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Retinal Physician

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Bilateral Iluvien with Long-term Follow-up

A single fluocinolone implant stabilizes anatomy and vision in DME patient for a year

Retinal Physician September 1, 2016

Iluvien (fluocinolone acetonide intravitreal implant 0.19 mg, Alimera Sciences) is the newest option retina specialists can consider for the treatment of patients with diabetic eye disease. According to its FDA labeling, Iluvien is indicated for the treatment of diabetic macular edema (DME) in patients who have been previously treated with a course of corticosteroids and did not have a clinically significant rise in intraocular pressure. When a patient meets the FDA label requirements and also demonstrates a limited response to anti-VEGF therapy, a good response to corticosteroids, and DME requiring repeat injections, I consider him or her to be a good candidate for Iluvien. In the case I describe here, the patient met all of these criteria. Anti-VEGF agents had not been effective in controlling her DME; therefore, management depended on using corticosteroids. The DME was temporarily responsive to intravitreal triamcinolone and the dexamethasone intravitreal implant (Allergan), neither of which caused her IOP to increase to a level of concern, but chronic therapy was required.

Iluvien OD

The patient is a 71-year-old pseudophakic female who had been diagnosed as having diabetes in 1973. She also has high blood pressure and had developed moderate nonproliferative diabetic retinopathy in both eyes. In 2011, DME was diagnosed in both eyes. She was treated with multiple bevacizumab injections OU by another physician, who reported there was no benefit. Following that course of therapy, I treated her with focal laser twice in each eye, 10 triamcinolone injections in each eye, a dexamethasone intravitreal implant OD and two dexamethasone intravitreal implants OS.

While the triamcinolone injections and dexamethasone intravitreal implant temporarily controlled DME for this patient, she lived 90 minutes away from our offices and was growing tired of the injections and frequent visits for treatment. On Feb. 18, 2015, the patient’s central retinal thickness (CRT) in the right eye as measured by OCT had increased from the prior visit to 343 µm, visual acuity (VA) was 20/40, and Iluvien was implanted (Figure 1).

Figure 1. Prior to Iluvien implantation OD, despite frequent steroid treatments, DME recurred.
Figure 1. Prior to Iluvien implantation OD, despite frequent steroid treatments, DME recurred.

At the follow-up visit 1 month after Iluvien implantation, March 16, 2015, CRT decreased to 257 µm and VA improved to 20/32 (Figure 2). For the next several months, CRT and VA were stable. It wasn’t until a year later, on Feb. 22, 2016, that CRT increased to 290 µm. At the patient’s next visit, March 21, 2016, with CRT essentially unchanged since the previous visit, the dexamethasone intravitreal implant was used as a treatment “booster.” One month later, on April 25, 2016, 14 months after the patient received Iluvien, DME OD was under control. Central retinal thickness measured 230 µm and VA was 20/40 (Figure 3). IOP measured 20 mmHg at one visit with Iluvien in the eye but otherwise ranged from 11 to 19 mmHg at each visit.

Figure 2. At 1 month post Iluvien implantation OD, central retinal thickness decreased from 343 µm to 257 µm and VA improved from 20/40 to 20/32.
Figure 2. At 1 month post Iluvien implantation OD, central retinal thickness decreased from 343 µm to 257 µm and VA improved from 20/40 to 20/32.
Figure 3. With an Iluvien implant and one subsequent dexamethasone implant for break-through DME, central retinal thickness and visual acuity OD were stable for 14 months.
Figure 3. With an Iluvien implant and one subsequent dexamethasone implant for break-through DME, central retinal thickness and visual acuity OD were stable for 14 months.

Iluvien OS

On June 1, 2015, Iluvien was implanted in the patient’s left eye for the same reasons it was used in the right eye: limited response to anti-VEGF therapy, a good response to corticosteroids, and recurrent DME requiring repeat injections. According to the previous OCT, which was obtained on May 18, 2015, CRT was 368 µm and VA was 20/32 (Figure 4).

Figure 4. The left eye after multiple treatments for DME, prior to Iluvien implantation.
Figure 4. The left eye after multiple treatments for DME, prior to Iluvien implantation.

One month after the patient received Iluvien OS, July 1, 2015, CRT improved to 261 µm and VA improved to 20/25. Throughout the nine subsequent months, with no additional treatment, CRT and VA remained consistent (Figure 5) and the highest IOP recorded was 16 mmHg. The one Iluvien treatment the patient received in that span of a year was far less of a burden than the frequent treatments she had been undergoing.

Figure 5. At 10 months after Iluvien was placed in the left eye, visual acuity and central retinal thickness remained stable.
Figure 5. At 10 months after Iluvien was placed in the left eye, visual acuity and central retinal thickness remained stable.

Favorable DME Control With Minimal Treatment Burden

While DME may exacerbate from time to time during this patient’s second 2 years with the Iluvien implant, requiring “booster injections” of the dexamethasone intravitreal implant or triamcinolone, the patient and I are satisfied with the disease control achieved in both eyes with the continuous low-level steroid delivery of Iluvien. With proper patient selection and consistent monitoring of IOP, it works very well to safely control DME with a minimal treatment burden. •

Dr. Holekamp is director of retina services in the Center for Macular Degeneration at the Pepose Vision Institute in St. Louis.

Dr. Holekamp is director of retina services in the Center for Macular Degeneration at the Pepose Vision Institute in St. Louis.

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