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Pseudophakic patients with diabetic macular edema may benefit from steroid therapy
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VANCOUVER, British Columbia — Intravitreal therapy with prompt laser may be an option for patients with pseudophakic lens status seeking treatment for diabetic macular edema, although the risk of adverse events is higher compared with patients treated with anti-VEGF therapy.
The recently reported DRCR.net protocol I study, which compared prompt or deferred laser and Lucentis (ranibizumab, Genentech), or triamcinolone plus laser or laser alone, found significantly improved vision in both anti-VEGF groups compared with either laser alone or triamcinolone and laser.
According to Carl W. Baker, MD, a subgroup analysis of study patients revealed that the results were not affected by history of prior diabetic macular edema treatment, baseline visual acuity, baseline central subfield thickness, baseline level of diabetic retinopathy or whether edema was focal or diffuse.
However, Dr. Baker said at the American Society of Retina Specialists annual meeting, among patients who were pseudophakic at baseline and treated in the triamcinolone group, visual gain was on par with visual gain in the two anti-VEGF groups. Phakic patients in the triamcinolone group did not have a similar result.
"This is presumed to be due to cataract induced by the triamcinolone," Dr. Baker said.
The subset analysis of pseudophakic DME patients treated with IVTA in combination with laser in the Diabetic Retinopathy Clinical Research Network protocol presented by Dr. Carl Baker at ASRS shows a significant visual benefit comparable to that seen with ranibizumab, but with significantly fewer injections. Clinicians frequently note a rapid clinical benefit in both anatomy and function after IVTA injections, and emerging clinical trial data from steroid-based drug delivery systems such as the Iluvien and Ozurdex devices suggest further benefit. While steroids continue to be associated with increased rates of cataract and glaucoma compared to anti-VEGF agents, the durability and extent of the clinical response may be superior with steroids. The complexity of the cascade of events leading to DME, as well as the diverse effect of steroids at a molecular level in combination with the observed clinical benefit, suggest a strong ongoing role for steroids in the treatment of DME.
– Baruch D. Kuppermann, MD, PhD
Irvine,
Calif.