EyeWorld India December 2018 Issue

67 EWAP PHARMACEUTICALS December 2018 the fluid. “There are some patients who have diffuse and cystic fluid with a lot of outer retinal atrophy and loss,” he said. “I will start considering steroid use at a very early stage for those patients, especially if after initiation of anti-VEGF therapy, they have not shown a response.” In cases where there is even a mild response either in terms of visual acuity or central foveal thickness or macular volume, Dr. Luo will continue patients on anti- VEGF therapy. “I want to see how much better the patient can get with a safer side effect profile than with steroids,” he said. “However, if there is no response or a wors- ening, I will consider a relatively early change.” That said, however, based on the DRCR.net Protocol T recom- mendations, 1 which compared three anti-VEGF agents for diabet- ic macular edema, he will choose the anti-VEGF to use, keeping pa- tients’ acuity in mind. “I will start with Avastin in the majority of my patients who have good vision and diabetic macular edema,” Dr. Luo said. “However, if they have less than 20/50 vision, I will start with intravitreal Eylea.” If they do not improve, he moves quickly to a steroid. The one caveat is for those with better vision who he starts on Avastin. Even if the patient does not have much of a response, he will switch to a full three- course treatment of Eylea, which in some patients may have higher efficacy than Avastin. However, if this is not effective, he considers intravitreal steroid use. Steroid challenge requirement Practitioners cannot move directly to Iluvien use without trying an- other steroid first, Dr. Luo pointed out. “Because of the way the FDA worded the label, there’s no re- quirement for what type of steroid to use in the eye,” he said. “You can use drops, you can use intra- vitreal Ozurdex, you can use intra- vitreal triamcinolone, as long as it is given to ensure that patients have a lessened risk of a steroid re- sponsive intraocular pressure rise.” He prefers a course of intravitreal Ozurdex because he thinks this has the most comparable mecha- nism of action to Iluvien. By con- trast, with triamcinolone, the side effect and therapeutic profile is more variable. “With Ozurdex, it is a controlled 3-month response, and if they’re going to have a pres- sure rise I expect to see that about 6 weeks after implantation.” Likewise, Dr. Stoller prescribes Ozurdex first for patients since this implant lasts for up to 6 months. “If you’re going to have a steroid-induced glaucoma, better it be from something that goes away quicker than something that lasts for 3 years,” he said. Eye of a diabetic macular edema patient upon rst receiving the Iluvien implant in Octo- ber 2016, with baseline vision of 20/50 The same eye in August 2017 without further treatment and vision now of 20/25 Source (all): Caesar Luo, MD continued on page 68