Managing uveitic macular edema

Intravitreal injections of triamcinolone acetonide and intravitreal dexamethasone implant achieve better results than periocular triamcinolone acetonide in patients with uveitic macular edema in a study.

Reviewed by Jennifer E. Thorne, MD, PhD

Macular edema is a common complication in patients with uveitis-so much so that about 40% of patients who participated in the Multicenter Uveitis Steroid Treatment (MUST) Trial had baseline uveitic macular edema. Though it can be treated and controlled, macular edema also can be stubborn, require additional treatment, and worse yet, compromise sight.

The results of the PeriOcular versus INTravitreal corticosteroids for Uveitic Macular Edema (POINT) study-a comparison of the regional go-to corticosteroids for uveitic macular edema-indicated that direct injection of corticosteroids into the eye was superior to a therapy that is administered periocularly, said Jennifer E. Thorne, MD, PhD. Interestingly, an intravitreal dexamethasone implant was not associated with lower rates of IOP elevations as expected.

This study originated out of the recognition that few comparisons of the common treatments for uveitic macular edema had been undertaken, and the best and safest of the regional corticosteroids had yet to be determined, said Dr. Thorne, the Cross Family Professor of Ophthalmology, and chief, Division of Ocular Immunology, Wilmer Eye Institute, and professor of epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore.

Therapies frequently used in this patient population are periocularly administered triamcinolone acetonide (Kenalog, Bristol-Myers Squibb), intravitreally administered triamcinolone acetonide (Triesence, Alcon Laboratories), and the intravitreal dexamethasone implant (Ozurdex, Allergan), and they all provide good results. However, there have been limited head-to-head comparisons of these three drugs, she noted.

Diving deeper
The POINT Study hypothesized that intravitreal triamcinolone and the intravitreal dexamethasone sustained-release implant would be better for treating uveitic macular edema than the periocularly administered triamcinolone, and the dexamethasone implant would not be inferior to intravitreal triamcinolone. The study also hypothesized that the dexamethasone implant would be associated with a low rate of IOP elevations compared with intravitreal triamcinolone.

The 192 patients with uveitic macular edema in this multicenter trial were randomly assigned to one of three treatments:

• periocular triamcinolone 40 mg (74 eyes),

• intravitreal triamcinolone 4 mg (82 eyes), or

• the intravitreal dexamethasone implant 0.7 mg (79 eyes). Patients underwent ophthalmic examinations with optical coherence tomography (OCT) testing at baseline and at 4, 8, 12, 20, and 24 weeks after the start of treatment. The investigators recently published their findings (Ophthalmology. 2019;126:283-295).

The primary study outcome compared the proportion of improvement of OCT central subfield thickness from baseline to the 8-week primary outcome visit. Secondary outcomes included a greater than 20% improvement in and resolution of macular edema on OCT, best-corrected visual acuity (BCVA), and the IOP events over the 24- week study, according to Dr. Thorne. At the primary outcome visit, the macular edema improved in all treatment groups.

The injections of the two intravitreally administered treatments resulted in greater reductions (p < 0.0001) in uveitic macular edema at 8 weeks compared with the periocularly administered triamcinolone; no significant difference was seen between the two intravitreal treatments at 8 weeks.

The decreases in the macular edema obtained with intravitreal triamcinolone, intravitreal implant, and periocular triamcinolone were 39%, 46%, and 23%, respectively. BCVA improved in all three groups, but the intravitreal drugs were superior to periocular therapy.

Intravitreal triamcinolone and the dexamethasone implant resulted in significant (p < 0.004) improvements in BCVA that were 5 letters greater than in the periocular drug group at the 8-week evaluation.

The risk of an IOP elevation was greater in the intravitreally injected groups when compared with the periocular group, but the occurrence of IOP elevations over 30 mm Hg were low for all three groups. The dexamethasone implant had risks of IOP elevation similar to intravitreal triamcinolone.

The authors concluded that intravitreal triamcinolone acetonide and the dexamethasone implant were superior to periocular triamcinolone for treating uveitic macular edema with modest increases in the risk of IOP elevation. This risk did not differ significantly between intravitreal treatments.

Disclosures:

Jennifer E. Thorne, MD, PhD
E: jthorne@jhmi.edu
This article was adapted from Dr. Thorne’s presentation during Uveitis Subspecialty Day at the 2018 meeting of the American Academy of Ophthalmology. This study was supported by grants from grants from National Eye Institute/National Institutes of Health and Allergan. Dr. Thorne is on the advisory boards for AbbVie, Clearside, and Santen, and is a consultant for Gilead and NightstaRx.