TO review the role of steroids in the management of uveitic macular edema.
Methods.
Review of recent literature on the physiopathology of macular edema and clinical trials involving steroids as main treatment of uveitic macular edema.
Results.
The steroid-glucocorticoid receptor complex regulates the action of specific steroids allowing transactivation or repression of a common as well as a unique set of genes. This specificity may help explain differences observed in the side effect profile of commonly used intraocular steroids (dexamethasone, fluocinolone, triamcinolone) whose ability to activate glucocorticoid receptors in model systems is very similar. Sustained delivery devices provide long-term remission of macular edema but with an increased incidence of cataract and glaucoma procedures. The exact incidence is dependent on the specific steroid, the mode of delivery, and the time since injection/placement. Steroid therapy is able to target many important pathways in uveitic macular edema, achieving good clinical results.
Secondary adverse effects are still a matter of concern limiting their use.
Conclusions.
Steroid therapy remains a mainstay in the management of uveitic macular edema. Lo-cal administration precludes systemic adverse effects even though the risk of developing cataract or glaucoma remains an important issue. New slow release devices are thought to improve safety profile while keeping therapeutic advantages.
MiyakeK., OtaI., IbarakiN.Enhanced disruption of the blood-aqueous barrier and the incidence of angiographic cystoid macular edema by topical timolol and its preservative in early postoperative pseudophakia. Arch Ophthalmol2001; 119: 387–94.
6.
CatierA., TadayoniR., PaquesM.Characterization of macular edema from various etiologies by optical coherence tomography. Am J Ophthalmol2005; 140: 200–6.
7.
TranT.H., de SmetM.D., BodaghiB., FardeauC., CassouxN., LehoangP.Uveitic macular oedema: correlation between optical coherence tomography patterns with visual acuity and fluorescein angiography. Br J Ophthalmol2008; 92: 922–7.
8.
AcharyaN.R., HongK.C., LeeS.M.Ranibizumab for refractory uveitis-related macular edema. Am J Ophthalmol2009; 148: 303–9.
9.
MarkomichelakisN.N., HalkiadakisI., PanteliaE.Pat-terns of macular edema in patients with uveitis: qualitative and quantitative assessment using optical coherence tomography. Ophthalmology2004; 111: 946–53.
10.
van KooijB., RothovaA., RijkersG.T., de Groot-MijnesJ.D.Distinct cytokine and chemokine profiles in the aqueous of patients with uveitis and cystoid macular edema. Am J Ophthalmol2006; 142: 192–4.
11.
ProbstK., FijnheerR., RothovaA.Endothelial cell activation and hypercoagulability in ocular Behçet's disease. Am J Ophthalmol2004; 137: 850–7.
12.
CurnowS.J., FalcianiF., DurraniO.M.Multiplex bead immunoassay analysis of aqueous humor reveals distinct cytokine profiles in uveitis. Invest Ophthalmol Vis Sci2005; 46: 4251–9.
13.
RhenT., CidlowskiJ.A.Antiinflammatory action of glucocorticoids: new mechanisms for old drugs. N Engl J Med2005; 353: 1711–23.
14.
SmoakK.A., CidlowskiJ.A.Mechanisms of glucocorticoid receptor signaling during inflammation. Mech Ageing Dev2004; 125: 697–706.
15.
OakleyR.H., SarM., CidlowskiJ.A.The human glucocorticoid receptor beta isoform. Expression, biochemical properties, and putative function. J Biol Chem1996; 271: 9550–9.
16.
NehméA., LobenhoferE.K., StamerW.D., EdelmanJ.L.Glucocorticoids with different chemical structures but similar glucocorticoid receptor potency regulate subsets of common and unique genes in human trabecular meshwork cells. BMC Med Genomics2009; 2: 58.
NarayananR., MungcalJ.K., KenneyM.C., SeigelG.M., KuppermannB.D.Toxicity of triamcinolone acetonide on retinal neurosensory and pigment epithelial cells. Invest Ophthalmol Vis Sci2006; 47: 722–8.
19.
ChungH., HwangJ.J., KohJ.Y., KimJ.G., YoonY.H.Triamcinolone acetonide-mediated oxidative injury in retinal cell culture: comparison with dexamethasone. Invest Ophthalmol Vis Sci2007; 48: 5742–9.
20.
HomikJ., Suarez-AlmazorM.E., SheaB., CranneyA., WellsG., TugwellP.Calcium and vitamin d for corticosteroid-induced osteoporosis. Cochrane Database Syst Rev2000; CD000952.
21.
HomikJ.E., CranneyA., SheaB.A metaanalysis on the use of bisphosphonates in corticosteroid induced osteoporosis. J Rheumatol1999; 26: 1148–57.
22.
CurtisJ.R., WestfallA.O., AllisonJ.Population-based assessment of adverse events associated with long-term glucocorticoid use. Arthritis Rheum2006; 55: 420–6.
23.
CunninghamM.A., EdelmanJ.L., KaushalS.Intravitreal steroids for macular edema: the past, the present, and the future. Surv Ophthalmol2008; 53: 139–49.
24.
SallamA., ComerR.M., ChangJ.H.Short-term safety and efficacy of intravitreal triamcinolone acetonide for uveitic macular edema in children. Arch Ophthalmol2008; 126: 200–5.
25.
KokH., LauC., MaycockN., McCluskeyP., LightmanS.Outcome of intravitreal triamcinolone in uveitis. Ophthalmology2005; 112: 1916e1–7.
26.
ByunY.S., ParkY.H.Complications and safety profile of posterior subtenon injection of triamcinolone acetonide. J Ocul Pharmacol Ther2009; 25: 159–62.
27.
HiranoY., ItoT., NozakiM.Intraocular pressure elevation following triamcinolone acetonide administration as related to administration routes. Jpn J Ophthalmol2009; 53: 519–22.
28.
VenkateshP., KumarC.S., AbbasZ., GargS.Comparison of the efficacy and safety of different methods of posterior subtenon injection. Ocul Immunol Inflamm2008; 16: 217–23.
29.
IpM.S., ScottI.U., VanVeldhuisenP.C.A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with observation to treat vision loss associated with macular edema secondary to central retinal vein occlusion: the standard care vs corticosteroid for retinal vein occlusion (score) study report 5. Arch Ophthalmol2009; 127: 1101–4.
30.
BeerP.M., BakriS.J., SinghR.J., LiuW., PetersGBIII, MillerM.Intraocular concentration and pharmacokinetics of triamcinolone acetonide after a single intravitreal injection. Ophthalmology2003; 110: 681–6.
31.
DriotJ.Y., NovackG.D., RittenhouseK.D., MilazzoC., PearsonP.A.Ocular pharmacokinetics of fluocinolone acetonide after Retisert intravitreal implantation in rabbits over a 1-year period. J Ocul Pharmacol Ther2004; 20: 269–75.
32.
PavesioC., ZierhutM., BairiK., ComstockT.L., UsnerD.W.Evaluation of an intravitreal fluocinolone acetonide implant versus standard systemic therapy in noninfectious posterior uveitis. Ophthalmology2010; 117: 567–75.
33.
KaneF.E., BurdanJ., CutinoA., GreenK.E.Iluvien: a new sustained delivery technology for posterior eye disease. Expert Opin Drug Deliv2008; 5: 1039–46.
34.
CampochiaroP.A., HafizG., ShahS.M.Sustained ocular delivery of fluocinolone acetonide by an intravitreal insert. Ophthalmology2010; 117: 1393–1399.
35.
KuppermannB.D., BlumenkranzM.S., HallerJ.A.Randomized controlled study of an intravitreous dexamethasone drug delivery system in patients with persistent macular edema. Arch Ophthalmol2007; 125: 309–17.
36.
HallerJ.A., BandelloF., BelfortR.Jr.Randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with macular edema due to retinal vein occlusion. Ophthalmology2010; 117: 1134–46.
