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John H Kempen, Michael M Altaweel, Lea T. Drye, Janet T. Holbrook, Douglas A Jabs, Elizabeth A Sugar, Jennifer E Thorne, Multicenter Uveitis Steroid Treatment (MUST) Trial and Follow-up Study Research Group; Benefits of Systemic Anti-inflammatory Therapy Versus Fluocinolone Acetonide Intraocular Implant for Intermediate, Posterior and Panuveitis: 54 month results of The Multicenter Uveitis Steroid Treatment Trial and Follow-up Study. Invest. Ophthalmol. Vis. Sci. 2015;56(7 ):3209.
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To compare the benefits of fluocinolone acetonide implant therapy versus systemic corticosteroid therapy supplemented with immunosuppression when indicated for intermediate, posterior, and panuveitis.
255 subjects with intermediate, posterior, or panuveitis previously randomized to implant or systemic therapy were followed through 54 months from original randomization, 79.2% completing the 54 month visit. Masked best-corrected visual acuity, visual field mean deviation, activity of uveitis, and presence of macular edema per reading center grading were ascertained prospectively.
The average trajectory of visual function in uveitic eyes was similar over 54 months in both groups, with best-corrected visual acuity improving from baseline by 2.4 and 3.1 letters at 54 months (p=0.73) in the implant and systemic group respectively. The automated perimetry mean deviation score remained similar to baseline throughout 48 months’ follow-up. Overall control of inflammation was superior in the implant group at all time points assessed (p<0.016), although most eyes in the systemic therapy arm also had substantial inflammatory improvement, achieving control or low levels of inflammation. While macular edema improved significantly more often with implant treatment within the first six months, the systemic group gradually improved over time thereafter such that the proportions with macular edema converged in the two groups by 36 months and were overlapping thereafter (p=0.41 at 48 months).
Visual outcomes of fluocinolone acetonide implant and systemic treatment for intermediate, posterior, and panuveitis are similarly favorable through 54 months. The implant maintains a clear advantage in controlling inflammation through 54 months. However, with systemic therapy a large majority of patients also experienced greatly improved inflammatory status and macular edema improved equally with longer follow-up. Based on cost-effectiveness and side effect considerations, systemic therapy seems indicated as the initial treatment for most bilateral uveitis cases. Implant therapy is a reasonable alternative approach, especially for unilateral cases, and in situations where systemic therapy is not feasible or is not successful.
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