ARVO 2023: Early adoption of triamcinolone acetonide suprachoroidal injection for uveitic macular edema

Peter Chang, MD, FACS sat down with David Hutton, Managing Editor, Ophthalmology Times®, to discuss his poster about the early adoption of triamcinolone acetonide suprachoroidal injection for uveitic macular edema at this year's ARVO meeting.

Video transcript

Editor’s note: This transcript has been edited for clarity.

David Hutton:

I'm David Hutton of Ophthalmology times. The Association for Research in Vision and Ophthalmology recently held its annual meeting in New Orleans. I'm joined today by Dr. Peter Chang, who presented a poster at the event. Thank you so much for joining us today. Dr. Chang, tell us about your poster.

Peter Chang, MD, FACS:

Thank you, David. So the title of my poster at ARVO is called "Early Adoption of Triamcinolone Acetonide Suprachoroidal Injection for Uveitic Macular Edema: A Physician Survey."

In a nutshell, it's basically a collective experience of 12, retina uveitis specialists throughout different parts of the United States. We put together our experience and kinda sort of demonstrate ... and most of our most of these 12 doctors have done at least 10 suprachoroidal triamcinolone injections some of us have a lot more. And this, remind you, this meeting took place a little more than six months ago. So since then we probably have a lot more injections under our belt. But at the point of this sort of collective survey we conducted we have almost 300 suprachoroidal injections done and most of us have very positive experience.

So we have wanted to share our clinical experience and real world experience with our colleagues and hence the conception of this particular abstract/poster. So Triamcinolone Acetonide Suprachoroidal also called XIPERE. It's made by Bausch + Lomb with a clear injector that's a property of Clearside Biomedical. And basically it's a very unique novel way to deliver triamcinolone steroids into the eye without having the steroids directly entering the vitriol cavity, because everything's contained in the suprachoroidal space. So the theoretical advantage of this versus intravitreal or periocular steroids, that you got a much higher drug concentration, going where it's supposed to go.

In this case, we're talking about uveitic macular edema, so it's very far back in the eye. And you get all these drugs that's concentrated in the area that it's supposed to target versus a periocular steroids where the steroid depends on the particular technique a doctor utilizes, the steroids may not go where it's supposed to go, especially the macula. If also in contrast to intravitreal steroids and traditional steroids, you got steroids inside the eye, the particles of steroid particle come in contact with a lens, come in contact with the trabecular meshwork, which can cause cataract and increased IOP respectively. So the theoretical advantages to suprachoroidal delivery is that it's contained, it's very targeted.

Hopefully, the concentration is also very high. Higher than what we will usually see versus other modality of delivery. And our experience in the survey is pretty much very, very positive. That kind of goes to show most of us had utilized the injection and various types of pathologies, whether it's posterior uveitis or more interior uveitis with significant macular edema. And we have seen very, very good outcome, most of us have observed at least two or three lines, a BCVA improvement, even within two to three weeks of injection, and we see often the duration of the action, less than more than three, even four months.

And so and then in terms of the IOP elevation, it's pretty negligible. We some of us have even used it in non-steroid responder with minimal IOP elevation. Now, of course, it's a relatively small sample, and certainly, you know, with longer follow up, we might see different trends. But as far as these 12 specialists, the collected experience show, the suprachoroidal injection was pretty safe and well tolerated and very, very effective. And most of us have seen significant reduction of central subfield thickness of somewhere between 100 to 150 micrometers. And you can see that the response even within the first two to four weeks, so the the results is actually very impressive.

And in terms of sort of the technique itself, we have all use sort of different, each of us has different preference. Some of us topical anesthetic, some use subconjunctiva, some people use a little trocar that comes with the injector to measure the distance of which the injector should go through. Some use a q tip or caliber and whatnot.

So really the technique generally ranges but in general, we recommended starting with a shorter 900 micron needles going somewhere, maybe inferior temporal, maybe some superior temporarily somewhere where there's great good exposure of the sclera and going somewhere between 4.5 to 5 millimeter posterior to the Limbus a little behind where you were usually enter with an intravitreol because we think that it would actually help separate the suprachoroidal space a little more easily if you go slightly further back. And once that, and you want to enter the eye very perpendicularly so that the needle gets through the sclera without going in obliquely, so you get the needle right in the suprachoroidal space.

You're really tight. It's more of a manual procedure for most of us, it requires sort of, you know, both tactile and also visual feedback to make sure you get the drug deliver into the right space. and also, you want to do it in a very pretty control way. Because it's not like an intravitreol injection, where just push the plunger, get everything in there and get in and get out. This is usually a technique where you want to take your time as injection should last somewhere between 7 to 10 seconds, ideally, so that because there's going to be certain degree of discomfort, and most of our patients have some degree of discomfort, although very rarely intolerable. And people have this discomfort as you enter the suprachoroidal space creating a suprachoroidal bleb.

And I think it's natural that everyone's going to feel something. So definitely, you know, you want to provide some verbal anesthesia in addition to real anesthesia. Let your patient know that, hey, it's going to be slightly more uncomfortable, but it's worth the pain. So, and overall, I think we you know, most of us found the technique, the injection technique to be a steeper learning curve, initially, but with after maybe two or three injections that I think that curve becomes progressively flatter and you'll get a hang of it pretty quickly.

There are there is now some of these specialists are also XIPERE trainers, myself included. So we go on these web based portal and actually teach physicians around the United States how to use the injector. So we have your get a training kit from Bosch + Lomb you'll have a plastic eye you can practice the injectors with I think it's a very useful model. And it's a very unique way to teach so many thousands of you know, Retina uveitis to specialists across a big demographic, a big, big geographic area, how to use his new injector. We felt we felt that most of us find the training platform to be extremely helpful.

So overall, our impression our conclusion of the paper is that you know, most of us who are considered early adopters of the suprachoroidal triamcinolone injections, were very pleased with the both of the efficacy and the safety profile and certainly the technique, once you have a couple you know sort of under your belt, the injection definitely will get easier.

So it's very common for the first one or two or even three injections to be pretty challenging, you're probably going to see some of the medication reflux that a lot of people might complain of. But you know, don't give up and just keep practicing just like you know, you do with all the new surgical technique. I think it will become a second nature in no time. and that's pretty much a summary of my poster. Thank you very much