Eyeworld

EW RETINA 142 April 2016 by Adrianne Resek Initial impressions of Iluvien for treatment of DME Ophthalmologists share experiences using Iluvien S ufferers of diabetic macular edema (DME) have sev- eral avenues of treatment available. Most patients are typically treated with laser photocoagulation, which can decrease the incidence of vision loss by up to 50%. 1 In the last few years, intravitreal injections of anti-VEGF agents have proven to be effective and grown in popularity. Ranibi- zumab (Lucentis, Genentech, South San Francisco), aflibercept (Eylea, Regeneron, Tarrytown, New York), and bevacizumab (Avastin, Genentech) has been shown to be successful in reducing central macular thickness and improving visual acuity over a 12- to 36-month follow-up. 2 However, these treatments are not always sufficient. When patients are non-responders to anti-VEGF or require additional treatment, corticosteroids can be effective in reducing inflammation, edema, and damage. 3 With any medication, the less burdensome the dosing sched- ule, the better. Implants can ease the drug burden and improve patient compliance by allowing for sus- tained release of the medication. Implants such as Ozurdex (dexamethasone, Allergan, Dublin) and triamcinolone suspensions such as Triesence (Alcon, Fort Worth, Texas) and Trivaris (Allergan) are efficacious and typically require injections every few months. Iluvien (fluocinolone acetonide intravitreal implant, Alimera Sciences, Alpharet- ta, Georgia), an injectable implant that releases a low dose of fluocino- lone acetonide, is a longer lasting approach. Once injected into the vitreous, it releases the drug for 3 years with 1 implant. 4 Two ophthalmologists share their experiences with Iluvien here. Stephanie Vanderveldt, MD, is a retina specialist at Georgia Retina, and William Benedict, MD, is a ret- ina specialist with the Eye Care Cen- ter of Northern Colorado, director of the Retinal Center of Northern Colo- rado, and assistant clinical professor of ophthalmology at the University of Colorado Medical School. Dr. Vanderveldt's experience "In my office, the patients who are good candidates for Iluvien are those who have experience with steroid injections and typically those who have undergone anti-VEGF treat- ments as well. It is best to know how well patients tolerate steroids before implanting a long-acting agent into their eye. Some of these patients failed on anti-VEGF, although others did well with both VEGF inhibitors and steroids yet prefer less frequent injections. The implant allows the patient to receive treatments that we know work, while eliminating the need for frequent injections. "One particular patient with diabetic retinopathy and DME had gone through laser treatments and anti-VEGF treatments and his edema remained uncontrolled. His DME was finally well controlled with cor- ticosteroids, but enduring frequent injections was still a significant burden. He has had Iluvien bilater- ally for several months now and is doing quite well. For the first time in years he does not need to endure injections every 3 months. "I tend to be very conservative with steroids because of the possible IOP response and the serious risk of damaging the patient's optic nerve if an elevated IOP is not treated. I tend to be cautious when implanting a long-term drug such as with Iluvien without knowing a patient's pro- pensity for an elevation of pressure. However, this is not necessarily a reason to withhold steroids. If I have a patient who does have an IOP rise and it is manageable with medica- tion, I will repeat the steroid treat- ment along with a pressure-manag- ing drop as the pressure will most likely rise once a new injection is administered. "For patients who do not have previous steroid experience, some physicians may try using a steroid drop initially to test if there is a steroid response. I prefer to admin- ister a medication that will help to improve the condition needing treatment. I typically begin with an injection of triamcinolone aceton- ide, or I may administer a short-act- ing implant such as Ozurdex. If the patient does well with these, Iluvien may be the next step. "The implant is extremely small and therefore difficult at times to see once it is in the eye. However, if there is ever any doubt that the drug was actually implanted, the sur- geon can simply check the injector cartridge to ensure it is empty, or do a B-scan to locate the implant in the eye. "While Iluvien has not been available for long, my initial impres- sions are favorable, and none of my patients has experienced a rise in IOP. I would like to see it available for use with other conditions such as uveitis or vein occlusions that of- ten require a steroid or repeated and frequent injections. I look forward to future indications." Dr. Benedict's experience "My Iluvien candidates are typi- cally those who are doing well on steroids and want the convenience of eliminating frequent injection treatments. Most of my patients be- gin with VEGF inhibitors, although the rare patient may have extrafo- veal, focal edema that I think will respond well to a more traditional thermal macular laser. If the VEGF inhibitor fails or is insufficient, I will add MicroPulse laser treatment [Iridex, Mountain View, California]. If additional treatment is still need- ed, I start the patient on steroids. I prefer Ozurdex to Triesence because injections are needed less frequent- ly, and the medication does not fill up the eye with micro particles of steroid that inhibit vision. "Iluvien takes this convenience a step further by eliminating the need for repeated injections. It is potentially a considerable improve- ment as it significantly reduces the treatment burden for the patient as well as the discomfort and risk while increasing convenience. "When it comes to injecting the implant, there is a slight learn- ing curve as the injector does not work the same as similar devices such as Ozurdex. Many experienced surgeons will not feel the need to Size of Iluvien compared to a grain of rice Source: Alimera Sciences Iluvien applicator prepared for injection

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