Incidenza di complicazioni nel FAME study
Nel FAME study, già esaminato in precedenza, in cui si confrontavano le due diverse dosi degli impianti di FA sono emerse le due complicazioni oculari più frequenti
derivanti dall'uso dei corticosteroidi: progressione della cataratta ed incremento della pressione oculare. La cataratta è stata riscontrata nel 42.7% del gruppo di pazienti trattati con la dose più bassa di farmaco e nel 51.7% del gruppo ad alta dose, rispetto al gruppo placebo in cui tale percentuale si fermava al solo 9.7%. Nel caso dei pazienti fachici tale percentuale saliva all'81.7% di quelli trattati con l'inserto a bassa dose, e all'88.7% di quelli trattati ad alta dose rispetto al 27.3% dei pazienti trattati con placebo, e, un'operazione chirurgica è stata richiesta nell'80%, nell'87.2% e nel 27.3% dei pazienti rispettivamente. Per quanto riguarda l'aumento di pressione intraoculare, valori superiori a 30 mmHg sono stati registrati nel 37.1% dei pazienti del gruppo a bassa dose (di questi l'1.3% è stato trattato con trabeculoplastica laser, e il 4.8% con incisional IOP-lowering surgery) e nel 45.5% del gruppo dei pazienti ad alta dose (2.5% trattato con trabeculoplastica laser, e 8.1 incisional IOP-lowering
surgery) rispetto all'11% del gruppo placebo (0%, 0.5%) [Campochiaro PA, 2012;
Sarao V, 2014; Haritoglu C, 2013].
Conclusioni
L'uso di steroidi intravitreali sembra essere un'opzione molto valida per il trattamento dell'EMD. Un crescente numero di oftalmologi fa utilizzo di steroidi intravitreali per il trattamento di vari disturbi del segmento posteriore, specialmente quando i tradizionali metodi terapeutici hanno fallito. Il triamcinolone acetonide è stato uno dei primi farmaci utilizzati, ed è stato studiato in numerosi test clinici per il trattamento di patologie oculari. Tuttavia, la sua necessità di ripetute iniezioni, ed i potenziali effetti collaterali hanno portato allo sviluppo di sistemi alternativi per il rilascio di questi tipi di farmaci nell'occhio. I sistemi di rilascio di DEX e FA richiedono infatti una minore
frequenza di somministrazione rispetto ai trattamenti con TA, riducendo il rischio di endoftalmiti e migliorando la compliance del paziente. Gli impianti, inoltre, grazie ad un rilascio graduale, riducono il rischio di complicazioni dovute all’agente steroideo, che tuttavia rimane elevato. Comparando i due sistemi di rilascio prolungato possiamo affermare che l'impianto con DEX ha il vantaggio di una facile somministrazione, la procedura d'impianto può infatti essere svolta in ambito ambulatoriale, e la matrice di polimero biodegradabile permette il ritrattamento senza la necessità di dover prima rimuovere l'impianto preesistente. Il FA ha invece, rispetto al DEX, il vantaggio di una durata d'azione molto più elevata. Un punto molto importante nel confronto tra i due farmaci è sicuramente l'incidenza di complicazioni oculari, su tutte, l'aumento della pressione intraoculare e l'insorgenza di cataratta. Il DEX è meno lipofilo del fluocinolone acetonide e mostra quindi un minor sequestro nel cristallino e nella reta trabecolare, motivo per il quale presenta, potenzialmente, un minor rischio di causare cataratta ed elevata pressione intraoculare. Anche rispetto ai farmaci Anti-VEGF, i sistemi a rilascio prolungato richiedono una minore frequenza di ri-iniezione, il che si traduce in una minore incidenza di complicazioni correlate a trattamenti frequenti, una maggiore compliance del paziente ed una riduzione sostanziale dei costi di trattamento, che ad esempio, nel caso di ranibizumab e di aflibercept possono essere molto elevati. Appare difficile che i corticosteroidi possano sostituire i VEGF come terapia di prima linea nel trattamento dell'edema maculare diabetico a causa dell' elevato rischio di complicazioni intraoculari correlate agli steroidi. Tuttavia, grazie alle favorevoli proprietà farmacocinetiche potrebbero costituire un'ottima terapia di prima linea per l'EMD in occhi vitrectomizati, nei quali i farmaci Anti-VEGF sono meno efficaci a causa della loro emivita più breve. Inoltre sembrano essere una sensata opzione terapeutica nei casi di EMD persistente o
resistente agli anti-VEGF e alla laser terapia.
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