RESOLUTION OF SEROUS MACULAR DETACHMENT AFTER INTRAVITREAL TRIAMCINOLONE ACETONIDE TREATMENT OF PATIENTS WITH BRANCH RETINAL VEIN OCCLUSION

A comparison of the effect of intravitreal dexamethasone implant on macular and branch retinal vein occlusion. A real life experience

PURPOSE

This study aimed to compare the effects of intravitreal dexamethasone (IVDx) implants on branch retinal vein occlusions (BRVOs) and macular vein occlusions (MVOs).

METHODS

Seventeen consecutive patients with MVO and 18 patients with BRVO, whose foveal thicknesses were greater than 300 µm, were recruited for this study. BRVO and MVO patients were diagnosed by means of fundus fluorescein angiography. Patients were treatment-naive. Initially, each patient in both the BRVO and MVO groups received an IVDx implant, and then a pro re nata IVDx regimen was initiated. Primary outcomes included VA gain, intraocular pressure (IOP) changes, macular ischemia, central macular thickness, retinal neovascularization, and number of IVDx injections. Follow-up time was 12 months.

RESULTS

The MVO group initially had significantly lower central macular thickness and a lower percentage of macular ischemia and systemic hypertension than those in the BRVO group (p = 0.001, 0.045, and 0.010, respectively). There was a statistically significant VA gain in both groups (p < 0.001), but the VA gain of the MVO group was greater than that of the BRVO group (p < 0.001). The mean total number of IVDx injections administered throughout the study period was significantly lower in the MVO group than in the BRVO group (1.3 ± 0.4 vs 2.0 ± 0.0; p = 0.001).

DISCUSSION

MVO and BRVO have different disease characteristics, and IVDx implants were more effective on the visual gain in patients with MVO than that of patients with BRVO who had higher numbers of IVDx injections.

Comparison of Ranibizumab versus Aflibercept in Treating Macular Edema among Patients with Serous Retinal Detachment Secondary to Branch Retinal Vein Occlusion

Purpose: To compare the effectiveness of ranibizumab and aflibercept in macular edema (ME) with serous retinal detachment (SRD) following branch retinal vein occlusion (BRVO).Methods: Once every month for 3 months, 33 patients were treated with ranibizumab (Group 1), whereas 30 others were treated with aflibercept (Group 2). In 9 months after that, patients were evaluated every 4 weeks and received additional injections if they met prespecified criteria for retreatment. Corrected visual acuity (BCVA), central foveal thickness (CFT), and height of SRD was measured.Results: During the first 3 months, the improvement of CFT, BCVA, and height of SRD were greater in Group 2 than Group 1. Those differences disappeared in the subsequent 9 months, and changes in CFT, BCVA, and height of SRD were similar between groups at all other visits.Conclusion: Aflibercept was more effective than ranibizumab from baseline to Month 3 in ME with SRD following BRVO.

Effect of intravitreal ranibizumab on serous retinal detachment in branch retinal vein occlusion

Purpose

The aim of this study was to evaluate the effect of initial intravitreal ranibizumab injection on visual acuity (VA) and central macular thickness (CMT) for the treatment of macular edema (ME) with and without serous retinal detachment (SRD) secondary to branch retinal vein occlusion (BRVO).

Materials and methods

Fifty-two BRVO eyes, treated with intravitreal ranibizumab injection for ME with and without SRD, were retrospectively reviewed. Patients were divided into two groups according to spectral domain optical coherence tomography (SD-OCT). The efficacy of intravitreal ranibizumab injection at first month was assessed by analyzing the change in best-corrected VA and reduction in CMT with SD-OCT.

Results

There were 21 patients with SRD and 31 patients with only CME (no-SRD). CMT was significantly greater in the SRD group than in the CME group (451±62.2 µm vs 383.5±37.2 µm, respectively, P<0.05). After initial intravitreal ranibizumab injection, mean VA improved from 0.87±0.26 logarithm of the minimum angle of resolution (LogMAR) to 0.54±0.27 LogMAR (P<0.01) and CMT decreased from 451±62.2 µm to 379.3±58.6 µm (P<0.001) in the SRD group. In the no-SRD group, mean VA improved from 0.69±0.25 LogMAR to 0.44±0.25 LogMAR (P<0.001) and the CMT decreased from 383.5±37.2 µm to 337.7±39.4 µm (P<0.001) at the first month visit. Eyes with SRD revealed better anatomic results and greater reduction of CMT after intravitreal ranibizumab injection (P<0.01).

Conclusion

VA and CMT can be improved by intravitreal ranibizumab injection in BRVO patients with and without SRD. However, more marked improvement in macular morphology was achieved in patients with SRD than those without SRD.

Five-year outcomes of pars plana vitrectomy for macular edema associated with branch retinal vein occlusion

Purpose

Long-term outcomes of pars plana vitrectomy (PPV) for macular edema (ME) associated with branch retinal vein occlusion (BRVO) have been previously reported, but the studies did not report the number of additional treatments after surgery. During 5 years of follow-up, we therefore investigated the efficacy and safety of PPV for BRVO and evaluated the incidence of additional treatments.

Methods

We retrospectively reviewed the medical records of 25 eyes of 24 patients who underwent PPV for ME associated with BRVO and were followed up for at least 5 years. Best-corrected visual acuity was measured, and foveal thickness was assessed by optical coherence tomography. Additional treatments were also investigated.

Results

The logarithm of the minimal angle of resolution (logMAR) improved from 0.53±0.23 at baseline to 0.16±0.25 at 5 years (P<0.0001). The foveal thickness decreased from 535±222 µm at baseline to 205±143 µm at 5 years (P<0.0001). For the eyes with residual ME, the following additional treatments were performed within 5 years of follow-up: sub-Tenon injection of triamcinolone acetonide in two eyes, intravitreal injection of bevacizumab in three eyes, grid laser photocoagulation in one eye, and direct photocoagulation of macroaneurysm in one eye. Additional surgeries were performed in two eyes: for one eye, phacoemulsification extraction of the ocular lens and intraocular lens implantation were performed because of cataract progression, and for the other eye, additional PPV was done for postoperative retinal detachment.

Conclusion

PPV was effective for resolution of ME associated with BRVO and improved visual acuity with a small number of additional treatments during long-term follow-up.

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.

Effect of posterior sub-tenon triamcinolone in macular edema due to non-ischemic vein occlusions

PURPOSE

To study the efficacy and safety of Posterior Sub-Tenon Triamcinolone acetonide (PSTT) in the treatment of macular edema in retinal vein occlusions. The efficacy is studied by anatomical and visual improvements.

BACKGROUND

Macular edema is the most common cause of visual loss in retinal vein occlusions. Many treatments have been advocated including laser, PSTT etc. The most recent trend is the usage of intravitreal Anti-VEGF (Vascular Endothelial Growth Factor) agents and steroids. Intravitreal injections have more complications.

METHODS

This study was a prospective interventional case series. 24 eyes of 24 patients (13 male and 11 female) with recent onset non-ischemic RVO (Retinal Vein Occlusion) underwent Posterior Sub-Tenon Triamcinolone (PSTT). Of the 24 eyes treated, 18 eyes were of BRVO (Branch Retinal Vein Occlusion) and 6 were CRVO (Central Retinal Vein Occlusion). All the eyes received 40 mg of Triamcinolone Acetonide (TA) in 1ml through posterior sub-tenon route. All the eyes were examined at baseline and after four weeks of being injected with TA. Changes in the best corrected visual acuity {letters of ETDRS (Early Treatment Diabetic Retinopathy Study) chart} and Central Macular Thickness (CMT) were studied. A gain of more than 5 letters was considered as effective. The eyes were examined for raised IOP (Intra-Ocular Pressure) and other complications.

RESULTS

Out of the 24 eyes 19 (79%) showed an improvement of more than 5 letters after a month of treatment. All the patients exhibited a certain degree of decrease in CMT. The mean BCVA increased from 30.08±10.16 to 40.21±8.93 (p<0.05). The mean CMT decreased from 575.08±131.55 to 282.08±163.99 (p<0.05). Out of them 3 eyes developed raised IOP of more than >21mmHg, which was controlled with medication. There were no other complications observed in any of the patients.

CONCLUSION

PSTT is an effective modality of treatment with minimal complications for macular edema associated with Non-Ischemic RVO with minimal complications. In view of the more severe complications associated with intravitreal injections, PSTT can be used as the first line of treatment before contemplating intravitreal injections. Multicenter randomised trials with longer periods of follow-up are needed to evaluate the long term safety and efficacy of this treatment. Furthermore, comparative studies are required to compare it with intravitreal Anti-VEGF or TA.

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).

Retinal sensitivity improvement after intravitreal triamcinolone acetonide injection for macular edema secondary to branch retinal vein occlusion

Purpose:

To evaluate the effect of intravitreal triamcinolone acetonide (IVTA) on retinal sensitivity in cases of macular edema(ME) secondary to branch retinal vein occlusion (BRVO).

Materials and Methods:

Total of 14 eyes of 14 cases of BRVO were included in this prospective study. In each eye, at baseline and 1, 3, and 6 months after IVTA injection, logMAR visual acuity, central 4° retinal sensitivity by MP-1 microperimetry, and optical coherence tomography foveal thickness were assessed.

Results:

Cases ages ranged from 60 to 79 years (mean 68 ± 8 years). At 1, 3, and 6 months, the logMAR visual acuity had increased from 0.71 ± 0.21 to 0.42 ± 0.21, 0.46 ± 0.30, and 0.46 ± 0.27; the mean foveal thickness had decreased from 540 ± 88 μm to 254 ± 51 μm, 288 ± 84 μm, and 280 ± 91 μm; and the mean retinal sensitivity had increased from 4.7 ± 2.5 dB to 7.9 ± 2.7 dB, 8.2 ± 3.6 dB, and 8.3 ± 4.6 dB, respectively.

Conclusion:

In eyes with ME secondary to BRVO, IVTA injections result in a significant increase in not only the visual acuity but also the central 4° retinal sensitivity in 6 months follow-up.

Fundus autofluorescence and optical coherence tomography findings in branch retinal vein occlusion

Purpose. To describe the findings of fundus autofluorescence (FAF) and optical coherence tomography (OCT) in patients with branch retinal vein occlusion (BRVO). Methods. In this institutional, retrospective, observational case series, FAF was evaluated in 65 eyes with BRVO in 64 consecutive patients and compared with visual acuity, OCT findings, and other clinical observations. Results. Five types of autofluorescence appeared during the course of BRVO: (1) petaloid-shaped hyperautofluorescence in the area of macular edema and (2) hyperautofluorescence coincident with yellow subretinal deposits. (3) Diffuse hyperautofluorescence appeared within the area of serous retinal detachment (SRD) and OCT showed precipitates on the undersurface of the retina in 5/5 of these eyes (100%). (4) The area of vein occlusion showed diffuse hyperautofluorescence after resolution of the retinal bleeding. (5) Hard exudates exhibited hyper- or hypoautofluorescence. OCT indicated that most of the hard exudates with hyperautofluorescence were located on the retinal pigment epithelium. Conclusions. Hyperautofluorescence associated with subretinal fluid or hard exudate appeared in the subretinal space. This type of hyperautofluorescence may be attributed to blood cell or macrophages. FAF and OCT are noninvasive modalities that provide additional information regarding macular edema due to BRVO.

Comparison of the efficacy of intravitreal triamcinolone acetonide for cystoid macular edema with versus without serous retinal detachment in branch retinal vein occlusion: influence on macular sensitivity and morphology

BACKGROUND

The influence of serous retinal detachment (SRD) on visual acuity, macular sensitivity, and macular thickness is unclear after intravitreal injection of triamcinolone acetonide (IVTA) for macular edema with branch retinal vein occlusion (BRVO).

METHODS

Twenty-one eyes of 21 BRVO patients with macular edema received IVTA. Patients were divided into two groups by optical coherence tomography findings: 11 patients who had cystoid macular edema (CME) with SRD (SRD (+) group) and 10 patients who had CME without SRD (SRD (-) group). Microperimetry was performed with a Micro Perimeter 1 before and at 3 and 6 months after IVTA. Macular thickness was measured by optical coherence tomography. We exchanged the superior and inferior regions to separate the regions into those with and without occlusion. As a result, the superior region was always the occluded region and the inferior region was non-occluded.

RESULTS

In both the SRD (-) group and the SRD (+) group, the mean macular thickness within the central 4° field and the 10° and 20° fields of the occluded region decreased significantly from baseline to 3 and 6 months after IVTA (all P <0.01). Visual acuity also improved significantly in both groups from baseline to 3 and 6 months after IVTA (both P <0.05). In both groups, the mean macular sensitivity (measured with by microperimetry) within the central 4° field and the 10° and 20° fields of the occluded region showed a significant increase from baseline to 3 and 6 months after IVTA (all P <0.05). The trend profiles of macular thickness within the 10° and 20° fields of the occluded region showed significant differences, but there were no significant differences with respect to the trend profiles of visual acuity and macular sensitivity within the central 4° field and the 10° and 20° fields of the occluded region.

CONCLUSIONS

These results suggest that IVTA may achieve more marked improvement of macular morphology in BRVO patients with SRD than in those without SRD, while this therapy may have a similar effect on macular function in BRVO patients with or without SRD.

Vitreous inflammatory factors and serous macular detachment in branch retinal vein occlusion

PURPOSE

To investigate whether vascular endothelial growth factor, soluble intercellular adhesion molecule-1 (sICAM-1), and pigment epithelium-derived factor are associated with serous retinal detachment (SRD) secondary to branch retinal vein occlusion.

METHODS

The subjects were 44 branch retinal vein occlusion patients with macular edema and 16 controls. Patients were divided into 2 groups by optical coherence tomography findings, that is, 18 patients with SRD and 26 with cystoid macular edema. The area of capillary nonperfusion was measured with fluorescein angiography and Scion Image software. Vitreous fluid samples obtained during pars plana vitrectomy were examined by enzyme-linked immunosorbent assay.

RESULTS

The incidence of major branch retinal vein occlusion was significantly higher in SRD patients (17/18, 94%) than in cystoid macular edema patients (15/26, 58%, P = 0.007), while the nonperfused retinal area was significantly larger in SRD patients (P = 0.006). Vitreous fluid levels of vascular endothelial growth factor and soluble intercellular adhesion molecule-1 (sICAM-1) showed a significant increase across the 3 groups (control group, cystoid macular edema group, and SRD group) (P trend < 0.001 and P trend < 0.001, respectively), while the pigment epithelium-derived factor level showed a significant decrease across the 3 groups (P trend < 0.001).

CONCLUSION

An excessive increase of vascular permeability secondary to upregulation of vascular endothelial growth factor and soluble intercellular adhesion molecule-1 (sICAM-1) along with downregulation of pigment epithelium-derived factor may contribute to the development of SRD in BRVO patients.

Visual function and serous retinal detachment in patients with branch retinal vein occlusion and macular edema: a case series

BACKGROUND

The influence of serous retinal detachment (SRD) on retinal sensitivity in patients with branch retinal vein occlusion (BRVO) and macular edema remains unclear. This is despite the frequent co-existence of SRD and cystoid macular edema (CME) in BRVO patients on optical coherence tomography (OCT) and the fact that CME is the most common form of macular edema secondary to BRVO. We investigated visual function (visual acuity and macular sensitivity), macular thickness, and macular volume in patients with BRVO and macular edema.

METHODS

Fifty-three consecutive BRVO patients (26 women and 27 men) were divided into two groups based on optical coherence tomography findings. Macular function was documented by microperimetry, while macular thickness and volume were measured by OCT.

RESULTS

There were 15 patients with SRD and 38 patients with CME. Fourteen of the 15 patients with SRD also had CME. Visual acuity was significantly worse in the SRD group than in the CME group (P = 0.049). Also, macular thickness and macular volume within the central 4°, 10°, and 20° fields were significantly greater in the SRD group (P = 0.008, and P = 0.007, P < 0.001 and P < 0.001, and P < 0.001 and P < 0.001, respectively). However, macular sensitivity within the central 4°, 10°, and 20° fields was not significantly worse in the SRD group than in the CME group.

CONCLUSIONS

SRD itself may decrease visual acuity together with CME, because nearly all SRD patients also had CME. SRD does not seem to influence macular function on microperimetry.

Association between integrity of foveal photoreceptor layer and visual outcome in retinal vein occlusion

PURPOSE

To investigate the correlation between integrity of foveal photoreceptor layer and initial as well as final visual acuity (VA) after successful resolution of macular oedema (ME) associated with retinal vein occlusion (RVO).

METHODS

We retrospectively studied 31 eyes of 31 patients with resolved ME secondary to RVO. The integrity of foveal photoreceptor layer was studied using the junction between photoreceptor inner and outer segment (IS/OS) on spectral domain optical coherence tomography (SD OCT). The study eyes were categorized into three groups at final visit; V group with completely visible IS/OS, P group with partially detected IS/OS and I group with invisible IS/OS. Disrupted length of IS/OS and external limiting membrane (ELM) were measured.

RESULTS

Final VA (logMAR) was closely associated with the IS/OS integrity at final visit; final VA in V group (0.03 ± 0.05) was better than that in P group (0.21 ± 0.23) (p = 0.027) and final VA in P group was better than that in I group (0.70 ± 0.36) (p = 0.004). Better initial VA (logMAR) and shorter length of disrupted IS/OS at initial visit were closely associated with better final VA (logMAR). In addition, final VA (logMAR) was closely associated with the length of disrupted IS/OS and ELM at final visit.

CONCLUSIONS

  After resolution of ME associated with RVO, the final VA is associated with the integrity of foveal photoreceptor layer. Better VA and the smaller length of disrupted IS/OS on SD OCT at initial visit are indicators of better visual outcome in patients with RVO.

Early serous macular detachment after phacoemulsification surgery

We report 2 cases of serous macular detachment with intraretinal fluid accumulation that developed 1 day after uneventful phacoemulsification surgery. Because of a dilution error, both eyes received 2 mg/0.1 mL of intracameral cefuroxime at the end of surgery. On postoperative day 1, the corrected distance visual acuity (CDVA) was 20/400 in both eyes. Optical coherence tomography revealed intraretinal fluid accumulation with serous macular detachment, and central foveal thickness measurements were 909 μm and 559 μm in Case 1 and Case 2, respectively. Case 1 responded to systemic acetazolamide, but the condition recurred after cessation of therapy; it then responded to systemic steroid treatment. Case 2 responded to an intravitreal injection of 4 mg of triamcinolone and remained stable throughout the follow-up. The final CDVA was 20/20 in Case 1 and 20/25 in Case 2, and central foveal thickness measurements were 205 μm and 208 μm, respectively.

Serous retinal detachment associated with retinal vein occlusion

PURPOSE

To study the pathomorphology of serous retinal detachment (RD) associated with retinal vein occlusion by optical coherence tomography (OCT).

DESIGN

Retrospective chart review.

METHODS

Ninety-one eyes of 91 patients with macular edema associated with retinal vein occlusion had undergone a comprehensive ophthalmologic examination, including measurement by spectral-domain OCT.

RESULTS

Eyes with macular edema associated with retinal vein occlusion typically showed foveal cystoid spaces and marked retinal swelling, especially in the outer retina. In addition, 76 eyes (83.5%) showed serous RD involving the fovea, which ranged in thickness from 64 microm to 871 microm (219.2 +/- 161.6 microm). Fifty-two eyes showed a small pointed RD, with a small base. The point of the RD was always located beneath the fovea, where the outer surface of the swollen neurosensory retina seemed to be contracted inward, resulting in development of the pointed RD. Two eyes with no RD at the initial visit developed such a pointed RD during follow-up. In contrast, 24 eyes showed a more dome-shaped RD, with a large base, and in 18 eyes, a pointed RD seen at the initial visit changed into a dome-shaped RD during follow-up. In some cases, small outer retinal discontinuity was seen on the external surface of the swollen neurosensory retina.

CONCLUSIONS

In eyes with retinal vein occlusion, a small pointed RD initially developed just beneath the fovea, but subsequently changed into a dome-shaped RD. Based on the findings by OCT, we hypothesize that the foveal architecture, especially that of the Müller cell cone, is involved in the formation of serous RD.

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.

Changes of aqueous vascular endothelial growth factor and interleukin-6 after intravitreal triamcinolone for branch retinal vein occlusion

BACKGROUND

To investigate sequential changes of aqueous vascular endothelial growth factor (VEGF) and interleukin (IL)-6 in macular oedema secondary to branch retinal vein occlusion after single intravitreal injection of triamcinolone acetonide (IVTA).

METHODS

We recruited 10 healthy controls and 30 patients at Chonnam National University Hospital, Gwangju, Korea. Aqueous and plasma levels of VEGF and IL-6 were measured by enzyme-linked immunosorbent assay at the time of IVTA and 3 months later. Non-response to IVTA was defined as showing persistent macular oedema based on a reduction of central macular thickness by less than 20% from baseline measurements by optical coherence tomography and vision improvement by less than 0.3 logMAR. Fluorescein angiography was performed 6 months after IVTA. We compared aqueous levels of VEGF and IL-6 between responders and non-responders.

RESULTS

The aqueous levels of VEGF and IL-6 were significantly higher in 12 non-responders than in 18 responders at baseline measurements (511 +/- 245 pg/mL vs. 230 +/- 108 pg/mL, P < 0.001; 38 +/- 31 pg/mL vs. 16 +/- 13 pg/mL, P < 0.001, respectively). Aqueous levels of VEGF were still higher in non-responders (312 +/- 64 pg/mL) 3 months after IVTA, and aqueous levels of VEGF in responders returned to normal (86 +/- 21 pg/mL, P < 0.001). Aqueous levels of IL-6 normalized in all patients 3 months after IVTA. Fluorescein angiography revealed that non-responders showed higher frequencies of macular ischaemia and ischaemic branch retinal vein occlusion.

CONCLUSIONS

IL-6-independent VEGF secretion may contribute to persistent macular oedema associated with ischaemic BRVO after IVTA.

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.

Intravitreal triamcinolone acetonide in the treatment of macular retinal detachment associated with morning glory anomaly

PURPOSE

To report the successful treatment of a case of recurrent macular retinal detachment associated with morning glory anomaly using intravitreal triamcinolone acetonide.

METHODS

A 53-year-old man with a history of bilateral morning glory anomaly and recurrent macular detachment of the left eye refractory to multiple surgical interventions, including 3 vitrectomies with endolaser photocoagulation, gas tamponade, and fibrin glue, underwent an intravitreal injection of 4 mg triamcinolone acetonide.

RESULTS

A single treatment with intravitreal triamcinolone acetonide resulted in resolution of a macular retinal detachment and intraretinal fluid within 2 weeks.

CONCLUSION

Treatment with intravitreal triamcinolone acetonide may be beneficial in cases of macular retinal detachment associated with morning glory anomaly.

Efficacy and complications of intravitreal injection of triamcinolone acetonide for refractory cystoid macular edema associated with intraocular inflammation

PURPOSE

To assess the effects and complications of intravitreal injection of triamcinolone acetonide (IVTA) for posterior sub-Tenon injection of triamcinolone acetonide (PSTA)-resistant cystoid macular edema (CME) with intraocular inflammation.

METHODS

Medical records of eight eyes of six patients with PSTA-resistant CME were retrospectively examined. Each eye received a 4-mg IVTA, and an additional injection was performed when CME recurred. Visual acuity as logarithm of the minimum angle of resolution (logMAR), intraocular pressure (IOP), and central macular thickness (CMT) were assessed before and after each treatment.

RESULTS

CME improved in six eyes (75%) with mean visual acuity recovering from 0.56+/-0.29 to 0.41+/-0.195 (logMAR, P=0.13) and mean CMT decreasing from 470 microm (range, 275-660 microm) to 297 microm (range, 150-697 microm) (P=0.04) 2 months after the initial IVTA. CME recurred an average of 9 months (range, 5-11 months) after IVTA. A higher dose (16-mg) IVTA was effective for two eyes refractory to repeated 4-mg IVTA. IOP was elevated in two eyes (25%), of which one required filtration surgery (12.5%). In phakic eyes, cataracts progressed and necessitated surgery.

CONCLUSIONS

IVTA is effective for PSTA-resistant CME with intraocular inflammation, and its efficacy might be dose dependent.

Exacerbation of central serous chorioretinopathy following intravitreal triamcinolone injection

BACKGROUND

This report describes a case of central serous chorioretinopathy following intravitreal triamcinolone acetonide injection.

METHODS

A 42-year-old man presented with a 4-month history of decreased visual acuity (0.4) in his left eye. The left eye demonstrated macular edema due to branch retinal vein occlusion. Triamcinolone acetonide 4 mg/ 0.1 mL was injected intravitreally to treat the macular edema.

RESULTS

Pigmentary retinal discoloration, retinal pigment epithelium leakage and a slight neurosensorial detachment with cystoid macular edema at the temporal macula were present prior to intravitreal triamcinolone injection. Three weeks after injection, visual acuity had decreased to 0.2 and metamorphopsies appeared in the left eye. A sharply demarcated serous macular elevation and a progressively increasing hyperfluorescence of the pre-existing leakage point led to the diagnosis of "exacerbation of the pre-existing asymptomatic central serous chorioretinopathy" following intravitreal triamcinolone injection. Macular elevation spontaneously resolved by the 4th month post-injection. At the 6th month, the patient experienced recurrence of a small serous detachment at the temporal macula.

CONCLUSION

Central serous chorioretinopathy exacerbation may arise as a complication of intravitreal triamcinolone acetonide injection.

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.

Foveal photoreceptor layer in eyes with persistent cystoid macular edema associated with branch retinal vein occlusion

PURPOSE

To study the correlation of visual acuity and the foveal photoreceptor layer in eyes with persistent cystoid macular edema associated with branch retinal vein occlusion (BRVO).

DESIGN

Retrospective chart review.

METHODS

We studied retrospectively the medical records of 42 eyes of 42 patients with persistent cystoid macular edema secondary to BRVO, eyes in which the foveal thickness was greater than 250 microm at final examination. On the vertical image obtained by optical coherence tomography at the final examination, we measured thickness of the foveal photoreceptor layer that was beneath the foveal cystoid spaces. We also assessed status of the junction between inner and outer segments of the photoreceptors (IS/OS) in the fovea.

RESULTS

The photoreceptor layer beneath the foveal cystoid spaces was detected as a distinct layer with thickness varying between 33 microm and 124 microm (mean, 71.1 +/- 26.8 microm). Final visual acuity showed no correlation with total foveal thickness (r = 0.336, P = .092). However, it did show a close correlation with thickness of the foveal photoreceptor layer (r = -0.571, P < .0001). Of the 42 eyes, 15 showed a continuous IS/OS line in the fovea. Visual acuity in these eyes with a continuous IS/OS line in the fovea was significantly better than that in eyes with a discontinuous or interrupted IS/OS line (P < .0001).

CONCLUSIONS

Both the thickness and the integrity of the foveal photoreceptor layer are associated with visual function in eyes with persistent cystoid macular edema associated with BRVO.

Intravitreal injection of triamcinolone acetonide for serous macular detachment in a patient with systemic lupus erythematosus

PURPOSE

To report our experience with intravitreal triamcinolone acetonide treatment of serous macular detachment in a patient with active systemic lupus erythematosus (SLE).

METHODS

Interventional case report.

RESULTS

A 38-year-old man who had SLE with bilateral serous macular detachment and retinopathy was treated with a single intravitreal injection of triamcinolone acetonide in one eye and two intravenous injections of a megadose steroid. Serous detachment in the eye injected with intravitreal steroid showed more significant improvement than that in the fellow eye.

CONCLUSION

Our case suggests that intravitreal triamcinolone acetonide injection may be considered for treatment of SLE-related serous macular detachment that does not respond to systemic steroid therapy.

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.

Association between integrity of foveal photoreceptor layer and visual acuity in branch retinal vein occlusion

AIM

To study the correlation between integrity of the photoreceptor layer after resolution of macular oedema (MO) associated with branch retinal vein occlusion (BRVO) and final visual acuity (VA), and to determine prognostic factors for visual outcome.

METHODS

We retrospectively studied 46 eyes from 46 patients with resolved MO secondary to BRVO, the foveal thickness of which was less than 250 microm at final observation. We assessed the status of the third high reflectance band (HRB) in the fovea using optical coherence tomography (OCT) at final observation, and studied OCT images taken at the initial visit in the hope of identifying a factor that would be prognostic of visual outcome.

RESULTS

No differences were found in initial VA or in foveal thickness between eyes with or without complete third HRB at final observation. However, final VA in eyes without a complete HRB was significantly poorer (p<0.002). Additionally, initial status of the third HRB in the parafoveal area of unaffected retina was associated with final VA; lack of visualisation of the third HRB at 500 microm (p = 0.0104) or 1000 microm (p = 0.0167) from the fovea on initial OCT images was associated with poor visual recovery after resolution of the MO.

CONCLUSION

Integrity of the photoreceptor layer in the fovea is associated with VA in resolved MO, and status of the third HRB before treatment might be predictive of visual outcome.

Interventions for branch retinal vein occlusion: an evidence-based systematic review

TOPIC

To assess the evidence on interventions to improve visual acuity (VA) and to treat macular edema and/or neovascularization secondary to branch retinal vein occlusion (BRVO).

CLINICAL RELEVANCE

Branch retinal vein occlusion is the second most common retinal vascular disease.

METHODS/LITERATURE REVIEWED

English and non-English articles were retrieved using a keyword search of Medline (1966 onwards), Embase, the Cochrane Collaboration, the National Institute of Health Clinical Trials Database, and the Association for Research in Vision and Ophthalmology Annual Meeting Abstract Database (2003-2005). This was supplemented by hand searching references of review articles. Two investigators independently identified all randomized clinical trials (RCTs) with more than 3 months' follow-up.

RESULTS

From 4332 citations retrieved, 12 RCTs were identified. There were 5 RCTs on laser photocoagulation. Grid macular laser photocoagulation was effective in improving VA in 1 large multicenter RCT, the Branch Vein Occlusion Study (BVOS), but 2 smaller RCTs found no significant difference. The BVOS showed that scatter retinal laser photocoagulation was effective in preventing neovascularization and vitreous hemorrhage in patients with neovascularization, but a subsequent RCT found no significant effect. Randomized clinical trials evaluating intravitreal steroids (n = 2), hemodilution (n = 3), ticlopidine (n = 1), and troxerutin (n = 1) showed limited or no benefit.

CONCLUSIONS

There is limited level I evidence for any interventions for BRVO. The BVOS showed that macular grid laser photocoagulation is an effective treatment for macular edema and improves vision in eyes with VA of 20/40 to 20/200, and that scatter laser photocoagulation can effectively treat neovascularization. The effectiveness of many new treatments is unsupported by current evidence.

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.