Intravitreal triamcinolone acetonide for ischaemic macular oedema caused by branch retinal vein occlusion

Safety of intravitreal triamcinolone and its impact on optic nerve morphology in patients treated for diabetic macular edema

PURPOSE

To assess the impact of one intravitreal injection (IVT) of Triamcinolone Acetonide (TA) on intraocular pressure (IOP) and optic nerve structural parameters in patients treated for Diabetic Macular Edema (DME).

METHODS

This retrospective study included patients with DME that were naïve to intraocular steroids and underwent one IVT of TA of 4 mg/0.1 mL and age-matched controls with DME without criteria for IVT. Patients records were reviewed for IOP (at baseline and a month after IVT) and optic nerve parameters measured by optical coherence tomography (up to 6 months before and 6 months after IVT). Exclusion criteria included glaucoma and treatment with hypotensive agents.

RESULTS

Twenty-six eyes were included in the Control Group and 29 in the IVT Group, with a mean age of 65.10 ± 10.08 and 67.30 ± 4.71 years, respectively (p = 0.06). At baseline, IOP and optic nerve measurements were equivalent between groups (p > 0.05). One month after IVT, mean IOP measurements in IVT Group were higher than those of controls (17.84 ± 4.50 vs 11.59 ± 3.09 mmHg, p < 0.001). Ocular hypertension (OHT) developed in 17.24% of cases and reversed with topical medication. After one IVT, vertical cup/disc ratio was higher (0.57 ± 0.25 vs 0.60 ± 0.14, p = 0.04) and retinal nerve fiber layer thickness was globally lower (mean: 91.03 ± 4.25 vs 81.33 ± 19.10 µm, p = 0.001) in the IVT Group.

CONCLUSION

Our results confirmed that intravitreal TA results in IOP increase. This seems to negatively affect optic nerve morphology, even in patients without OHT or adequately treated with hypotensive agents.

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.

Long-term efficacy and duration of action of dexamethasone implant, in vitrectomised and non-vitrectomised eyes with persistent diabetic macular oedema

PURPOSE

To evaluate the efficacy and duration of action of an intravitreal (dexamethasone (Ozurdex)) implant in vitrectomised and non-vitrectomised eyes with persistent diabetic macular oedema (DMO).

METHODS

We retrospectively analysed the records for 18 eyes that had or had not been vitrectomised but required an intravitreal dexamethasone implant for DMO after a poor response to anti-vascular endothelial growth factor. Optical coherence tomography and visual acuity (VA) examinations were performed before and 1, 3 and 6 months after implantation. The six months following implantation constituted one treatment round; up to three rounds were studied.

RESULTS

Ten of 18 eyes had undergone vitrectomy. Best-corrected visual acuity (BCVA) and central macular thickness (CMT) were significantly improved by months 1-3 after implantation of the Ozurdex device in all rounds of treatment. The BCVA and CMT deteriorated gradually after month 3 through to month 6 post implantation. There were no statistically significant differences between the vitrectomised and non-vitrectomised groups at any time point. When the implantation interval was <6 weeks from the end of each treatment round, the improvement in BCVA and CMT was obvious even after 18 months of treatment.

CONCLUSIONS

Vitrectomy did not have a negative effect on the duration of action or efficacy of the Ozurdex implant in patients with persistent DMO. The implant started working from the first month after implantation regardless of whether vitrectomy had or had not been performed. The maximum functional and anatomic improvement was achieved in the first 3 months post implantation in all treatment rounds.

Intravitreal Triamcinolone Acetonide for Treatment of Central Retinal Vein Occlusion

PURPOSE

To evaluate the effect of intravitreal triamcinolone acetonide on visual acuity and intraocular pressure in patients with central retinal vein occlusion.

METHODS

This prospective comparative non-randomized clinical interventional study included 32 patients (33 eyes) with central retinal vein occlusion. The study group (12 patients; 13 eyes) received an intravitreal injection of about 20 mg of triamcinolone acetonide. The control group (20 patients) did not receive any treatment. Mean follow-up was 10.1+/-8.6 months in the study group and 6.0+/-5.2 months in the control group.

RESULTS

In the study group, mean visual acuity increased significantly (p=0.018) from 0.11+/-0.11 preoperatively to a best visual acuity during follow-up of 0.18+/-0.15. An improvement in visual acuity by at least 2 Snellen lines and 3 Snellen lines, respectively, was found for 8 (62%) eyes and 5 (38) eyes. Visual acuity measurements determined 1 month (p=0.038) and 3 months (p=0.046) after the injection were significantly higher than the baseline values. Increase in visual acuity was higher in the non-ischemic subgroup than in the ischemic subgroup. In the control group, baseline visual acuity and best visual acuity during the followup did not vary significantly (p=0.33). Visual acuity decreased significantly (p=0.007) towards the end of the follow-up. Comparing study group and control group, gain in visual acuity was significantly (p=0.01) higher in the study group. In the study group, intraocular pressure increased significantly (p=0.018) from 14.4+/-3.9 mmHg to a mean maximal value of 21.6+/-9.2 mmHg (range, 10-44 mmHg), and re-decreased (p=0.012) towards the end of follow-up to 15.3+/-5.1 mmHg (range, 10-21 mmHg).

CONCLUSIONS

Intravitreal triamcinolone acetonide temporarily increases visual acuity in central retinal vein occlusion. It is accompanied by an increase in intraocular pressure.

Prospective Evaluation of Intravitreal Triamcinolone Acetonide Injection in Macular Edema Associated with Retinal Vascular Disorders

Purpose

To evaluate the effect of intravitreal triamcinolone acetonide on visual acuity and macular thickness using optical coherence tomography (OCT) in macular edema associated with various retinal vascular disorders.

Methods

This prospective nonrandomized clinical interventional study included 81 eyes (76 patients) comprised of Group I, 57 eyes (51 patients) with diabetic macular edema; Group II, 10 eyes (10 patients) with branch retinal vein occlusion; and Group III, 13 eyes (13 patients) with central retinal vein occlusion. All eyes received an intravitreal injection of 4 mg triamcinolone acetonide (with the solvent) in the operation theater under sterile conditions.

Results

Mean preinjection central macular thickness was 531.84±132 μm in Group I, 458.4±149 μm in Group II, and 750.81±148 μm in Group III. All groups showed a statistically significant decrease in mean central macular thickness at 1 month (300.7±119 μM in Group I, 218.2±99 μm in Group II, and 210.5 ±56 μm in Group III) and 3 months (253.19±109 μm in Group I, 187±47 μm in Group II, and 182±50 μm in Group III) after injection (p<0.05). Mean follow-up was 22±2.4 weeks. Mean visual acuity increased in all three groups (preoperative visual acuity in Group I, 1.2±0.4 logMAR units; Group II, 1.24±0.5 logMAR units; Group III, 1.1 ±0.4 logMAR units; 1 month postinjection in Group I, 0.88±0.3 logMAR units; Group II, 0.67±0.3 logMAR units; Group III, 0.86±0.4 logMAR units; 3 months postinjection in Group I, 0.84±0.4 logMAR units; Group II, 0.59±0.3 logMAR units; Group III, 0.82±0.5 logMAR units) (p<0.05). Forty-one eyes completed 6 months and 20 eyes completed 9 months follow-up. Twelve of 20 (41%) eyes in Group I, 2/6 (33%) eyes in Group II, 3/6 (50%) eyes in Group III, and 8/15 (53%) eyes in Group I, 1/3 (33%) eyes in Group II, and 2/2 (100%) eyes in Group III developed recurrence of macular edema with worsening of visual acuity at 6 and 9 months, respectively. Thirty-three (40.7%) eyes developed IOP elevation (at least one reading > 24 mmHg). One eye developed infective endophthalmitis.

Conclusions

Intravitreal injection of triamcinolone acetonide may be considered as an effective treatment for reducing macular thickening due to diffuse diabetic macular edema, venous occlusion associated macular edema, and may result in increase in visual acuity at least in the short term. Further follow-up and analysis is required to demonstrate its long-term efficacy.

Role of aflibercept for macular edema following branch retinal vein occlusion: comparison of clinical trials

For years, the standard of care for branch-retinal-vein-occlusion-associated macular edema was initial observation followed by grid-pattern laser photocoagulation for persistent edema. Newer pharmacologic options have revolutionized the management of branch-retinal-vein-occlusion-associated macular edema, and the visual outcomes of these eyes are better than ever. However, a variety of available treatment options including intravitreal corticosteroids and intravitreal anti-vascular endothelial growth factor agents have established novel challenges with regard to appropriate drug selection. This review summarizes the available clinical studies with special emphasis on the comparison of intravitreal aflibercept with ranibizumab, bevacizumab, and steroid agents.

The comparison of intravitreal triamcinolone and bevacizumab in patients with macular edema secondary to branch retinal vein occlusion

Purpose

This study was conducted to compare the efficacy and safety of intravitreal triamcinolone acetonide (IVTA) and intravitreal bevacizumab (IVB) in the treatment of macular edema related to branch retinal vein occlusion (BRVO), using the new optical coherence tomography parameters.

Material and methods

The medical records of 62 patients (IVTA n=26; IVB n=36) with macular edema secondary to BRVO and at least 12 months follow-up between 2007 and 2011 were evaluated by within-group and inter-group comparisons.

Results

Both groups were similar in terms of demographic characteristics (P>0.05). Best corrected visual acuity (BCVA) improvement and central subfoveal thickness (CST) reduction were significantly higher in the IVTA group at only the third month (P<0.05). In nonischemic BRVO, while BCVA improvement was significantly higher in the IVTA group at the third and sixth months (P<0.05), no significant difference was found in CST reduction at all visits (P>0.05). In ischemic BRVO, no significant difference was found in BCVA improvement at all visits, but CST reduction was significantly higher in the IVTA group at the first and third months. Logarithmic optical coherence tomography change (LogOCTc) and relative change in retinal thickness (RCRT) showed the same levels of significance in the comparisons. Relative change in retinal thickening (RCRTing) was more valuable compared to the other parameters in the subgroup analyses.

Conclusion

There was no difference between groups at the 12th month. IVTA was more efficient than IVB in regard to BCVA improvement in nonischemic BRVO in the early follow-up. IVTA made significant retinal thinning compared to IVB in ischemic BRVO in the early period. RCRTing and LogOCTc are important parameters used to monitor the response to treatment in BRVO. Because of the similar levels of significance, RCRT and LogOCTc can be used interchangeably.

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.

Relationship between grades of macular perfusion and foveal thickness in branch retinal vein occlusion

BACKGROUND

To study the relationship between retinal perfusion around the macula and the foveal thickness in branch retinal vein occlusion (BRVO).

METHODS

Seventy-four eyes of 74 consecutive patients with BRVO were enrolled. We developed a new grading system to evaluate the status of retinal perfusion around the macula in three grades: full perfusion area (FPA), partial perfusion area (PPA), and nonperfusion area (NPA), using fluorescein angiography. The correlation was assessed between these grades and the central foveal thickness (CFT) measured by optical coherence tomography. We also determined the area with the closest correlation between the perfusion status and the foveal thickness by comparing the correlation coefficient in areas of 1-, 2-, and 3-disc diameter (DD) horizontal hemicircles centered at the fovea. The correlation was determined between the extent of each perfusion grade and CFT.

RESULTS

We found a significant negative correlation between the CFT and the FPA (r = 0.31, P = 0.006) and a significant positive correlation between the CFT and the PPA (r = 0.45, P < 0.001) in the three areas. The most significant correlations were found in the 2-DD area. Interestingly, the NPA has not correlated with the foveal thickness in any areas.

CONCLUSION

The areas of partial but not complete capillary loss seem to be responsible for the macular edema associated with BRVO. Treatments targeting leakage from the dilated capillaries in the PPA should be investigated.

Hypothalamic-pituitary-adrenal axis function following intravitreal triamcinolone acetonide injection

To evaluate the pituitary-adrenal axis function by means of the adrenocorticotropic hormone (ACTH) stimulation test following a single intravitreal injection of triamcinolone acetonide (IVTA). Prospective comparative clinical interventional study. Twenty-eight patients (28 eyes) received a single IVTA (4 mg in 0.1 ml) for macular edema. The basal cortisol level and the response to 1 μg adrenocorticotropic hormone stimulation were determined on the morning before IVTA injection and at 1 day and 1, 2, and 4 weeks after IVTA injection. Results were compared with those obtained from a control group of 50 healthy subjects. All patients in the study had normal basal cortisol and normal response to ACTH challenge before receiving IVTA. 1 day following IVTA, basal cortisol was suppressed in one patient in the study group. Fasting serum cortisol levels at 1, 2, and 4 weeks after IVTA injection were normal in all patients in the study group. 1 day following IVTA, the peak response to ACTH at 30 min was blunted in four patients (14.3 % of the study group, p = 0.05) and the cortisol response at 60 min was suppressed (p = 0.009). 1 week following IVTA, the response to ACTH challenge was blunted in only one patient. A single IVTA injection may be associated with impaired hypothalamic-pituitary-adrenal function in some patients during the first 24 h following IVTA.

Chemokines in aqueous humour before and after intravitreal triamcinolone acetonide in eyes with macular oedema associated with branch retinal vein occlusion

PURPOSE

To determine the aqueous humour levels of chemokines before and after an intravitreal injection of triamcinolone acetonide (IVTA) in eyes with macular oedema associated with a branch retinal vein occlusion (ME-BRVO).

DESIGN

  Single-centre, prospective, consecutive interventional case series.

PARTICIPANTS

Seventeen eyes of 17 consecutive patients with ME-BRVO who underwent IVTA were studied. Seven eyes without retinal vascular disease served as control.

INTERVENTION

All patients with ME-BRVO underwent IVTA.

MAIN OUTCOME MEASURES

The optical coherence tomographically determined foveal thickness (FT) and the aqueous humour levels of inflammatory chemokines of the C-C subfamily, including eotaxin, monocyte chemotactic protein-1 (MCP-1), macrophage inflammatory protein-1α (MIP-1α), β (MIP-1β), and RANTES was determined before the IVTA (baseline) and at 1 week after the IVTA.

RESULTS

At the baseline, only MCP-1 and MIP-1β were detected in the aqueous, and MIP-1β was significantly higher in eyes with a ME-BRVO than in controls (p = 0.004). The level of both of these chemokines was not correlated with the FT (p = 0.654 and p = 0.608, respectively). One week after IVTA, the FT was significantly decreased (p < 0.001), and the levels of MCP-1 and MIP-1β were also significantly reduced (p < 0.001 and p = 0.044, respectively). The decrease in the FT was correlated with the decrease in only MIP-1β (r = 0.58, p = 0.020).

CONCLUSIONS

Alterations of the aqueous level of MIP-1β reflect the improvement of the macular oedema after IVTA in eyes with ME-BRVO. This indicates that the steroid-dependent ME-BRVO was closely related with the level of MIP-1β.

Intravitreal injection of autologous plasmin enzyme for macular edema associated with branch retinal vein occlusion

PURPOSE

To investigate the effects of an intravitreal injection of autologous plasmin enzyme for macular edema associated with a branch retinal vein occlusion (BRVO).

DESIGN

Prospective, interventional case studies.

METHODS

Twenty-six eyes of 26 patients (14 men and 12 women) with macular edema resulting from a BRVO were studied. None of the eyes had a posterior vitreous detachment (PVD). The average age at the onset of BRVO was 58.7 ± 6.6 years. The interval between onset of the macular edema and injection of autologous plasmin enzyme was 4.2 months. One international unit of autologous plasmin enzyme in 0.1 mL was injected into each vitreous. The presence of a PVD was evaluated 1 week after the injection, and the visual acuity and macular thickness were measured before and 1 week and 1, 3, 6, and 12 months after the autologous plasmin enzyme injection.

RESULTS

After the autologous plasmin enzyme injection, a total PVD was observed in 23 eyes and no PVD was observed in 3 eyes. The visual acuity gradually recovered after the injection, improved by 2 lines or more in 23 eyes, and remained unchanged in the 3 eyes. The retinal thickness also recovered gradually at 1, 3, 6, and 12 months. The mean retinal thickness was reduced from 602.12 to 253.62 μm at 12 months after surgery. It was reduced significantly after 1, 3, 6, and 12 months (P < .0001).

CONCLUSIONS

Intravitreal autologous plasmin enzyme may lead to an improvement of visual acuity and a reduction of macula edema in eyes with BRVO.

Pharmacotherapeutic efficacy of preservative-free intravitreal triamcinolone acetonide

Preservative-free formulations of triamcinolone acetonide have recently been introduced to the market over concerns of local toxicity of the vehicle and preservatives, including benzyl alcohol in the original formulation, which was not designed for intraocular use. The pharmacokinetics and pharmacodynamics of intravitreal triamcinolone (IVTA) are discussed. The therapeutic effects of IVTA include improvement of visual acuity and reduction of macular edema. However, ongoing treatment is usually required to maintain its effects. The efficacy of IVTA for both FDA-approved and 'off-labeled' indications is reviewed. Elevation of intraocular pressure and cataract formation are the two major side effects of IVTA; these are manageable but require close long-term follow-up. More studies are required to determine the optimal dosage and treatment frequency in different posterior segment disease.

Resource use and costs of branch and central retinal vein occlusion in the elderly

OBJECTIVE

To examine the incidence, prevalence, resource use, and costs associated with branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO) in elderly patients.

RESEARCH DESIGN AND METHODS

In a retrospective cohort study of a nationally representative sample of Medicare beneficiaries from 2001 through 2006, the authors identified patients with BRVO (n = 10,682) and CRVO (n = 6236) and controls with hypertension (n = 49,524) and glaucoma (n = 49,569) but no retinal vein occlusion. Incident cases were those with no claims listing a diagnosis for the same type of retinal vein occlusion in the previous 12 months. Prevalence was defined as the number of beneficiaries with a diagnosis of BRVO or CRVO. The authors summed Medicare reimbursements for all claims and used generalized linear models to estimate the effects of BRVO and CRVO on 1-year and 3-year costs compared with hypertension and glaucoma control groups. The authors also examined trends in the use of diagnostic and treatment modalities.

MAIN OUTCOME MEASURES

Resource use (fluorescein angiography, optical coherence tomography, intravitreal injection, laser photocoagulation, and vitrectomy) and direct medical costs (total Medicare reimbursement amounts as recorded on each inpatient, outpatient, home health, skilled nursing, hospice, durable medical equipment, and professional service claim) at 1 year and 3 years.

RESULTS

After adjustment for baseline characteristics, BRVO was associated with 16% higher 1-year costs and 12% higher 3-year costs compared with hypertension and 18% higher 1-year costs and 13% higher 3-year costs compared with glaucoma. CRVO was associated with 22% higher 1-year costs and 15% higher 3-year costs compared with hypertension and 24% higher 1-year costs and 16% higher 3-year costs compared with glaucoma. Use of fluorescein angiography and optical coherence tomography increased during the study. Use of intravitreal injections increased from less than 1% of patients overall to greater than 13% for BRVO and 16% for CRVO. The incidence of BRVO declined slightly during the study period, whereas the incidence of CRVO remained relatively flat. Prevalence increased in both groups.

LIMITATIONS

The results may not be generalizable to younger patients or managed-care beneficiaries. The study included only direct costs to Medicare, not nonmedical expenditures or outpatient prescription medications. Diagnosis and procedure codes may not have been complete. The study could not account for clinical variables, such as the amount of vision loss. It was not feasible to adjust for whether one or both eyes were affected or treated.

CONCLUSIONS

Although not common in the Medicare population, BRVO and CRVO are important independent predictors of total medical costs. Diagnostic and treatment modalities have changed over time.

Effect of triamcinolone acetonide on vascular endothelial growth factor and occludin levels in branch retinal vein occlusion

PURPOSE

To investigate the molecular mechanism by which triamcinolone acetonide (TA) may reduce edema in a porcine model of branch retinal vein occlusion (BRVO).

DESIGN

Animal study.

METHOD

After baseline ophthalmoscopic examination and fundus photography, a BRVO was created photothrombotically in each eye of 6 pigs, using argon green photocoagulation and intravenous Rose Bengal. Following this, the left eye was injected intravitreally with 4 mg/0.1 ml TA. After 11 weeks, the eyes were re-examined. Fluorescein angiography, in addition to ophthalmoscopy and fundus photography, was performed. Following sacrifice of the animals, the eyes were enucleated and processed. The distribution of vascular endothelial growth factor (VEGF), occludin, and glial fibrillary acidic protein (GFAP) were localized by immunofluorescence cytochemistry on 10 microm frozen retinal sections of TA-treated and untreated eyes.

RESULTS

Retinal VEGF levels were significantly lower in the TA-treated eyes as compared with the untreated eye (P = .002). Conversely occludin levels were significantly higher in the treated eye (P = .026). There was also a significant reduction in GFAP immunoreactivity in the Muller cells of the treated eyes (P = .015) with no statistical significance in the astrocytes (P = .065).

CONCLUSION

Intravitreal TA down regulates VEGF, which may prevent a decrease in occludin and also inhibits an increase in GFAP expression in Muller cells. These events may contribute to a reduction in the blood retinal barrier breakdown that occurs in BRVO and promote resolution of the associated retinal edema.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Use of intravitreal triamcinolone in the treatment of macular edema related to retinal vein occlusion

Objective:

To analyze the increasing trend of intravitreal triamcinolone (IVTA) use in the treatment of retinal vein occlusion-related macular edema.

Methods:

We performed MEDLINE/PUBMED searches (September 1984 - December 2007) to identify articles containing the keywords macular edema and triamcinolone. Case reports, reviews and abstracts were identified from references in the reviewed literature. This review focuses on literature published during the past 7 years with more than two-thirds of the articles that we reviewed being printed during the past 5 years. These reports analyzed the success of IVTA in the treatment of macular edema over a 12 month course of time.

Results:

The majority of studies suggested promising results for short time periods (4-6 months) after IVTA treatments. However, long term results were not encouraging.

Conclusions:

The success of IVTA therapy for short durations has been the impetus for development of sustained release devices to be used in the treatment of macular edema associated with various retinal diseases including edema related to retinal vein occlusion.

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.

Intravitreous bevacizumab in the treatment of macular edema from branch retinal vein occlusion and hemisphere retinal vein occlusion (an AOS thesis)

PURPOSE

To compare intravitreous bevacizumab to other current treatments of branch retinal vein occlusion (BRVO) and hemisphere retinal vein occlusion (HRVO) with consideration to visual outcome, cost, convenience, and risk of treatment.

METHODS

This is a retrospective chart review from a large referral retina practice. The data comprise 56 patients with BRVO and HRVO treated by intravitreous bevacizumab, with and without intravitreous triamcinolone acetonide. Initial visual acuities at the time of first bevacizumab injection, best acuities through the follow-up time, final acuity at last visit before review, initial macular thickness, and final macular thickness were measured. Changes in vision and thickness were calculated, as were the percentage of eyes improving, stabilizing, and worsening.

RESULTS

The data were compared to composite data derived from several current treatments of BRVO. The subgroup of 39 eyes that received only bevacizumab without triamcinolone acetonide had the most improvement in vision. The median change in visual acuity was 1.5 lines (P = .012) over a mean follow-up of 8.8 months. Twenty-three eyes (59%) improved visually, with 20 eyes (51%) improving 2 or more lines. These results are similar to those for eyes that received argon grid laser and chorioretinal anastomosis, but are worse than in eyes that received arteriovenous adventitial sheathotomy, macular decompression surgery, and intravitreous triamcinolone acetonide.

CONCLUSIONS

Visual benefit from intravitreous bevacizumab compares well against laser treatments for BRVO and HRVO but not as well opposed to surgical techniques and intravitreous triamcinolone acetonide. Intravitreous bevacizumab injection has a risk, cost, and convenience profile that is favorable.

Quantification of sedimented triamcinolone for intravitreal injection

PURPOSE

To develop a practical method to concentrate triamcinolone acetonide for intravitreal injection.

METHODS

A protocol using sedimentation was developed to increase the concentration of triamcinolone acetonide in a 0.1 mL dose. Two variables were investigated: sedimentation time and initial volume of triamcinolone acetonide. Predetermined volumes (0.2 mL to 1 mL) of triamcinolone acetonide were aspirated into tuberculin syringes. Each syringe was placed in a vertical position for a designated time (0 to 120 minutes). The supernatant was then discarded to reduce the volume to 0.1 mL. High-performance liquid chromatography was then used for quantification of the triamcinolone acetonide.

RESULTS

The greatest concentrations of triamcinolone acetonide were seen after 120 minutes of sedimentation. At that time point, the 0.2 mL, 0.3 mL, and 0.5 mL initial volumes resulted in, respectively, 7.4 mg +/- 0.8 mg (mean +/- SE), 9.8 mg +/- 0.2 mg, and 16.4 mg +/- 0.7 mg triamcinolone acetonide in 0.1 mL. The 1.0-mL initial volume resulted in 25.7 mg +/- 0.9 mg triamcinolone acetonide in 0.1 mL; this was the maximum concentration achieved in the experiment.

CONCLUSION

The authors have developed a simple protocol to use sedimentation to greatly increase the concentration of triamcinolone acetonide, starting from commercially available triamcinolone acetonide up to a maximum of 25.7 mg per 0.1 mL (257 +/- 9 mg/mL). This study demonstrates a practical and quantifiable method to increase triamcinolone concentration for intravitreal injections.

Patients' preferences in choosing therapy for retinal vein occlusions

PURPOSE

The purpose of this study was to assess preference values for vein occlusions with macular edema and to determine how this may affect patient perceptions of potential treatments.

METHODS

The Submacular Surgery Trials Vision Preference Value Scale and questions regarding enthusiasm for potential treatments were administered to 153 patients with vein occlusion. Univariate analyses identified predictors of preference values, followed by adjustment for potential confounders using multivariate linear regression. Relationships between preference values and enthusiasm for potential treatments were assessed.

RESULTS

The mean preference values +/- SD were similar for patients with branch vein occlusions and central vein occlusions (0.65 +/- 0.20). Lower preference values were associated with duration of occlusion of >2 years (P=0.03) and poorer last-recorded visual acuity (P=0.02). Approximately one half of patients were moderately or very enthusiastic about undergoing intravitreal injection. Sixty-nine percent of branch vein occlusion patients were moderately or very enthusiastic about the standard of care, laser photocoagulation; only one third of central vein occlusion patients were moderately or very enthusiastic about standard observation.

CONCLUSIONS

These data suggest that vein occlusion with macular edema has a significant impact on quality of life. Most patients were willing to undergo potentially invasive treatment.

RETINAL TOXICITY OF INTRAVITREAL KENALOG IN ALBINO RABBITS

PURPOSE

To evaluate possible toxicity of intravitreal Kenalog (commercial triamcinolone acetonide) to the retina of albino rabbits.

METHODS

Forty-three albino rabbits were injected intravitreally with 0.1 mL of experimental solution to the right eye and 0.1 mL of saline to the left eye (control). Rabbits in Group A (n=28) were injected with 4 mg/0.1 mL of Kenalog suspension; rabbits in Group B (n=8) were injected with 0.1 mL of Kenalog vehicle; and rabbits in Group C (n=7) were injected with 4 mg/0.1 mL of triamcinolone acetonide. Rabbits were examined ophthalmoscopically and by electroretinogram (ERG) recordings before and at different time intervals after injection. At the end of follow-up, animals were killed and the retinas were prepared for light microscopy.

RESULTS

Thirty-eight rabbits completed 4 weeks of follow-up. Follow-up for 8 and 17 weeks was completed by 29 and 3 rabbits, respectively. Intravitreal commercial Kenalog or its vehicle alone caused approximately 50% reduction in the ERG b-wave amplitude at the end of follow-up. Pure triamcinolone acetonide caused only mild (up to 14%) reduction of the ERG b-wave amplitude. Histologic examination of retinas exposed to Kenalog or its vehicle showed severe damage to all retinal layers in areas close to the site of Kenalog injection.

CONCLUSIONS

Intravitreal injection of 4 mg Kenalog suspension is retinotoxic to albino rabbit eyes. The vehicle of Kenalog is probably the main cause of this toxicity.

Comparative study on efficacy of a combination therapy of triamcinolone acetonide administration with and without vitrectomy for macular edema associated with branch retinal vein occlusion

AIMS

To compare the efficacy ofa combination therapy of triamcinolone acetonide (TA) administration with and without vitrectomy in eyes with macular edema associated with branch retinal vein occlusion over a 1-year period.

METHODS

A retrospective, case-control study was conducted in 15 eyes of 15 patients with macular edema associated with branch retinal vein occlusion. Eight eyes underwent simultaneous intravitreal and posterior sub-Tenon capsule injections of TA (TA-injected group). Seven eyes underwent vitrectomy with intravitreal or simultaneous posterior sub-Tenon capsule injection of TA (vitrectomy with TA group). Macular thickness and visual acuity were measured before and at 1, 3, 6 and 12 months after the therapy.

RESULTS

Twelve months after the therapy, mean visual acuity improved significantly from baseline in both the TA-injected (p = 0.0069) and vitrectomy with TA groups (p = 0.0145). Macular thickness also improved significantly in both the TA-injected (p = 0.0065) and vitrectomy with TA groups (p = 0.0058). At 12 months after the therapy, there was no significant difference in visual acuity and macular thickness between the two groups (p = 0.3308 and 0.3711, respectively). At the early postoperative stage (1 and 3 months after the therapy), the central macular thickness in the TA-injected group was significantly less than that in the vitrectomy with TA group (p = 0.0140 and 0.0275, respectively); there was no significant difference in visual acuity between the two groups (p = 0.0796 and 0.3753, respectively).

CONCLUSION

TA injection without vitrectomy was as effective as a combination therapy of TA injection with vitrectomy.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Evaluation of Intravitreal Kenalog Toxicity in Humans

OBJECTIVE

To evaluate possible functional toxicity of intravitreal Kenalog (commercial triamcinolone acetonide) in patients' retinas.

DESIGN

Observational case series.

PARTICIPANTS

Thirty-two phakic eyes of 16 patients who had nonproliferative diabetic retinopathy and bilateral macular edema refractory to laser therapy, which had no other eye disorder and no previous ophthalmic operation.

INTERVENTION

Kenalog (4 mg/0.1 ml) was injected intravitreally to one eye, whereas the second eye served as the control. The experimental eye was chosen as the eye with worse visual acuity (VA).

MAIN OUTCOME MEASURES

Deterioration of electroretinogram parameters of the study eye measured at 3 months of follow-up when compared with the electroretinogram responses of the fellow, control eye and when compared with electroretinogram responses obtained before injection. Visual acuity, intraocular pressure (IOP), and eventual complications were assessed. No improvement or deterioration of VA or any increase in IOP was regarded as a secondary outcome.

RESULTS

Average maximal response amplitude ratios of the dark-adapted b-wave (treated/control eyes) of the electroretinogram were 0.93 before (P = 0.221) and 0.94 (P = 0.387) 3 months after Kenalog injection. Average ratios of the light-adapted b-wave amplitude (treated/control eyes) of the electroretinogram were 1.04 (P = 0.702) before and 0.86 (P = 0.138) 3 months after Kenalog injection. No significant differences (P>0.05) were found between the electroretinogram parameters obtained from all eyes before and 3 months after Kenalog injection. Average VAs in the treated eyes were 1.08, 0.8, and 1.0 logarithm of the minimum angle of resolution units before and 2 and 4 months after injection, respectively. Temporary elevation of IOP was found in 4 treated eyes of 4 patients (25%).

CONCLUSIONS

No electroretinographic evidence of a retinotoxic effect of intravitreal Kenalog was found in our patients.

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.

Intravitreal steroids in the management of macular oedema

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

Preoperative visual acuity as a prognostic indicator for laser treatment of macular edema due to branch retinal vein occlusion

BACKGROUND AND OBJECTIVE

To determine the visual outcome of laser treatments for macular edema due to branch retinal vein occlusion (BRVO) in patients with a preoperative visual acuity (VA) of 20/200 or worse compared to patients with a preoperative VA of better than 20/200.

PATIENTS AND METHODS

Records of 88 patients with macular edema secondary to BRVO undergoing laser treatment from 1984 to 2003 were reviewed. Mean VA was measured before and after each treatment and after the final treatment.

RESULTS

All patients received between one and five laser treatments. Preoperative VA was better than 20/200 in 56 patients (group 1) and 20/200 or worse in 32 patients (group 2). Patients in group 1 had a mean improvement of 0.48 lines and 57% had a final VA of 20/40 or better. Patients in group 2 had a mean improvement of 1.69 lines and 20% had a final VA of 20/40 or better.

CONCLUSIONS

Patients with poor VA (20/200 or worse) secondary to macular edema due to BRVO responded positively to laser treatment. The level of preoperative VA can be a useful predictor of visual outcome. These patients should consider laser treatment before alternative, more aggressive approaches.

One-year safety and efficacy of intravitreal triamcinolone acetonide for the management of macular edema secondary to central retinal vein occlusion

PURPOSE

To evaluate the safety and efficacy of intravitreal triamcinolone acetonide (IVTA) as treatment for macular edema associated with central retinal vein occlusion (CRVO).

METHODS

A retrospective review was performed of data for 40 consecutive patients (40 eyes) with CRVO and macular edema treated with IVTA at the Bascom Palmer Eye Institute (Miami, FL).

RESULTS

Median duration of symptoms before the first injection was 3 months (range, 1 day to 8 years). Median Snellen visual acuity was 20/400 at baseline (range, 20/60 to light perception; n = 40), 20/300 at 1 month (P = 0.010; n = 37), 20/300 at 3 months (P = 0.007; n = 33), 20/400 at 6 months (P = 0.726; n = 28), and 8/200 at 1 year (P = 0.569; n = 17). Vision improved by > or =3 lines in 21% of eyes at 1 month, 27% at 3 months, 14% at 6 months, and 12% at 1 year. Visual acuity was unchanged from baseline in 71% of eyes at 6 months and 1 year. By 1 year, 50% of eyes received more than one injection (mean = 1.6 injections; range 1-4 injections). Overall, intraocular pressure increased by > or =10 mmHg in 24% of eyes at 1 year. Trabeculectomy was performed on 2 of 12 eyes with preexisting open-angle glaucoma.

CONCLUSION

IVTA can substantially improve vision in some patients, but most patients have stable visual acuity compared with baseline at 1 year despite repeated injections.

Corticosteroid-induced glaucoma: a review of the literature

The intraocular pressure rise that can complicate the use of topical or systemic corticosteroid has been recognised for 50 years. More recently, following isolation of the myocilin gene (previously known as the trabecular meshwork inducible glucocorticoid response or TIGR gene), there has been renewed interest in this steroid-responsive phenomenon. Furthermore, the currently fashionable use of injectable intraocular steroids in the management of clinically significant subretinal fluid and macular oedema has resulted in an increased incidence. Animal studies, cell biology, molecular biology, and an improved knowledge of genetics have provided a better understanding of the mechanisms behind the response. The purpose of this review is to describe the risk factors for developing corticosteroid-induced glaucoma, to discuss the underlying mechanisms and genetics of the condition and to present management options.

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.

The management of retinal vein occlusion: is interventional ophthalmology the way forward?

Retinal vein occlusions (RVO) are the second commonest sight threatening vascular disorder. Despite its frequency treatments for RVO are unsatisfactory and include several that have not been tested by large, well designed, prospective, randomised controlled trials. There is also the lack of long term follow up in many of the available small uncontrolled studies, and the timings of interventions are haphazard. This review aims to evaluate the current knowledge relating to the pathogenesis, suggested treatments for the different types of RVO, and their complications. Isovolaemic haemodilution is of limited benefit and should be avoided in patients with concurrent cardiovascular, renal, or pulmonary morbidity. Evidence to date does not support any therapeutic benefit from radial optic neurotomy, optic nerve decompression, or arteriovenous crossing sheathotomy on its own. Vitrectomy combined with intravenous thrombolysis may offer promise for central RVO. Similarly, vitrectomy combined with arteriovenous sheathotomy intravenous tissue plasminogen activator may offer benefits for branch RVO. RVOs occur at significantly high frequency to allow future prospective randomised controlled studies to be conducted to evaluate the role of different therapeutic modalities singly or in combination.

Intravitreal triamcinolone for the treatment of ischemic macular edema associated with branch retinal vein occlusion

PURPOSE

To evaluate the safety and efficacy of intravitreal triamcinolone acetonide (IVTA) for ischemic macular edema associated with branch retinal vein occlusion (BRVO) and foveal ischemia.

DESIGN

Prospective interventional case series.

METHODS

setting: Clinical practice. study population: Eighteen eyes of 18 patients with macular edema associated with BRVO and foveal ischemia. intervention: Four mg IVTA. main outcome measures: Visual acuity (VA), optical coherence tomography, macular thickness measurements, and treatment-related complications.

RESULTS

The mean duration of BRVO before treatment was 14 months. All patients were followed for a minimum of nine months, and 12 patients completed 12 months follow-up. The mean logarithm of the minimum angle of resolution (logMAR) VA improved significantly from 0.81 +/- 0.36 at baseline to 0.65 +/- 0.30 at one month (P = .03) but did not vary significantly from baseline at three, six, nine, and 12 months. Macular thickness improved significantly in all eyes from a mean of 400 +/- 134 mum preinjection, to 228 +/- 58 mum at one month (P < .01) and 256 +/- 121 mum at three months (P < .01) but did not vary significantly from baseline at six, nine, and 12 months. Eight eyes developed posterior subcapsular cataract, intraocular pressure (IOP) exceeded 21 mm Hg in four eyes, and two eyes developed vitreomacular traction during follow-up.

CONCLUSIONS

IVTA is effective in reducing ischemic macular edema associated with BRVO and foveal capillary nonperfusion. This reduction is often associated with a temporary improvement in VA. Raised IOP and development of posterior subcapsular cataract are disadvantages of this treatment.

Cataract formation and other complications of intravitreal triamcinolone for macular edema

PURPOSE

To evaluate complications and results of intravitreal triamcinolone acetonide for treatment of macular edema.

DESIGN

Interventional, consecutive, retrospective case series.

METHODS

Ninety-three eyes with macular edema arising from retinovascular etiologies were treated with 4 mg intravitreal triamcinolone. Eyes were monitored after injection for visual acuity changes and complications, including cataract formation and increase in intraocular pressure (IOP). Cataract progression was analyzed by linear regression analysis of lens scores from lens opacity standards.

RESULTS

The mean visual acuity improved from 20/125 to -1 to 20/100 + 2 by one to two months after injection (P < .001) and was 20/100 at the final examination (P = .006) at a mean of 1.2 years after injection. Complications included a severe, culture-negative inflammatory reaction in one eye (1.1%). IOP increased to 30 mm Hg or more in nine (9.7%) of 93 eyes between 1 and 140 days after injection and was more frequent in eyes receiving one or more preinjection glaucoma drops (two of 13 eyes, 15.4%, vs seven of 80 eyes, 8.75%, without preinjection glaucoma drops). Nuclear sclerosis increased at a rate of 0.175 U per year, posterior subcapsular cataracts at 0.423 U per year, and cortical cataracts at 0.045 U per year. Posterior subcapsular cataract increased by > or = 1 U or required cataract surgery in 45.2% of eyes followed at least one year.

CONCLUSIONS

Intravitreal triamcinolone improves visual acuity in most eyes but eyes must be monitored carefully for increase in IOP. Posterior subcapsular cataract formation becomes visually significant in almost half of eyes by one year after injection.

Repeated intravitreal high-dosage injections of triamcinolone acetonide for diffuse diabetic macular edema

OBJECTIVE

To report the results of repeated intravitreal injections of triamcinolone acetonide for treatment of diffuse diabetic macular edema.

DESIGN

Retrospective interventional comparative study.

PARTICIPANTS

The investigation included a study group (the responders) of 19 patients (22 eyes) with diffuse diabetic macular edema, who showed an improvement in visual acuity after an intravitreal injection of approximately 20 mg triamcinolone acetonide, and who received a second intravitreal injection 10.0+/-3.8 months after the first injection. A control group consisted of 31 patients with diffuse diabetic macular edema without treatment during follow-up.

METHODS

Intravitreal injection of approximately 20 mg triamcinolone acetonide.

MAIN OUTCOME MEASURES

Visual acuity and intraocular pressure.

RESULTS

Follow-up after the second injection was 9.1+/-4.9 months. Four patients received a third injection at 9.7+/-3.7 months after the second injection, with a follow-up after the third injection that was at 7.9+/-11.5 months. After the second and third injections, visual acuity increased significantly (P = 0.002 and P = 0.068, respectively) by 1.8+/-2.1 and 4.0+/-2.6 Snellen lines, respectively. Eleven eyes (50%) showed an improvement in visual acuity by at least 2 Snellen lines after the second injection, and 3 patients (75%) experienced a gain in visual acuity by at least 2 Snellen lines after the third injection. Intraocular pressure increased significantly (P<0.01) after each injection, and returned to baseline values before each reinjection. Visual acuity improvement (P>0.05) and intraocular pressure rise did not differ significantly (P>0.55) between the various injections. Improvement in visual acuity and rise of intraocular pressure lasted approximately 6 to 8 months after each injection.

CONCLUSIONS

Intravitreal injection of approximately 20 mg triamcinolone acetonide may repeatedly lead to an improvement in visual acuity and a rise of intraocular pressure in patients with diffuse diabetic macular edema. The duration of the effect after each injection is approximately 6 to 8 months. Tachyphylaxis in visual acuity or intraocular pressure outcomes were not observed.

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.

Intravitreal triamcinalone acetonide for refractory uveitic cystoid macular oedema: longterm management and outcome

PURPOSE

To establish the role of intravitreal triamcinalone acetonide (TA) in the long term management of refractory uveitic cystoid macular oedema (CMO) and to determine the long term visual outcome in these patients.

METHOD

This is a retrospective observational case series. All patients had resistant CMO and active inflammation. The primary outcome measure was complete resolution of CMO on ocular coherence tomography. Visual acuity and intraocular pressure were also monitored. Twelve eyes of twelve patients received 2 (n = 10) to 4 (n = 2) mg of intravitreal TA. All had previously been unresponsive to orbital floor steroids. Fluorescein angiography was performed where indicated.

RESULTS

There was complete resolution of CMO in all patients. Nine patients had improvement in acuity at there final follow up (mean follow up 40.5 months). Seven had improved by 2 lines (58%). In 3 patients there was no visual improvement. These 3 failed to respond to re-treatment. Five other patients were re-treated because of recurring CMO and deteriorating VA (median time to re-treatment 4 mths). The mean number of re-treatments for this group with orbital floor TA was three. 41.6% of patients developed ocular hypertension (33.8 mhg mean). One required a trabeculectomy.

CONCLUSIONS

2 mg of intravitreal TA is effective even in cases of resistant uveitic CMO. Although re-treatment is often required, the initial response to treatment can be maintained by subsequent orbital floor steroid injections.

INTRAVITREAL TRIAMCINOLONE TREATMENT FOR MACULAR EDEMA ASSOCIATED WITH CENTRAL RETINAL VEIN OCCLUSION AND HEMIRETINAL VEIN OCCLUSION

PURPOSE

To assess the efficacy of intravitreal triamcinolone treatment for macular edema from central retinal vein occlusion (CRVO) and hemiretinal vein occlusion (HRVO).

METHODS

This study was a retrospective medical records review of 24 eyes of 24 patients (mean age, 71 years) that were injected with 4 mg of intravitreal triamcinolone acetonide for treatment of macular edema due to CRVO (n = 21) and HRVO (n = 3). Of the 24 eyes, 14 were injected once, 6 were injected twice, 3 were injected 3 times, and 1 received 4 injections. Mean follow-up time was 10 months (range, 3-24 months). The average time between onset of symptoms and first injection was 5.4 months (range, 2-48 months). Available documents on pre- and postinjection optical coherence tomography central foveal thickness in 23 of 39 total injections were evaluated.

RESULTS

All injections resulted in reduction in central foveal thickness as determined by optical coherence tomography. The mean central foveal thickness decreased to 55% of preinjection values ([n = 23] 635 vs. 352 mum, respectively; P < 0.001). The average gain in visual acuity was 1.3 Snellen lines (range, -3-7) over the course of the study period. Ten eyes gained > or =2 lines of visual acuity, 3 eyes improved 1 line, 7 eyes remained the same, and 4 eyes worsened. There was no correlation between improvement in foveal thickness and corresponding visual gain (P = 0.24). None of the eyes of diabetic patients (n = 6) or patients with ischemic CRVO (n = 2) improved in visual acuity. The difference in mean baseline (20/167) and mean final visual acuity (20/91) was statistically significant (P = 0.015). The mean best postinjection visual acuity (20/67) was also significantly higher than the mean final visual acuity (P = 0.019). When diabetic and ischemic CRVO patients were excluded, the difference between mean baseline visual acuity and mean final visual acuity was found to be highly significant ([n = 16] 20/133 vs. 20/67, respectively; P < 0.001), while mean final and best postinjection visual acuities (20/50) did not differ (P = 0.085). Eight of 16 phakic eyes showed progression of cataract, 2 of which underwent cataract extraction. Nine of 18 patients without a history of glaucoma developed ocular hypertension and required glaucoma medication during postinjection follow-up. Trabeculectomy was performed on two eyes with glaucoma. Two other eyes developed epiretinal membranes, one of which underwent vitrectomy.

CONCLUSIONS

Intravitreal triamcinolone may be effective in treating macular edema from CRVO and HRVO. Subjects with concurrent diabetes or ischemic central retinal vein were less likely to have visual improvement.