Intravitreal triamcinolone in recurrence of choroidal neovascularisation

Verteporfin Therapy and Triamcinolone Acetonide: Convergent Modes of Action for Treatment of Neovascular Age-Related Macular Degeneration

PURPOSE

Choroidal neovascularization associated with age-related macular degeneration is the primary cause of blindness in the elderly in developed countries, due to a number of pathogenic effects, including angiogenesis, cell-mediated inflammation, leukocyte adhesion and extravasation, and matrix remodeling.

METHODS

By producing photochemical effects at the site of target tissue (lesion), photodynamic therapy (PDT) can induce vascular damage and blood flow stasis, leading to occlusion of vascularization and lesion leakage.

RESULTS

PDT with verteporfin (Visudyne, Novartis) has been shown to be safe and effective in reducing the risk of vision loss in patients with classic containing subfoveal CNV and occult with no classic CNV. However, in predominantly occult CNV, the treatment may be most effective in smaller lesions, and less in larger lesions. Most important, visual acuity rarely is improved.

CONCLUSIONS

Pilot studies and large case series suggest that a combination of PDT and intravitreal triamcinolone acetonide has the potential to improve visual outcomes and reduce the need for additional treatments. Randomized, prospective clinical trials are underway to confirm the efficacy and safety of this novel treatment modality.

Steroid Hypopyon Following Intravitreal Triamcinolone Acetonide Injection in a Pseudophakic Patient

PURPOSE

A 64-year-old woman presenting with the complaint of 'white stuff' in her left eye one day after intravitreal triamcinolone injection for chronic pseudophakic cystoid macular edema after cataract extraction and anterior chamber intraocular lens implant is presented.

METHODS

Differential diagnosis included post-injection endophthalmitis versus 'steroid hypopyon.'

RESULTS

The patient was observed closely and the hypopyon cleared in four days. Three weeks after the injection, her visual acuity had improved from 20/200 to 20/70 with complete resolution of the macular edema.

CONCLUSION

Patients having no capsular barrier presenting with hypopyon one day after IVTA may be observed closely for a few days for resolution of hypopyon prior to being treated as endophthalmitis.

Visual acuity and intraocular pressure after high-dose intravitreal triamcinolone acetonide in selected ocular diseases

PURPOSE

Within the last 5 years, intravitreal injections of triamcinolone acetonide have been for a wide variety of ocular diseases with intraocular oedema and neovascularization. With clinical experience accumulating, the question arises for which indication the side effects outweigh the therapeutic efficacy of intravitreal triamcinolone monotherapy.

SCOPE

Comparing different diseases, increase in visual acuity was lower in patients receiving intravitreal triamcinolone monotherapy for exudative age-related macular degeneration than in patients with diabetic macular oedema, branch retinal vein occlusion, central retinal vein occlusion, uveitis, and pseudophakic cystoid macular oedema. Rise in intraocular pressure was significantly higher in relatively young patients with uveitis than in any other patient group.

CONCLUSIONS

Improvement in vision after intravitreal triamcinolone monotherapy is highest in non-ischaemic diseases with an intraretinal macular oedema such as pseudophakic cystoid macular oedema; it is lower in partially ischaemic diseases with intraretinal macular oedema such as diabetic macular oedema or retinal vein occlusions; and it is lowest in diseases with a primarily subretinal location of the disease such as exudative age-related macular degeneration. For the latter diseases, intravitreal triamcinolone monotherapy is, therefore, no longer up-to-date, particularly with the upcoming intravitreal application of vascular endothelial growth factor blocking drugs. For diseases with intraretinal oedema, the rule of thumb may be that intravitreal triamcinolone increases vision as much as retinal ischaemia and tissue destruction by the underlying disease allow it. The rise in intraocular pressure is higher in relatively young patients with uveitis than in elderly patients with other reasons for macular oedema.

Repeated intravitreal injection of triamcinolone for exudative age-related macular degeneration

BACKGROUND

Intravitreal triamcinolone acetonide has been discussed as treatment for exudative age-related macular degeneration (AMD).

OBJECTIVES

To give an updated report on repeated intravitreal injections of triamcinolone acetonide (IVTA) for the treatment of exudative AMD.

METHODS

The case-series study included 24 patients (24 eyes) with progressive exudative AMD who had shown an increase in, or stabilization of, visual acuity after a first IVTA, and who eventually experienced a deterioration of visual acuity. The 24 (6.5%) eyes were selected out of a total group of 369 eyes who had received IVTA for exudative AMD within the last 5 years. All patients of the study received a second IVTA (approximately 20 mg) 3.7-38.5 months after the first injection. Main outcome measure was visual acuity.

RESULTS

After the first injection, best corrected visual acuity improved significantly (p = 0.001) from 0.75 +/- 0.34 logMAR to a minimum of 0.58 +/- 0.30 logMAR during follow-up, with 10 (42%) eyes improving in visual acuity by two or more Snellen lines. Towards the end of follow-up after the first injection, best corrected visual acuity decreased significantly (p = 0.03) compared with the baseline value. After the second injection, visual acuity did not change markedly from baseline to a mean maximal visual acuity during follow-up. Comparing the last postoperative examination at the end of the follow-up after the second IVTA with the preoperative examination, a significantly (p = 0.001) higher number of eyes lost in visual acuity [19 (79%) eyes] than gained in visual acuity [3 (12%) eyes].

CONCLUSIONS

In selected eyes with an increase in visual acuity after a first IVTA (20 mg), repeated IVTA temporarily stabilizes visual acuity with a drop in visual acuity towards the end of follow-up.

Visual Acuity Change After Intravitreal Triamcinolone in Various Types of Exudative Age-Related Macular Degeneration

OBJECTIVE

The aim of this study was to compare the visual acuity change after an intravitreal high-dose injection of triamcinolone acetonide (TA) in various types of exudative age-related macular degeneration (AMD).

PARTICIPANTS

The interventional comparative case series study included 142 patients (146 eyes) with progressive exudative AMD differentiated into the occult type (n = 78; 53.4%), minimal classic type (n = 45; 30.8%), predominantly classic type (n = 17; 11.6%), and the purely classic type (n = 6; 4.1%). Mean follow-up was 9.7 +/- 7.0 months (3-35.7 months).

METHODS

Single intravitreal injection of approximately 20 mg of TA.

OUTCOME MEASURES

Visual acuity, intraocular pressure (IOP).

RESULTS

Gain in visual acuity measured at 1 month (P = 0.20), 2 months (P = 0.43), and at 3 months (P = 0.38) after the intravitreal injection of triamcinolone and maximal gain in visual acuity during the whole follow-up (P = 0.81) did not vary significantly between the 4 study groups. Correspondingly, the size of a retinal pigment epithelium detachment was not significantly associated with the change in visual acuity at 1 month (P = 0.62), 2 months (P = 0.24), 3 months (P = 0.96), or the maximal gain in visual acuity during follow-up (P = 0.93). The amount of rise in IOP, compared with the baseline value (6.5 +/- 7.4 mmHg), was statistically not associated with the type of subfoveal membrane (P = 0.20; 95% confidence interval: -0.52, 2.45).

CONCLUSIONS

The change in visual acuity and the rise in IOP in patients with exudative AMD receiving an intravitreal triamcinolone monotherapy is statistically independent of the type of subfoveal membrane, including the size of a retinal epithelium detachment.

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.

Duration of the Effect of Intravitreal Triamcinolone Acetonide in Eyes with Exudative Age-Related Macular Degeneration

OBJECTIVE

The aim of this study was to evaluate the duration of the effect of an intravitreal injection of approximately 20 mg of triamcinolone acetonide (TA) on visual acuity and intraocular pressure (IOP) in patients with exudative age-related macular degeneration (AMD) with subfoveal choroidal neovascularization.

PARTICIPANTS

The prospective, clinical, interventional, case series study included 69 patients (71 eyes) with exudative AMD who showed an increase in visual acuity by at least 2 Snellen lines after an intravitreal injection of approximately 20 mg TA. Mean follow-up was 11.5 +/- 7.4 months (3.3-35.7 months). The main outcome measure was visual acuity.

RESULTS

Within the first week after the injection, visual acuity and IOP started to increase significantly (P < 0.001) by reaching a plateau-like maximum at 1-6 months after the injection. Visual acuity and IOP returned to baseline values 7-9 months after the injection. Increase of IOP was statistically (P = 0.72) independent of the change in visual acuity.

CONCLUSIONS

In patients with exudative AMD, who have shown an increase of at least 2 Snellen lines in visual acuity, the effect of intravitreal TA (dosage approximately 20 mg) lasts 7-9 months with respect to an increase in visual acuity and IOP.

Carboxymethylcellulose as a new carrier substance for intravitreal injection of reproducible amounts of triamcinolone

BACKGROUND

Intravitreal application of triamcinolone acetonide has become increasingly popular for the treatment of various retinal disorders. However, dosage, mode of preparation and application differ worldwide. The aim of this study was to find a safe vehicle that would allow intravitreal injection of an exact amount of triamcinolone acetonide without potentially retinotoxic preservatives.

METHODS

Solutions of triamcinolone acetonide with a theoretical concentration of 4 mg/0.2 ml were prepared following one sedimentation (A) and two filtration (B, C) methods. In addition, a filtration method using carboxymethylcellulose 2% as a carrier (D) was established. During processing and after injection into an eye model, the crystals were quantified by weight and high-performance liquid chromatography (HPLC), and, hence, the rate of crystal loss during this process was determined.

RESULTS

The initial preparation contained 93-106% of the calculated quantity. Method A, containing the entire vehicle, delivered 45%+/-7.3% of the target quantity to the eye model, whereas the vehicle-free methods B and C delivered 15%+/-6.9% and 11%+/-3.2%, respectively. Using carboxymethylcellulose 2% as a preservative-free vehicle, we found 93%+/-3.7% of the calculated amount in the eye model. The missing crystals were mainly sticking to the walls of the syringes and needles used for transfer.

CONCLUSION

Common methods for preparing triamcinolone acetonide vary in the amount of drug actually injected intravitreally. Carboxymethylcellulose is an ideal carrier substance for intravitreal application of an exact dose of triamcinolone acetonide without preservatives.

Verteporfin and intravitreal triamcinolone acetonide combination therapy for occult choroidal neovascularization in age-related macular degeneration

PURPOSE

To evaluate the efficacy and safety of photodynamic therapy (PDT) with verteporfin combined with intravitreal triamcinolone (IVTA) in occult choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD).

DESIGN

Single center, nonrandomized interventional case series.

METHODS

A prospective, noncomparative, interventional case series of 41 eyes of 41 patients with a two-year follow-up period. Verteporfin PDT was performed using the recommended standard procedure for approved forms of AMD. A solution containing 25 mg of crystalline triamcinolone acetonide was injected intravitreally 16 hours post PDT. The procedure was repeated after three months in case of persistent CNV leakage.

RESULTS

The mean number of treatments needed was 1.8. Thirty-four eyes (82.9%) required one retreatment at three months. No additional retreatments were necessary. Visual acuity improved gradually in most of the patients with mean values of 20/133 and 20/115 at baseline and three months; 20/101 and 20/84 at six and twelve months; and 20/83 and 20/81 at eighteen and twenty-four months. Eleven of 41 treated study eyes (26.8%) underwent cataract surgery between six and fifteen months after the first treatment. Nine patients required local or systemic glaucoma therapy because of a transient steroid induced intraocular pressure increase.

CONCLUSIONS

Verteporfin PDT combined with intravitreal triamcinolone may improve the outcome of standard verteporfin PDT in the treatment of occult CNV secondary to AMD. An improvement in visual acuity was observed in most of the treated patients and was maintained during a two-year follow-up period. Retreatment numbers were lower than expected from monotherapy trials.

Intravitreal triamcinolone acetonide for treatment of intraocular oedematous and neovascular diseases

Intravitreal triamcinolone acetonide (IVTA) has increasingly been applied as treatment for various intraocular neovascular and oedematous 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 (VA) has been achieved for intraretinal oedematous diseases such as diffuse diabetic macular oedema, branch retinal vein occlusion, central retinal vein occlusion and pseudophakic cystoid macular oedema. In eyes with various types of non-infectious uveitis, including acute or chronic sympathetic ophthalmia and Adamantiadis-Behcet's disease, VA increased and the degree of intraocular inflammation decreased. Some studies have suggested that intravitreal triamcinolone may be useful as angiostatic therapy in eyes with iris neovascularization and proliferative ischaemic retinopathies. Intravitreal triamcinolone may possibly be helpful as adjunct therapy for exudative age-related macular degeneration (AMD), particularly in combination with photodynamic therapy. In eyes with chronic, therapy-resistant ocular hypotony, intravitreal triamcinolone can induce an increase in intraocular pressure (IOP) 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 IOP 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% of elderly patients within 1 year of injection; postoperative infectious endophthalmitis occurring at a rate of about one per 1000; non-infectious endophthalmitis, perhaps due to a reaction to the solvent agent, and pseudo-endophthalmitis with triamcinolone acetonide crystals appearing in the anterior chamber. Intravitreal triamcinolone injection can be combined with other intraocular surgeries, 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 the resultant benefits decrease after the initial IVTA injection. In non-vitrectomized 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. So far, it has remained unclear whether the solvent agent should be removed, and if so, how.

Follow-up after intravitreal triamcinolone acetonide for exudative age-related macular degeneration

PURPOSE

To report on the follow-up of patients who received an intravitreal triamcinolone acetonide injection (IVTA) as treatment of exudative age-related macular degeneration.

METHODS

The clinical interventional case-series study included 205 patients (222 eyes) with progressive exudative age-related macular degeneration with subfoveal neovascularization who consecutively received an IVTA of about 20 mg as only therapeutic procedure and for whom follow-up was at least 3 months. Mean follow-up was 10.4+/-7.1 months (range, 3-35.7 months).

RESULTS

Visual acuity improved significantly (P<0.001) from baseline (0.90+/-0.45 logarithm of the minimum angle of resolution (LogMar)) to a mean minimum of 0.79+/-0.42 LogMar during follow-up. In 86 (38.7%) eyes and in 55 (24.8%) eyes, best visual acuity increased by at least two and three Snellen lines, respectively. Comparing the measurements at specific postinjection examination dates showed that visual acuity measurements taken at 1, 2, and 3 months after injection were not significantly different from the baseline value. Measurements taken at 6, 9, and 12 months after the injection were significantly (P<0.001) lower than the measurements at baseline. Mean loss at 6 months was 1.4+/-3.8 Snellen lines, at 9 months, 2.5+/-4.6 lines, and at 12 months after the injection, 2.6+/-4.0 lines. Intraocular pressure increased significantly (P<0.001) during the first 6 months, and returned to baseline at 9 months after injection.

CONCLUSIONS

Single injection high-dosage IVTA did not show an apparent benefit at 12 months after injection in patients with neovascular age-related macular degeneration.

INTRAVITREAL TRIAMCINOLONE ACETONIDE FOR DIABETIC MACULAR EDEMA

PURPOSE

Intravitreal injection of triamcinolone acetonide has been advocated to treat exudative diabetic macular edema. The purpose of the study was to evaluate the clinical outcome of an intravitreal injection of triamcinolone acetonide as treatment for diffuse diabetic macular edema.

METHODS

This study was a retrospective, interventional, clinical case series examining 210 eyes of 174 patients who received an intravitreal injection of 1 or 4 mg of triamcinolone acetonide for treatment of diffuse diabetic macular edema. Inclusion criteria were clinically significant macular edema, visual acuity loss, and leakage shown by fluorescein angiography. Main outcome measures were visual acuity and intraocular pressure. Mean follow-up time +/- SD was 6.6 +/- 3.1 months.

RESULTS

In the study group, visual acuity improved significantly (P < 0.001) from a median of 20/200 (mean logMAR, 0.92) at baseline to 20/80 (mean logMAR, 0.82) at 6 months. Mean intraocular pressure +/- SD increased from 15.4 +/- 3.4 mmHg (median, 16 mmHg; range, 6-26 mmHg) to a maximal value of 20.4 +/- 6.2 mmHg (median, 19 mmHg; range, 12-51 mmHg) during the follow-up period. Complications included culture-negative sterile endophthalmitis in six cases and cataract extraction in five eyes.

CONCLUSIONS

Intravitreal injection of 1 to 4 mg of triamcinolone acetonide may benefit patients by improving visual acuity in eyes with clinically significant diabetic macular edema. This study did not provide significant evidence to justify its routine use in clinical practice for all patients with diabetic macular edema. A randomized clinical trial on this issue would provide more conclusive evidence and help identify those patients most likely to benefit from intravitreal triamcinolone acetonide.

Indocyanine green-mediated photothrombosis with and without intravitreal triamcinolone acetonide for subfoveal choroidal neovascularization in age-related macular degeneration: a pilot study

PURPOSE

To determine the feasibility, safety, and clinical effect of treating patients with subfoveal choroidal neovascularization (CNV) in age-related macular degeneration (AMD) with indocyanine green (ICG)-mediated photothrombosis (IMP) with and without intravitreal triamcinolone acetonide (TA).

METHODS

Fifteen patients (19 eyes) participated in the study. Nine eyes of seven patients were treated with IMP immediately followed by an intravitreal injection of 4 mg of TA (Group A), and 10 eyes of 8 patients were treated with IMP only (Group B). Patients had a mean follow-up of 6.9 months (range: 3 to 12 months). Patients underwent single or two sessions of IMP.

RESULTS

In Group A, visual acuity (VA) showed stability in 6 eyes (66.7%), improvement of VA in 2 eyes (22.2%), and worsening of VA in 1 eye (11.1%). Group B presented VA stability in 9 eyes (90%), and improvement in 1 eye (10%). In total, of the 15 patients (19 eyes) with IMP with or without intravitreal TA, 3 eyes (15.8%) showed improvement, 15 eyes (78.9%) stability, and 1 eye (5.3%) showed worsening of VA. A significant regression of the CNV and diminishing of subretinal fluid was demonstrated with fluorescein angiography and optical coherence tomography in both groups. No patient in Group A required retreatment. Four of 10 eyes (40%) in Group B required one retreatment during the study period.

CONCLUSIONS

ICG-mediated photothrombosis with and without intravitreal TA may provide stability or improvement in visual acuity and fundus findings in subfoveal CNV in AMD. Further evaluation in a multicenter, randomized, placebo-controlled clinical trial with longer follow-up is needed to accurately assess the safety and efficacy of this new treatment modality.

Intravitreal triamcinolone acetonide for treatment of intraocular proliferative, exudative, and neovascular diseases

Within the last three years, triamcinolone acetonide has increasingly been applied intravitreally as treatment option for various intraocular neovascular edematous and proliferative disorders. The best response in terms of gain in visual acuity after the intravitreal injection of triamcinolone acetonide was found in eyes with intraretinal edematous diseases such as diffuse diabetic macular edema, branch retinal vein occlusion, central retinal vein occlusion, and pseudophakic cystoid macular edema. Visual acuity increased and degree of intraocular inflammation decreased in eyes with various types of non-infectious uveitis including acute or chronic sympathetic ophthalmia and Adamantiadis-Behcet's disease. Intravitreal triamcinolone may be useful as angiostatic therapy in eyes with iris neovascularization and proliferative ischemic retinopathies. Possibly, intravitreal triamcinolone may be helpful as adjunct therapy for exudative age-related macular degeneration, possibly 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, cataractogenesis, postoperative infectious and non-infectious endophthalmitis, and pseudo-endophthalmitis. Intravitreal triamcinolone injection can be combined with other intraocular surgeries including cataract surgery. Cataract surgery performed some months after the injection does not show a markedly elevated rate of complications. If vision increases and eventually decreases again after an intravitreal triamcinolone acetonide injection, the injection can be repeated. The duration of the effect of a single intravitreal injection of triamcinolone depended on the dosage given. Given in a dosage of about 20mg to non-vitrectomized eyes, the duration of the effect and of the side-effects was 6-9 months. Intravitreal triamcinolone acetonide may offer a possibility for adjunctive treatment of intraocular edematous and neovascular disorders. One has to take into account the side-effects and the lack of long-term follow-up observations.

Cataract surgery combined with intravitreal injection of triamcinolone acetonide

PURPOSE

To evaluate whether the addition of cataract surgery to an intravitreal injection of triamcinolone acetonide markedly increases frequency and spectrum of complications.

METHODS

The comparative nonrandomized clinical interventional investigation included a study group of 60 eyes (56 patients) undergoing cataract surgery and additionally receiving an intravitreal injection of about 20 mg of triamcinolone acetonide and a triamcinolone control group of 290 eyes (262 patients) that consecutively received an intravitreal injection of about 20 mg triamcinolone acetonide without cataract surgery. Reasons for intravitreal injection of triamcinolone acetonide were exudative age-related macular degeneration (n=228; 65%), diffuse diabetic macular edema (n=94; 27%), central retinal vein occlusion (n=17; 5%), and branch retinal vein occlusion (n=11; 3%). Mean follow-up was 8.6+/-6.8 months. A second control group included 1068 patients (1068 eyes) who consecutively underwent routine cataract surgery without intravitreal injection.

RESULTS

Study group and triamcinolone control group did not vary significantly in best visual acuity during follow-up (p=0.08), final visual acuity at the end of follow-up (p=0.30), maximal intraocular pressure during follow-up (p=0.99), frequency of an intraocular pressure higher than 21 mmHg (p=0.66), and intraocular pressure at the end of follow-up (p=0.06). Postoperative infectious endophthalmitis, wound leakage or other corneal wound healing problems, persisting corneal endothelial decompensation, rhegmatogenous retinal detachment, marked postoperative pain, or a clinically significant decentration of the intraocular lens were not observed. Study group and the non-triamcinolone control group did not vary significantly in the rate of posterior lens capsule rupture (p=0.11), postoperative infectious endophthalmitis, and persisting postoperative corneal endothelial decompensation.

CONCLUSIONS

The addition of cataract surgery to an intravitreal injection of triamcinolone acetonide may not markedly increase amount and frequency of side effects and complications of intravitreal triamcinolone acetonide. No safe conclusions can be reached regarding differences in frequency of postoperative infectious endophthalmitis.

Effect of triamcinolone acetonide on proliferation of retinal endothelial cells in vitro and in vivo

AIM

To assess the effect of crystalline triamcinolone acetonide on retinal endothelial cell proliferation in vivo and in vitro.

METHODS

For in vitro analysis, a sprouting assay was employed. Bovine retinal endothelial cells were stimulated with basic fibroblast growth factor (bFGF) and incubated with different concentrations of triamcinolone acetonide (0.05 mg/ml to 8 mg/ml). For in vivo analysis, a retinopathy of prematurity (ROP) model was used. 16 C57BL/J6 mice were exposed to 75% oxygen from postnatal day 7 to day 12. On day 12, triamcinolone acetonide was intravitreally injected into one eye ("study eye") and isotonic saline into the contralateral eye ("control eye"). On day 17, the mice were sacrificed and the eyes removed for quantitative analysis of preretinal neovascularisation. Four non-exposed mice served as negative control.

RESULTS

The sprouting assay demonstrated a dose dependent inhibition of bovine retinal endothelial cell proliferation from 0.05 mg triamcinolone acetonide/ml (no inhibition) to 3 mg triamcinolone acetonide/ml (complete inhibition). Dosages of more than 2 mg/ml resulted in cytotoxic changes of endothelial cells. The ROP model demonstrated a significantly lower neovascular cell count of 58% in the study group compared to the control group (6.35 (SD 2.1) cells per histological section versus 14.9 (SD 5.3) cells; p<0.005).

CONCLUSIONS

Triamcinolone acetonide inhibits bFGF induced proliferation of retinal endothelial cells in vivo and in vitro. These findings contribute to understanding the mode of action and effects of triamcinolone acetonide on retinal neovascularisation.

Intereye difference in exudative age-related macular degeneration with minimally classic or occult subfoveal neovascularization after unilateral intravitreal injection of triamcinolone acetonide

PURPOSE

To report on visual outcome after intravitreal injection of triamcinolone acetonide for exudative age-related macular degeneration.

DESIGN

Interventional comparative non-randomized clinical trial.

METHODS

SETTING

Institutional.

PATIENTS

Twenty consecutive patients with bilateral exudative age-related macular degeneration with minimally classic or occult subfoveal neovascularisation.

INTERVENTIONS

Unilateral intravitreal injection of about 20 mg triamcinolone acetonide into the eye (study group) more severely affected or showing more pronounced progression of the disease. Mean follow-up was 13.5 +/- 4.1 months.

MAIN OUTCOME MEASURES

Visual acuity.

RESULTS

In the study group, visual acuity increased significantly (P < 0.001) from 0.96 +/- 0.32 logMar to a mean maximum of 0.76 +/- 0.30 logMar during follow-up. An increase in best visual acuity during follow-up was found in 18 (90%) eyes. In 11 (55%) eyes and 7 (35%) eyes, respectively, best visual acuity increased by at least two Snellen lines and three Snellen lines, respectively. In the control group, visual acuity at baseline and the highest visual acuity measurements during follow-up did not vary significantly (P = 0.90). Comparing study group and control group, visual acuity gain was significantly (P = 0.003) higher in the study group. Correspondingly, the number of eyes with an increase in visual acuity (P = 0.002) and with an increase in visual acuity higher > or = 3 lines compared to a loss of > or = 3 lines was significantly (P = 0.027) higher in the study group.

CONCLUSIONS

Intravitreal triamcinolone acetonide may temporarily increase visual acuity in eyes with exudative age-related macular degeneration.

Indocyanine green-mediated photothrombosis with intravitreal triamcinolone acetonide for subfoveal choroidal neovascularization in age-related macular degeneration

BACKGROUND

There is a need for alternative treatments for the management of exudative age-related macular degeneration (AMD). The purpose of this paper is to determine the feasibility, safety, and clinical effect of indocyanine green (ICG)-mediated photothrombosis (IMP) combined with intravitreal triamcinolone acetonide (TA) in patients with subfoveal choroidal neovascularization (CNV) in AMD.

METHODS

Thirty-one eyes of 26 patients who were treated with IMP immediately followed by an intravitreal injection of 4 mg of TA were investigated in the study. The patients had a mean follow-up of 9 months (range 3 months to 26 months). Patients underwent one to four sessions of IMP combined with intravitreal TA.

RESULTS

Visual acuity showed stability in 19 eyes (61.3%), improvement of visual acuity (VA) in seven eyes (22.6%), and worsening of VA in five eyes (16.1%). A significant regression of the CNV, and diminishing of subretinal fluid, was demonstrated with fluorescein angiography and optical coherence tomography. We found no complications associated with the intravitreal injection procedure or IMP. Five (16.1%) eyes developed an increase in intraocular pressure related to the presence of TA in the vitreous cavity. However, it was medically controlled with topical anti-glaucoma medications. Nineteen of 31 eyes (61.2%) required at least one re-treatment (mean 1.7; range 1-4) during the study period.

CONCLUSIONS

Combined IMP and intravitreal TA may provide stability or improvement in visual acuity and fundus findings in choroidal neovascularization. Further evaluation in a multicenter, randomized, placebo-controlled clinical trial with longer follow-up is needed to accurately assess the safety and efficacy of this new treatment modality.

Factors influencing visual acuity after intravitreal triamcinolone acetonide as treatment of exudative age related macular degeneration

AIM

To evaluate factors influencing change in visual acuity (VA) after intravitreal injection of triamcinolone acetonide as treatment of exudative age related macular degeneration (AMD).

METHODS

This prospective, interventional, comparative non-randomised clinical case series study included 94 patients (99 eyes) showing progressive exudative AMD with occult (n = 61 eyes), minimally classic (n = 18), predominantly classic (n = 1), or totally classic (n = 8) subfoveal neovascularisation. Mean follow up was 8.5 (SD 4.7) months (median, 7.3 months; range 3.1-24.5 months). All patients received an intravitreal injection of 20-25 mg of triamcinolone acetonide.

RESULTS

An increase in best VA of at least one line on the Snellen charts was found in 63 (63.1%) eyes. Correspondingly, mean VA increased significantly (p<0.001) from 0.17 (SD 0.13) to 0.22 (SD 0.17) after the injection. Postoperative increase in VA was significantly (p<0.001) and negatively correlated with preoperative VA (correlation coefficient, -0.49). Gain in visual acuity was significantly (p = 0.009) higher if preoperative visual acuity was less than 0.08 (gain: 3.2 (SD 2.9) Snellen lines) than if preoperative VA ranged between 0.08 and 0.20 (gain: 1.2 (SD 2.2) Snellen lines). Change in VA was significantly (p = 0.016) less if preoperative VA was higher than 0.20 (change: -0.8 (SD 3.4) Snellen lines). Maximal gain in VA was significantly (p = 0.035) larger in eyes with retinal pigment epithelium detachment than in eyes with minimally classic subfoveal neovascularisation. This was statistically independent of age (p = 0.99), refractive error (p = 0.88), sex (p = 0.92), and duration of follow up (p = 0.46).

CONCLUSIONS

Gain in VA after intravitreal injection of 20-25 mg of triamcinolone acetonide is significantly and negatively correlated with preoperative VA. It is significantly larger in eyes with retinal pigment epithelium detachment than in eyes with minimally classic subfoveal neovascularisation.

Exudative age-related macular degeneration treated by intravitreal triamcinolone acetonide. A prospective comparative nonrandomized study

PURPOSE

To report on visual outcome of patients receiving an intravitreal injection of triamcinolone acetonide as treatment of progressive exudative age-related macular degeneration.

METHODS

The prospective comparative nonrandomized clinical interventional study included 187 consecutive patients with progressive exudative age-related macular degeneration, divided into a study group of 115 patients receiving an intravitreal injection of 25 mg triamcinolone acetonide, and a control group of 72 patients without treatment. The mean follow-up was 6.0+/-4.2 months.

RESULTS

Visual acuity increased significantly (P=0.03) in the study group, and decreased significantly (P=0.01) in the control group, at 1 month and 3 months after start of the study. Between the study group and control group, the differences in change of visual acuity were significant (P=0.001). In the study group, the number of patients with an increase in visual acuity of 2 or more Snellen lines was significantly (P=0.001) larger than in the control group. Correspondingly, the number of patients with a decrease of 2 or more Snellen lines was significantly (P=0.007) smaller in the study group. In all, 43 (37.4%) patients of the study group experienced an increase in best visual acuity by 2 or more Snellen lines.

CONCLUSIONS

Visual acuity increased in patients with exudative age-related macular degeneration at 1 month and 3 months after an intravitreal injection of 25 mg triamcinolone acetonide.

Cataract surgery after intravitreal injection of triamcinolone acetonide

PURPOSE

To report the clinical outcome of patients undergoing cataract surgery after one or repeated intravitreal injections of triamcinolone acetonide as treatment of intraocular neovascular or oedematous diseases.

METHODS

The interventional clinical case series study included all patients (n=22) who presented with cataract which had progressed after a single or repeated intravitreal injection of 25 mg of triamcinolone acetonide as treatment of exudative age-related macular degeneration (n=18) or diffuse diabetic macular oedema (n=4). Duration of the follow-up period was 3.76+/-4.99 months. With topical anaesthesia, the patients underwent standard cataract surgery including clear cornea incision, phakoemulsification and aspiration of the lens nucleus and cortex, and implantation of a foldable posterior chamber lens. The main outcome measures were frequencies of capsular rupture, vitreous loss, postoperative infectious endophthalmitis, secondary cataract, and decentration of the intraocular lens, visual acuity and intraocular pressure.

RESULTS

Intraoperative dialysis of the lens zonules occurred in one (4.5%) eye and resulted in a loss of vitreous. Secondary cataract leading to Nd : YAG laser capsulotomy was observed in one (4.5%) eye. An optically significant decentration of the IOL or infectious endophthalmitis was not encountered in any patient. Visual acuity increased from 0.11+/-0.10 to 0.13+/-0.94 during the follow-up. Within 1 week after surgery, intraocular pressure was in the normal range in all the eyes.

CONCLUSIONS

Cataract surgery after single or repeated intravitreal injection of 25 mg of triamcinolone acetonide does not harbour a markedly elevated frequency or a markedly changed profile of surgical complications.

[Intravitreal triamcinolone acetonide for the treatment of intraocular edematous and neovascular diseases]

BACKGROUND

Within the last 2 years, intravitreal application of triamcinolone acetonide has exponentially increased as a treatment option for various intraocular neovascular and edematous proliferative disorders.

METHODS AND RESULTS

The best response to intravitreal triamcinolone acetonide injection in terms of gain in visual acuity was obtained for eyes with intraretinal edematous diseases such as diffuse diabetic macular edema, branch retinal vein occlusion, central retinal vein occlusion, and pseudophakic cystoid macular edema. Visual acuity increased and degree of intraocular inflammation decreased in eyes with various types of noninfectious uveitis including sympathetic ophthalmia. Intravitreal triamcinolone may be useful as angiostatic therapy in eyes with iris neovascularization and proliferative ischemic retinopathies. Possibly, intravitreal triamcinolone may be helpful for exudative age-related macular degeneration, alone or 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, such as secondary ocular hypertension in about 40% of the eyes injected, cataractogenesis, postoperative infectious and noninfectious endophthalmitis, and pseudo-endophthalmitis will be covered in another article. Intravitreal triamcinolone injection can be combined with other intraocular surgeries including cataract surgery. Cataract surgery performed some months after the injection did not show a markedly elevated rate of complications. If vision increases after the intravitreal triamcinolone injection, the injection can be repeated. The duration of the effect of a single intravitreal injection of triamcinolone ranges between 2 and 9 months, probably depending on the dosage used.

CONCLUSIONS

Intravitreal triamcinolone acetonide may offer a possibility for adjunctive treatment of intraocular oedematous and neovascular disorders. One has to take into account the side effects and the lack of long-term follow-up observations.

Intravitreal triamcinolone acetonide for exudative age related macular degeneration

AIM

To evaluate the effect of intravitreal triamcinolone acetonide on the visual acuity of patients with exudative age related macular degeneration, to assess the duration of a possible effect, and to evaluate clinical side effects of the treatment.

METHODS

The study included 67 patients (71 eyes) who presented with exudative age related macular degeneration of predominantly or total occult type (n = 68) or classic type (n = 3), and who received once, or repeatedly, an intravitreal injection of 25 mg of crystalline triamcinolone acetonide. Mean follow up time was 7.46 (SD 3.54) months (range 3.1-19.57 months).

RESULTS

Visual acuity increased significantly (p <0.001) from 0.16 (0.11) to a mean maximum of 0.23 (0.17). Postoperative visual acuity was highest 1-3 months after the injection. 47 (66.2%) eyes gained in maximal visual acuity and 11 (15.5%) eyes lost in visual acuity. Intraocular pressure increased significantly (p <0.001) from 15.1 (3.1) mm Hg at baseline to a maximal value of 23.0 (8.25) mm Hg. At the end of follow up, intraocular pressure again decreased significantly (p<0.001) to 16.8 (4.9) mm Hg. No cases of postoperative infectious endophthalmitis, rhegmatogenous retinal detachment, or proliferative vitreoretinopathy occurred. Owing to a decrease in visual acuity after an initial increase, six patients received a second intravitreal triamcinolone acetonide injection after which visual acuity increased again in three eyes.

CONCLUSIONS

Intravitreal injection of 25 mg of crystalline triamcinolone acetonide merits further study for the treatment of exudative age related macular degeneration.