#9: Intravitreal Steroids

The first pilot study of the use of intravitreal steroids began in 1995, with 30 eyes of patients with acute age-related macular degeneration (AMD) treated with intravitreal triamcinolone. The results of that small trial− decreased exudation and improved vision in patients with wet AMD and subfoveal and juxtafoveal choroidal neovascularization – spurred a wave of interest in intravitreal steroids across a variety of ophthalmic conditions.

Because of their anti-inflammatory and antiangiogenic properties, intravitreal steroids are effective for the treatment of multiple retinal conditions, including diabetic and vasculoocclusive macular edema, exudative macular degeneration, pseudophakic cystoid macular edema, and posterior uveitis.

A Retisert® (fluocinolone acetonide intravitreal implant) implant

However, there have been complications associated with the use of intravitreal steroids – most notably corneal opacification and intraocular pressure (IOP) elevation – which have restricted their use. In one study by the Diabetic Retinopathy Clinical Research Network, IOP-lowering medications were needed in 28% of patients with DME treated with intravitreal triamcinolone. Similar rates of IOP elevation were replicated in other studies. Consequently, for several years, ophthalmologists struggled with the risk vs. benefit debate with intravitreal steroids. There is currently no proven way to determine which patients are most likely to develop glaucoma as a result of corticosteroid use.

To address the concern of IOP elevation, sustained-release intravitreal implants were developed. Intravitreal implants of both dexamethasone and fluocinolone acetonide are available both in Europe and the United States. These implants have demonstrated less risk of IOP elevation compared to traditional steroids.

The advent of anti-VEGF agents has impacted the use of intravitreal steroids in several indications. Many ophthalmologists will currently only use intravitreal steroids in patients who first fail to respond to anti-VEGF therapy. Ultra-widefield angiography is commonly used to assess the extent of peripheral ischemia in patients who require additional interventions following initial anti-VEGF use. Combination therapies that utilize both an anti-VEGF and steroid are currently being explored as well.