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Emerging Drug Delivery Options for Retinal Disease by STEVEN YEH, MD; THOMAS A

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Emerging Drug Delivery Options for Retinal Disease by STEVEN YEH, MD; THOMAS A COVER STORY A Peek Down the Pipeline: Emerging Drug Delivery Options for Retinal Disease BY STEVEN YEH, MD; THOMAS A. ALBINI, MD; AND ANDREW A. MOSHFEGHI, MD, MBA he range of intravitreal therapeutics available to AVAILABLE IMMEDIATELY OR NEARLY the retinal specialist for the treatment of chronic IMMEDIATELY retinal disease including age-related macular Although AMD, RVO, and DME are the major retinal degeneration (AMD), retinal vein occlusion diseases cared for by vitreoretinal providers, posterior uve- (RVO),T diabetic macular edema (DME), and posterior itis was the initial disease condition whereby strides in sus- uveitis has continued to expand significantly, providing tained-release drug delivery were made. The parallel among excellent options for improved visual acuity and quality- these disease processes is in their chronicity, thus man- of-life outcomes.1-4 With multiple medications target- dating long-term therapy. It was in this context that the ing VEGF (ranibizumab [Lucentis, Genentech], beva- Retisert implant (fluocinolone acetonide, Bausch + Lomb) cizumab [Avastin, Genentech], and aflibercept [Eylea, was designed and eventually FDA-approved for the treat- Regeneron]) available in the United States for AMD, ment of posterior uveitis.5-7 The Retisert implant is a corti- RVO, DME, and with the intravitreal sustained-release costeroid-eluting, surgically implanted device that releases corticosteroid dexamethasone formulation (0.7 mg; medication for 3 years and has demonstrated efficacy Ozurdex, Allergan) approved by the US Food and Drug for decreasing inflammation and improving visual acuity Administration (FDA) for RVO, DME, and posterior and quality-of-life metrics. However, the need for cataract uveitis, a major compelling arena of discussion for both surgery (90%) and incidence of glaucoma requiring filtra- patients and providers involves the future of drug deliv- tion surgery (25–40%) is a concern that is integral to every ery to improve patient care from a treatment burden patient-physician discussion about efficacy and long-term standpoint. side effects.5-7 Two major questions arise in considering drug delivery The Ozurdex implant (DEX) is a sustained-release to the posterior segment: (1) Can the drug delivery sys- intravitreal injectable therapeutic, which lasted from tem provide sustained release or prolonged therapeutic 4 to 6 months in clinical trials.8-10 It is injected in the levels of medication for the specific disease process? clinic, avoiding the need for a surgical procedure. The And (2) Does the drug delivery system provide thera- DEX implant has been FDA-approved for RVO, posterior peutic levels to appropriate ocular tissue compartments uveitis, and, recently, for DME in pseudophakic patients in which the disease process is implicated (ie, vitreous, and phakic patients scheduled for cataract surgery.8-10 retina, retinal pigment epithelium, suprachoroidal space) Boyer et al recently reported the 3-year outcomes of as opposed to anterior segment structures? 2 randomized, multicenter, sham-controlled phase 3 This article summarizes some of the promising meth- trials on the DEX intravitreal implant for patients with ods of drug delivery in development, which provide DME.10 In 1048 patients with DME, the percentage of future options for retinal disease therapy (Table). patients with 15-letter or greater improvement was 22% 70 RETINA TODAY JULY/AUGUST 2014 COVER STORY and 18% in 0.7 mg and 0.35 mg DEX implant groups, with a microcatheter and the use of hollow microneedles respectively, compared with 12% in the sham control for suprachoroidal drug delivery. group (P ≤ .018). Patients receiving the DEX implant also demonstrated greater improvements in central retinal Suprachoroidal Drug Delivery Via a Microcatheter thickness measured with optical coherence tomography In a primate and porcine animal study, Olsen et al (OCT), with greater than 100-µm improvement in both evaluated the surgical technique, safety profile, and phar- treatment groups, compared with a reduction of 40 µm macokinetics of triamcinolone acetonide introduced via in sham (P < .001). Rates of cataract-related changes surgical microcatheter cannulation of the suprachoroidal were 67%, 64%, and 20% in the DEX 0.7 mg, 0.35 mg, and space.14 To access the suprachoroidal space, a conjunc- sham groups (P < .001), respectively, while intraocular tival peritomy and radial incision was made 3 to 4 mm pressure elevations were controlled medically or without posterior to the limbus to expose bare choroid. Healon therapy.10 Prior clinical trials have also demonstrated (Abbott Medical Optics) was used to viscodissect the the efficacy of the DEX implant for posterior uveitis and choroid from bare sclera; following this, the posterior RVO, and this device has received FDA approval for both drug delivery system (PDS) was introduced. A light pipe indications.8-9 was inserted through a second sclerotomy to visualize Iluvien is an intravitreally injected fluocinolone aceton- the beacon probe tip. Once the beacon probe tip was in ide implant (190 mg; Alimera Sciences) that is delivered position posterior to the area centralis—or the porcine via a proprietary 25-gauge injector system. In 2 parallel, foveal equivalent—the drug was injected. prospective, randomized, sham-controlled multicenter In this study in 94 animals, successful and reproduc- clinical trials, patients with DME were randomized in a ible suprachoroidal cannulation was performed in 1:2:2 ratio to sham injection (n = 185), low-dose insert 93 of 94 animals with a low incidence of complications. (n = 375), or high-dose insert (n = 393). Twenty-eight per- Postoperative inflammation (6/94 animals) was infre- cent of eyes receiving either a low- or high-dose fluocino- quently observed; endophthalmitis and wound abscess lone acetonide implant achieved improvement in their were notably rare (1/94). The pharmacokinetics of a ETDRS visual acuity by 15 letters or more compared with 3-mg dose of suprachoroidal triamcinolone demonstrat- 16% in the sham group (P = .002 for both comparisons). ed sustained levels for up to 120 days at study termina- Cataract surgery was more frequent in eyes receiving the tion (compared with approximately a 3-month duration implants compared with control patients, and glaucoma of effect of 4-mg triamcinolone acetonide injection). occurred in 3.7%, 7.6%, and 0.5% of low-dose, high-dose, Based on this initial study of this anatomic space for drug and sham groups, respectively. Notably, although both delivery, further clinical studies were recommended for the high-dose and low-dose groups benefited from the role of suprachoroidal drug delivery.14 the insert, the risk-benefit ratio favored the low-dose More recently, prospective studies in patients with insert.11-12 The Iluvien implant has received approval for the microcathether suprachoroidal drug delivery system marketing in a number of European countries including (iTrack 400, iScience Interventional Corporation) have Austria, France, Germany, Italy, Portugal, Spain, and the shown encouraging results, albeit in small series at this United Kingdom; the company is currently seeking FDA point. This microcatheter, commercially available for the approval for the drug in the United States. delivery of fluid infusion and aspiration in ophthalmic microsurgery, features a 370-µm diameter width and has SUPRACHOROIDAL DRUG DELIVERY an illuminating and atraumatic tip for suprachoroidal drug Topical application and periocular and intravitreal delivery and a lumen for drug/fluid administration. Similar injections of anti-VEGF medications and corticosteroids to the technique described by Olsen et al, a conjunctival are currently a mainstay of therapy for posterior seg- peritomy and scleral cutdown are performed to expose ment disease. However, the development of cataract bare choroid. A Sinskey hook is then used for dissection of and glaucoma with corticosteroid delivery associated deeper scleral lamellae, followed by viscoelastic hydrodis- with these methods of delivery remains an ongoing con- section to expand the sclera and choroid. As the micro- cern, particularly with repeated injections.13 In addition, cathether is marked at 5-mm intervals, its subsequent the inherent risks (even if they are minimal) and bio- correct anatomic localization within the suprachoroidal availability limitations with intravitreal injections place space and underneath the area of regard (ie, the fovea in suprachoroidal drug delivery at the forefront of current initial studies) is then monitored through the operating research. microscope via direct visualization of the illuminated tip Options studied for suprachoroidal delivery include of the microcatheter. Successful drug delivery can then be the surgical catheterization of the suprachoroidal space verified once the microcatheter is in its correct position.15 JULY/AUGUST 2014 RETINA TODAY 71 COVER STORY In a prospective, interventional pilot study using this segment structures. The achieved levels (ie, chorioretinal technique, Rizzo et al evaluated 6 eyes of 6 patients with selectivity) of suprachoroidal delivery of sodium fluores- retinal vascular disease (ie, central or branch RVO or cein was an order of magnitude greater when compared DME) with massive refractory subfoveal hard exudates with levels achieved by intravitreal injection.18 Further who received combination bevacizumab and triamcino- work in a porcine model of uveitis showed that supracho- lone using suprachoroidal drug delivery.15 Successful
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