Intravitreal Steroids in Diabetic Macular Edema

Abstract

Over the past decade, great strides have been made in the management of diabetic macular edema (DME). Therapeutic alternatives now include focal/grid laser photocoagulation, vitreo-retinal surgery, and intraocular injection of anti-angiogenic and steroid molecules. Intravitreal administration of steroids represents a fundamental alternative for recalcitrant and naive eyes with DME, especially in those cases when anti-vascular endothelial growth factor (VEGF) agents are contraindicated or a treatment regimen with fewer intravitreal injections is required. Currently, 3 intravitreal corticosteroid options for DME treatment are available: the dexamethasone delivery system, the fluocinolone acetonide insert, and off-label intravitreal triamcinolone acetonide. All 3 agents are associated with risk of cataract progression and intraocular pressure elevation, but they maintain a good safety profile. In patients who remain unresponsive to anti-VEGF therapy, are pseudophakic, at low risk for glaucoma, or who have significant cardiovascular risk, treatment with long-lasting intraocular steroids is suggested. There still remain many unanswered questions about intravitreal drugs, regarding dose, frequency, the correct regimen of each treatment, and the potential long-term side effects.

Diabetic Retinopathy: Pathophysiology and Treatments

“…Intravitreal corticosteroids have become increasingly important in the treatment of DME, especially in refractory DME and cases lacking a response to anti-VEGF therapy [ 53 ]. Refractory cases of DME and nonresponders to anti-VEGF are presumed to be driven by multiple cytokines.…”

Adipose stem cells and their paracrine factors are therapeutic for early retinal complications of diabetes in the Ins2Akita mouse

“…Intraocular pharmacotherapy involving intravitreal injection of anti-VEGF agents and/or corticosteroids has also shown promising results in stabilizing DME and reducing retinal thickness [ 12 – 17 ] as well as in improving visual acuity in PDR [ 18 , 19 ]. Currently available local treatments for DR are not intended for the early stages of DR but rather for more advanced processes like DME or PDR that may have produced irreversible vision loss prior to treatment [ 20 , 21 ]. Consequently, there is a pressing need for the development of disease-modifying therapeutics that can mitigate or halt the progression of NPDR by mediating inflammation and oxidative stress prior to the development of DME or PDR by targeting multiple complex pathways of the retinal neurovascular unit leading to DR [ 22 ].…”

Extracellular Vesicles and MicroRNA: Putative Role in Diagnosis and Treatment of Diabetic Retinopathy

“…Currently, corticosteroids are viewed as a second-line therapy for DR patients that are poorly responsive to anti-VEGF therapy in cases of DME [166]. Triamcinolone acetonide, fluocinolone acetonide, and dexamethasone sodium phosphate have been successfully used as an intravitreal steroid treatment to reduce the frequency of anti-VEGF intravitreal injections, which is particularly useful in patients with contraindications for anti-VEGF therapy, such as those with coronary diseases [166].…”

“…Currently, corticosteroids are viewed as a second-line therapy for DR patients that are poorly responsive to anti-VEGF therapy in cases of DME [166]. Triamcinolone acetonide, fluocinolone acetonide, and dexamethasone sodium phosphate have been successfully used as an intravitreal steroid treatment to reduce the frequency of anti-VEGF intravitreal injections, which is particularly useful in patients with contraindications for anti-VEGF therapy, such as those with coronary diseases [166]. Mounting evidence show that glucocorticoids exert anti-inflammatory activities by reducing the expression of adhesion molecules related to leukostasis (such as ICAM-1 and E-selectin), decreasing the release of other pro-inflammatory mediators (namely IL-6, NF-kB, TNF-α, and IFN-γ, etc.)…”