2816 eyes). The collected data included sex, age of uveitis onset, age of UME onset, anatomical classification of uveitis, and the treatment administered to UME patients. Of the 1946 patients with noninfectious uveitis, 929 (47.74%) were male and 1017 (52.26%) were female. The average age of all participants in the study was 42.19 ± 15.34years, with average age at uveitis onset of 39.50 ± 15.52years. Among the patients, 1003 (51.54%), 239 (12.28%), 410 (21.07%), and 294 (15.11%) had anterior uveitis, intermediate uveitis, posterior uveitis, and panuveitis, respectively. UME was observed in 134 (6.89%) of the uveitis patients. The average age of UME patients was 47.33 ± 17.17years, with average age at uveitis onset of 45.78 ± 17.20years. Out of the 134 UME patients, 3 (0.30%), 15 (6.28%), 47 (11.46%), and 69 (23.47%) had anterior uveitis, intermediate uveitis, posterior uveitis, and panuveitis, respectively. Among them, 37 were lost to follow-up, 44 received adalimumab (ADA) combined with low-dose prednisone and with or without conventional immunosuppressants, 19 received interferon-α2a therapy, 14 received intravitreal corticosteroid injections (such as dexamethasone implant or fluocinolone acetonide), 11 received low-dose corticosteroids combined with conventional immunosuppressants, 5 received only oral prednisone, and 4 received repeated peribulbar or subconjunctival injections of triamcinolone acetonide. At our tertiary ophthalmic center in Shaanxi Province, China, only 6.89% of patients with noninfectious uveitis were diagnosed with UME. The primary treatment modality for UME in our center is ADA, in accordance with treatment guidelines and the Chinese medical insurance reimbursement system.

Optimizing treatment for diabetic macular edema during cataract surgery.

Diabetic macular edema (DME) causes visual impairment in diabetic retinopathy (DR). Diabetes mellitus is a global epidemic and diabetic individuals are at risk of developing DR. Approximately 1 in 10 diabetic patients suffers from DME, which is the commonest cause of vision-threatening DR at primary-care screening. Furthermore, diabetes predisposes to a higher frequency and a younger onset of cataract, which further threatens vision in DME patients. Although cataract extraction is an effective cure, vision may still deteriorate following cataract surgery due to DME progression or recurrence, of which the risks are significantly higher than for patients without concurrent or previous history of DME at the time of operation. The management of pre-existing DME with visually significant cataract is a clinical conundrum. Deferring cataract surgery until DME is adequately treated is not ideal because of prolonged visual impairment and maturation of cataract jeopardizing surgical safety and monitoring of DR. On the other hand, the progression or recurrence of DME following prompt cataract surgery is a profound disappointment for patients and ophthalmic surgeons who had high expectations for postoperative visual improvement. Prescription of perioperative anti-inflammatory eye drops is effective in lowering the risk of new-onset DME after cataract surgery. However, management of concurrent DME at the time of cataract surgery is much more challenging because DME is unlikely to resolve spontaneously even with the aid of anti-inflammatory non-steroidal or steroid eye drops. A number of clinical trials using intravitreal injection of corticosteroids and anti-vascular endothelial growth factor (anti-VEGF) as first-line therapy have demonstrated safety and efficacy to treat DME. These drugs have also been administered perioperatively for the prevention of DME worsening in patients undergoing cataract surgery. This article reviews the scientific evidence to guide ophthalmologists on the efficacy and safety of various therapies for managing patients with DME who are particularly vulnerable to cataract surgery-induced inflammation, which disintegrates the blood-retinal barrier and egression of fluid in macular edema.

Vasoproliferative retinal tumors: Clinical presentation and treatment outcome.

To study the clinical presentation and treatment outcomes of patients with vasoproliferative retinal tumor (VPRT) in India. Retrospective study of 50 eyes in 47 patients. Of the 50 eyes, 25 (50%) were primary and 25 (50%) were secondary. Common ocular pathologies related to secondary VPRT included retinal detachment (n = 8, 32%) and Coats disease (n = 7, 28%). Overall, the mean age at presentation was 35 years (range; 3-74 years) and included 30 (64%) males and 17 (36%) females. The lesions were unilateral in 44 (94%) patients. Secondary retinal features included intra/subretinal exudation (n = 41, 82%), vascularity (n = 32, 64%), subretinal fluid (n = 21, 42%), retinal neovascularisation (n = 9, 18%) and vitreous hemorrhage (n = 8, 16%). Thirty-four eyes (68%) underwent cryotherapy, of which 16 eyes (47%) received adjunct intravitreal anti-VEGF (12 eyes) or corticosteroid injection (4 eyes). Primary surgery included vitrectomy with/without encirclage and cryotherapy (n = 12, 24%) and plaque brachytherapy (n = 3, 6%). At last follow-up (mean 9.7 months, range 3-67 months), 42 eyes (84%) had complete tumor regression with no improvement in visual outcomes when comparing presenting and final best corrected visual acuity. Comparing primary versus secondary VPRT, secondary VPRT presented a decade earlier (31 vs 40 years), needed surgical intervention (48% vs 20%), had poor tumor control (72% vs 92%) and worse visual outcomes (p < 0.05). VPRTs commonly present as a unilateral lesions in the adult population with equal prevalence of primary and secondary variants. Compared with primary VPRT, secondary VPRTs require surgical treatment and are associated with poor visual outcome.

СОВРЕМЕННЫЕ ПОДХОДЫ К ЛЕЧЕНИЮ РЕТИНАЛЬНЫХ ОККЛЮЗИЙ ВЕН СЕТЧАТКИ, ЛИТЕРАТУРНЫЙ ОБЗОР

Retinal vein occlusion (RVO) is the second among acquired vascular eye diseases, giving priority only to diabetic retinopathy. The severity of retinopathy depends on the location of the occlusion and the development of collateral vessels. RVO is not accompanied only by a decrease in visual acuity (VA), but also by the development of such complications as recurrent intravitreal hemorrhages, traction retinal detachment, secondary neovascular glaucoma. It causes the disability of patients and loss of professional fitness in people of working age. The treatment of RVO focuses on two main goals. The first one is the identification of risk factors and their drug therapy, and the second one is the identification and treatment of complications of retinal vein occlusion. The treatment of any pathology depends on early diagnosis, as well as a quick and well-chosen algorithm for managing the patient. The macular edema is treated by intravitreal injections of corticosteroids, antiVEGF, laser photocoagulation of the retina. Intraocular injections is currently the only way to provide a high intravitreal and intraretinal concentration of the drug. This review describes an algorithm for choosing the optimal treatment for RVO.

Diabetic macular edema

AbstractThe main diabetic macular edema (DME) treatment options include intravitreal injections of anti‐VEGF agents and intravitreal injections of corticosteroids. In the past, macular laser photocoagulation (LP) was a standard of DME treatment, however, now it is utilized as an additional treatment. Two most important techniques of LP in patients with DME include focal photocoagulation and the grid laser. According to European Society of Retina Specialists (EURETINA) guidelines focal or grid laser should be utilized mainly for non‐center involving DME. In recent years anti‐VEGFs were found superior over typical laser treatment in DME patients. However, new tissue‐sparing technique, subthreshold micropulse laser (SML), avoids protein coagulation and prevents retinal scars, allowing retinal anatomic and functional preservation. It helps to improve or stabilize visual function and decrease macular thickness in treatment of DME.Corticosteroids are often used as an alternative therapy for eyes with insufficient response to anti‐VEGF treatment because they act on different targets than anti‐VEGF agents leading to by inflammation reduction, decrease in the disruption of the blood‐retinal barrier, and retinal angiogenesis. The major steroids used in the treatment of DME include triamcinolone acetonide (TA), dexamethasone (DEX) and fluocinolone acetonide (FA). It is known, however, that steroids frequently increase the intraocular pressure, and are related with the risk of cataract development.

Association between Obstetric Complications and Intravitreal Anti-Vascular Endothelial Growth Factor Agents or Intravitreal Corticosteroids.

This nationwide population-based cohort study aimed to describe the use of intravitreal injections (IVTs) of anti-vascular endothelial growth factor (anti-VEGF) agents and corticosteroids in pregnant women in France and to report on the incidence of obstetric and neonatal complications. All pregnant women in France who received any anti-VEGF or corticosteroid IVT during pregnancy or in the month preceding pregnancy from 1 January 2009 to 31 December 2018 were identified in the national medico-administrative databases. Between 2009 and 2018, there were 5,672,921 IVTs performed in France. Among these IVTs, 228 anti-VEGF or corticosteroid IVTs were administered to 139 women during their pregnancy or in the month preceding their pregnancy. Spontaneous abortion or the medical termination of pregnancy occurred in 10 women (16.1%) who received anti-VEGF agents and in one (3.1%) of the women who received corticosteroids (p = 0.09). This is the first national cohort study of pregnant women treated with anti-VEGF or corticosteroid IVTs. We found a high incidence of obstetric complications in pregnant women treated with anti-VEGF or corticosteroid IVTs but could not demonstrate a statistically significant association between the intravitreal agents and these complications. These agents should continue to be used with great caution in pregnant women.

New Insights into Treating Early and Advanced Stage Diabetic Retinopathy.

Diabetic retinopathy (DR) is the leading cause of preventable blindness in the working-age population. The disease progresses slowly, and we can roughly differentiate two stages: early-stage (ESDR), in which there are mild retinal lesions and visual acuity is generally preserved, and advanced-stage (ASDR), in which the structural lesions are significant and visual acuity is compromised. At present, there are no specific treatments for ESDR and the current recommended action is to optimize metabolic control and maintain close control of blood pressure. However, in the coming years, it is foreseeable that therapeutic strategies based in neuroprotection will be introduced in the clinical arena. This means that screening aimed at identifying patients in whom neuroprotective treatment might be beneficial will be crucial. Regarding the treatment of ASDR, the current primary course is based on laser photocoagulation and intravitreal injections of anti-angiogenic factors or corticosteroids. Repeated intravitreal injections of anti-VEGF agents as the first-line treatment would be replaced by more cost-effective and personalized treatments based on the results of “liquid biopsies” of aqueous humor. Finally, topical administration (i.e., eye drops) of neuroprotective, anti-inflammatory and anti-angiogenic agents will represent a revolution in the treatment of DR in the coming decade. In this article, all these approaches and others will be critically discussed from a holistic perspective.

Efficacy of Combined Vitrectomy with Intravitreal Corticosteroid Injection for Idiopathic Epiretinal Membrane Removal on Anatomical and Functional Outcomes: A Meta-Analysis

Background: Macular edema can be a cause of visual loss in eyes undergoing vitrectomy with epiretinal membrane (ERM) peeling. Objective: The objective of this study was to evaluate the efficacy of combined vitrectomy with intravitreal corticosteroid injection for ERM. Methods: We conducted a systematic literature review by searching PubMed, Embase, and Medline up to December 2020 for studies that evaluated the effect of intravitreal corticosteroid injection during vitrectomy for ERM. Follow-up data on postoperative best corrected visual acuity (BCVA) and central macular thickness (CMT) were collected and pooled using the standard mean deviation (SMD) with the corresponding 95% confidence interval (CI). Heterogeneity was statistically quantified using I² statistics, and a meta-analysis was performed using a random-effects model. Results: Eight studies provided data on a total sample of 443 eyes. The meta-analysis revealed that concomitant intravitreal corticosteroid administration during vitrectomy contributed to a significant reduction in CMT than vitrectomy alone at 3 months after operation (pooled SMD = −0.353; 95% CI: −0.594 to −0.111; p = 0.004). However, between the two groups, no significant difference was found in CMT reduction at 1 and 6 months after operation and in postoperative BCVA improvement at 1, 3, and 6 months after operation. Conclusion: Combined treatment with vitrectomy and intravitreal corticosteroid injection may accelerate CMT reduction 3 months after ERM surgery. However, it did not result in a significant change in CMT and BCVA compared with vitrectomy alone at the end of follow-up.

Effect of Alternate Treatment with Intravitreal Corticosteroid and Anti-VEGF for Macular Edema Secondary to Retinal Vein Occlusion.

Purpose To evaluate whether treatment with intravitreal corticosteroid and anti-vascular endothelial growth factor (VEGF) injections alternately can improve treatment outcomes of macular edema (ME) caused by retinal vein occlusion (RVO). Methods This dual-center retrospective study included 112 eyes with treatment-naïve ME secondary to RVO that were alternately treated with intravitreal corticosteroid and anti-VEGF injections (33 eyes, alternate group) or treated only with intravitreal anti-VEGF injections (79 eyes, anti-VEGF group) on a pro re nata basis. Results During the 12-month follow-up period, the alternate group achieved a visual acuity gain of 0.39 logMAR, while the anti-VEGF group achieved a gain of 0.21 logMAR (P=0.042). The alternate group demonstrated a reduction in the central macular thickness of 229.9-μm, while the anti-VEGF group achieved a reduction of 220.1 μm (P=0.887). The alternate group required an average of 5.2 injections, while the anti-VEGF received 4.2 injections (P < 0.001). In a propensity score-matched cohort to compensate for the differences in the injection numbers between the two groups, the alternate group achieved a better visual acuity gain than the anti-VEGF group at month 12 (0.39 logMAR vs. 0.17 logMAR, P=0.048). Conclusions In ME secondary to RVO, treatment with intravitreal corticosteroid and anti-VEGF injections alternately resulted in a more favorable visual outcome compared with intravitreal anti-VEGF monotherapy.

Intravitreal Pharmacotherapies for Diabetic Macular Edema: A Report by the American Academy of Ophthalmology

To review the evidence on the safety and efficacy of current anti-vascular endothelial growth factor (VEGF) and intravitreal corticosteroid pharmacotherapies for the treatment of diabetic macular edema (DME). Literature searches were last conducted on May 13, 2020, in the PubMed database with no date restrictions and limited to articles published in English. The combined searches yielded 230 citations, of which 108 were reviewed in full text. Of these, 31 were deemed appropriate for inclusion in this assessment and were assigned a level of evidence rating by the panel methodologist. Only the 21 articles with level I evidence were included in this assessment. Seventeen articles provided level I evidence for 1 or more anti-VEGF pharmacotherapies, including ranibizumab (14), aflibercept (5), and bevacizumab (2) alone or in combination with other treatments for DME. Level I evidence was identified in 7 articles on intravitreal corticosteroid therapy for treatment of DME: triamcinolone (1), dexamethasone (4), and fluocinolone acetonide (2). Review of the available literature indicates that intravitreal injections of anti-VEGF agents and corticosteroids are efficacious treatments for DME. Elevated intraocular pressure and cataract progression are important potential complications of corticosteroid therapy. Further evidence is required to assess the comparative efficacy of these therapies. Given the limited high-quality comparative efficacy data, choice of therapy must be individualized for each patient and broad therapeutic access for patients is critical to maximize outcomes.

What do Cochrane systematic reviews say about interventions for retinal vein occlusion

Abstract Purpose: To summarize the evidence from Cochrane systematic reviews on interventions for Central or Branch Vein Occlusion. Methods: We included and summarized the results from Cochrane systematic reviews on interventions for both types of occlusion. The initial search retrieved was 21 reviews and four of them were selected. Results: The four systematic reviews included evaluated the effects of laser techniques and intravitreal injections of Anti-Vascular Endothelial Growth Factor (anti-VEGF) and corticosteroids on Branch and Central Retinal Vein Occlusions. Conclusions: In Branch Retinal Vein Occlusion was found some benefits in the use of grid laser when comparable to no intervention but insufficient evidence about the use of early grid laser, subthreshold laser, intravitreal triamcinolone or anti-VEGF over macular grid laser photocoagulation. In Central Retinal Vein Occlusion with Macular Edema was found insufficient evidence to determine the benefits of intravitreo steroids but ranibizumab may improve clinical and visual outcomes at six and 12 months and repeated intravitreal injection of anti-VEGF agents improved visual outcomes at six months when compared to no treatment.

Safety and Tolerability of Topical Ophthalmic Triamcinolone Acetonide-Loaded Liposomes Formulation and Evaluation of Its Biologic Activity in Patients with Diabetic Macular Edema.

Intravitreal injections (IVTs) of corticosteroids as triamcinolone acetonide (TA) are frequently used for the treatment of many vitreous and retinal disorders. However, IVTs are related to severe ocular complications. Lately, a topical ophthalmic TA-loaded liposomes formulation (TALF) was designed to transport TA into the posterior segment of the eye when instilled on the ocular surface. To evaluate the safety, tolerability, and biological activity of TALF, an animal study and a phase I clinical assay were performed. Moreover, four patients with diabetic macular edema (DME) were treated with TALF in order to explore the biological activity of the formulation. No inflammation, lens opacity, swelling, or increase in intraocular pressure were recorded after the instillation of TALF in any of the animal or clinical studies. Mainly, mild and transient adverse events such as dry eye and burning were reported. TALF significantly improves visual acuity and diminishes central foveal thickness in patients with DME. The current data demonstrate the safety, tolerability, and biological activity of TALF. It seems that TALF can be used topically to treat vitreous and retinal diseases that respond to TA such as DME, avoiding the use of corticosteroid IVTs and their associated hazards.

Short-Term Effects of COVID-19-Related Deferral of Intravitreal Injection Visits.

PurposeTo determine secondary effects of the mandated COVID-19 pandemic closure period for elective treatment on non-elective, injection-based retina care and outcomes.Patients and MethodsIn this cross-sectional, retrospective analysis of a single-provider outpatient clinic across multiple satellites, consecutive patients returning for intravitreal injections (IVIs) of anti-vascular endothelial growth factor or corticosteroids were identified as “delayed” or “undelayed” during a six-week study interval during the COVID-19 pandemic that closely following a mandated period of prohibited elective encounters. A “delayed” encounter was defined as having a follow-up interval exceeding 33% of the recommended cycle. Patients seen for IVIs during the corresponding six-week interval a year previously were identified for study as pre-COVID-19 controls. Main outcome measures included best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) assessment based on findings of intraretinal or subretinal fluid consistent with new or recurrent neovascular events.ResultsThe study included 183 eyes of 144 patients who underwent IVI-based care from June 18, 2020, through August 7, 2020, compared to 193 eyes of 154 patients injected during the corresponding interval 1 year before. There were 62 eyes of 46 patients seen in the study period later than scheduled (among 144 patients of 183 eyes in total), which represented a larger proportion of delayed patients compared to the previous year (31.9% vs. 14.9%, p<0.0005). Considering the patterns from the control group, the attributed delay due to COVID-19 was 15.0% of patients. The delayed return eyes had a greater decline in BCVA (3 letters), higher rates of worsened OCT results (48%), and prompted reduction in previously prescribed injection intervals (p<0.02).ConclusionThe unintended consequence of delayed care of patients on established care regimens should be anticipated, and mitigate strategies considered if similar restrictions are mandated in the future.

Dril Influences Short-term Visual Outcome after Intravitreal Corticosteroid Injection for Refractory Diabetic Macular Edema

ABSTRACT Purpose: Intravitreal injections (IVI) of anti-vascular endothelial growth factor (anti-VEGF) are considered the gold standard for diabetic macular edema (DME). Despite adequate anti-VEGF treatments, many patients present persistent DME. The aim of this study is to identify systemic, ocular and anatomical characteristics influencing functional and anatomical outcomes in refractory DME patients treated with IVI of corticosteroid. Materials and Methods: Retrospective multicenter hospital-based cohort study including type 2 diabetic adult patients with refractory DME that switched from intravitreal anti-VEGF to intravitreal corticosteroid between January 2017 and September 2018. Sociodemographic, clinical data, DME and treatment characteristics were collected at baseline (visit before switch), as well as spectral domain OCT features. Results: A total of 101 eyes were included. The median number of anti-VEGF injections before switch was 5.0 (min-max: 4.0–9.0) and the median anti-VEGF treatment duration before switch was 33.2 (min-max: 19.5–50.3) months. More than half of the patients (56; 54.9%) were diagnosed with diffuse DME. At baseline, 80 (88%) patients had cystoid DME, 55 (62.5%) patients had disorganization of retinal inner layers (DRIL) and 16 (17.6%) had subretinal fluid. Dexamethasone was the corticosteroid more commonly used (71.4%), followed by triamcinolone (24.4%) and fluocinolone (4.2%). Regarding best corrected visual acuity (BCVA), post-switch results showed no statistically significant improvement at three-month follow-up (p = .048/0.096), but the mean central macular thickness (CMT) decreased significantly from 486.3 (SD = 159) µm to 369.3 (SD = 129) µm at three-month follow-up (p < .001). DRIL was the tomographic characteristic able to influence significantly both CMT and BCVA final results (p = .02 and 0.012, respectively). Conclusions: Subfoveal DRIL on structural OCT was the DME factor influencing significantly clinical and imaging outcomes in refractory DME patients treated with intravitreal corticosteroid. Portuguese care trend towards DME shows preference for the use of dexamethasone implant after therapeutic failure with ranibizumab or bevacizumab injection.

Clinical-Decision Criteria to Identify Recurrent Diabetic Macular Edema Patients Suitable for Fluocinolone Acetonide Implant Therapy (ILUVIEN®) and Follow-Up Considerations/Recommendations.

Current management of diabetic macular edema (DME) predominantly involves treatment with short-acting intravitreal injections of anti-vascular endothelial growth factors (anti-VEGFs) and/or corticosteroids; however, short-acting therapies (lasting between 1 and 6 months) require frequent injections to maintain efficacy, meaning a considerable treatment burden for diabetic patients with multiple comorbidities. Continuous injections needed in some cases are an economic burden for patients/healthcare system, so real-life clinical practice tends to adopt a reactive approach, ie, watch and wait for worsening symptoms, which consequently increases the risk of undertreatment and edema recurrence. On March 7th 2019, a group of experts in retinal medicine and surgery held a roundtable meeting in Madrid, Spain to discuss how to (1) optimize clinical outcomes through earlier use of fluocinolone acetonide (FAc) implant (ILUVIEN®) in patients with persistent or recurrent DME despite therapy; and, (2) to provide guidance to assist physicians in deciding which patients should be treated with ILUVIEN. In this regard, a 36-month follow-up consensus protocol is presented. In conclusion, patients that achieve a complete or partial anatomical, and preferably functional, response following one or two intravitreal dexamethasone implants, but with recurrence of edema after 3–4 months, are deemed by the authors most likely to benefit from ILUVIEN, and the switch to FAc implant should not be delayed more than 12 months after the initiation of at least the first dexamethasone implant.

Update on the Effects of Antioxidants on Diabetic Retinopathy: In Vitro Experiments, Animal Studies and Clinical Trials.

Current therapies for diabetic retinopathy (DR) incorporate blood glucose and blood pressure control, vitrectomy, photocoagulation, and intravitreal injections of anti-vascular endothelial growth factors or corticosteroids. Nonetheless, these techniques have not been demonstrated to completely stop the evolution of this disorder. The pathophysiology of DR is not fully known, but there is more and more evidence indicating that oxidative stress is an important mechanism in the progression of DR. In this sense, antioxidants have been suggested as a possible therapy to reduce the complications of DR. In this review we aim to assemble updated information in relation to in vitro experiments, animal studies and clinical trials dealing with the effect of the antioxidants on DR.