Identifying patients appropriate for treatment with fluocinolone acetonide (Iluvien®). When do we switch from anti-VEGF in diabetic macular oedema? A retrospective audit in a UK single-centre setting

Session Details

Session Title: Free Paper Session 24: Vascular Diseases & Diabetic Retinopathy VII

Session Date/Time: Sunday 10/09/2017 | 10:00-11:30

Paper Time: 11:12

Venue: Room 117

First Author: : D.Sahota UK

Co Author(s): :    H. Ibrahim   R. Sivaraj                          

Abstract Details

Purpose:

Research shows that a notable proportion of patients with diabetic macular oedema (DMO) remain insufficiently responsive to anti-VEGF treatment. NICE has approved the use of Illuvien when standard therapies show insufficient response. We aim to identify patients insufficiently responsive to anti-VEGF treatment, who could then benefit from treatment with Illuvien.

Setting:

Retrospective audit of patients receiving anti-VEGF for treatment of DMO in a UK single-centre setting (Heart of England NHS Foundation Trust, West Midlands) from June 2009 to December 2016.

Methods:

Search conducted using electronic patient record system Medisoft®. Entire Heart of England NHS Foundation Trust patient database searched. Including all pseudophakic DMO patients who have received anti-VEGF therapy. Excluding patients with current or previous steroid treatment, macular oedema not of diabetic aetiology and deceased patients. Data collection of demographics, BCVA and central macular thickness (CMT) at three timepoints: 1. before anti-VEGF therapy, 2. at date of best recorded BCVA 3. after final anti-VEGF injection. Insufficient response defined as a gain in BCVA <10 or <15 letters as per NICE guidelines. Data analysed with paired sample T-test and p<0.05 deemed statistically significant to identify patients with insufficient response.

Results:

Medisoft search yielded 190 eyes (147 patients). 140 eyes (104 patients) after exclusions. Mean patient age 70.26 years. Mean number of anti-VEGF injections 10, mean injection number at date of best BCVA 5. Patients taking various anti-VEGF included: a) 109 (77.9%) eyes received ranibizumab (Lucentis®); b) 4 (2.9%) eyes received aflibercept (Eylea®); and c) 27 (19.3%) eyes received both Lucentis® and Eylea®. Baseline mean BCVA 51.49 letters, mean CMT 417.26μm. At date of best reponse mean BCVA 68.42 letters and mean CMT 310.73μm. After final anti-VEGF injection, mean BCVA 58.87 letters and mean CMT 297.09μm Before anti-VEGF therapy to date of best BCVA: mean change in BCVA +16.93 letters (p<0.0001), mean change in CMT -110.70μm (p<0.0001). Before anti-VEGF to after anti-VEGF: mean change in BCVA +7.38 letters (p<0.0001) and mean change in CMT -121.53μm (p<0.0001). Defining insufficient response as “<10 letter gain in BCVA”, 43/140 (31%) eyes at best BCVA response and 84/140 (60%) eyes after final anti-VEGF injection are insufficiently responsive. Stricter criteria of insufficient response being “<15 letter gain in BCVA”, 65/140 (46%) eyes at best BCVA response and 101/140 (72%) eyes after final anti-VEGF injection are insufficiently response.

Conclusions:

This audit reveals that between 31-72% of pseudophakic patients with DMO receiving anti-VEGF therapy at Heart of England NHS Foundation Trust are suitable for switching to Illuvien. The figure depends on the definition of 'insufficient response to treatment' employed. We also show how electronic patient records can be used to efficiently and effectively identify relevant patients. Limitations apply, and thorough documentation of current lens status and ocular comorbidities is necessary for the effective identification of suitable patients. A significant number of pseudophakic patients with DMO receiving anti-VEGF may benefit from switching treatment from anti-VEGF and we have constructed and recommended a listing proforma to help identify such patients in the eye clinic to help optimise their care.

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