Treatment of diabetic macular edema with sustained-release glucocorticoids: intravitreal triamcinolone acetonide, dexamethasone implant, and fluocinolone acetonide implant.

INTRODUCTION: Diabetic macular edema (DME) can be treated with intravitreal glucocorticoids, particularly triamcinolone acetonide, dexamethasone (DEX), and fluocinolone acetonide (FA). AREAS COVERED: The pathophysiology of DME includes multiple growth factors such as VEGF and also inflammatory mediators. Glucocorticoids act on DME through multiple pathways, and current research into their efficacy, safety, and therapeutic potential when administered intravitreally is discussed. CONCLUSION: The intravitreal route of administration minimizes systemic side effects of glucocorticoids. Furthermore, sustained-release low-dose delivery via the DEX implant or the FA implant will limit frequent intravitreal injection and possibly some cost associated with intravitreal anti-VEGF therapy. In addition, the durable action of these treatments facilitates combination therapy. Patients can receive these implants as foundational therapy, and then receive additional treatment with laser or intravitreal anti-VEGF agents as combination therapy, which may conceivably provide some synergistic benefit. While the FA implant lasts much longer than the DEX implant, potentially decreasing the visit and treatment burden on patients and their families, the FA implant appears to have a greater risk of inducing ocular hypertension and cataract. However, these modalities have not been directly compared in a clinical trial and there is insufficient evidence to draw more elaborate conclusions.

The influence of retinal blood flow on open-angle glaucoma in patients with and without diabetes.

PURPOSE: To evaluate the impact of retinal blood flow on optic nerve head (ONH) morphology in patients with open-angle glaucoma (OAG) with and without diabetes mellitus (DM). METHODS: A total of 66 patients with OAG (14 with DM, 52 without DM) were assessed at baseline and 3-year follow-up for retinal capillary blood flow using confocal scanning laser Doppler and ocular structure using Heidelberg retinal tomography and optical coherence tomography. RESULTS: Change in retinal tissue with zero blood flow in the superior and inferior retina was found to have a strong correlation with ONH changes in diabetic patients (r≥0.90, p≤0.03); however, no relation was found in the nondiabetic cohort. There were also significant changes in inferior mean flow that strongly correlated with changes in cup area (r = 0.97, p = 0.0029), cup/disc area ratio (r = 0.96, p = 0.0070), linear cup/disc ratio (r = 0.93, p = 0.0172), rim area (r = -0.97, p = 0.0036), and rim volume (r = -0.95, p = 0.0084) in diabetic patients only, while changes in the superior mean flow were only significantly associated with cup area (r = -0.30, p = 0.0498), cup volume (r = -0.36, p = 0.0178), and rim volume (r = 0.35, p = 0.0193) in nondiabetic patients. CONCLUSIONS: In this cohort of patients with OAG, changes in retinal capillary blood flow correlated more strongly with changes in ONH morphology in patients with DM than in those without DM. These data suggest that changes in retinal blood flow may play a larger role in glaucomatous ONH progression in patients with OAG with DM.