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Evaluation of uveitic macular edema in the First-line Antimetabolites as Steroid-sparing Treatment (FAST) Trial

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Abstract Number: 3856

AuthorBlock: Edmund Tsui1,2, Sivakumar Rathinam3, Radhika Thundikandy3, Anuradha Kanakath4, S Balamurugan5, R Vedhanayaki3, Lyndell L. Lim6, Eric B. Suhler7, Hassan Aldhibi8, John Alexander Gonzales1,2, Thuy Doan1,2, Jeremy Keenan1,2, Caleb Ebert1, Eric Kim1, Travis C. Porco1,2, Nisha Acharya1,2
1F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California, United States; 2Ophthalmology, University of California, San Francisco, San Francisco, California, United States; 3Uvea Services, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Madurai, India; 4Uvea Services, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Coimbatore, India; 5Uvea Services, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Pondicherry, India; 6Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Victoria, Australia; 7Casey Eye Institute, Oregon Health and Science University, Oregon, United States; 8Division of Vitreoretinal Surgery and Uveitis, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia;

DisclosureBlock: Edmund Tsui, None; Sivakumar Rathinam, None; Radhika Thundikandy, None; Anuradha Kanakath, None; S Balamurugan, None; R Vedhanayaki, None; Lyndell L. Lim, None; Eric B. Suhler, None; Hassan Aldhibi, None; John Alexander Gonzales, None; Thuy Doan, None; Jeremy Keenan, None; Caleb Ebert, None; Eric Kim, None; Travis C. Porco, None; Nisha Acharya, None;

Purpose
The First-line Antimetabolite as Steroid-sparing Treatment (FAST) Trial is a randomized comparative effectiveness trial to determine which treatment, methotrexate (MTX) 25mg once weekly or mycophenolate mofetil (MMF) 1.5g twice daily, is more effective as first-line corticosteroid-sparing treatment for patients with non-infectious intermediate, posterior, or panuveitis. As part of the FAST Trial, optical coherence tomography (OCT) imaging is obtained prospectively. We compare the outcomes of uveitic macular edema in the FAST Trial.

Methods
Patients were initiated on a standardized oral prednisone taper starting at 1 mg/kg and randomized to receive either oral MTX 25mg once weekly or oral MMF 1.5g twice daily. Patients underwent monthly clinical examinations and OCT imaging. OCT images were graded at the reading center for the presence or absence of macular edema. We included all patients with macular edema at baseline and excluded patients with a serous detachment in the setting of Vogt-Koyanagi-Harada (VKH) disease. Change in macular thickness and visual acuity (VA) between treatment groups was evaluated with a linear mixed effects model. The primary endpoint was 6 months.

Results
Of the 216 patients enrolled in the FAST Trial, after excluding eyes with serous detachment with VKH disease, there were n=42 eyes in the MTX group and n=55 eyes in the MMF group with baseline macular edema. In these eyes, baseline median logMAR VA was 0.40 (Snellen equivalent 20/50) and 0.38 (20/48) for the MTX and MMF groups, respectively. Median change in logMAR VA was -0.10 and -0.16 for patients in MTX and MMF groups, respectively (P=0.04). Final median logMAR VA was 0.20 (20/32) for both groups. Baseline median central subfield macular thickness was 359μm in the MTX group and 342μm in the MMF group. At 6 months, the median macular thickness decreased to 330μm with MTX and 309μm with MMF. The change in macular thickness was not significantly different between the two groups (P=0.95). At 6 months, 8 (19.0%) eyes in the MTX and 22 (40.0%) eyes in MMF groups had resolution of macular edema (P=0.06).

Conclusions
In eyes with uveitic macular edema, treatment with either MTX or MMF results in a similar decrease in macular thickness and rate of resolution of macular edema. Visual acuity improved in patients treated with either MTX or MMF and had similar visual acuities at the 6-month primary endpoint.

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