Anti-vascular endothelial growth factor (anti-VEGF) and corticosteroid injections are adding to the increased prevalence of glaucoma, according to J. Michael Jumper, MD. “We’re talking about glaucoma caused by retina specialists,” he said.
Dr. Jumper, a retina specialist and assistant clinical professor of ophthalmology, University of California, San Francisco, described how retina treatments relate to glaucoma–not only injections, but also vitrectomy and laser treatments can trigger glaucoma–during the Glaucoma Symposium CME at the 2016 Glaucoma 360 meeting.
Among Medicare fee-for-service patients, ophthalmologists will perform three times as many intravitreal injections as cataract surgeries in 2016, Dr. Jumper said. Most of these will be anti-VEGF injection therapy, but the number will also include injected corticosteroids, mainly triamcinolone, as well as implanted dexamethasone (Ozurdex, Allergan), and fluocinolone (Retisert, Bausch + Lomb, and IIluvien, Alimera Sciences).
Dr. Jumper cited a meta-analysis (Surv Ophthalmol. 2013 Jul-Aug;58(4):291-310) showing that the different drugs cause ocular hypertension at different rates.
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In that study, the researchers found that 32% of patients develop ocular hypertension following a 4-mg intravitreal triamcinolone injection, 66% following a 0.59-mg fluocinolone implant, 79% following a 2.1-mg fluocinolone implant, 11% following a 0.35-mg dexamethasone implant and 15% following a 0.7-mg dexamethasone implant.
Ocular hypertension was defined as either intraocular pressure (IOP) ≥ 21 mm Hg or ≥ 10 mm Hg from baseline or IOP ≥ 25 mm Hg or ≥ 10 mm Hg from baseline.
“You can get a hint that fluocinolone is going to create higher rates of ocular hypertensions,” said Dr. Jumper. “It’s important to note that the Retisert implant requires incisional surgery in about 45% of patients who receive it.”
The reason some corticosteroids are more likely to provoke ocular hypertension than others could be that they stimulate different kinds of gene expression within cells. “Their steroid response also definitely relates to the strength of the drug, the length of time it works, and the dose,” Dr. Jumper added.