Intravitreal therapy an ideal approach to treating uveitic macular oedema
Intravitreal triamcinolone acetonide (ITA) and the intravitreal dexamethasone implant (IDI) demonstrate superior efficacy over periocular triamcinolone acetonide (PTA) in the treatment of patients with uveitic macular oedema (ME), with only modest elevations in intraocular pressure (IOP), according to the results of the POINT* trial.
“These data suggest that intravitreal therapy may be the preferred initial therapy for uveitic ME. The IDI was judged noninferior to ITA at the 8-week visit, with the potential to be better, although it did not have a lower risk of IOP elevation than ITA as was originally expected,” the investigators said.
A total of 192 ME patients (mean age 55 years; 38 percent male) with noninfectious anterior, intermediate, posterior or panuveitis were randomized to receive one of the following therapies in the affected eye: PTA (n=65), ITA (n=63) and IDI (n=64). Those with bilateral ME were assigned the same treatment for both eyes. Retreatment was allowed at the 8-week visit for the PTA and ITA groups and at the 12-week visit for the IDI group provided retreatment criteria were met.
The primary outcome of central subfield thickness (CST) improved across all treatment groups during follow-up. At 8 weeks, CST decreased by 23 percent with PTA, 39 percent with ITA and 46 percent with IDI. [Ophthalmology 2019;126:283–295]
Both ITA and IDI yielded greater reductions in CST when compared with PTA (p<0.0001), with corresponding hazard ratios (HRs) of 0.79 (99.87 percent CI, 0.65–0.96) and 0.69 (0.56–0.86). IDI was noninferior to ITA at 8 weeks (HR, 0.88; 0.71–1.08), and both treatments bested PTA in terms of improving and resolving uveitic ME.
All treatment groups also showed best corrected visual acuity improvements throughout follow-up. At 8 weeks, the increase obtained with both ITA and IDI groups was five letters greater than that achieved with PTA (p<0.004).
However, intravitreal treatment was associated with slightly increased rates of mild IOP elevation compared with periocular treatment. The risk of having IOP ≥24 mm Hg was higher after receipt of ITA (HR, 1.83; 95 percent CI, 0.91–3.65) and IDI (HR, 2.52; 1.29–4.91) vs IDI but did not significantly differ between the two intravitreal therapies.
Despite the presence of limitations in the POINT trial, the findings indicate the superiority of ITA and IDI over PTA in both speed of improvement in or resolution of ME and sustainability of effect, the investigators said.
“Both intravitreal treatments had significantly higher proportions of eyes with ≥20-percent improvement and resolution of uveitic ME when compared with the periocular group, starting at the 4-week visit and continuing until the 12-week visit,” they pointed out.
Moreover, the primary outcome of macular thickness reduction is said to be anatomic, since such a reduction in eyes with uveitic ME has been demonstrated to reflect visual acuity improvement.
“Because uveitic ME represents a significant cause of ocular morbidity and remains a leading cause of visual impairment, having comparative data from a randomized trial with an objective and masked primary outcome measure is essential to understanding which regional corticosteroid offers the optimal balance of efficacy and safety in the management of these patients,” the investigators said.
*PeriOcular vs. INTravitreal corticosteroids for uveitic macular edema