Dexamethasone trumps MTX, ranibizumab in treatment of macular oedema

A recent study has found that dexamethasone delivers better outcomes than methotrexate (MTX) and ranibizumab in patients with persistent or recurrent uveitic macular oedema through 24 weeks. In addition, side effects are manageable.

In this randomized controlled trial, 194 patients with uveitic macular oedema from 33 centres were randomly assigned 1:1:1 to receive a sequence of intravitreal treatments with dexamethasone implant, MTX, or ranibizumab. Those with bilateral macular oedema received the same treatment bilaterally.

During 24 weeks of follow-up, the investigators permitted nonassigned treatments starting from 12 weeks for those meeting the retreatment criteria.

Of the participants (225 eligible eyes), 177 (207 eyes) completed 24 weeks of follow-up. Eyes treated with MTX (55 percent) and ranibizumab (37 percent) were more likely to receive nonassigned treatments (88 percent dexamethasone implant or intravitreal corticosteroid injection) than eyes treated with dexamethasone (7 percent).

In the as-assigned analysis, dexamethasone demonstrated better improvement in macular oedema relative to ranibizumab (central subfield thickness [CST], 34 percent vs 19 percent; p=0.01), but not to MTX (CST, 31 percent; p=0.59), after being superior to both other regimens at 12 weeks.

In the censored analysis, however, only dexamethasone showed improvements in macular oedema (CST, 24 percent vs 8 percent and 5 percent; p<0.001) and best-corrected visual acuity improvement of >5 letters compared with MTX and ranibizumab, respectively.

Notably, treatment with dexamethasone often resulted in intraocular pressure elevations of ≥24 mm Hg (32 percent) and of ≥30 mm Hg (10 percent).