Posterior Subtenon's Capsule Triamcinolone Acetonide Injection for the Treatment of Diabetic Macular Edema

Switching to subtenon triamcinolone acetonide does not jeopardize the functional and anatomic outcomes of dexamethasone implant treated eyes with diabetic macular edema

BACKGROUND

Intraocular dexamethasone implant (DEXi) is an efficient treatment for diabetic macular edema (DME). However, it may be unavailable or contraindicated. Triamcinolone acetonide is another corticosteroid that has proved to be safe and effective in treating macular edema complicating various diseases including diabetes. The purpose of this study is to evaluate the outcomes of a switch from DEXi to subtenon triamcinolone acetonide (STTA) and back, in eyes with DME.

METHODS

Retrospective study. DME eyes that had been treated with DEXi and switched to STTA between October 2018 and February 2019 (stock shortage of DEXi) were included. The functional and anatomical outcomes of the switch and switch-back were studied.

RESULTS

26 eyes of 17 patients (mean age 67.1 ± 8.2 years) were considered. The mean baseline visual acuity (VA) was 0.35 ± 0.17 decimals remaining stable after DEXi, STTA and switch-back to DEXi. The mean central macular thickness (CMT) was 492.7 ± 32.8 µm initially, decreasing to 294.3 ± 133.4 µm after DEXi, 369.9 ± 182.3 µm after STTA and 297.6 ± 72.0 µm after switching back to DEXi (all p < 0.05 versus baseline). Compared to baseline, the CMT reduction was numerically better after DEXi and switching back to DEXi than after STTA (mean reduction: -200.4 µm, -167.7 µm, and -95.08 µm respectively, p = 0.13). Intraocular pressure was comparable after DEXi and STTA.

CONCLUSION

DEXi is the steroid of choice in DME. However, STTA can be a cost-effective alternative when DEXi is unavailable or contraindicated. This study suggests that STTA may be used in the context of a step therapy in DME.

Intraocular pressure elevation after subtenon triamcinolone acetonide injection; Multicentre retrospective cohort study in Japan

Purpose

To evaluate real-world evidence for intraocular pressure (IOP) elevation after subtenon triamcinolone acetonide injection (STTA) in 1252 Japanese patients (1406 eyes) in the Japan Clinical REtina STudy group (J-CREST).

Methods

This was a multicentre retrospective study of the medical records of 1252 patients (676 men (758 eyes); mean age: 63.8 ± 12.9 years) who received STTA in participating centres between April 2013 and July 2017.

Results

IOP elevation was observed in 206 eyes (14.7%) and IOP increase ≥ 6 mmHg was found in 328 eyes (23.3%). In total, 106 eyes (7.5%) needed medication and two eyes (0.14%) needed surgical procedures. Younger age, higher baseline IOP, and steroid dose were risk factors associated with IOP elevation. Risk factors associated with IOP increase ≥ 6 mmHg were younger age, lower baseline IOP, steroid dose, and higher incidences of diabetic macular oedema (DME) and uveitis. In contrast, with steroid dose fixed at 20 mg, a lower incidence of DME was a risk factor for increased IOP, suggesting that STTA had dose-dependent effects on IOP increase, especially in patients with DME.

Conclusion

Our real-world evidence from a large sample of Japanese patients who received STTA showed that the incidence of IOP elevation after STTA was 14.7%, and was associated with younger age, higher baseline IOP, and steroid dose. Thus, IOP should be monitored, especially in patients with younger age, higher baseline IOP, and higher incidences of DME and uveitis.

Posterior subtenon infusion of triamcinolone acetonide as adjunctive treatment to panretinal photocoagulation using pattern scan laser for diabetic retinopathy

PURPOSE

To estimate the effect of sub-Tenon's capsule triamcinolone acetonide injection (STTA) combined with panretinal photocoagulation (PRP) using pattern scan laser (PSL) for high risk non-proliferative diabetic retinopathy (NPDR), in terms of the inflammation and the progression of diabetic macular edema (DME).

STUDY DESIGN

Retrospective comparative analysis.

METHODS

NPDR patients who underwent PRP using PSL with (STTA+PSL group, n=24) or without (PSL group, n=19) pretreatment of STTA were enrolled. We measured anterior flare intensity (AFI) and central retinal thickness (CRT) at day of STTA (day 0), and at 1, 3, 7, 11 and 15 weeks.

RESULTS

The CRT of the STTA+PSL group was significantly lower than that of the PSL group at 7 (308.15±69.16 μm versus 340.21±77.91 μm, p = 0.04), 11 (283.8±60.75 μm versus 335.7±67.70 μm, p = 0.01) and 15 weeks (281.13±35.29 μm versus 316.58±54.89 μm, p = 0.02). AFI levels in the STTA+PSL group were significantly lower than those in the PSL group at 11 (10.47±3.40 versus 15.85±8.38, p = 0.007) and 15 weeks (11.38±3.31 versus 14.37±3.85, p = 0.009). The significant improvement in CRT from baseline was noticed through the observational periods in STTA+PSL group, but not in the PSL group.

CONCLUSION

Pretreatment of STTA has the potential to not only prevent the worsening of DME, but also reduce the CRT and AFI of eyes with NPDR after PRP using PSL.

Diabetic macular edema in proliferative stage treated with anti-vascular endothelial growth factor agent and triamcinolone acetonide by laser-based strategies

AIM

To appraise the effect of treatment for diabetic macular edema (DME) in proliferative stage with sufficient panrentinal photocoagulation (PRP) therapy and intravitreal injections (IV) Conbercept and posterior subtenon's triamcinolone acetonide (STTA) sequential therapy.

METHODS

This prospective clinical randomized controlled trial of cross-over design was conducted in three phases. The participants included cases of DME in proliferative stage. They were divided into two groups and treated with PRP before enrollment. Group A were treated with IV-Conbercept 0.5 mg for one month in the 1^st phase. Group B were treated with STTA 40 mg (twice per two weeks). The interventions were exchanged in the second phase (2mo) between the two groups. In the third phase (3-6mo) no other treatment was given. Best corrected visual acuity (BCVA), central macular thickness (CMT) measured by OCT and complications were compared.

RESULTS

After phase I: in Group A, BCVA improved from 0.201±0.17 to 0.37±0.24 (F=5.88, P=0.004). CMT changed from 449±155.10 to 304.1±84.70 µm (F=14.9, P<0.01). In Group B, BCVA changed from 0.195±0.19 to 0.26±0.20 (F=0.76, P=0.41) while CMT changed from 463.82±152.92 to 366.00±115.40 µm (F=3.70, P<0.03). The improvement of BCVA was better in Group A (P<0.05). After phase II: in Group A, BCVA raised to 0.47±0.27 (F=0.26, P<0.01), CMT reduced to 260.67±62.97 µm (F=-188.3, P<0.01); in Group B, BCVA raised to 0.51±0.26 (F=0.31, P<0.01), CMT reduced to 261.93±50.15 µm (F=-201.9, P<0.01). But there were no difference between two groups (P>0.05). After phase III: in Group A, BCVA maintained 0.42±0.25 (F=0.22, P=0.001), CMT maintained 267.8±58.34 µm, (F=-0.27, P<0.01); in Group B, BCVA was 0.47±0.25 (F=-0.27, P<0.01), CMT was 272.71±49.16 µm (F=-191.1, P<0.01). No serious complications happened in all phases.

CONCLUSION

PRP+Conbercept is better than PRP+STTA in DME with proliferative stage but PRP+Conbercept+STTA sequential therapy may be a wiser choice for persistent effectiveness on anatomical as well as functional status.

Vessel diameter study: intravitreal vs posterior subtenon triamcinolone acetonide injection for diabetic macular edema

PurposeTo detect and compare the vessel diameter effect of intravitreal vs subtenon injection of triamcinolone for diabetic macular edema (DME).MethodsSixty patients with DME who underwent triamcinolone injection either intravitreally (N=30) or under the tenon capsule (N=30) were included. Non-injected fellow eyes served as control. The main outcome measures were central retinal artery equivalent (CRAE), central retinal vein equivalent (CRVE), and artery-vein ratio (AVR).ResultsIn the intravitreal group, pre-injection mean CRAE (147.07 μ) decreased to 141.03 μ at 1 week and to 139.43 μ at 1 month (P<0.001) while baseline CRVE (209.61 μ) decreased initially to 198.85 μ at 1 week then to 198.49 μ at 1 month (P<0.001). In the subtenon group, pre-injection CRAE (152.18 μ) decreased to 149.49 μ at 1 week and to 147.47 μ at 1 month (P=0.017), while baseline CRVE (215.60 μ) decreased initially to 208.69 μ at 1 week then to 207.25 μ at 1 month (P=0.003). Pre-injection AVR values did not change at 1 week and at 1 month in both injection groups (P=0.66 and P=0.196, respectively). In the control group, none of the 3 parameters changed throughout the study period compared to the baseline (P>0.28).ConclusionIn eyes with DME, both intravitreal and subtenon triamcinolone injection led to a significant constriction of retinal arteries and veins.