Advancements in the Management of Macular Edema following Retinal Vein Occlusion - Episode 8
Experts reflect on the role of steroids in macular edema following retinal vein occlusion and discuss the limited benefit of combination therapy.
Rishi P. Singh, MD: Since you talked about anti-VEGF [vascular endothelial growth factor] therapy, and some of those trials, you didn’t touch on steroids. Tell me about utilization of steroids. When you incorporate that with your vein occlusion patients?
Jayanth Sridhar, MD: As you said earlier, steroids have been around before anti-VEGF was around. Steroids are very efficacious, they are anti-inflammatory. They hit multiple mediators. Not just VEGF when they act. We all know the reasons that we don’t jump to, most of us don’t use steroids first-line because of adverse effects. Cataract formation in phakic patients and then intraocular pressure increase. I do have a subset of patients I use steroids in. What’s my typical steroid patient? Now there’s 2 scenarios. One is if there’s a patient, I’ve tried 1 anti-VEGF and they’re not responding, I switch to another 1. If they’re not responding, typically my switch drug is aflibercept. I don’t generally go to the third drug. A lot of times at that point I’ll pivot to a steroid. Either off-label triamcinolone or on-label dexamethasone. But I do have a subset of patients that they only respond well to steroids. More common than that, because it tends to be very VEGF responsive, is the patient who is on anti-VEGF but even on aflibercept or ranibizumab [Lucentis] can’t extend that far. And I take care of many patients who snowbird. They live in Florida part of the year. They travel somewhere else. Some of them snowbird to South America or other parts of the world where they may not want to go get injections every 6 or 7 weeks. And some of those patients, especially the older pseudo-phakic patients, I’ll trial a steroid. If there’s no IOP [intraocular pressure] increase, I’ll maintain them. And, a lot of times, I can maintain them with a couple injections. Two or 3 injections a year with a steroid that works really well. And I have a subset of patients on the dexamethasone implant injection who do well with that. Do you also incorporate steroids in a cellular manner or any other scenarios where you would likely use a steroid? Maybe pregnancy would be one.
Rishi P. Singh, MD: I follow that same kind of gestalt for most of my patients, too. I guess my only hesitancy would be I don’t think phakic status necessarily deters me from using it especially if a patient has an advanced cataract already and is headed for cataract surgery in the near-term future. I mean that could be a nice scenario to use an Ozurdex [dexamethasone intravitreal implant] or a steroid implant in that patient to get that steady state. We tend to want to make sure our patients don’t develop an IOP response. And there’s some interesting data that’s come out recently that’s helped with that more. Essentially what those patients want. Two medications are greater for glaucoma drops are the ones that are most sensitive or concerning for a steroid-related response. It’s important to make sure we differentiate those patients from the general routine clinical patient that we might see and generally separate them out. Because those patients are probably the highest risk. I don’t give anyone with multiple glaucoma medications an injection of a steroid in case that was the case with that patient. I focus on anti-VEGF therapy. We lack good head-to-head studies. There are some studies out there that compared the 2. I’m not sure that’s the best study we have. Do you know of any other combination treatments, or have you used combination treatments in your patients for that matter?
Jayanth Sridhar, MD: I have colleagues who have talked about that. I don’t have a lot of patients who I use combination therapy and maybe that’s just my bias. I find that combination therapy for other conditions is most effective where you need the double whammy. You need the dual mechanism to achieve the maximum anatomic effect. I find it uncommon to find a retinal vein occlusion patient with macular edema where the macular edema is nonresponsive to both anti-VEGF and a steroid and I need both. The steroids usually allow you such a long period between your injections when they do work that maybe adding a combination therapy between doesn’t have that extra added benefit for me. Do you use it in your practice?
Rishi P. Singh, MD: I don’t. I tend to either go 1 or the other. It’s just too hard because there’s not enough good data to overlying talk about it. If a patient I put with IOP response or they’re having issues with the steroids, then I’ll switch back to the anti-VEGF, but I don’t tend to do hormonal therapy or bi-hormonal therapy for those patients. There’s not a lot to go on regarding that.
Jayanth Sridhar, MD: You referenced the 2-drop scenario. The other lesson I’ve learned from my glaucoma clients—I used to be petrified about using steroids in any glaucoma patient—if they’ve already had some sort of surgery, filtering surgery, a tube, something that’s bypassing the trabecular meshwork, they’re a much lower risk at that point. Which makes intuitive sense, but I needed my glaucoma colleagues to talk to me and say you can use a steroid and this patient should be OK. We’ll monitor them. Those are scenarios too if you have because we know glaucoma is a risk factor. Advanced glaucoma you already had a tube in place. You think they might do well with a steroid. It’s something to run it by the glaucoma person but usually they’ll give you the blessing to go ahead.
Rishi P. Singh, MD: I couldn’t agree more. Thank you all for watching this HCPLive® Peers & Perspectives. If you enjoyed this content, please subscribe to our e-newsletter to receive upcoming Peers & Perspectives and other great content right in your inbox. Thank you for watching.
Transcript edited for clarity.