Danny A. Mammo, MD, a staff vitreoretinal surgeon and assistant professor of ophthalmology at the Cleveland Clinic Lerner College of Medicine, has performed hundreds of suprachoroidal injections to date.
He joins Rishi P. Singh, MD, FASRS, Chair of Ophthalmology at Mass General Brigham and Professor at Harvard Medical School, on Evidence Based Retina to share what he has learned about XIPERE (triamcinolone acetonide injectable suspension 40 mg/mL, Bausch+Lomb), which individuals it benefits the most, and why his most difficult patients are now his most interesting ones.
XIPERE fast facts
- Approved for uveitic macular edema.
- Delivered directly into the suprachoroidal space, bypassing the vitreous entirely and concentrating the drug where it is needed most.
- In the phase 3 PEACHTREE trial, nearly 3 times as many treated patients gained 15 or more ETDRS letters compared to sham at week 24.1
- In the follow-up study MAGNOLIA, 50% of all treated patients went up to 9 months without needing rescue therapy after just 2 injections.2
- Real-world durability ranges from 3 to 9 months, with some patients stretching well beyond what the trials predicted.
Addressing IOP spikes in uveitic macular edema
Every retina and uveitis specialist knows the patient—uveitic macular edema that keeps coming back. A history of IOP spikes with every steroid: Pred Forte, Durezol, and intravitreal dexamethasone. It works on the edema and wrecks the pressure. You treat one problem and create another. Dr. Mammo calls them the bane of the uveitis specialist’s existence.
It is precisely these patients that pushed him toward the suprachoroidal space.
When Dr. Mammo started using XIPERE, he noticed something he was not expecting. His steroid responders were not responding the way he anticipated. The IOP spikes he had come to predict would happen sometimes, but were not showing up at the same rate. He started reaching out to colleagues across the country who were seeing the same thing, and together they put together a real-world series of 59 eyes.3
Findings on the effect of XIPERE on IOP in patients with a history of steroid response
The findings were striking. In patients with a documented history of steroid response, 79% did not experience an IOP rise of 5mmHg or more with suprachoroidal triamcinolone.3 And when they removed patients who had undergone incisional surgery like trabeculectomy or tube placement, that number dropped only slightly to 69%.3
Patients who had IOP responded to everything else (i.e., Pred Forte, Durezol, intravitreal dexamethasone), were not responding to this. Why? The honest answer is that nobody knows for certain.
A pharmacokinetic study comparing suprachoroidal versus intravitreal triamcinolone found that drug concentrations in the aqueous humor and iris ciliary body were significantly lower with the suprachoroidal route, despite comparable retinal levels.4 That difference in anterior segment exposure may be part of the explanation, but Dr. Mammo is careful not to overstate it, as the mechanism is still being worked out.
What the PEACHTREE data shows is that the IOP profile of XIPERE compares favorably to other steroids. In PEACHTREE, about 15 to 16% of treated patients had an IOP rise, compared to roughly 30% reported in the MEAD trial for intravitreal dexamethasone.1,5
They are different trials with different populations and that comparison has real limits. But for clinicians managing steroid responders with nowhere left to turn, these numbers are worth knowing.
Key takeaways
- Steroid responders are no longer automatically disqualified, as 69% of patients with a documented steroid response history did not have an IOP rise with suprachoroidal triamcinolone in Dr. Mammo's real-world series.3
- Aphakic patients, post-vitrectomy eyes, and patients with scleral fixated or sutured IOLs were Dr. Mammo's first candidates and remain strong ones.
- Start with the 900-micron needle on everyone; Dr. Mammo has had zero cases of inadvertent intravitreal triamcinolone acetonide with this stepwise approach. Document in the EMR if a patient needs the 1,100 so you go straight to it next time.
- The mechanism behind the favorable IOP profile is not fully understood, but lower anterior segment drug exposure is the leading hypothesis.4
- Learn the suprachoroidal space now. Other medications are coming and the technique will only become more relevant.
Looking ahead
Suprachoroidal triamcinolone is one product in what Dr. Mammo believes will become a more crowded and important delivery space. Other companies are actively investigating the suprachoroidal route for additional indications.
The technique itself is learnable, the learning curve is real but manageable, and the patients who stand to benefit most are exactly the ones who have been hardest to treat.
Watch the full conversation for Dr. Mammo's step-by-step injection pearls, his troubleshooting approach when the 900-micron needle does not cooperate, and his thoughts on what post-procedure monitoring actually looks like in practice.
This article was written by Keren Beki, based on the recorded video conversation between Drs. Singh and Mammo.
