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Meta-Analysis
. 2016 Feb 12;2(2):CD010469.
doi: 10.1002/14651858.CD010469.pub2.

Corticosteroid implants for chronic non-infectious uveitis

Christopher J Brady  1 , Andrea C Villanti, Hua Andrew Law, Ehsan Rahimy, Rahul Reddy, Pamela C Sieving, Sunir J Garg, Johnny Tang
Affiliations
Meta-Analysis

Corticosteroid implants for chronic non-infectious uveitis

Christopher J Brady et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Uveitis is a term used to describe a heterogeneous group of intraocular inflammatory diseases of the anterior, intermediate, and posterior uveal tract (iris, ciliary body, choroid). Uveitis is the fifth most common cause of vision loss in high-income countries, accounting for 5% to 20% of legal blindness, with the highest incidence of disease in the working-age population.Corticosteroids are the mainstay of acute treatment for all anatomical subtypes of non-infectious uveitis and can be administered orally, topically with drops or ointments, by periocular (around the eye) or intravitreal (inside the eye) injection, or by surgical implantation.

Objectives: To determine the efficacy and safety of steroid implants in people with chronic non-infectious posterior uveitis, intermediate uveitis, and panuveitis.

Search methods: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (Issue 10, 2015), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to November 2015), EMBASE (January 1980 to November 2015), PubMed (1948 to November 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to November 2015), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) (last searched 15 April 2013), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic search for studies. We last searched the electronic databases on 6 November 2015.We also searched reference lists of included study reports, citation databases, and abstracts and clinical study presentations from professional meetings.

Selection criteria: We included randomized controlled trials comparing either fluocinolone acetonide (FA) or dexamethasone intravitreal implants with standard-of-care therapy with at least six months of follow-up after treatment. We included studies that enrolled participants of all ages who had chronic non-infectious posterior uveitis, intermediate uveitis, or panuveitis with vision that was better than hand-motion.

Data collection and analysis: Two review authors independently reviewed studies for inclusion. Two review authors independently extracted data and assessed the risk of bias for each study.

Main results: We included data from two studies (619 eyes of 401 participants) that compared FA implants with standard-of-care therapy. Both studies used similar standard-of-care therapy that included administration of prednisolone and, if needed, immunosuppressive agents. The studies included participants from Australia, France, Germany, Israel, Italy, Portugal, Saudi Arabia, Spain, Switzerland, Turkey, the United Kingdom, and the United States. We assessed both studies at high risk of performance and detection bias.Only one study reported our primary outcome, recurrence of uveitis at any point during the study through 24 months. The evidence, judged as moderate-quality, showed that a FA implant probably prevents recurrence of uveitis compared with standard-of-care therapy (risk ratio (RR) 0.29, 95% confidence interval (CI) 0.14 to 0.59; 132 eyes). Both studies reported safety outcomes, and moderate-quality evidence showed increased risks of needing cataract surgery (RR 2.98, 95% CI 2.33 to 3.79; 371 eyes) and surgery to lower intraocular pressure (RR 7.48, 95% CI 3.94 to 14.19; 599 eyes) in the implant group compared with standard-of-care therapy through two years of follow-up. No studies compared dexamethasone implants with standard-of-care therapy.

Authors' conclusions: After considering both benefits and harms reported from two studies in which corticosteroids implants were compared with standard-of-care therapy, we are unable to conclude that the implants are superior to traditional systemic therapy for the treatment of non-infectious uveitis. These studies exhibited heterogeneity in design and outcomes that measured efficacy. Pooled findings regarding safety outcomes suggest increased risks of post-implant surgery for cataract and high intraocular pressure compared with standard-of-care therapy.

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Conflict of interest statement

CJB: none known ACV: none known HAL: none known ER: none known RR: consultancy and speakership for Allergan on projects with no relevance to current study PCS: none known SJG: principal investigator of the Allergan Ozurdex Uveitis Trial at Wills Eye Institute JT: none known

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Forest plot of comparison: 1 Fluocinolone implant versus standard of care, outcome: 1.2 Cataract surgery through 24 months.
4
4
Forest plot of comparison: 1 Fluocinolone implant versus standard of care, outcome: 1.6 IOP‐lowering surgery performed through 24 months.
1.1
1.1. Analysis
Comparison 1 Fluocinolone implant versus standard‐of‐care, Outcome 1 Cataract formation or progression through 24 months.
1.2
1.2. Analysis
Comparison 1 Fluocinolone implant versus standard‐of‐care, Outcome 2 Cataract surgery through 24 months.
1.3
1.3. Analysis
Comparison 1 Fluocinolone implant versus standard‐of‐care, Outcome 3 Elevated intraocular pressure > 10 mmHg cumulative through 24 months.
1.4
1.4. Analysis
Comparison 1 Fluocinolone implant versus standard‐of‐care, Outcome 4 Endophthalmitis through 24 months.
1.5
1.5. Analysis
Comparison 1 Fluocinolone implant versus standard‐of‐care, Outcome 5 Retinal detachment through 24 months.
1.6
1.6. Analysis
Comparison 1 Fluocinolone implant versus standard‐of‐care, Outcome 6 IOP‐lowering surgery performed through 24 months.
1.7
1.7. Analysis
Comparison 1 Fluocinolone implant versus standard‐of‐care, Outcome 7 Hypotony through 24 months.
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