Intravitreal versus retrobulbar injections of triamcinolone for macular edema associated with branch retinal vein occlusion

SCORE2 Report 24: Nonlinear Relationship of Retinal Thickness and Visual Acuity in Central Retinal and Hemiretinal Vein Occlusion

PURPOSE

To investigate whether a nonlinear association between central subfield thickness (CST) on spectral-domain OCT and concurrent visual acuity letter score (VALS) exists in eyes treated initially with aflibercept or bevacizumab for macular edema associated with central retinal vein occlusion (CRVO) or hemiretinal vein occlusion (HRVO) in the Study of Comparative Treatments for Retinal Vein Occlusion 2 (SCORE2).

DESIGN

Long-term follow-up after a randomized clinical trial from 64 centers in the United States.

PARTICIPANTS

Participants were followed up to 60 months and treated at investigator discretion after completing the 12-month treatment protocol.

METHODS

Two-segment linear regression models were compared with simple linear regression models of VALS on CST. Pearson correlation coefficients were calculated to assess strength of CST and VALS associations.

MAIN OUTCOME MEASURES

Central subfield thickness was measured by OCT and VALS by the electronic Early Treatment Diabetic Retinopathy Study methodology.

RESULTS

Estimated inflection points, reflecting turning points at which the CST and VALS association changes from positive to negative, calculated at 7 postbaseline visits, range from 217 to 256 μm. A strongly positive correlation exists to the left of each estimated inflection point, ranging from 0.29 (P < 0.01 at month 60) to 0.50 (P < 0.01 at month 12), and a strongly negative correlation exists to the right of each estimated inflection point, ranging from -0.43 (P < 0.01 at month 1) to -0.74 (P < 0.01 at month 24). Randomization statistical tests showed that 2-segment models are favored over 1-segment models for all postbaseline months (P < 0.001 for all tests performed).

CONCLUSIONS

The relationship between CST and VALS in eyes with CRVO or HRVO after treatment with anti-vascular endothelial growth factor (VEGF) therapy is not simply linear. The usually modest correlations between OCT-measured CST and visual acuity belie strong left and right correlations present in 2-segment models. Post-treatment CST close to the estimated inflection points showed the best expected VALS. The SCORE2 participants with a post-treatment CST after treatment close to the estimated inflection points of 217 to 256 μm showed the best VALS. In patients treated with anti-VEGF for macular edema associated with CRVO or HRVO, a thinner retina is not always associated with better VALS.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Nanotechnology-based ocular drug delivery systems: recent advances and future prospects

Ocular drug delivery has constantly challenged ophthalmologists and drug delivery scientists due to various anatomical and physiological barriers. Static and dynamic ocular barriers prevent the entry of exogenous substances and impede therapeutic agents' active absorption. This review elaborates on the anatomy of the eye and the associated constraints. Followed by an illustration of some common ocular diseases, including glaucoma and their current clinical therapies, emphasizing the significance of drug therapy in treating ocular diseases. Subsequently, advances in ocular drug delivery modalities, especially nanotechnology-based ocular drug delivery systems, are recommended, and some typical research is highlighted. Based on the related research, systematic and comprehensive characterizations of the nanocarriers are summarized, hoping to assist with future research. Besides, we summarize the nanotechnology-based ophthalmic drugs currently on the market or still in clinical trials and the recent patents of nanocarriers. Finally, inspired by current trends and therapeutic concepts, we provide an insight into the challenges faced by novel ocular drug delivery systems and further put forward directions for future research. We hope this review can provide inspiration and motivation for better design and development of novel ophthalmic formulations.

Glaucoma and Systemic Disease

Glaucoma is the leading cause of irreversible blindness in the world. Due to its potential to cause permanent vision loss, it is important to understand how systemic conditions and their respective treatments can be associated with or increase the risk for developing glaucoma. In this review, we examined the literature for up-to-date discussions and provided commentary on glaucoma, its pathophysiology, and associated risk factors. We discuss systemic diseases and the impact, risk, and mechanism for developing glaucoma, including pharmacologically induced glaucoma; inflammatory and auto-immune conditions; infectious, dermatologic, cardiovascular, pulmonary, renal, urologic, neurologic, psychiatric and systemic malignancies: intraocular tumors; as well as pediatric, and genetic conditions. The goal of our discussion of systemic conditions including their commonality, mechanisms, treatments, and associations with developing glaucoma is to emphasize the importance of ocular examinations and follow-up with the multidisciplinary teams involved in the care of each patient to prevent unnecessary vision-loss.

In Situ Formation of Injectable Gelatin Methacryloyl (GelMA) Hydrogels for Effective Intraocular Delivery of Triamcinolone Acetonide

A novel drug delivery system designed for intraocular injection, gelatin methacryloyl (GelMA), has attracted much attention due to its sustained-release character and low cytotoxicity. We aimed to explore the sustained drug effect of GelMA hydrogels coupled with triamcinolone acetonide (TA) after injection into the vitreous cavity. The GelMA hydrogel formulations were characterized using scanning electron microscopy, swelling measurements, biodegradation, and release studies. The biological safety effect of GelMA on human retinal pigment epithelial cells and retinal conditions was verified by in vitro and in vivo experiments. The hydrogel exhibited a low swelling ratio, resistance to enzymatic degradation, and excellent biocompatibility. The swelling properties and in vitro biodegradation characteristics were related to the gel concentration. Rapid gel formation was observed after injection, and the in vitro release study confirmed that TA-hydrogels have slower and more prolonged release kinetics than TA suspensions. In vivo fundus imaging, optical coherence tomography measurements of retinal and choroid thickness, and immunohistochemistry did not reveal any apparent abnormalities of retinal or anterior chamber angle, and ERG indicated that the hydrogel had no impact on retinal function. The GelMA hydrogel implantable intraocular device exhibited an extended duration, in situ polymerization, and support cell viability, making it an attractive, safe, and well-controlled platform for treating the posterior segment diseases of the eye.

Ocular Drug Delivery: a Comprehensive Review

The human eye is a sophisticated organ with distinctive anatomy and physiology that hinders the passage of drugs into targeted ophthalmic sites. Effective topical administration is an interest of scientists for many decades. Their difficult mission is to prolong drug residence time and guarantee an appropriate ocular permeation. Several ocular obstacles oppose effective drug delivery such as precorneal, corneal, and blood-corneal barriers. Routes for ocular delivery include topical, intravitreal, intraocular, juxtascleral, subconjunctival, intracameral, and retrobulbar. More than 95% of marketed products exists in liquid state. However, other products could be in semi-solid (ointments and gels), solid state (powder, insert and lens), or mixed (in situ gel). Nowadays, attractiveness to nanotechnology-based carries is resulted from their capabilities to entrap both hydrophilic and lipophilic drugs, enhance ocular permeability, sustain residence time, improve drug stability, and augment bioavailability. Different in vitro, ex vivo, and in vivo characterization approaches help to predict the outcomes of the constructed nanocarriers. This review aims to clarify anatomy of the eye, various ocular diseases, and obstacles to ocular delivery. Moreover, it studies the advantages and drawbacks of different ocular routes of administration and dosage forms. This review also discusses different nanostructured platforms and their characterization approaches. Strategies to enhance ocular bioavailability are also explained. Finally, recent advances in ocular delivery are described.

Ocular microcirculation changes, measured with laser speckle flowgraphy and optical coherence tomography angiography, in branch retinal vein occlusion with macular edema treated by ranibizumab

PURPOSE

This study searched for early predictive vascular biomarkers for visual outcomes in eyes with macular edema caused by branch retinal vein occlusion (BRVOME).

METHODS

Twenty-four eyes of 24 subjects with BRVOME were treated with the intravitreal injection of ranibizumab (IVR) for at least 6 months. We measured mean blur rate (MBR) in the optic nerve head (ONH) and vessel density (VD) in the macula with laser speckle flowgraphy and optical coherence tomography angiography, respectively.

RESULTS

Six-month post-IVR best-corrected visual acuity (BCVA) was correlated positively with age, pre-IVR BCVA, 1-month post-IVR BCVA, 3-month post-IVR BCVA and pre-IVR systolic blood pressure (P < 0.001, P < 0.001, P < 0.001, P < 0.001 and P = 0.02, respectively) and negatively with pre-IVR overall MBR, 1-month post-IVR overall MBR, 6-month post-IVR overall MBR, 3-month post-IVR deep retinal capillary plexus (DCP) VD and 6-month post-IVR DCP VD (P = 0.03, P = 0.03, P = 0.02, P = 0.01 and P = 0.005, respectively). Furthermore, a multiple regression analysis showed that pre-IVR overall MBR (β =  - 0.67, P = 0.009) was among independent prognostic factors predicting 6-month post-IVR BCVA. Six-month post-IVR DCP VD was also correlated with overall MBR at all time points.

CONCLUSION

ONH blood flow may be a pre-IVR biomarker of both visual outcomes and post-IVR deep macular microcirculation in eyes with BRVOME.

New Developments in the Classification, Pathogenesis, Risk Factors, Natural History, and Treatment of Branch Retinal Vein Occlusion

For years, branch retinal vein occlusion is still a controversial disease in many aspects. An increasing amount of data is available regarding classification, pathogenesis, risk factors, natural history, and therapy of branch retinal vein occlusion. Some of the conclusions may even change our impression of branch retinal vein occlusion. It will be beneficial for our doctors to get a deeper understanding of this disease and improve the treatment skills. The aims of this review is to collect the information above and report new ideas especially from the past a few years.

Clinical Manifestations, Complications and Treatment of Ocular Sarcoidosis: Correlation between Visual Efficiency and Macular Edema as Seen on Optical Coherence Tomography

Sarcoidosis is a chronic systemic autoimmune disease which belongs to a group of systemic granulomatous diseases. It can be confirmed through characteristic systemic and ocular manifestations and histological findings. Biopsy is the golden standard for diagnosing sarcoidosis. Ocular sarcoidosis can be confirmed, probable, or possible. Over a two-year period, ocular manifestations were studied on a sample of 52 patients, each followed for four months and diagnosed with some form of systemic sarcoidosis. Most frequent systemic manifestations in patients with ocular sarcoidosis were pulmonary, skin, glandular, and systemic generalized sarcoidosis. The disease was diagnosed four times more frequently in females than males (42:10, respectively; p < 0.05). Most frequent, and statistically significant, manifestation of ocular sarcoidosis is anterior uveitis (64.61%; p < 0.01). Macular edema and periphlebitis associated with periarteritis were frequent, and statistically significant (43.90% and 29.26%, respectively; p < 0.05). Overall, with regards to gender and location (right eye; left eye), visual acuity was >0.5 and of statistical significance (76.92%; p < 0.01). The most common therapy consisted of systemic corticosteroids (26.67%) and/or a combination of corticosteroids and immunosuppressive drugs (23.33%). In 16 eyes treated with repeated doses of sub-Tenon's injections, both initial and control visual acuity correlated with average thickness. There was positive correlation between several optical coherence tomography findings before and after treatment.

Combination therapy of intravitreal bevacizumab with single simultaneous posterior subtenon triamcinolone acetonide for macular edema due to branch retinal vein occlusion

PurposeTo evaluate efficacy and safety of combination therapy of intravitreal bevacizumab (IVB) with single simultaneous posterior subtenon triamcinolone acetonide (STA) for treatment of macular edema (ME) secondary to branch retinal vein occlusion (BRVO).MethodsThis was a prospective, randomized, interventional comparative study conducted in 45 eyes with ME secondary to BRVO who were treated primarily with IVB 1.25 mg (23 eyes, IVB group) or combination therapy of IVB 1.25 mg with a single simultaneous STA 40 mg (18 eyes, IVB/STA group). Reinjections were performed with IVB if optical coherence tomography (OCT) showed recurrent ME associated with decreased visual acuity. The main outcome measurement was the number of additional IVB injections, and changes of best-corrected visual acuity (BCVA) and central macular thickness (CMT) during a 6-month follow-up period were compared.ResultsBCVA showed significant improvement in two groups at 6 months. In addition, CMT showed significant decrease in two groups at 6 months. No significant differences in the change of BCVA and CMT at 6 months after injection (P=0.973, P=0.639) were observed between the two groups. A statistically significant difference was found regarding the number of additional IVB injections (IVB group 0.96±0.83; IVB/STA group 0.44±0.70, P=0.034).ConclusionAlthough combination therapy of IVB with a single simultaneous STA for treatment of ME secondary to BRVO did not affect the visual outcomes compared with IVB monotherapy, it had a benefit of reducing the number of additional IVB injections.

Factors correlated with the resolution of macular oedema after one dose injection of intravitreal triamcinolone acetonide treatment in branch retinal vein occlusion

Objective

To investigate the predictive baseline factors for a successful outcome following one dose of intravitreal triamcinolone acetonide (IVTA) in patients with macular oedema (ME) caused by branch retinal vein occlusion (BRVO).

Methods

This retrospective study enrolled patients with ME (macular retinal thickness [MRT] ≥ 300 µm) due to BRVO who still had ME 3 months after grid laser photocoagulation. Patients were divided according to treatment into an IVTA group and a laser-only group. The resolution of ME was documented at months 3 and 6.

Results

A total of 154 eyes with ME were investigated: IVTA group (90 eyes) and laser-only group (64 eyes). Predictive factors for successful IVTA treatment were younger age, shorter duration of ME, initial onset ME, accompanied by serous retinal detachment, few concomitant systemic diseases and nonischaemic BRVO. A broken foveal capillary ring was related to a poor treatment outcome. Eyes with cystoid spaces in the outer plexiform layer were more likely to have a good treatment response.

Conclusion

IVTA is effective for resolving ME due to BRVO after grid laser photocoagulation treatment.

Epidemiology and disease burden of pathologic myopia and myopic choroidal neovascularization: an evidence-based systematic review

PURPOSE

To summarize the epidemiology of pathologic myopia and myopic choroidal neovascularization (CNV) and their impact on vision.

DESIGN

Systematic literature review of all English-language studies evaluating the epidemiology and visual burden of pathologic myopia or myopic CNV.

METHODS

PubMed and EMBASE were searched with no time limits using predefined search strings for English-language studies evaluating the epidemiology and visual burden of pathologic myopia and myopic CNV.

RESULTS

In total, 39 relevant publications were identified. Population-based studies reported pathologic myopia to be the first to third most frequent cause of blindness. The prevalence of pathologic myopia was reported to be 0.9%-3.1%, and the prevalence of visual impairment attributable to pathologic myopia ranged from 0.1%-0.5% (European studies) and from 0.2%-1.4% (Asian studies). The prevalence of CNV in individuals with pathologic myopia was reported to be 5.2%-11.3%, and was bilateral in approximately 15% of patients. All studies of visual outcome in patients with myopic CNV (duration ranging from less than 3 months to 21.5 years) reported deterioration in best-corrected visual acuity over time. Older age, subfoveal CNV location, and larger baseline lesion size were predictors of worse visual outcomes.

CONCLUSIONS

Pathologic myopia is an important cause of vision loss worldwide, affecting up to 3% of the population. Of these, a substantial proportion of patients develop myopic CNV, which mostly causes a significant progressive decrease in visual acuity. This condition should therefore be a target for new treatment strategies.

Branch retinal vein occlusion: treatment modalities: an update of the literature

BACKGROUND

Retinal vein occlusion is the second most common retinal vascular disorder after diabetic retinopathy and is considered to be an important cause of visual loss. In this review, our purpose is to update the literature about the treatment alternatives for branch retinal vein occlusion.

METHODS

Eligible papers were identified by a comprehensive literature search of PubMed, using the terms "branch retinal vein occlusion," "therapy," "intervention," "treatment," "vitrectomy," "sheathotomy," "laser," "anti-VEGF," "pegaptanib," "bevacizumab," "ranibizumab," "triamcinolone," "dexamethasone," "corticosteroids," "non-steroids," "diclofenac," "hemodilution," "fibrinolysis," "tPA," and "BRVO." Additional papers were also selected from reference lists of papers identified by the electronic database search.

RESULTS

Treatment modalities were analyzed.

CONCLUSIONS

There are several treatment modalities for branch retinal vein occlusion and specifically for its complications, such as macular edema, vitreous hemorrhage, retinal neovascularization, and retinal detachment, including anti-aggregative therapy and fibrinolysis, isovolemic hemodilution, vitrectomy with or without sheathotomy, peripheral scatter and macular grid retinal laser therapy, non-steroid agents, intravitreal steroids, and intravitreal anti-vascular endothelial growth factors (anti-VEGFs).

The therapeutic potential of intraocular depot steroid systems: developments aimed at prolonging duration of efficacy

BACKGROUND

Corticosteroids play a major role in the treatment of many diseases of the posterior ocular segment. Systemically or topically administered steroids usually do not attain therapeutic concentrations in the retina, as they must first cross the blood-retina barrier. Intravitreal application is a useful alternative means of achieving therapeutic concentrations in the posterior segment but must be repeated every few weeks, because drugs given in this way have a short half-life. Intraocular sustained-release implants have been now developed in order to prolong the effect of intravitreal drugs and to lessen the need for repeated application. Macular edema is a typical indication for intravitreal steroid treatment.

METHODS

Selective review of the literature.

RESULTS

Various intravitreal corticosteroid implants have been evaluated in prospective, randomized clinical trials in recent years, and some have been approved for clinical use. Implants are either longer-acting and non-resorbable (fluocinolone acetonide implants) or shorter-acting and resorbable (dexamethasone implants). Major adverse effects of intravitreal corticosteroids include the induction or worsening of cataracts and elevated intraocular pressure. The likelihood of a complication varies from implant to implant and depends on the duration of action of the particular one used.

CONCLUSION

Intravitreal corticosteroid implants are a new option in the treatment of diseases of the posterior ocular segment. Long-term results are not yet available. The optimal treatment for these diseases will need to be the focus of further clinical research.

Preparation, characterization, and in vivo evaluation of triamcinolone acetonide microspheres after intravitreal administration

PURPOSE

The aim of this study was to evaluate the intraocular pressure (IOP) increasing effect and bioavailability of triamcinolone acetonide (TA) microspheres, as a novel drug delivery system, after intravitreal administration.

METHODS

Microspheres loaded by TA were prepared by the solvent evaporation method. After encapsulation, the final microspherical formulation was tested in an animal model. The left eyes of rabbits received microspherical TA and the right eyes were injected with conventional TA suspension. The drug concentration in the vitreous samples at days 7, 14, 28, and 56 after the injection was determined by high-performance liquid chromatography. The IOP was also checked at the same days with the Schiotz tonometer.

RESULTS

There was no statistically significant (P>0.05) difference between mean concentration of TA in the vitreous of right and left eyes at the different sampling times except day 56. Mean IOP of eyes that received microspherical TA was increased less than that of the eyes injected with TA suspension, and the difference was statistically significant (P<0.05) for each measurement day. TA was detectable in both eyes after 8 weeks. Both TA microsphere and suspension showed the sustained release profile.

CONCLUSION

The results of this study showed less IOP increasing effect of triamcinolone microspheres in comparison with suspension form.

[SERV clinical practice guidelines: management of retinal vein occlusion. Sociedad Española de Retina y Vitreo]

PURPOSE

A guidelines for the management of retinal vein occlusion is presented. This is necessary because at this moment several therapeutic alternatives have been developed although their role is not yet sufficiently defined.

METHODS

Review of the literature for evidence published up to date. Relevant literature was identified and the level of evidence graded. Evidence was then assessed for consistency, applicability and clinical impact. The information was contrasted with those guides published in other countries.

RESULTS

Taking into account the different options of treatment that are currently used, several modes of action are suggested. The role of the various complementary examinations are discussed and it is recommended that criteria for the treatment are based on clinical, angiographic, and tomographic findings.

CONCLUSIONS

Although there is no overall consensus, these guidelines promote a good standard of clinical practise and provide an update of the management of retinal vein occlusion.

Intravitreal injection of therapeutic agents

BACKGROUND

Intravitreal injection (IVI) with administration of various pharmacological agents is a mainstay of treatment in ophthalmology for endopthalmitis, viral retinitis, age-related macular degeneration, cystoid macular edema, diabetic retinopathy, uveitis, vascular occlusions, and retinal detachment. The indications and therapeutic agents are reviewed in this study.

METHODS

A search of the English, German, and Spanish language MEDLINE database was conducted. A total of 654 references spanning the period through early 2008 were individually evaluated.

RESULTS

The advantage of the IVI technique is the ability to maximize intraocular levels of medications and to avoid the toxicities associated with systemic treatment. Intravitreal injection has been used to deliver several types of pharmacological agents into the vitreous cavity: antiinfective and antiinflammatory medications, immunomodulators, anticancer agents, gas, antivascular endothelial growth factor, and several others. The goal of this review is to provide a detailed description of the properties of numerous therapeutic agents that can be delivered through IVI, potential complications of the technique, and recommendations to avoid side effects.

CONCLUSION

The IVI technique is a valuable tool that can be tailored to the disease process of interest based on the pharmacological agent selected. This review provides the reader with a comprehensive summary of the IVI technique and its multitude of uses.

A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular Edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6

OBJECTIVE

To compare the efficacy and safety of 1-mg and 4-mg doses of preservative-free intravitreal triamcinolone with standard care (grid photocoagulation in eyes without dense macular hemorrhage and deferral of photocoagulation until hemorrhage clears in eyes with dense macular hemorrhage) for eyes with vision loss associated with macular edema secondary to branch retinal vein occlusion (BRVO).

METHODS

Multicenter, randomized clinical trial of 411 participants. Main Outcome Measure Gain in visual acuity letter score of 15 or more from baseline to month 12.

RESULTS

Twenty-nine percent, 26%, and 27% of participants achieved the primary outcome in the standard care, 1-mg, and 4-mg groups, respectively. None of the pairwise comparisons between the 3 groups was statistically significant at month 12. The rates of elevated intraocular pressure and cataract were similar for the standard care and 1-mg groups, but higher in the 4-mg group.

CONCLUSIONS

There was no difference identified in visual acuity at 12 months for the standard care group compared with the triamcinolone groups; however, rates of adverse events (particularly elevated intraocular pressure and cataract) were highest in the 4-mg group. Application to Clinical Practice Grid photocoagulation as applied in the SCORE Study remains the standard care for patients with vision loss associated with macular edema secondary to BRVO who have characteristics similar to participants in the SCORE-BRVO trial. Grid photocoagulation should remain the benchmark against which other treatments are compared in clinical trials for eyes with vision loss associated with macular edema secondary to BRVO. Trial Registration clinicaltrials.gov Identifier: NCT00105027.

Triamcinolone acetonide preparations: impact of crystal size on in vitro behavior

PURPOSE

To characterize the in vitro behavior of three preparations of triamcinolone acetonide (TA).

METHODS

Three preparations of TA were mixed with Balanced Salt Solution Plus: commercially available TA (Kenalog 40, Bristol-Myers Squibb, Princeton, NJ), compounded preservative-free triamcinolone acetonide (PFTA, New England Compounding Center, Framingham, MA), and triamcinolone acetonide injectable suspension (TAIS, TRIESENCE, Alcon, Inc., Fort Worth, TX). We determined the mean number of crystalline aggregates per high-power deconvolution microscopy field, largest aggregate area, and spectroscopic photometric absorption.

RESULTS

Preservative-free triamcinolone acetonide had larger mean number of aggregates compared with TA (time 0 P = 0.002, 10 minutes P < 0.001) and TAIS (time 0 P < 0.001, 10 minutes P = 0.003). Aggregate size varied at both 0 and 10 minutes: TAIS > TA > PFTA. Spectroscopic photometric absorption decreased in direct correlation to aggregate size over time for all three preparations.

CONCLUSION

In vitro, PFTA in Balanced Salt Solution Plus had more aggregates of smaller size than either TA or TAIS. By contrast, TAIS had much larger aggregate size than both PFTA and TA, and this increased over time. These findings correlate with the clinical observations that PFTA and TA tend to disperse throughout the vitreous, whereas TAIS tends to conglomerate and gravitate toward the most dependent portion of the eye in a globular fashion.

Dexamethasone posterior-segment drug delivery system in the treatment of macular edema resulting from uveitis or Irvine-Gass syndrome

PURPOSE

To evaluate the effects of a dexamethasone intravitreous drug delivery system (dexamethasone DDS) in patients with persistent macular edema (ME) resulting from uveitis or Irvine-Gass syndrome.

DESIGN

Randomized, prospective, single-masked, controlled trial.

METHODS

Three hundred and fifteen patients with persistent (>or= 90 days) ME were randomized in a multicenter study to surgical placement of 350 or 700 microg dexamethasone DDS or observation. This study evaluated the subset of patients with uveitis or Irvine-Gass syndrome (n = 41). The primary outcome measure was the proportion of patients achieving a 10-letter or more improvement in best-corrected visual acuity (BCVA) at day 90. Change in fluorescein angiographic leakage and safety also were evaluated.

RESULTS

At day 90, a 10-letter or more BCVA improvement was seen in 41.7% (5/12) of patients in the 350-microg group, in 53.8% (7/13) of patients in the 700-microg group, and in 14.3% (2/14) of patients in the observation group (P = .029 vs the 700-microg group). Improvement in visual acuity persisted to day 180. A 15-letter or more improvement was achieved in 53.8% (7/13) of 700-microg patients vs 7.1% (1/14) of observed patients (P = .008). There were significantly greater reductions in fluorescein leakage in treated patients than in observed patients. Dexamethasone DDS was well tolerated. Throughout the study, an increase in intraocular pressure of 10 mm Hg or more was seen in 5 of 13 patients in the 700-microg group, in 1 of 12 patients in the 350-microg group, and in no patients in the observation group. There were no reports of endophthalmitis.

CONCLUSIONS

In patients with persistent ME resulting from uveitis or Irvine-Gass syndrome, 700-microg dexamethasone DDS was well tolerated and produced statistically significant improvements in visual acuity and fluorescein leakage.

Vitrectomy alone versus vitrectomy with simultaneous intravitreal injection of triamcinolone for macular edema associated with branch retinal vein occlusion

BACKGROUND AND OBJECTIVE

To evaluate the efficacy of vitrectomy with simultaneous intravitreal injection of triamcinolone acetonide for macular edema associated with branch retinal vein occlusion.

PATIENTS AND METHODS

A retrospective study of 45 eyes with macular edema associated with branch retinal vein occlusion. A posterior vitreous detachment was created and the vitreous cortex was completely removed, after which 23 eyes immediately had an intravitreal injection of triamcinolone acetonide (triamcinolone acetonide group) and 22 eyes did not (no triamcinolone acetonide group). Visual acuity, fluorescein angiograms, and foveal thickness determined by optical coherence tomography were examined preoperatively and postoperatively.

RESULTS

Mean postoperative visual acuity at 12 months was significantly better than the preoperative visual acuity in both groups. The fovea was significantly thinner 1 month postoperatively in both groups. Foveal thickness gradually decreased until 12 months in the no triamcinolone acetonide group; however, foveal thickness increased for 12 months in the triamcinolone acetonide group. A recurrence of macular edema was more frequent in the triamcinolone acetonide group than in the no triamcinolone acetonide group (P = .006).

CONCLUSIONS

Because there was no significant difference in the improvement of best-corrected visual acuity between the groups 12 months postoperatively, there may be no benefit in the use of intraoperative intravitreal triamcinolone acetonide.

SCORE Study report 1: baseline associations between central retinal thickness and visual acuity in patients with retinal vein occlusion

OBJECTIVE

To investigate the relationship between baseline center point retinal thickness measured by optical coherence tomography (OCT) and best-corrected visual acuity in eyes with macular edema associated with retinal vein occlusion and to investigate other factors associated with baseline visual acuity letter score.

DESIGN

The Standard Care versus COrticosteroid for REtinal Vein Occlusion (SCORE) Study includes 2 multicenter, randomized clinical trials: one evaluating participants with central retinal vein occlusion (CRVO) and the other evaluating participants with branch retinal vein occlusion (BRVO).

PARTICIPANTS

After omitting 17 participants with missing or unreliable OCT measurements, analyses proceeded with 665 enrolled SCORE Study participants (665 eyes), including 262 with CRVO and 403 with BRVO.

METHODS

At baseline, center point thickness was measured by OCT (Stratus OCT 3 [n=663] and OCT2 [n=2]; Carl Zeiss Meditech, Dublin, CA), and visual acuity was measured by the electronic Early Treatment Diabetic Retinopathy Study (E-ETDRS) methodology.

MAIN OUTCOME MEASURES

Center point thickness and best-corrected E-ETDRS visual acuity letter score.

RESULTS

The correlation coefficient for the association between baseline OCT-measured center point thickness and best-corrected E-ETDRS visual acuity letter score is -0.27 (95% confidence limit: -0.38 to -0.16) for participants in the CRVO trial and -0.28 (95% confidence limit: -0.37 to -0.19) in the BRVO trial. Regression modeling estimated the following decrease in baseline visual acuity letter score for every 100-microm increase in OCT-measured center point thickness: 1.7 letters (P=0.0007) for CRVO and 1.9 letters (P<0.0001) for BRVO. On the basis of multivariate regression models, baseline factors significantly associated (P<0.05, after adjusting for multiple testing) with baseline visual acuity letter score include age and duration of macular edema for CRVO participants and center point thickness and presence of cystoid spaces for BRVO participants.

CONCLUSIONS

The correlation between OCT-measured center point thickness and visual acuity letter score is modest. OCT-measured center point thickness represents a useful tool for the detection and monitoring of macular edema in retinal vein occlusion, but it cannot reliably substitute for visual acuity measurements.

Combined intravitreal triamcinolone injection and laser photocoagulation in eyes with persistent macular edema after branch retinal vein occlusion

BACKGROUND

To determine the efficacy of combined intravitreal triamcinolone (TA) injection and laser photocoagulation in persistent macular edema after branch retinal vein occlusion (BRVO).

METHODS

Follow-up analysis of a case series of 24 patients with macular edema after BRVO (15 of 24 non-ischaemic, 9 of 24 ischaemic). Patients received an intravitreal injection of 4 mg TA followed by laser photocoagulation within the previously edematous area, applied in one or two sessions. Standardized clinical examinations included best corrected visual acuity testing, anterior and posterior segment biomicroscopy, intraocular pressure, and optical coherence tomography (OCT). Fluorescein angiography was performed before treatment and 3 and 6 months later.

RESULTS

Median visual acuity improved significantly from 0.58 logMAR (95%-confidence interval (KI): 0.54-0.75, decimal 0.27) at baseline to 0.41 logMAR (KI: 0.37-0.64, decimal 0.39) at 1 month (p = 0.001), 0.33 logMAR (KI: 0.32-0.62, decimal 0.47) at 3 months (p = 0.002), and 0.41 logMAR (KI: 0.33-0.67, decimal 0.39) at 6 months (p = 0.016). A gain of one or more logarithmic lines was evaluated in 16/24 eyes (67 %) and a gain of 3 lines or more in 8/24 eyes (33 %) at 6 months. Three eyes had lost more than 1 line during the follow-up period. Median change of visual acuity at 6 months was +2.0 lines (KI: 0.2-2.4). Median central foveal thickness (OCT-CFT) was 423 microm (KI: 378-456, n = 24) at baseline and decreased to 270 microm (KI: 249-311, n = 24) at 1 month (p < 0.0001), 265 microm (KI: 254-344, n = 24) at 3 months (p < 0.0001), and 266 microm (KI: 259-365, n = 18) at 6 months (p = 0.001).

CONCLUSIONS

Macular edema after BRVO can effectively be treated by a combination of intravitreal TA injection and subsequent laser photocoagulation. During a 6-month follow-up this combination treatment resulted in a significant reduction of central foveal thickness and improvement of visual acuity.

Branch retinal vein occlusion: pathogenesis, visual prognosis, and treatment modalities

In branch retinal vein occlusion (BRVO), abnormal arteriovenous crossing with vein compression, degenerative changes of the vessel wall and abnormal hematological factors constitute the primary mechanism of vessel occlusion. In general, BRVO has a good prognosis: 50-60% of eyes are reported to have a final visual acuity (VA) of 20/40 or better even without treatment. One important prognostic factor for final VA appears to be the initial VA. Grid laser photocoagulation is an established treatment for macular edema in a particular group of patients with BRVO, while promising results for this condition are shown by intravitreal application of steroids or new vascular endothelial growth factor inhibitors. Vitrectomy with or without arteriovenous sheathotomy combined with removal of the internal limiting membrane may improve vision in eyes with macular edema which are unresponsive to or ineligible for laser treatment.

Posterior subtenon triamcinolone, intravitreal triamcinolone and grid laser photocoagulation for the treatment of macular edema in branch retinal vein occlusion

PURPOSE

To evaluate the efficacy of posterior subtenon triamcinolone (PSTT), intravitreal triamcinolone (IVT) injections and grid laser photocoagulation (GLP) in eyes with macular edema secondary to branch retinal vein occlusion (BRVO).

MATERIAL AND METHODS

Patients with macular edema due to BRVO treated with PSTT, IVT injections or GLP were evaluated retrospectively. Complete ophthalmic examination with fluorescein angiography and optic coherence tomography were noted before and in the 1st, 3rd, and 6th months of the treatment. The visual and anatomical responses were evaluated and compared between the groups using paired t test and one-way ANOVA test.

RESULTS

There were 20, 35 and 24 eyes in the PSTT, IVT and GLP groups. In the PSTT group, the mean visual acuity (VA) and central foveal thickness (CFT) were 0.23 +/- 0.23 and 413.2 +/- 143.5 microm before treatment and 0.23 +/- 0.18 and 358.7 +/- 109.2 microm at the 3rd month, respectively (p = 0.504 and p = 0.031). The mean VA increased from 0.14 +/- 0.15 to 0.33 +/- 0.26 and the mean CFT decreased from 518.2 +/- 145 to 292.9 +/- 121 microm in IVT group at the 3rd month (p = 0.001). The mean VA increased from 0.29 +/- 0.25 to 0.47 +/- 0.32 (p = 0.001); CFT decreased from 397.3 +/- 105.9 to 307.1 +/- 88.4 microm (p = 0.005) in the GLP group. VA and CFT changes were significantly different between the groups at the 3rd month (p = 0.031). VA increase was significantly greater in the IVT group than in the PSTT group. Decrease in CFT was the highest in the IVT group (Tukey, p = 0.001).

CONCLUSIONS

IVT and GLP seemed to be more effective than PSTT for the treatment of BRVO-associated macular edema. Possible complications of IVT and GLP must be weighted with the advantages of each treatment modality for each patient.

Intravitreal triamcinolone for cystoid macular edema related to branch retinal vein occlusion

We retrospectively evaluated the effectiveness of intravitreal triamcinolone in treating 19 eyes with macular edema related to branch retinal vein occlusion (BRVO). Eyes with nonischemic BRVO respond more favorably than those with ischemic BRVO. A single injection of intravitreal triamcinolone led to elevated intraocular pressure in 3 of 19 eyes (16%). Half of phakic eyes had progression of cataract. Retreatment may be necessary.

Adverse events after intravitreal triamcinolone in patients with and without uveitis

PURPOSE

To evaluate the rates of adverse ocular events after intravitreal triamcinolone acetonide (IVTA) injection in patients with and without uveitis.

DESIGN

Retrospective observational case series.

PARTICIPANTS

Two hundred twenty-two eyes of 173 patients were included in the study: 45 eyes of 31 patients with macular edema (ME) due to uveitis and 177 eyes of 142 patients with ME secondary to other etiologies.

METHODS

Retrospective review of patients who received IVTA at the Cole Eye Institute for ME attributable to various causes between the years 2001 and 2005. Data review of clinical records included patient demographics, etiology of ME, and adverse outcomes after injection. Rates of adverse outcomes in patients with and without uveitis were compared.

MAIN OUTCOME MEASURES

Intraocular pressure (IOP) elevation and posterior subcapsular cataract (PSC) progression.

RESULTS

Uveitis patients were significantly younger, more likely to be female, and more likely to have had prior posterior sub-Tenon's capsule steroid injection and/or glaucoma therapy than their nonuveitis counterparts. In a multivariate analysis adjusting for the differences in these factors, the presence of uveitis was the strongest risk factor for an adverse IOP event (odds ratio, 2.5; 95% confidence interval [CI], 1.0-6.1; P = 0.05). The odds of having a documented increase in PSC after IVTA injection were 5.6 times greater in uveitis eyes (P = 0.007; 95% CI, 1.6-19.6).

CONCLUSIONS

Intraocular pressure elevation and PSC progression occurred with greater frequency in uveitis patients receiving IVTA. Patients with uveitis treated with IVTA should be counseled about these risks and monitored closely.

The use of intravitreal corticosteroids, evidence-based and otherwise

PURPOSE OF REVIEW

To provide a current update on the use of intravitreal corticosteroids as a treatment for a variety of retinal diseases.

RECENT FINDINGS

Pharmacokinetic studies demonstrate that a single 4 mg injection of intravitreal triamcinolone acetonide is present in the vitreous for up to 3 months. Many recent studies demonstrate a significant reduction in macular edema often with a significant improvement in vision for up to several months followed by a waning of treatment effect and recurrence of macular edema. Retreatments have been shown to be efficacious. Intravitreal triamcinolone acetonide may help lead to a reduction in subfoveal hard exudates in diffuse diabetic macular edema. It has been shown to be a more potent treatment than sub-Tenon's and retrobulbar triamcinolone acetonide for persistent macular edema. It may also be a significant adjunctive treatment for choroidal neovascularization treated with photodynamic therapy. Intravitreal corticosteroid implants have also been shown to be beneficial in early trials for persistent macular edema.

SUMMARY

Intravitreal triamcinolone acetonide provides a potent short-term treatment for persistent macular edema and may be a useful adjunctive treatment for choroidal neovascularization. It remains to be determined whether intravitreal corticosteroids can provide long-term visual gain or stabilization. The side-effect profile of intravitreal corticosteroids is significant with corticosteroid-induced intraocular pressure rises. With longer-term studies, the rate of posterior subcapsular cataract formation is higher than previously reported, and there is a small but potential risk of endophthalmitis.

Early versus late intravitreal triamcinolone acetonide for macular edema associated with branch retinal vein occlusion

Purpose

To compare the effect of early versus late intravitreal injection of triamcinolone in patients with macular edema due to branch retinal vein occlusion (BRVO).

Methods

Twenty eyes of 20 patients with macular edema from BRVO, including 10 with duration after onset of ≤3 months and 10 with duration of >3 months, were treated using a single intravitreal triamcinolone injection (4 mg/0.1 ml). Best-corrected visual acuity and foveal thickness by optical coherence tomography were measured 1, 3, and 6 months post-injection.

Results

In patients that received treatment after a disease duration of ≤3 months, visual acuity and foveal thickness significantly improved from baseline over 6 months of follow-up. However, in those with a duration of > 3 months, improvements in visual acuity and foveal thickness, though apparent at 1 month, were not maintained at 3 and 6 months post-triamcinolone.

Conclusions

Intravitreal triamcinolone is more effective in patients with BRVO who are treated earlier.

The effect of povidone iodine flush versus drops on conjunctival colonization before intravitreal injections

BACKGROUND

To determine the most effective method of applying povidone iodine 5% to decrease conjunctival colonization before intravitreal injections.

METHODS

Twenty-eight patients from two tertiary care centers undergoing intravitreal injection for diffuse diabetic macular edema, exudative age-related macular degeneration, venous occlusive disease, or refractory pseudophakic cystoid macular edema were prospectively randomized to two study arms. One arm received 2-3 drops of 5% povidone iodine (drops group) and the second received a 10 ml flush of the same solution (flush group). The inferior conjunctival fornix was cultured before and after antiseptic technique was performed in all patients. Three culture media, thioglycollate broth, chocolate agar and blood agar, were used for each sample.

RESULTS

Each study group had 14 patients. Prior to antisepsis, 22 of the 28 (78.6%) subjects had positive conjunctival cultures. 16 and 14 bacterial organisms were isolated in the first and second groups, respectively. After using 2-3 drops of 5% povidone iodine in the first study arm of patients, three of 16 (18.7% reduction) bacterial organisms were no longer isolated in thioglycollate broth media. With flush irrigation of 10 ml of 5% povidone iodine, seven of 14 (50% reduction) bacterial organisms were no longer isolated (P-value 0.07) in broth media. No difference in reduction of bacterial colonization was found on plated media (chocolate agar and blood agar).

CONCLUSIONS

Irrigating the conjunctival fornix with 5% povidone iodine results in greater reduction of bacterial colonization compared with drop application of the same solution. Flush irrigation may provide better protection against the risk of endophthalmitis with intravitreal injections.

Early treatment of severe cystoid macular edema in central retinal vein occlusion with posterior sub-tenon triamcinolone acetonide

PURPOSE

To evaluate the clinical outcomes of posterior sub-Tenon (PST) injection of triamcinolone acetonide (TA) in the early treatment of severe cystoid macular edema (CME) in central retinal vein occlusion (CRVO).

METHODS

In a noncomparative, prospective study, 18 eyes of 18 patients with severe CME (central macular thickness, CMT >450 microm) secondary to recent-onset CRVO (the onset of symptoms < or =4 weeks) and a decrease in visual acuity (< or =80 letters of Early Treatment Diabetic Retinopathy Study [ETDRS] scores, 20/50) were included. PST injection of 40 mg of TA was given under topic anesthesia. All patients received three biweekly injections and were evaluated at baseline and at 1 day, 1, 2, 4, 6, and 8 weeks, and 3, 6, and 9 months after injection. The main outcome measures were ETDRS scores, CMT, intraocular pressure (IOP), cataract progression, and frequency of complications.

RESULTS

The mean age of the 18 patients was 61.17 years (range, 24-81 years) and the mean duration of symptoms was 15.28 days (range, 9-28 days). Eight eyes were diagnosed with ischemic CRVO and 10 eyes with nonischemic CRVO. Mean baseline ETDRS visual acuity (VA) score was 36.89 +/- 18.22 in all affected eye. There was a significant improvement in VA at 1, 3, 6, and 9 months of follow-up. The mean VA at these time points were 46.61 +/- 20.21, 58.11 +/- 22.19, 59.39 +/- 22.98, and 58.67 +/- 23.27 (all P < 0.001), respectively. Both nonischemic and ischemic eyes benefited with a statistically significant VA improvement at each time point. A comparison of the gain in VA between two subgroups was not significant at 1 and 3 months (P > 0.05), but was statistically significant at 6 and 9 months (P = 0.009 and 0.008, respectively). VA gain of 10 or more letters was found in all nonischemic eyes (10/10) and 3 ischemic eyes (3/8) at the 9-month follow-up. Two ischemic eyes were found to have no gain of letters in VA at the 9-month follow-up. The mean baseline CMT for all eyes was 566 +/- 42 microm. There was a 29% reduction with a mean CMT of 404 +/- 49 microm (P < 0.001) at 1 month, 51% reduction with a mean CMT of 278 +/- 40 microm (P < 0.001) at 3 months, 61% reduction with a mean CMT of 222 +/- 56 microm (P < 0.001) at 6 months, and 63% reduction with a mean CMT of 210 +/- 30 microm (P < 0.001) at 9 months. Both nonischemic and ischemic eyes demonstrated a statistically significant reduction in CMT (all P < 0.001). A comparison of the reduction in CMT between these two subgroups was not significant at each visit (all P > 0.05). For both subgroups, there was no statistically significant difference in IOP change at baseline, 1 week, 1, 3, 6, and 9 months of follow-up. Only two patients required topic antiglaucoma drops for elevated IOP. Three patients developed a recurrence of CME accompanied with visual decrease. No cataract progression or other complications were observed.

CONCLUSIONS

PST injection of TA is effective in reversing CME and improving visual acuity in recent-onset CRVO in the first 9 months. Patients with nonischemic CRVO may respond more favorably than patients with ischemic CRVO. Early treatment may be better for visual improvement before longstanding macular edema results in irreversible photoreceptor damage. Further study with longer follow-up period is necessary.

Intravitreal steroids in the management of macular oedema

The use of intravitreal corticosteroids in the management of macular oedema has recently gained widespread acceptance. New long-acting steroid preparations and methods of delivery have facilitated the use of these new modalities. This review describes the various types of macular oedema for which this therapeutic option is used and the results.

Intravitreal triamcinolone acetonide: a change in a paradigm

BACKGROUND

Based on experimental studies and clinical observations by Robert Machemer, Gholam Peyman and others, the vitreous cavity has increasingly been used as a reservoir of drugs for the direct treatment of intraocular diseases.

METHODS AND RESULTS

The most widely injected drug so far has been triamcinolone acetonide for various intraocular neovascular and edematous diseases. Comparing the various diseases with respect to effect and side effects of the treatment, the best response in terms of gain in visual acuity has been achieved for intraretinal edematous diseases such as diffuse diabetic macular edema, branch retinal vein occlusion, central retinal vein occlusion, and pseudophakic cystoid macular edema. In eyes with various types of noninfectious uveitis including acute or chronic sympathetic ophthalmia and Adamantiadis-Behçet's disease, visual acuity increased and the degree of intraocular inflammation decreased. Some studies have suggested that intra- vitreal triamcinolone may be useful as an angiostatic agent in eyes with iris neovascularization and proliferative ischemic retinopathies. Intravitreal triamcinolone may possibly be helpful as adjunct therapy for exudative age-related macular degeneration, particularly in combination with photodynamic therapy. In eyes with chronic, therapy-resistant ocular hypotony, intravitreal triamcinolone can induce an increase in intraocular pressure and may stabilize the eye. The complications of intravitreal triamcinolone therapy include secondary ocular hypertension in about 40% of the eyes injected; medically uncontrollable high intraocular pressure leading to antiglaucomatous surgery in about 1-2% of the eyes; posterior subcapsular cataract and nuclear cataract leading to cataract surgery in about 15-20% in elderly patients within 1 year after injection; postoperative infectious endophthalmitis with a rate of about 1:1,000; noninfectious endophthalmitis, perhaps due to a reaction to the solvent agent, and pseudoendophthalmitis with triamcinolone acetonide crystals appearing in the anterior chamber. Intravitreal triamcinolone injection can be combined with other types of intraocular surgery including cataract surgery, particularly in eyes with iris neovascularization. Cataract surgery performed some months after the injection does not show a markedly elevated complication rate. The injection may be repeated, if vision redecreases. In nonvitrectomized eyes, the duration of the effect and side effects of a single intravitreal injection of triamcinolone is about 6-9 months for a dosage of about 20 mg, and about 2-4 months for a dosage of 4 mg. It has remained unclear so far, whether and how to remove the solvent agent. In the future, intravitreal triamcinolone may be combined with other antiangiogenic drugs for the treatment of exudative age-related macular degeneration or with neuroprotective drugs for treatment of diabetic retinopathy.

CONCLUSIONS

Despite an exponentially increasing number of mostly case-series studies, the intravitreal injection of triamcinolone may still be considered an experimental procedure until randomized studies have been presented.