Intravitreal corticosteroids for diabetic macular edema: a network meta-analysis of randomized controlled trials

Abstract

Background To evaluate the efficacy and safety of different intravitreal corticosteroids for treating diabetic macular edema (DME). Methods Four databases were systematically searched for randomized controlled trials comparing different intravitreal corticosteroids for treating DME. The primary outcome was the change in best-corrected visual acuity (BCVA) within 6 months after the first injection (short-term BCVA). Secondary outcomes were the change in BCVA over 1 year (long-term BCVA) and changes in central macular thickness (CMT) and intraocular pressure (IOP) within 6 months after the first injection. Network meta-analysis was performed to aggregate the results from the individual studies. Results Nineteen trials involving 2839 eyes were included. Intravitreal triamcinolone acetonide (TA) injections (≥ 8 mg and 4–8 mg), fluocinolone acetonide (FA) implants (0.5 µg/day) and dexamethasone (DEX) implants (700 µg) improved short-term BCVA (mean changes in logMAR [95% confidence interval] − 0.27 [− 0.40, − 0.15]; − 0.12 [− 0.18, − 0.06]; − 0.10 [− 0.21, − 0.01]; and − 0.06 [− 0.11, − 0.01]). Intravitreal TA injections (4 mg, multiple times), FA implants (0.5 µg/day and 0.2 µg/day), and DEX implants (350 µg) improved long-term BCVA (mean changes in logMAR [95% confidence interval] − 0.11 [− 0.21, − 0.02]; − 0.09 [− 0.15, − 0.03]; − 0.09 [− 0.14, − 0.02]; and − 0.04 [− 0.07, − 0.01]). All intravitreal corticosteroids reduced CMT, and different dosages of TA did not show significant differences in increasing IOP. Conclusions Intravitreal corticosteroids effectively improved BCVA in DME patients, with higher dosages showing greater efficacies. TA was not inferior to FA or DEX and may be considered a low-cost alternative choice for DME patients. The long-term efficacy and safety of different corticosteroids deserve further investigation. Trial registration Prospectively registered: PROSPERO, CRD42020219870

Intravitreal Triamcinolone Acetonide for Diabetic Macular Edema and Macular Edema Secondary to Retinal Vein Occlusion: A Meta-Analysis

“…Our meta-analysis found that high-dose IVTA was associated with a higher incidence of IOP-related complications relative to low-dose IVTA in ME secondary to RVO but not in DME. This expands upon the work of Gao et al [38] which found no significant difference in the risk of IOP elevation in DME patients across six studies between <4 mg, 4–8 mg, and ≥8 mg IVTA and control conditions of sham or no treatment [38]. A randomized trial by Spandau et al [37] also found that rises in IOP were independent of IVTA dose in DME patients.…”

“…Given its availability, low cost, and dose-dependent duration of effect, IVTA is often used in the treatment of DME [35]. A recent network meta-analysis comparing intravitreal corticosteroids to sham or no treatment found that higher doses of IVTA resulted in greater short-term improvements in visual acuity [38]. Our finding that high-dose IVTA had a better change in BCVA than low-dose IVTA at months 4-6 was potentially mediated by the longer persistence of a higher steroid dose.…”

Anatomical and visual outcomes of Retreatment with Intravitreal Dexamethasone Implant versus shifting to intravitreal Aflibercept for refractory Diabetic macular edema after an initial Intravitreal Dexamethasone Implant.

“…been commonly encountered by retina specialists, due to the chronicity of the underlying pathology and the frequency of anti-VEGF treatments. It has been managed by one or more of the following options: Ranibizumab 6,11 , Aflibercept [19][20][21][22] , IVTA 12,13 , DEX [14][15][16][17][18] , and pars plana vitrectomy [7][8][9] .…”

“…Although its anti-inflammatory properties have been proven to reduce macular thickness, its 176 use has been limited due to its effects on intraocular pressure (causes IOP to spike). 12,13 Intravitreal Dexamethasone implants (DEX) (0.7 mg) (Ozurdex, Allergan, Inc, Irvine, CA, USA) have a better safety and efficacy profile than the alternative therapies of DME. It is a micronized dexamethasone, that is placed in a biodegradable copolymer of polylactic-co-glycolic acid, which slowly releases dexamethasone into the vitreous over a period of up to six months.…”

Comparison of intravitreal Diclofenac-Sodium Versus intravitreal Triamcinolone in diabetic Macular Edema

“…This results in improvement in visual acuity. 1 Despite its good response in cases of macular edema, its benefits need to be weighed against its harmful effect on intraocular pressure (IOP) and lens opacification. 2,3 Anti vascular endothelial growth factors (anti-VEGF) have shown promising results in macular edema caused by various diseases.…”