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Editors Selection IGR 19-2

Intraocular pressure: FA implants and IOP

Comment by Augusto Azuara Blanco on:

19901 Intraocular pressure in patients with uveitis treated with fluocinolone acetonide implants, Goldstein DA; Godfrey DG; Hall A et al., Archives of Ophthalmology, 2007; 125: 1478-1485

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Fluocinolone acetonide (FA) intravitreal implants have recently been introduced to manage patients with non-infectious posterior uveitis. These implants provide sustained release of this potent steroid for approximately 2.5 years, helping to control inflammation and improving visual acuity. Two FA implants are currently available (0.59 mg and 2.1 mg). The most common complication is elevated intraocular pressure (IOP) Goldstein et al. (1361) pooled data from three randomized controlled trials to evaluate the incidence and management of IOP elevation in patients undergoing FA intravitreal implant. A total of 294 and 290 eyes received the 0.59 mg and 2.1 mg implant, respectively. IOP lowering therapy was initiated at the discretion of the clinician. The incidence of elevated IOP was high. An IOP elevation > 10 mmHg at any time occurred in 71.0% of implanted eyes versus 21.2% of controls. IOP reached 30 mmHg, 40mmHg or 50 mmHg in 55.1%, 24.7%, and 6.2% implanted eyes, respectively. Overall there were minimal differences between both implants.

Of implanted eyes, 74.8% received IOP-lowering medication, while 36.6% required glaucoma surgery, most of which were trabeculectomies (76.2%). The median time from implantation to initiation of therapy was 197 days. Surgical success (IOP of 6-21 mmHg with our without medication) was noted in 85.1% of eyes at one year. Post-operative hypotony occurred in 42.5% of operated eyes, with similar frequency after trabeculectomy and glaucoma drainage device. Overall, this study provided useful data on IOP elevation after FA intravitreal implants. However, some important questions have not been answered: Was there any correlation between IOP elevation and inflammation control? Was visual acuity influenced by the occurrence of elevated IOP, as other studies have suggested? What is the long-term outcome of these patients? The answers to the above questions are relevant because there are now diverse and potent immunosuppressive agents that might be an alternative to intravitreal steroid implants.

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