Fluocinolone acetonide implant in diabetic macular edema: International experts’ panel consensus guidelines and treatment algorithm

Abstract

Center-involving diabetic macular edema (DME) is a leading cause of vision impairment in working-age adults. While its management is particularly challenging in a poorly compliant population, continuous innovation and the advent of new molecules have improved its outcome. The control of glycemia and of systemic aggravating factors remain essential to slow down progression of disease complications including DME. The indications for macular laser photocoagulation has progressively been phased out as a standard of care and replaced by local intraocular anti-VEGFs biologics and glucocorticoids (GCs). Intravitreal GCs in controlled-release drug delivery systems have allowed to reduce injection frequency and treatment burden. The non biodegradable Fluocinolone Acetonide (FAc) implant allows a long-lasting stabilization of both functional and anatomic improvements. However, adequate patient selection and monitoring through regular follow-up are essential for optimal results. Based on their experience and the latest literature, the aim of the present review is to provide international expert panel consensus on the place of the FAc implant in the treatment algorithm of DME, as well as its safety profile and how to manage it.

Management of Patients with Diabetic Macular Edema Switched from Dexamethasone Intravitreal Implant to Fluocinolone Acetonide Intravitreal Implant

“…Indeed, in our study, 73.5% of eyes received their FAc injection ≤8 weeks after their last DEX injection, meaning that the intravitreal concentration of dexamethasone was maximum when the FAc injection was given [40]. As the pattern of mean change in VA and CMT observed reflects the kinetics of dexamethasone release [16,25], improvements in BCVA and CMT were therefore almost maximum before the FAc injection [41]. Thus, the benefit of FAc in terms of BCVA was expected to be lower in these eyes than in eyes experiencing DME recurrence before FAc injection [33,36].…”

“…Thus, as the peak in efficacy after FAc injection is delayed compared to that of DEX, the switch from DEX to FAc could be anticipated and adjusted according to the history and response to previous treatments of the eye. The objective would be to limit CMT variations by maintaining effective steroid intravitreal levels when switching from DEX to FAc [41].…”

Efficacity and Safety of the Fluocinolone Acetonide Implant in Uveitic Macular Edema: A Real-Life Study from the French Uveitis Network

“…In this cohort, patients received FAi after a mean time of 5 months after the latest DEXi, which is longer than the 4- to 8-week interval that the French Uveitis Network currently recommends (data not published). In fact, it has been shown elsewhere that the best functional and anatomical results are reached faster in patients injected with FAi at the time of DEXi peak of action (i.e., around 4–8 weeks) [ 27 , 28 ].…”

Current Treatments and Innovations in Diabetic Retinopathy and Diabetic Macular Edema

“…Concerning raised IOP with treatment, 25% of patients in the FAME studies needed antihypertensive drops, and 14.3% needed glaucoma surgery despite topical therapy; these results not being supported by real-life studies demonstrated fewer ocular hypertension issues [ 83 , 84 ]. Careful selection of patients is important to avoid complications [ 85 ].…”