PURPOSE:The purpose of this study was to correlate the degree of ocular hypertension with the number of Ozurdex injections.METHODS:Intraocular pressure (IOP) fluctuations for a total of 183 injections were studied over a period of at least 12 months. The main indications for treatment were uveitis, diabetic macular edema, and retinal vein occlusion.RESULTS:Results of the study demonstrate that repeated Ozurdex injections do not increase the frequency of IOP spikes beyond 30 mmHg. For lower IOPs, however, a positive correlation exists. Furthermore, patients with primary open angle glaucoma and uveitis had the highest IOP response to repeated injections. On average, patients with an IOP of ≥28.6 mmHg received pressure lowering medications, after which their IOP reached a stable level (16.7 mmHg) without the need for additional interventions.CONCLUSION:The data support the conclusion that multiple Ozurdex injections does not increase the frequency of IOP spikes beyond 30 mmHg, but patients still must be closely monitored if they have a history of primary open angle glaucoma.

Background One limitation of anti-VEGF therapy is the need for monthly retreatment to maintain efficacy. The purpose of this study was to determine the duration of effect in eyes with macular edema (ME) secondary to branch or central retinal vein occlusion (BRVO or CRVO) treated with anti-VEGF therapy plus sustained-release dexamethasone (DEX implant; Ozurdex). Materials and methods This open-label, interventional case series included 62 eyes with ME due to RVO, central foveal thickness (CFT) >300 μm, and best-corrected visual acuity (BCVA) of 20/40 or worse. Each treatment cycle included an anti-VEGF injection followed 2 weeks later with DEX implant. Patients were eligible for retreatment if CFT increased to >290 μm or increased by >50 μm from the lowest measurement, or if BCVA decreased by six or more Snellen letters. Efficacy and safety were evaluated 2 and 4–6 weeks after the beginning of each treatment cycle and every 4 weeks thereafter until retreatment criteria were met. The primary outcome measure was time to retreatment. Secondary outcome measures included BCVA, CFT, and safety parameters. Results The mean reinjection interval for all patients was 135.5±36.4 days. There was no statistically significant difference in mean intertreatment interval for up to six cycles of treatment or between eyes with BRVO or CRVO (P≥0.058). Mean peak change in BCVA was 13.8 letters, and 47.6% of eyes gained three or more lines of BCVA. The mean peak decrease in CFT across all treatment cycles was 200.9 μm for eyes with BRVO and 219.2 μm for eyes with CRVO. The percentage of patients with CFT ≤300 μm at any time during a given treatment cycle ranged from 78% to 94% among eyes with BRVO and from 85% to 100% among eyes with CRVO. Intraocular pressure increased in 19 of 62 eyes, and 26 of 44 phakic eyes underwent cataract surgery. Conclusion In eyes with ME due to RVO, treatment with an anti-VEGF agent plus DEX implant provided a predictable duration of effect, as well as significant improvements in BCVA and CFT.

BACKGROUND AND OBJECTIVE:The purpose of this study is to compare cancellation and no-show rates in patients with diabetic macular edema (DME) and exudative macular degeneration (wet AMD).PATIENTS AND METHODS:An anonymous survey was sent to 1,726 retina specialists inquiring as to the number of appointments their patients with DME and wet AMD attended, cancelled, or did not show up for in 2014 and 2015.RESULTS:Data were obtained on 109,599 appointments. Patients with DME in the U.S. had a 1.591-times increased odds of cancelling or no-showing to their appointments than patients with wet AMD (P < .0001). Patients with DME in Europe had a 1.918-times increased odds of cancelling or no showing to their appointments than patients with wet AMD (P < .0001).CONCLUSION:Patients with DME in the U.S. and Europe cancelled and no-showed to their appointments significantly more often than patients with wet AMD. These findings can be taken into consideration when establishing treatment plans for patients with DME. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:186-190.].

Macular grid laser photocoagulation was the standard therapy for RVO (retinal vein occlusion) for many years, but several newer studies have come along in the last 6 years that introduced new injectable agents like anti-vascular endothelial growth factor (anti-VEGF) and corticosteroids. The BRAVO, CRUISE, Galileo and Copernicus studies looked at anti-VEGF as treatment, and the Ozurdex/Geneva study and SCORE involved corticosteroids.The Ozurdex/Geneva study compared intravitreally injected dexamethasone implant with a sham in both CRVO and BRVO patients. Patients received either 2 injections of 700-μg dexamethasone intravitreal implant (Ozurdex, Allergan) 6 months apart or 1 sham injection and then 1 implant injection 6 months later. The data showed that sustained-release dexamethasone (Ozurdex, Allergan) was effective in treating macular edema in BRVO and CRVO, and patients had a mean improvement in BCVA (best corrected visual acuity) of about 10 letters. When patients were reinjected, they achieved the same improvement in visual acuity in the second 6 months. The SCORE study investigated a special preparation of triamcinolone (Trivaris, Allergan). Patients were injected with the agent every 4 months. The results showed that for CRVO, triamcinolone was superior to observation, and for BRVO, laser was better than triamcinolone. The BRAVO and CRUISE studies observed how well intravitreal injections of ranibizumab worked to treat BRVO and CRVO, respectively. The BRAVO data showed a gain of 18.3 letters in BCVA with a 0.5-mg injection, 16.6 letters with a 0.3-mg injection, and 7.3 letters in the sham group. The CRUISE study showed similar 6-month results, with patients gaining 14.9 letters in the 0.5-mg group, 12.7 letters in the 0.3-mg group, and 0.8 letters in the sham group. The Galileo and Copernicus studies evaluated monthly aflibercept for the treatment of macular edema in patients with CRVO. In both studies, patients received monthly injections for 6 months with the agent or with a sham injection. In Copernicus, all patients were switched to as needed dosing at 6 months, while in Galileo only patients initially treated with the agent were retreated on an as-needed basis. At 1 year, the mean change in vision was + 16.2 letters in the aflibercept group in Copernicus and + 16.9 letters in the Galileo group, versus + 3.8 letters in both sham groups. A recent emerging idea is to treat RVO with both intravitreal sustained-release dexamethasone and anti-VEGF agents (combination therapy) which has been shown to improve visual acuity and prolong the time between injections (reinjection interval). In our study, patients with both CRVO and BROV received anti-VEGF injections (either bevacizumab, ranibizumab, or aflibercept) followed by 0.7-mg dexamethasone intravitreal implant (Ozurdex) 2 weeks later. Patients were evaluated every 2-4 weeks until the next anti-VEGF injection. The mean BCVA increased from 9.4 to 16.8 letters during the course of the initial study (by 6 months), and the mean peak improvement in BCVA across all re-treatment cycles was 12.5 letters for BRVO and 20.1 letters for CRVO (a longer term evaluation). This study showed that the addition of dexamethasone intravitreal implant 2 weeks following anti-VEGF therapy provides improvements in BCVA and macular thickness in patients with RVO and increases the percentage of patients whose macula was essentially fluid-free compared with anti-VEGF therapy alone.

Diabetic macular edema is a serious visual complication of diabetic retinopathy. This article reviews the history of previous and current therapies, including laser therapy, anti-vascular endothelial growth factor agents, and corticosteroids, that have been used to treat this condition. In addition, it proposes new ways to use them in combination in order to decrease treatment burden and potentially address other causes besides vascular endothelial growth factor for diabetic macular edema.

Diabetic macular edema is a serious visual complication of diabetic retinopathy. This article reviews the history of previous and current therapies, including laser therapy, anti-vascular endothelial growth factor agents, and corticosteroids, that have been used to treat this condition. In addition, it proposes new ways to use them in combination in order to decrease treatment burden and potentially address other causes besides vascular endothelial growth factor for diabetic macular edema.

by Michael E. Jansen, MD, and Michael A. Singer, MD For this Practical Retina column, Michael A. Singer, MD, and Michael E. Jansen, MD, from San Antonio were asked to comment on the evolving treatments for treating diabetic macular edema (DME). The approval of ranibizumab (Lucentis; Genentech, South San Francisco, CA) for the treatment of DME in 2012 via the RISE/RIDE FDA registration trials was monumental given that it was the first U.S. Food and Drug Administration (FDA)-approved pharmacotherapy for the treatment of DME. The efficacy seen in treating DME with ranibizumab was without compare at the time. However, since then, the community has seen FDA approvals of aflibercept (Eylea; Regeneron, Tarrytown, NY), the intravitreal dexamethasone implant (Ozurdex; Allergan, Irvine, CA), and the fluocinolone implant (Iluvien; Alimera Sciences, Alpharetta, GA), which have all decreased treatment burden compared to ranibizumab. Only recently has our community begun figuring out the place for each of the four treatments in the DME treatment paradigm either as monotherapy or combination therapy. To make things more interesting, numerous clinical trials are underway to add therapies to our arsenal for managing patients with DME. These anticipated FDA approvals will only add to the questions regarding role of various therapies to manage patients with this condition. Drs. Singer and Jansen will comment on past, present, and future treatments for DME, discussing unmet needs, treatment burdens of the various agents, and how innovation in this landscape will hopefully improve outcomes and patients’ perceptions of their disease. Seenu M. Hariprasad