C. Stephen Foster, MD

Disclosures

June 08, 2012

Uveitic Macular Edema at ARVO 2012

Uveitic macular edema has been investigated by many research groups, who reported their results at the 2012 annual meeting of the Association for Research in Vision and Ophthalmology (ARVO). These efforts attest to the importance of this matter in the hands of uveitis experts who are frustrated by the persistence of such vision-compromising edema even after the patients' active uveitis has been pushed into remission with immunomodulatory therapy and other techniques.

A Brief Overview of Treatment Studies

Civera and associates[1]reported the effects of an intravitreal dexamethasone (DEX) 0.7-mg implant (Ozurdex®; Allergan, Inc., Irvine, California) for the treatment of persistent uveitic macular edema. They identified 16 patients (23 eyes) with persistent (≥ 90 days) uveitic macular edema who were treated with an intravitreal DEX 0.7-mg implant. Main outcome measures were improvement of central retinal thickness measured with optical coherence tomography (OCT) and changes in best corrected visual acuity. At a mean postoperative follow-up of 5.3 months, central retinal thickness on OCT examinations was significantly reduced (P < .001) at 1 month and 3 months. At day 60, a 10-letter or more improvement in best corrected visual acuity was seen in 60.86% (14/23) of eyes. A 15-letter or more improvement was achieved in 34.78% (8/23) of eyes. Macular edema relapsed in 21.73% (5/23) and an additional intravitreal injection of DEX 0.7 mg implant was performed. The investigators concluded that the intravitreal DEX 0.7-mg implant is safe and effective for treatment of persistent uveitic macular edema.

Owen and associates[2] administered intravitreal injections of methotrexate to 6 patients with cystoid macula edema secondary to noninfectious uveitis. Three patients had idiopathic intermediate uveitis. The others had chronic anterior uveitis, autoimmune-associated retinopathy, and birdshot retinochoroidopathy. All patients were on oral immunosuppressive drugs. Three were known to be steroid responders. The investigators concluded that intravitreal methotrexate is safe to use in patients with macula edema secondary to noninfectious uveitis, and some patients responded positively to the intravitreal methotrexate.

Kramer and colleagues[3] evaluated the efficacy of anti-tumor necrosis factor (TNF)-alpha agents compared with other immunosuppressive therapies for uveitis-related cystoid macular edema. They retrospectively analyzed 18 patients (27 eyes; group A) treated with conventional immunosuppressive therapy for chronic cystoid macular edema (periocular and systemic steroids, methotrexate, azathioprine, cyclosporine, and mycophenolate) and 9 patients (15 eyes; group B) treated with either infliximab or adalimumab. Mean visual acuity improved in both groups, with maximal improvement at 3 months (group A, P = .03; group B, P = .01) and a reduced effect approaching 12 months. Mean visual acuity at 12 months was similar for both groups. The investigators concluded that treatment of uveitis-related cystoid macular edema with anti-TNF-alpha agents is effective and lasting.

Deuter and colleagues[4] evaluated the long-term efficacy of interferon (IFN) alpha for chronic uveitic cystoid macular edema. Patients whose uveitis had been treated with IFN alpha sometimes had chronic cystoid macular edema in at least 1 eye, even though their uveitis clinically appeared to be in remission. Treatment with IFN alpha-2a was started at an initial dose of 3-6 million IU per day subcutaneously for approximately 4 weeks. Afterwards, the dose of IFN alpha-2a was tapered stepwise to the lowest possible dose that kept the cystoid macular edema in remission, and it was eventually discontinued if possible. Of the 58 patients treated with IFN alpha for chronic uveitic cystoid macular edema since 2003, follow-up was completed for at least 24 months in 38 patients who were eligible for further analysis. Localization of uveitis was anterior in 6, intermediate in 28, and posterior in 4 patients. IFN alpha was effective (complete and sustained resolution of disease) in at least 1 eye in 26 patients (68.4%), partly effective (reduction of disease) in 9 patients (23.7%), and not effective (no response or early relapse of disease) in 3 patients (7.9%). The mean follow-up period was 56.3 months (range, 24-104 months) and the mean duration of IFN alpha treatment was 47.2 months (range, 1-100 months). During follow up, 6 patients (15.8%) stopped IFN alpha treatment after 1-88 months due to inefficacy or side effects. In 4 patients (10.5%), IFN alpha could be discontinued for remission after 25-100 months; 1 patient relapsed after a month. In 28 patients (73.7%), treatment with IFN alpha was ongoing at last visit in our hospital (duration of IFN alpha treatment, 24-100 months).

Deuter and colleagues[4] concluded that IFN alpha can induce complete or partial resolution of chronic uveitic cystoid macular edema in a substantial proportion of affected patients, but most patients need long-term treatment with IFN alpha to maintain absence of disease.

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