Intraocular Corticosteroids Linked to Vision Gains in Uveitis-Related Macular Edema

Douglas A. Jabs, MD

Credit: AOP Congress

Repeat treatment with corticosteroid injections in eyes with persistent or recurrent uveitis-related macular edema was superior to two other therapies in improving vision, according to new research.¹

Patients receiving a dexamethasone implant were able to achieve greater reductions in retinal swelling when compared with methotrexate or ranibizumab intravitreal injections and the therapy was the only to achieve improvements in vision.

“Prior to this study, we didn’t know the best treatment for persistent or recurrent macular edema, a major cause of vision loss in people with uveitis,” Douglas A. Jabs, MD, the chair of the study from the Johns Hopkins Bloomberg School of Public Health said in a statement.² “This trial strongly indicates that repeat intraocular corticosteroid injections are superior to either intravitreal injections of methotrexate or ranibizumab.”

Initial treatment options for uveitis-related macular edema look to control inflammation and reduce fluid build-up under the retina. Some patients can achieve this with oral corticosteroids, but most with macular edema require intraocular corticosteroid injections, such as the dexamethasone intraocular implant. However, intraocular corticosteroids can raise intraocular pressure (IOP), a key risk factor for glaucoma, as well as lead to cataracts, which decreases vision.

For this study, the investigative team compared 3 treatments for uveitis-related macular edema: an additional intraocular corticosteroid injection, the anti-vascular endothelial growth factor (anti-VEGF) drug ranibizumab, or an injection of the anti-inflammatory drug methotrexate. Previous, small pilot studies suggested that ranibizumab injections and the anti-inflammatory nature of methotrexate may reduce uveitis-related macular edema. For the current analysis, the primary outcome at 12 weeks was a reduction in central subfield thickness (CST), assessed with spectral-domain optical coherence tomography (OCT).

The trial enrolled a total of 194 participants (n = 225 study eyes) with well-controlled uveitis, but persistent or recurrent macular edema, across 33 clinical centers. Of this population, 65 participants received a dexamethasone corticosteroid, 65 received methotrexate, and 64 participants received ranibizumab. Injection schedules for each group were based on how each treatment is generally used in clinical practice.

Participants in the corticosteroid group received 1 dexamethasone implant injection at baseline and if macular edema had not resolved, received another injection at 8 weeks. The methotrexate group received 1 baseline injection, then repeat injections at 4 and 8 weeks if the macular edema did not resolve. The ranibizumab group received injections at baseline, 4 weeks, and 8 weeks, even if macular edema resolved.

At the 12-week primary outcome point, results showed significant reductions in CST relative to baseline in all 3 treatment groups. The reduction was greatest in the dexamethasone group (35%), compared with ranibizumab (20%) and methotrexate (11%). Data show the reduction of macular edema was significantly greater in the dexamethasone group than for either methotrexate (P <.01) or ranibizumab (P = .0180).

The analysis showed the dexamethasone group experienced more occurrences of mild increases in IOP, by 10 mmHg, to ≥24 mmHg, or both. However, IOP spikes to ≥30 mmHg was uncommon and not significantly difference between groups.

Moreover, the investigative team noted only the dexamethasone group showed a statistically significant improvement in BCVA during follow-up (4.86 letters; P <.001). Reductions in BCVA of ≥15 letters were more common in the methotrexate group, and investigators typically attributed it to persistent macular edema.

“Intraocular corticosteroid treatment remains the most effective therapy for uveitis-related macular edema,” Nisha Acharya, MD, lead author of the study from the University of California, San Francisco said in a statement.² “The vision gains in participants who received the corticosteroid treatment were very promising.”

References

1. Acharya NR, Vitale AT, Sugar EA, et al. Intravitreal therapy for Uveitic macular edema—ranibizumab versus methotrexate versus the dexamethasone implant. Ophthalmology. Published online June 13, 2023. doi:10.1016/j.ophtha.2023.04.011
2. Nateyeinstitute. Intraocular corticosteroids best for treating complications of chronic inflammatory eye condition. EurekAlert! June 13, 2023. Accessed June 14, 2023. https://www.eurekalert.org/news-releases/991853.