www.diabeticretinopathy.org.uk

Intravitreal steroid implants (IVSI)

 

David Kinshuck

Introduction: IVSI, intravitreal steroid implants

IVSI are a new way of treating eye conditions, particularly macular oedema in retinal vein occlusion, uveitis, and less commonly diabetic retinopathy and other conditions. The steroid drug is prepared in a tiny capsule, and this is inserted into the eye with a small injection.

The steroid is released slowly over the next few months. Details are discussed on this page. There are 2 implants, Osurdex (dexamethasone) and Retisert. Osurdex will be he commonest implant used for the conditions here; Retisert will be used for uveitis, not discussed here in detail. IVSI are used to reduce this leakage (macular oedema), that may occur in

Iluvien is likely to be helpful, as the benefit lasts nearly 9 months, and usually does not need to be repeated. It is not yet available for NHS UK use. As the drug causes cataracts, it is ideal if the diabetic macular oedema is in patients who have had cataract surgery. About 20% patients will need anti-glaucoma treatment afterwards, and of course there is ~100% cataract formation.

 

Macular oedema (diabetes, retinal vein occlusion, etc)

 

macular oedema

Macular oedema shown in green by the arrow. Macular oedema affects the centre of the retina which is responsible for sharp vision, see
The front of the eye is on the left, and the retina is shown in red

 

 

The macula is the central retina, the part of the retina that is needed to read or watch television or see any details.

Macular oedema is waterlogging of this central area of the retina. It is caused when the central retina is damaged and starts to leak fluid. (The fluid originates from blood. Essentially the fluid is blood without the red blood cells.)

The leak causes poor sight, that is difficult reading, watching TV. Your central or 'sharp' vision becomes blurred.

Laser remains part of the treatment, but IVSI will help if there is macular oedema. Risk factors should be controlled (blood pressure, smoking, cholesterol etc). IVSI will be particularly helpful if the macular oedema is very central as laser would not so helpful. Oph 2011  Oph 14 Retina 17   Scarring etc BJO17

Macular oedema in uveitis

IVSI will be particularly helpful in posterior uveitis patients, particularly in unilateral (or mainly unilateral) posterior uveitis. In addition to reducing the leakage, the steroid reduces the inflammation itself.  Retina 2013   Very helpful Retina15

 

osurdex steroid  implant, click for link to video

Osurdex is a steroid implant that reduces macular oedema. A tiny capsule of the drug is injected into the eye.

 

The procedure

 

Iodine allergy

 

After the injection

By one month the drugs should be working. Many people will notice some improvement in vision. Generally this improvement is temporary, and the injection may be offered again months later. The macular oedema reduces, with a maximum reduction at 2 weeks, and starts to wear off after 3 months (see). It gives a chance for laser treatment and lower blood pressure etc  to have their effect. Further injections are usually needed, but as this treatment is new there is no definite treatment plan available.

 

Risks etc

Hours

The injection will put the eye pressure up for a few hours. It is therefore riskier is you have glaucoma, but this is generally not a major problem. There should not be much pain. You may see the drug floating around your eye for the next few hours.

 

Night

Days

About 1/1000 people will develop a serious eye infection. The day after the injection your eye should be comfortable, there should be very little pain. If your eye starts to get red, with misty vision (there may be no pain), perhaps 2-5 days after the injection, you should suspect an infection and attend your eye department urgently. In Birmingham this is the Birmingham and Midland Eye Centre Casualty at the
Birmingham & Midland Eye Centre, City Hospital, Dudley Road, Birmingham B18 7QH
Tel: 0121-554 3801. Avastin, infection..preventing.

A scratchy after injentiosn is normal; a painful achy eye may be infected.

Check pressure 4, 8, & 16 weeks after injection EJO15 .


 

Symptoms of infection

These are the common symptoms that patients notice   Eye 12  

  1. blurred vision........96%
  2. pain/photophobia...73%
  3. redness ...............50%
  4. floaters................25%
  5. lid swelling ...........10%
  6. discharge .............10%

Months..sight

The drugs will reduce the retinopathy, both the leakage and new vessel growth. Laser...if it has not been carried out already will be needed, on many occasion. Rarely the drugs will cause some loss of sight...there is no detailed information as to the exact risk. Unlike a steroid, there should be no long term pressure effects.

Years

IVL or IVA may hasten cataract development or to vitreomacular traction Eye 17.

 

Pregnancy

Please tell your doctor is you are pregnant, and try and avoid getting pregnant for the 6 weeks following the injection. This is a new drug and is probably UNWISE IN PREGNANCY. In any respect, pregnancy makes active diabetic retinopathy MUCH worse.Retina 2012

 

Retinal tears

There is a 1% risk of a retinal tear after this injection. Please seek attention (within 24 hours....the next day is usually OK) from an ophthalmologist if you develop the symptoms of a tear, that is (all of a sudden) a sudden shower of floaters and flashes of light. These may happen in the months after the injection.

 

Anticoagulants ...extra precautions

You should remind your ophthalmic team you use anticoagulants and ask for specific advice. Treatment is safe continuing the anticoagulents (Retina 2010).  Epidemiology 2010

 

Extra precautions for Triamcinolone (steroid) and steroid implants Osardex and Iluvien

 

Herpes simplek keratitis or uveitis

Months...Eye pressure

Renal Failure or Diamox allergies

Diamox is a drug given to lower eye pressure, and is generally not used in renal failure as it it can make some patients very ill. If this drug cannot be avoided, you must take precautions..as your your ophthalmic team may not realise you aware you have renal failure. Occasionally the benefits will outweigh the risks, but discuss this with your ophthalmic and renal team. Naturally it should not be given if you are allergic to it....remind your ophthalmic team.

Pre-existing glaucoma

As IVT may put up your eye pressure, IVT is a problem (and ideally would be avoided) in glaucoma patients. However, on most occasions the pressure rise can be treated.

Follow up Schedule

This is an idea of your follow up schedule if your eye pressure (IOP, intraocular pressure) stays low: 4 weeks IOP,  12 week IOP & clinic, 6 months IOP , 12 months IOP, every 12 months IOP. The steroid effect wears off, and often the injections needs to be repeated.

Years

IVT hastens cataract development.

Pregnancy

Please tell your doctor if you are pregnant, and try and avoid getting pregnant for the 6 weeks following the injection. Glaucoma treatment is not ideal in pregnancy.

 

Types of IVSI implant

Osurdex (dexamethasone)

Iluvien

 

Retsert

Intravitreal Methotrexate

This is a new treatment proposed and being carried out at Moorfields Eye Hospital. It is for uveitis, and looks exceedingly promising 2009.

An example

osurdex steroid implant, vision improved

Before on right, after Osurdex left. Haemorrhages have reduced and macular oedema has reduced. Vision improved from 6/18 to 6/9 so patient can drive (other eye was an amblyopic eye). Did develop glaucoma, controlled with drops.  enlarge