ASRS 2024: The effect of suprachoroidal triamcinolone acetonide in non-infectious uveitis

Danny Mammo, MD, sat down with Sydney M. Crago, Assistant Managing Editor of Ophthalmology Times and Modern Retina, to discuss the effect of suprachoroidal triamcinolone acetonide in non-infectious uveitis, patients which he is presenting at the American Society of Retina Specialists (ASRS) meeting held in Stockholm, Sweden.

Video Transcript:

Editor's note: The below transcript has been lightly edited for clarity.

Sydney M. Crago:

Hi I'm Sydney Crago with Modern Retina, and I'm here today with Dr. Danny Mammo to talk about his upcoming ASRS presentation. Dr. Mammo? Can you give us a short summary of what you'll be presenting at this meeting?

Danny Mammo, MD:

Thanks for having me. So at ASRS, looking forward to presenting a multicenter real-world study, that's retrospective, looking at the effect of suprachoroidal triamcinolone acetonide in non-infectious uveitis patients, and the effect on intraocular pressure, specifically in a high-risk group of patients that have a known history of glaucoma, ocular hypertension, or steroid response.

SC: For this study, can you talk a little bit about the setup and how you gathered the data from these patients?

DM: So uveitic macular edema is leading cause of vision loss and uveitis patients, and for non-infectious uveitis patients. We know that using corticosteroids it's very effective at treating the macular edema. And we also know that interocular steroids have been more effective than periocular, but they do have more IOP side effects, and treating these patients that have a known history of IOP issues can be very challenging. And we have a variety of options for interocular steroid delivery.

During the MAGNOLIA and PEACHTREE trials, which helped get the suprachoroidal triamcinolone acetonide injection approved in October of 2021, in these trials, the IOP rises in the study populations were less than IOP rises in study population seen in other registration trials, for example, for the intravitreal dexamethasone implant, or intravitreal fluocinolone acetonide implant. So this led to a few of us wondering if using this medication may be a little more safer in these higher risk group of patients.

We looked at patients with a known history of glaucoma, which was defined as having had the diagnosis from a comprehensive ophthalmologist or glaucoma specialist and they were on glaucoma drops or had prior glaucoma surgery or glaucoma procedures, ocular hypertension, which was defined as any recording in the chart of an IOP greater than 21 millimeters of mercury, or steroid responders. These are patients that could have received any steroid, even just drops, and they had an IOP response of 5 millimeters of mercury or greater. So from 5 sites, we looked at all noninfectious uveitis patients with macular edema that received suprachoroidal triamcinolone acetonide from October of 2021 until end of 2023. In these patients, we had 60 Eyes of 54 patients, and of these patients, 40% were prior steroid responders, 22% had a diagnosis of primary open-angle glaucoma, 22% had a diagnosis of another type of glaucoma, and the remaining 17% had ocular hypertension. And the mean IOP at first injection of the supercritical triamcinolone acetonide was 14.3 millimeters of mercury. At the first follow-up, it rose to 15.6, so, a change of 1.3.

And what was good about the study was there's a mean follow up of 41.7 days, so almost 6 weeks, which is classically around when standard response may occur. So we were just looking at patients just 2 weeks after. So this is a real-world study. So, some patients have incisional glaucoma surgery and some don't. So we looked at both groups of patients; 27% of our patients had prior tube or trab, and none of these patients experienced IOP rise of 5 millimeters of mercury or greater. Now 62% of eyes and a patient population, or 39 eyes, were prior stared responders. So this is a group that's very difficult to treat. Of these patients, they had a mean increase of 1.2 millimeter mercury. Now, these were patients with either prior incisional surgery or without. When we take out people that had tubes of trabs, which was 13 patients of the 39, that leaves 26 stared responders with no history of incisional glaucoma surgery. And of these patients there was a mean IOP increase from injection to first follow-up of 2.4 millimeters of mercury, so a little bit higher, and 8 eyes or 31% experienced IOP rise of 5 millimeters of mercury or more. In other words 70% of steroid responders without any tube or trab or incisional glaucoma surgery did not experience an IOP rise with a mean follow up of 6 weeks after 1 suprachoroidal triamcinolone acetonide injection.

This tells us that the suprachoroidal triamcinolone acetonide seems to be safer, but not totally safe, compared to other interocular injections in terms of IOP response in treating these difficult macular edema patients with history of IOP issues. You know the study is limited by being retrospective. It could use a longer follow-up, and IOP measurements across sites were not standardized in terms of how they were measured applanation versus not. And it's important to note that all patients, even those of suprachoroidal triamcinolone acetonide. Need IOP monitoring after local steroid use.

We're having more and more options to treat these macular edema patients, and I think each patient is different, and the best treatment choice should be personalized for them. And I think the suprachoroidal approach is unique in that it allows some patients that have contraindications to the other options, have another steroid option to use to help make them see better and rely less on drops or more invasive surgery.