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    Selecting the right DME patients for long-term steroidal implants


    A clinically significant increase in IOP due to steroids is possible in some patients and is simply known as a “steroid response.” Patients with a history of glaucoma and a cup to disc ratio > 0.8 are also contraindicated. In my practice, I rule out patients with a clinically significant increase in IOP in response to either a topical or intravitreal steroid. While I prefer to exercise caution rather than treat increases in IOP with another pharmacological intervention on top of the steroid, patients must be evaluated on an individual basis. If the patient is insufficiently responsive to anti-VEGF or laser therapies, do you let the retina deteriorate rather than risk a manageable IOP rise?

    Additionally, patients with a compromised lens capsule or zonular dehiscence caused by trauma or prior procedures/treatments do not make ideal candidates for these types of implants. Although unusual, capsular compromise or zonular dehiscence might be a pathway for the implant to migrate into the anterior chamber. Finally, I exclude patients sensitive to floaters. Although none of my patients thus far have complained of floaters as a side effect of the implant, it is a theoretical risk.

    To determine the subset of patients likely to experience an unacceptable increase in IOP, I inject a shorter term (clinical efficacy typically up to six months), bioerodable intravitreal steroid implant (Ozurdex, Allergan) to ensure the patient can tolerate the sustained administration of steroids. I prefer to test my patients using the short-term implant rather than with just a topical steroid because it offers the best simulation of how the eye will respond to a long-term intravitreal steroid. If the patient has a good response to the implant without a significant rise in pressure, I can safely conclude they will do well with a longer-term corticosteroid treatment.

    For patients meeting the treatment criteria, a long-term steroidal treatment, (such as Iluvien, Alimera Sciences) is an attractive option. The nonbioerodable implant is designed to deliver a continuous microdose of fluocinolone acetonide (FAc) to treat DME. Designed specifically for intraocular use, the tiny implant (3.5 mm x 0.37 mm) lasts for 36 months and may possibly eliminate, or at least significantly reduce, the need for and frequency of anti-VEGF or steroid injections.


    Joshua Mali, MD
    Joshua Mali, MD, is a vitreoretinal surgeon at The Eye Associates, a private multispecialty ophthalmology practice in Sarasota, Florida.

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