Eyeworld

77 EW RETINA September 2018 what type of steroid to use in the eye," he said. "You can use drops, you can use intravitreal Ozurdex, you can use intravitreal triamcino- lone, as long as it is given to ensure that patients have a lessened risk of a steroid responsive intraocular pressure rise." He prefers a course of intravitreal Ozurdex because he thinks this has the most comparable mechanism of action to Iluvien. By contrast, with triamcinolone, the side effect and therapeutic profile is more variable. "With Ozurdex, it is a controlled 3-month response, and if they're going to have a pressure rise I expect to see that about 6 weeks after implantation." Likewise, Dr. Stoller prescribes Ozurdex first for patients since this implant lasts for up to 6 months. "If you're going to have a steroid-in- duced glaucoma, better it be from something that goes away quicker than something that lasts for 3 years," he said. He views those who have had a positive response to Ozurdex or intravitreal triamcinolone without a steroid-induced elevation in IOP to be excellent candidates for Iluvien. Dr. Luo will likewise consider switching a patient to Iluvien if the fluid melts away without any side effects after Ozurdex. "I will have that discussion with them at the 6-week follow-up when I see their OCT," Dr. Luo said. He tells patients that there's another implant option that has a longer duration of action, which may be able to reduce their overall treatment burden. He usually starts considering Iluvien after one Ozurdex insertion. However, there are some additional patient factors to take into account. For instance, since the Iluvien im- plant lasts for so long, it's vital that the patient return to check for pres- sure rises. Dr. Luo also stressed that it's important to weigh the patient's overall health. "If they have a lot of other doctors to see and their care- givers have difficulty getting them in, I sometimes give Iluvien sooner because it may be able to reduce their overall treatment burden if I can follow them every 3–4 months instead of every month," he said. He finds that it's important to still mon- itor those on Iluvien quarterly since the FAME trials 2,3 indicated that their pressure might rise up to 1 year after implantation. He continues to check for a pressure rise as well as to see if they have any new fluid that needs to be addressed. Dr. Luo finds that many patients do well with Iluvien alone. "I see about 60% of patients who have a single injection of Iluvien and have not needed another treatment," he said. "About 40% in my data set have needed a supplemental therapy." Dr. Luo keeps this in mind when he speaks to patients. "What I tell my patients now is that the expectation is to be able to reduce the overall treatment burden," Dr. Luo said. "So instead of getting a monthly anti-VEGF treatment, they may need one every 6 months or every year." For example, Dr. Luo has a pa- tient who failed anti-VEGF therapy for 1 year before coming to him. She did well on the Ozurdex he gave her, as well as on the subsequent Iluvien implant for about 3 months. When she had some fluid recurrence, he gave her two Eylea injections to supplement the Iluvien. In the more than 6 months since, she has not needed another anti-VEGF shot. Dr. Stoller also finds that the Ilu- vien monotherapy suffices for some and that for others this can decrease the need for further anti-VEGF ther- apy. There is also likely a subset of patients who require the anti-VEGF to be given with the same frequency to supplement the Iluvien to get better control of the edema than could be obtained with anti-VEGF monotherapy. Dr. Stoller and Dr. Luo have not had to remove an Iluvien implant. Dr. Luo noted that there are two situations that might necessitate removal. The first would be a patient who experiences an uncontrolled pressure rise even after receiving all of the pressure-lowering drops they can, as well as undergoing laser trabeculoplasty and surgery. The second would be if the implant ended up in the front of the eye and started causing corneal change. "I have a patient that has an implant that migrated forward," Dr. Luo said. "But she has no corneal sequelae and her vision is excellent, so we left the implant." Overall, Dr. Stoller considers the advent of sustained delivery devices such as the Iluvien implant as a real advance in the ability to treat dia- betic macular edema. "Not everyone responds to anti-VEGF therapy, so it enhances our ability to take care of patients and may reduce treatment burden for both the patient and the doctor," Dr. Stoller said. EW References 1. Cai S, Bressler NM. Aflibercept, bevacizum- ab or ranibizumab for diabetic macular oe- dema: recent clinically relevant findings from DRCR.net Protocol T. Curr Opin Ophthalmol. 2017;28:636–643. 2. Campochiaro PA, et al. Sustained delivery fluocinolone acetonide vitreous inserts provide benefit for at least 3 years in patients with diabetic macular edema. Ophthalmology. 2012;119:2125–32. 3. Parrish RK 2nd, et al. Quantitative assess- ment of optic nerve changes in patients with diabetic macular edema treated with fluocino- lone acetonide vitreous implants. Ophthalmic Surg Lasers Imaging Retina. 2016;47:418–25. Editors' note: Dr. Luo has financial interests with Alimera Sciences, Aller- gan, Genentech, Iridex (Mountain View California), and Lumenis (Yokneam, Is- rael). Dr. Stoller has financial interests with Genentech, Roche (Basel, Switzer- land), Allergan, and KalVista Pharma- ceuticals (Cambridge, Massachusetts). Contact information Luo: caesarluomd@gmail.com Stoller: glstoller@gmail.com The same eye in August 2017 without further treatment and vision now of 20/25 Source (all): Caesar Luo, MD

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