Use of intravitreal dexamethasone implants in the treatment of diabetic macular edema: Expert recommendations using a Delphi approach

Layana, Alfredo García; Adán, Alfredo; Ascaso, Francisco J.; Cabrera, Francisco; Donate-López, J.; Barranco, Jose Juan Escobar; Peralta, G.; García, Rebeca Reyes; Maqueda, Mariano Rodríguez; Ruiz-Moreno, José M.; Vinagre, Irene

doi:10.1177/1120672119861623

Cited by 21 publications

(28 citation statements)

References 33 publications

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“…In practice, a physician may switch to intravitreal corticosteroid if DME persists after the anti-VEGF loading phase. 7,8 Early switching in nonresponders could benefit visual outcome. 5,6 Therefore, these patients, together with those who require frequent anti-VEGF injections, were all classified into group 2 in our study.…”

Section: Discussionmentioning

confidence: 99%

“…5,6 It could also reduce the treatment burden and improve patient compliance. 7,8 Multimodal images are useful tools for the diagnosis and the monitoring of DME. Fluorescein angiography (FA) has been regarded as the gold standard for evaluating microvascular structural and functional changes in retinal vascular diseases.…”

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confidence: 99%

“…This may help customize treatment strategies in DME. (8) poor OCTA image quality (scan quality index < 6/10), (9) timing of OCTA capture > 24 months from baseline; and (10) follow-up duration < one year or inadequate for determining the clinical course.…”

mentioning

confidence: 99%

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Foveal Microvascular Integrity Association With Anti-VEGF Treatment Response for Diabetic Macular Edema

Huang

Lai

Chuang

et al. 2021

Invest. Ophthalmol. Vis. Sci.

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To investigate the association between foveal microvascular integrity and antivascular endothelial growth factor (VEGF) treatment response for diabetic macular edema (DME).METHODS. This retrospective study enrolled 58 eyes (from 45 patients) with DME. Treatment strategy was three to five monthly anti-VEGF injections followed by a PRN protocol. Treatment with an intravitreal corticosteroid would be considered for persistent DME after five consecutive anti-VEGF injections. Eyes achieving a treatment-free interval ≥ four months within two years were classified into the good clinical course group (group 1). Eyes with frequent recurrent edema (treatment-free interval < four months) or requiring an intravitreal corticosteroid within two years were classified into the suboptimal clinical course group (group 2). Foveal microvascular integrity was evaluated by two continuous variables, that is, vessel density (%) within a width of 300 μm around the foveal avascular zone (FD-300) on optical coherence tomography angiography (OCTA) and perifoveal leakage (area %) on fluorescein angiography (FA). RESULTS.There were 37 eyes in group 1 and 21 eyes in group 2. FD-300 (odds ratio 0.733, 95% CI 0.620-0.867, P < 0.001) and perifoveal leakage (odds ratio 1.064, 95% CI 1.007-1.124, P = 0.027) were significantly associated with suboptimal clinical course. Area under curve (AUC) was 0.820 for FD-300 and 0.723 for perifoveal leakage in predicting clinical course. FD-300 was negatively correlated with perifoveal leakage (coefficient = −0.325, P = 0.014). CONCLUSIONS.Compromised foveal microvascular integrity, represented by lower FD-300 and more severe perifoveal fluorescein leakage, was associated with suboptimal clinical course in anti-VEGF treatment for DME. A negative correlation between FD-300 and perifoveal leakage existed.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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Foveal Microvascular Integrity Association With Anti-VEGF Treatment Response for Diabetic Macular Edema

Huang

Lai

Chuang

et al. 2021

Invest. Ophthalmol. Vis. Sci.

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“…Spanish MOMENTUM-D study group has concluded that DEX implant is particularly beneficial in the DME treatment in patients with a history of major cardiovascular event, vitrectomized patients, pseudophakic patients, non-compliant patients, patients requiring cataract surgery, and patients with substantial inflammatory component. The consensus paper has also recommended that switching to DEX implant should be considered after three anti-VEGF injections[ 42 ].…”

Section: Expert Recommendations For the Management Of Dme With Dex Implant In Real-life Practicementioning

confidence: 99%

Place of intravitreal dexamethasone implant in the treatment armamentarium of diabetic macular edema

Kartı

Saatçi

2021

WJD

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Diabetic macular edema (DME) is a very important and well-known cause of visual loss in diabetics. Blood–retina barrier disruption and consequent intraretinal fluid accumulation may lead to retinal thickening at the posterior pole namely DME. Even though it is not clearly understood, current evidence suggests that chronic low-grade inflammation characterized with various cytokines has a major role in the occurrence of DME. Clinical trials are continuously shaping our treatment approaches for the eyes with DME. Today, vascular endothelial growth factor (VEGF) inhibitor and steroid administrations are the main alternatives in DME treatment. Dexamethasone (DEX) implant (Ozurdex ®; Allergan, Inc., Irvine, CA, United States) was approved by the United States Food & Drug Administration in 2014 for DME treatment. The implant is made up of a biodegradable solid copolymer that is broken down by releasing its active ingredient into the vitreous cavity over time. Biphasic release feature of this sustained-release drug delivery system ensures its efficacy for up to 6 mo with an acceptable and manageable safety profile. DEX implant provides a favorable anatomical and functional outcome in DME as shown in several randomized-controlled studies but has a relatively higher ocular side-effect profile such as increased risk of cataract formation and raised intraocular pressure when compared to the gold standard anti-VEGF agents. Thus, DEX implant becomes the second-line treatment option demonstrating inadequate clinical response to anti-VEGF therapy. However, it can be preferred as the first-line treatment in vitrectomized and pseudophakic eyes. Even in some selected conditions DEX implant is favored over anti-VEGF agents where the use of VEGF-inhibitors is either inappropriate or contraindicated such as the patients with a recent history of a major cardiovascular or cerebrovascular event, pregnancy and noncompliant to frequent visits. This mini-review briefly overviews the efficacy, safety profile and complications of DEX implant and summarizes the outcome of DEX implant administration in major clinical studies on DME treatment.

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“…The experts' panel agreed that intravitreal dexamethasone implants are useful in the treatment of patients with DME with different profiles. 122 Examples of such patients include pseudophakic, poor adherents, vitrectomized, candidates for cataract surgery, patients with a high inflammatory component, and with a history of cardiovascular events. The use of intravitreal dexamethasone reduces the number of visits and facilitates compliance.…”

Section: Introductionmentioning

confidence: 99%

Saudi Arabia Guidelines for diabetic macular edema

Alqahtani

Hazzazi²,

Waheeb

et al. 2021

SMJ

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Diabetes mellitus (DM) and its complications are major public health burdens in Saudi Arabia. The prevalence of diabetic retinopathy (DR) is 19.7% and the prevalence of diabetic macular edema (DME) is 5.7% in Saudi Arabia. Diabetic macular edema is a vision-threatening complication of DR and a major cause of vision loss worldwide. Ocular treatments include retinal laser photocoagulation, anti-vascular endothelial growth factor (anti-VEGF) agents, intravitreal corticosteroids, and vitreoretinal surgery when necessary. The present consensus was developed as a part of the Saudi Retina Group’s efforts to generate Saudi guidelines and consensus for the management of DME, including recommendations for its diagnosis, treatment, and best practice. The experts’ panel stipulates that the treatment algorithm should be categorized according to the presence of central macula involvement. In patients with no central macular involvement, laser photocoagulation is recommended as the first-line option. Patients with central macular involvement and no recent history of cardiovascular (CVS) or cerebrovascular disorders can be offered anti-VEGF agents as the first-line option. In the case of non-responders (defined as an improvement of <20% in optical coherence tomography or a gain of fewer than 5 letters in vision), switching to another anti-VEGF agent or steroids should be considered after 3 injections. Within the class of steroids, dexamethasone implants are recommended as the first choice. In patients with a recent history of CVS events, the use of anti-VEGF agents is not recommended, regardless of their lens status. The experts’ panel recommends that a future study be conducted to provide a cut-off point for early switching to steroid implants in pseudo-phakic eyes.

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Use of intravitreal dexamethasone implants in the treatment of diabetic macular edema: Expert recommendations using a Delphi approach

Cited by 21 publications

References 33 publications

Foveal Microvascular Integrity Association With Anti-VEGF Treatment Response for Diabetic Macular Edema

Foveal Microvascular Integrity Association With Anti-VEGF Treatment Response for Diabetic Macular Edema

Place of intravitreal dexamethasone implant in the treatment armamentarium of diabetic macular edema

Saudi Arabia Guidelines for diabetic macular edema

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