Issue link: https://optometricmanagementsupplements.epubxp.com/i/531600
8 • INTEGRATED CROSS-DISCIPLINARY APPROACHES TO THE MANAGEMENT OF DIABETIC EYE DISEASES DR. DUNBAR: Do you see a role for anti-VEGF therapy in treating proliferative disease, perhaps in combination with panretinal photocoagulation? DR. ALBINI: Standard of care for proliferative dis- ease is still panretinal photocoagulation. I think it's one of the most useful things I do. The DRCR.net is performing a study, Protocol S, comparing panretinal photocoagulation to anti-VEGF therapy. We'll see more defnitive data upon the conclusion of that study. STEROID THERAPY DR. PIZZIMENTI: Dr. Albini, how are intravitreal steroids being used to treat DME? DR. ALBINI: Even prior to the availability of anti- VEGF agents to treat DME, retina specialists had been using intravitreal steroids as an adjunct to focal laser. In addition to inhibiting VEGF, steroids inhibit many other infammatory cytokines that are involved in the pathophysiology of DME. 20 They restore patency to the retinal vessels and decrease vascular leakage. A downside to steroids used in the eye is that they may cause cataracts and elevated intraocular pressure. DR. PIZZIMENTI: Under what circumstances would you use steroids to treat DME? DR. ALBINI: Steroids may be benefcial in patients who don't respond or only partially respond to anti-VEGF agents. A head-to-head comparison with anti-VEGF therapy is not available. Although anti-VEGF is our most common frst-line treatment for DME, steroids may be making a comeback, par- ticularly the newer sustained-release formulations. DR. PIZZIMENTI: Tell us about those novel delivery devices. DR. ALBINI: The dexamethasone intravitreal im- plant 0.7 mg (Ozurdex, Allergan) was approved last fall for the treatment of DME, based on the effcacy and safety results from the MEAD trial. 22 The bio- degradable device releases medication for 4 to 6 months, which reduces the injection burden. DR. PIZZIMENTI: How does the fuocinolone implant (Iluvien, Alimera Sciences) compare with the dexamethasone implant? DR. ALBINI: The fuocinolone acetonide intravitreal implant 0.19 mg was also approved last fall for the treatment of DME, based on the effcacy and safety results from the FAME trial. 23 The FAME and MEAD trials showed similar improvements in macu- lar edema and visual acuity; however, there are some notable differences between the two implants. The fuocinolone implant, which is nonbiodegradable, is injected through a smaller needle than what's used to implant the dexamethasone device. A single injection of fuocinolone has a 3-year duration of effect. It's important to note that Iluvien can only be used in patients previously treated with corticosteroid who did not experience elevated IOP. DR. PIZZIMENTI: Have you developed some general guidelines or preferences for when you would use anti-VEGF therapy versus steroids versus combina- tion therapy with either laser and anti-VEGF or anti-VEGF and a steroid? DR. ALBINI: Until we have a comparative study, we won't know if one approach works better than another, so it's tough to answer that question. One other factor I consider is injection burden, because the great beneft of the steroid modalities is the decreased need for injections. So I do have that discussion with patients when we're initiating treatment.