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 Iluvien Osurdex will be he commonest implant used for the conditions here.  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   If there is scarring sight will not improve.

 

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.   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

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: symptoms

An infection... common symptoms   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. Anti-VEGF may hasten 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

Treatment is safe continuing the anticoagulants.

 

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

Trivaris

is preservative free triamcinolone and may be safer than triamcinolone with preservative

 

Herpes simplek keratitis or uveitis

The drugs are unsafe generally, as they are likely to cause a recurrence that is difficult to treat.

 

Months...Eye pressure

Renal Failure or Diamox allergies

Diamox is a drug given to lower eye pressure, and is used in a lower dose with renal failure, If this drug cannot be avoided, you must take precautions..as your your ophthalmic team may not realise you aware you have renal failure.

Pre-existing glaucoma

As intratvitreal steroids may put up your eye pressure, the treatment is  generally avoided in glaucoma patients. However, on most occasions the pressure rise can be treated, although rarely surgery is needed.

 

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 after3 years, 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