EyeWorld India December 2018 Issue

66 EWAP PHARMACEUTICALS December 2018 New non-bioerodible intravitreal implant by Maxine Lipner EyeWorld Senior Contributing Writer Elucidating Iluvien use F or patients with diabetic macular edema, one new treatment method gaining notice is Iluvien (fluocinolone acetonide intravit- real implant, Alimera Sciences, Alpharetta, Georgia). This non- bioerodible implant continuously elutes the steroid fluocinolone acetonide at a low dose for up to 3 years, according to Caesar Luo, MD , Bay Area Retina Associates, Walnut Creek, California. This implant is capped at one end and has a polyvinyl alcohol matrix that dissolves over time, releasing a slow and steady thera- peutic dose of fluocinolone aceto- nide for treating diabetic macular edema, Dr. Luo explained. Integrating Iluvien The Iluvien implant is one of two FDA-approved steroid devices used in the eye as a second-line therapy, Dr. Luo noted. “The standard of care for most retinal physicians is to start with an antivascular endothelial growth factor (anti-VEGF) medication,” he said, adding that unless the macular edema is well outside the center of vision, primary therapy is usually the anti-VEGF approach. “Then most of us are treating once a month to deter- mine the responsiveness of the macular edema to anti-VEGF therapy,” Dr. Luo said. “If we think the patient is a suboptimal responder or failing anti-VEGF therapy, we consider use of steroid inside the eye.” Glenn Stoller, MD , Oph- thalmic Consultants of Long Island, Rockville Centre, New York, pointed out that the issue with first-line diabetic retinopa- thy treatment compounds such as Eylea (aflibercept, Regeneron, Tarrytown, New York), Lucentis (ranibizumab, Genentech, South San Francisco), or Avastin (beva- cizumab, Genentech) is that they only block VEGF. “Exudative age- related macular degeneration is primarily a VEGF driven disease. However, the pathogenesis of dia- betic macular edema can be much more complicated,” Dr. Stoller said. “There are different factors that cause swelling of the retina; it’s not only VEGF.” Some of these other factors are addressed by intravitreal steroids. The second-line approach involves use of intravitreal ster- oids in the form of either Ozur- dex (Allergan, Dublin, Ireland), which elutes dexamethasone, or the Iluvien implant. Aside from the different steroids, there are similarities between the two, such as that both implants come preloaded in a dispenser with a sharp needle. “You insert the needle into the eye and press an actuator that causes the implant to be delivered into the vitreous cavity,” Dr. Stoller said. One key difference between the two is that one implant is bioerodible while the other is not. Initially, Dr. Stoller usually gives three to four injections of anti-VEGF to see how a diabetic macular edema patient is respond- ing before considering moving on to an intravitreal steroid approach. Still, consideration of intravitreal steroid use may come down to patient selection and weighing risk factors. “There are a number of variables to consider, such as the patient’s lens status, history of glaucoma, history of a steroid response, the degree of residual swelling, the amount of associated vision loss, and what the vision in the patient’s fellow eye is,” Dr. Stoller said. Dr. Luo also starts with anti-VEGF therapy. Determin- ing how long to stick with this strategy can be a balancing act. Dr. Luo pointed out that in some instances even when it appears the medication isn’t working, it is just a question of time. “There is a subset of patients who will improve with a longer course of monthly injections,” Dr. Luo said. “They may not see a response for 6 months or even 1 year.” The problem is that there is also a sub- set of patients who don’t recover even with monthly injections of anti-VEGF therapy. “There’s the risk that you have left some of these patients undertreated for an extended period of time,” he said. He relies on patient signs to determine the best course. If the macular edema is getting worse, Dr. Luo will quickly consider using an intravitreal steroid. He also examines the appearance of