DOI: 10.1097/IIO.0000000000000075

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PMID: 26035760

Issn Print: 0020-8167

Publication Date: 2015/07/01


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Intraocular Sustained-release Steroids for Uveitis

Nidhi Relhan; Steven Yeh; Thomas A. Albini

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Excerpt

Uveitis is a leading cause of visual morbidity. The annual incidence of uveitis has been reported to be 14 to 22.5 per 100,000 by previous US and European studies.1 Worldwide prevalence of uveitis ranges from 38 to 730 per 100,000.1,2 Ten percent to 15% of total blindness in USA is attributed to uveitis.3,4 As uveitis often affects working-age adults, it has significant economic consequences. Uveitis is clinically classified into anterior uveitis, intermediate uveitis, posterior uveitis, and panuveitis.5 Approximately 50% of uveitis is noninfectious. The posterior segment of the eye is affected in 15% to 22% of uveitis cases and often results in compromised visual acuity.6 Ocular inflammation and sight threatening complications such as cystoid macular edema (CME) in cases of noninfectious uveitis are managed with corticosteroids by systemic, topical, periocular, or intravitreal route. Corticosteroids have been used to treat uveitis for >60 years.7 The mechanism of action of corticosteroids is incompletely understood but includes reduction in leukocyte chemotaxis, inhibition of the release of arachidonic acid from the phospholipid membrane,8 reduction in the expression of matrix metalloproteinase, downregulation of intercellular adhesion molecule 1 on endothelial cells,9,10 and inhibition of transcription factor NF-κβ.11 Systemic corticosteroids especially when given chronically are associated with systemic side effects including hypertension, diabetes mellitus, osteoporosis, infections, adrenal suppression, and Cushing syndrome. Periocular and intravitreal depot steroid injections provide quick and direct delivery of drug to the eye but need to be repeated approximately every 3 months to maintain adequate disease control. Between injections local drug concentrations often drop to subtherapeutic levels. Complications such as cataract formation, ocular hypertension and glaucoma, globe perforation, orbital fibrosis, and ptosis12 have been reported with periocular injections. Intravitreal injections are associated with potential complications such as cataract, glaucoma, retinal break, retinal detachment, and vitreous hemorrhage.13
Intraocular devices or implants with the capacity for slow and prolonged release of corticosteroids address some of the weaknesses of systemic and regional steroids. Implants are long lasting and avoid multiple repeated injections. These devices facilitate the chronic use of corticosteroids for ocular inflammation without the systemic complications of chronic oral steroids. Three sustained-release steroid implants are Food and Drug Administration (FDA) approved for ocular disease: the anchored fluocinolone implant (Retisert; Bausch and Lomb, Rochester, NY); the injectable dexamethasone implant (Ozurdex; Allergan Inc., Irvine, CA); and the injectable fluocinolone insert (pSivida, Watertown, MA and Allimera, Alpharette, GA). We will discuss the application of these implants in the treatment of chronic noninfectious uveitis.
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