Drug Therapy Superior to Implant for Uveitis Treatment

Systemic therapy observed to be more effective at preserving vision than intraocular implants in uveitis.

A 7-year study funded by the National Eye Institute showed that systemic therapy with corticosteroids and immunosuppressants was more effective than a corticosteroid intraocular implants for uveitis.

The authors discovered that drug therapy was able to better preserve visual acuity and elicit less side effects than the implant. Patients receiving systemic therapy were observed to have stable visual acuity after 7 years, but patients with the implant had a decline of 6 letters, according to a press release.

“This trial provides good evidence that for the average patient with uveitis, systemic therapy would be the first choice of treatment,” said John Kempen, MD, PhD, of Massachusetts Eye and Ear/Harvard Medical School, Boston, chair of the writing committee for the report. “The visual outcome over the long run was better, on average, there were fewer adverse outcomes, and the cost is less.”

Uveitis in a major contributor to vision loss and blindness in the United States. The creation of the intraocular implant was the result of concerns regarding the side effects of systemic corticosteroid and immunosuppressants. In 2005, the fluocinolone intraocular implant was approved by the FDA, but early findings suggested that it elicited ocular side effects, according to the release.

The Multicenter Uveitis Steroid Treatment Trial (MUST) was launched to determine whether the implant offered patients with uveitis additional benefits than systemic therapies.

Included in the study were 255 patients with uveitis who were randomized to receive treatment with the fluocinolone implant or systemic therapy with corticosteroids and immunosuppresants.

Corticosteroids are an FDA-approved treatment for uveitis that reduces inflammation, but may have systemic side effects. Immunosuppressants are not an FDA-approved treatment for uveitis, but can reduce the immune response, therefore, lessening the amount of corticosteroids needed.

The authors found that visual acuity remained similar among both treatment groups through the first 2 years. After 7 years, visual acuity was stable among patients on systemic therapy, but declined in the implant group.

After approximately 5 years, patients with the intraocular implant experienced reactivations of uveitis, which lead to a decline in visual acuity. The authors attributed the vision loss among these patients to increased damage to the retina and choroid, according to the study.

“These results emphasize the importance of longer follow-up for studies of treatments for chronic diseases that are likely to require years of treatment,” said Elizabeth Sugar, PhD, of Johns Hopkins University, Baltimore, chair of the statistical analysis committee for the MUST research group and lead statistician for the manuscript.

Compared with those treated with systemic therapy, patients with the implant were more likely to experience ocular side effects, including cataracts, intraocular pressure that required surgery, and glaucoma.

Patients treated with systemic therapy were more likely than other patients to require antibiotics, according to the study. The authors noted that other than antibiotics, patients treated with systemic therapy did not have a large increase in adverse events associated with corticosteroids, according to the study.

“We were able to avoid most of the systemic adverse outcomes that people worry about with systemic corticosteroid and immunosuppressive therapy by following expert panel guidelines,” Dr Kempen said. “The result is meaningful not just in ophthalmology but in other disease areas, because many different fields use this strategy to treat the inflammatory diseases of many different organs.”

The mitigation of side effects linked to cortiocosteroids, such as high blood pressure or diabetes, along with preservation of vision, suggests that the systemic therapy treatment option may be more beneficial to certain patients with uveitis, according to the study.

“The results of this trial suggest that oral corticosteroids and immunosuppression may be a preferable initial choice for therapy of more severe uveitis,” said Douglas A. Jabs, MD, of the Icahn School of Medicine at Mount Sinai, New York City, and chair of the MUST Research Group. “However, the implant may have a role in treating patients where systemic therapy fails to control inflammation or patients cannot tolerate the oral medications.”