Presentation is loading. Please wait.

Presentation is loading. Please wait.

Steroids and DME Scott E. Pautler, M.D. Associate Clinical Professor of Ophthalmology University of South Florida Tampa, FL.

Similar presentations


Presentation on theme: "Steroids and DME Scott E. Pautler, M.D. Associate Clinical Professor of Ophthalmology University of South Florida Tampa, FL."— Presentation transcript:

1 Steroids and DME Scott E. Pautler, M.D. Associate Clinical Professor of Ophthalmology University of South Florida Tampa, FL

2 Case Presentation 71 year old woman with type 2 diabetes for 12 years with gradually decreasing vision OU Visual acuity: R-20/50, L-20/125 Slit lamp: 2+ nuclear sclerosis IOP 18 OU Fundus: DME OU; moderate NPDR OU

3

4 3/23/2009

5 Right EyeLeft Eye Treatments: Focal – 2 IVK – 10 CE/IOL Treatments: Focal – 3 IVK – 13 CE/IOL VTX/ILM peel PRP -2

6 2/5/2014

7 Visual Acuity and OCT Outcomes DateEyeCSMT (µ)VA 3/23/2009Right39820/50 Left39720/125 2/5/2014Right26720/20 Left49020/100

8 Steroid Mechanism of Action Decrease VEGF production Widespread anti-inflammatory effects More rapid onset and more profound initial effect on edema than anti-VEGF agents Adverse effects: cataract, glaucoma Pre-injection IVTA1 month later

9 Steroid Agents

10 Triamcinolone vs Focal/Grid Laser DRCR Protocol B: 840 eyes Three-year results Problems: 79% of eyes were phakic and IVTA dosing interval was ≥ 4 months TreatmentMean BCVA gains Δ CSMT In microns Cataract Surgery Glaucoma Surgery Glaucoma Drops Focal/Grid+5 letters-158003% IVTA 1 mg0 letters-10346%02% IVTA 4 mg0 letters-11483%4 (1.6%)12%

11 Combination IVTA + Focal/Grid Laser (FGL) DRCR Protocol I: Pseudophakic eyes (206) – Two-year results TreatmentMean Δ BCVA (letters) Mean Δ CSMT (μ) IVTA 4 mg + FGL+8-128 Sham + FGL+5-145 IVR + Prompt FGL+5-126 IVR + Deferred FGL+9-148

12 Triamcinolone Options TriamcinoloneFDA approve d Crystal Size Dissolution Profile CostPseudo Endophth PreservedNo18.86 μFaster$9.32≤7% Preservative- Free Yes11.51 μSlower$157.58≤1%

13 Dexamethasone Implant Recently approved by FDA for DME Bio-erodible Duration ≤6 months Ozurdex MEAD Study Group 2014: – 1048 eyes; 20/50-20/200; CRT ≥300μ; 3-year Treatment≥15 letter improvement Mean  CRT (μ) CataractGlaucoma Surgery Sham injection12%-4220%0% Dex 0.35 mg18.4%-10864%0.3% Dex 0.70 mg22.2%-11268%0.6%

14 Dexamethasone Implant BEVORDEX Study (AAO subspecialty meeting) – 1-year result of RCT – bevacizumab vs dexamethasone – Dexamethasone superior functional and anatomic outcomes in pseudophakic eyes – Mean number of injections: 3.7 Dexamethasone injections 8.6 bevacizumab injections

15 Fluocinolone Implant Recently approved by FDA for DME Non-responders; Duration ≤3 years FAME Study 2012: – 953 eyes; failed FLT; 20/50-20/400; CRT ≥250μ; 3-year study Treatment≥15 letter improvement Mean  CRT (μ)CataractGlaucoma Surgery Sham injection*21%NG51%0.5% Fluo 0.2 μg/d33%NG82%4.8% Fluo 0.5 μg/d32%NG89%8.1% *Rescue treatment with focal laser and/or anti-VEGF occurred more often in Sham

16 Steroids and IOP Risk Factors: Glaucoma, OHT, steroid response, young age, higher loading dose Steroid Agent (values adjusted by control group) ≥10mm over baseline ≥25mm at any exam Any IOP meds Surgery For IOP Attrition by 3 years Triamcinolone 1 mg 18% (14%)-2% (0%)0% (0%)64% Triamcinolone 4 mg 33% (29%)-12% (9%)4% (4%)64% Dexamethasone Impl 0.70 mg 28% (24%)32% (28%)42% (33%)1% (1%)42% Fluocinolone Impl 0.19 mg 34% (24%)20% (16%)38% (24%)5% (4%)30%

17 Case Selection Pseudophakic, Non-Glaucoma/Suspect Eyes – AC IOL: consider avoiding an implant – Post vitrectomy: consider avoiding IVTA (storm) – Prior glaucoma surgery offers limited protection against steroid-IOP response

18 Case Selection DME resistant to anti-VEGF/laser* Macula-threatening exudates (BEVORDEX) One-time use for DME prior to surgery: – PRP laser – cataract surgery * Fluocinolone implant relatively more effective in chronic edema (>3yrs)

19 Steroid Selection Triamcinolone – Less expensive (Kenalog®) – More frequent injection – Greater peak/trough effect Steroid implant – More expensive – Fewer injections – Better pharmacokinetics (Iluvien®>Ozurdex®)

20 Thank you Scott E. Pautler, M.D. Tampa, FL


Download ppt "Steroids and DME Scott E. Pautler, M.D. Associate Clinical Professor of Ophthalmology University of South Florida Tampa, FL."

Similar presentations


Ads by Google