Pars Plana Vitrectomy and Removal of the Internal Limiting Membrane in Diabetic Macular Edema Unresponsive to Grid Laser Photocoagulation

PURPOSE

To evaluate the effectiveness of pars plana vitrectomy (PPV) with removal of the internal limiting membrane (ILM) in diabetic patients with macular edema unresponsive to grid laser photocoagulation.

METHODS

In this randomized controlled study, 20 eyes of 10 patients with diabetic macular edema unresponsive to grid laser photocoagulation were evaluated. PPV with ILM removal was performed randomly in one eye each of 10 patients and taken as the study group; the untreated fellow eyes were taken as the control group. Main outcome measures were foveal thickness changes measured with optical coherence tomography and preoperative and post-operative visual acuity. Mann-Whitney U, Wilcoxon, and chi-square tests were used in statistical analysis.

RESULTS

The mean age of the patients was 61.5+/-6 years (range 51 to 71). All patients were followed up for 12 months. In the study group, mean foveal thickness was 391.3+/-91.6 microm preoperatively and 225.5+/-49.4 microm postoperatively (p=0.009). In the control group, mean foveal thickness was 356.2+/-140 microm at baseline and 318.4+/-111.1 microm at 12-month follow-up (p=0.138). Mean decrease in foveal thickness was 165.8+/-114.8 microm in the study group and 37.8+/-71.2 microm in the control group (p=0.016). In the study group, best-corrected log-MAR visual acuity was 0.71+/-0.43 preoperatively and 0.54+/-0.45 postoperatively (p=0.125). In the control group, best-corrected logMAR visual acuity was 0.43+/-0.44 at baseline and 0.59+/-0.55 at 12-month follow-up (p=0.235). In the study group, visual acuity improved by two or more lines in 4 eyes (40%) and remained stable in 6 eyes (60%). In the control group, visual acuity improved by two or more lines in 1 eye (10%) and decreased by two or more lines in 3 eyes (30%).

CONCLUSIONS

PPV with ILM removal appears to be an effective procedure for reducing diabetic macular edema unresponsive to grid laser photocoagulation. A further study with a large number of patients is required to assess the effectiveness and safety of this procedure.

Intravitreal Triamcinolone Acetonide as Primary Treatment for Diffuse Diabetic Macular Edema: A Prospective Noncomparative Interventional Case Series

Purpose

To evaluate the efficacy and safety of one intravitreal injection of 25 mg of triamcinolone acetonide as primary treatment for diffuse diabetic macular edema.

Methods

Intravitreal triamcinolone acetonide injection was performed in 30 eyes with previously untreated diabetic macular edema. The main outcome measures were logMAR visual acuity (VA) and central macular thickness (CMT) at 1, 3, and 6 months. A secondary outcome was intraocular pressure progression.

Results

Visual acuity results for 30 eyes that had a follow-up of at least 6 months are presented. Twenty of them were followed up to 10.1 ±2.38 months. Preoperatively, VA was 0.54±0.27. At 1, 3, and 6 months follow-up, VA was 0.44±0.29 (p=0.001), 0.43±0.28 (p=0.001), and 0.45±0.29 (p=0.006), respectively. Preoperatively, CMT was 417.3±143.5 μm. At 1, 3, and 6 months follow-up, CMT was 277.3 +74.0 μm (p<0.0001), 279.6±94.4 μm (p<0.0001), and 297.07±114.87 μm (p=0.002), respectively. For the 20 eyes with a follow-up of 10.1±2.38 months, VA was 0.5±0.25 and 0.50±0.32 at baseline and at the last follow-up visit, respectively (p>0.05). Preoperatively, intraocular pressue (IOP) was 15.13±1.48 mmHg. IOP was 18.26±2.71 mmHg, 20.07±4.27 mmHg, and 20.4±6.18 mmHg, at 1, 3, and 6 months, respectively (p<0.0001). Four eyes underwent uncomplicated filtrating surgery for intractable glaucoma.

Conclusions

Intravitreal triamcinolone as primary treatment effectively increases VA and reduces CMT due to diffuse diabetic macular edema. Longer follow-up and randomized clinical trial are war ranted. Safety results highlight the need to further study the relationship between triamcinolone and intraocular pressure.

Follow-Up after Intravitreal Triamcinolone Acetonide for Diabetic Macular Edema

PURPOSE

To report on the follow-up of patients who received an intravitreal high-dosage injection of triamcinolone acetonide (IVTA) as treatment of diffuse diabetic macular edema.

METHODS

The clinical interventional case-series study included 109 eyes (90 patients) with diffuse diabetic macular edema who consecutively received an IVTA of about 20 mg. Mean follow-up was 11.2 +/- 6.2 months.

RESULTS

Visual acuity improved significantly (p<0.001) from 0.89 +/- 0.33 logMAR to a best minimum of 0.65 +/- 0.35 logMAR. An increase in best visual acuity by at least 1 Snellen line, 2 lines, and 3 lines was found in 91 (83%) eyes, 68 (62%) eyes, and 45 (41%) eyes, respectively. Differences in visual acuity between baseline and follow-up examinations were significant for measurements performed at 1 month (p<0.001), 2 months (p<0.001), 3 months (p<0.001), and at 6 months (p=0.001) after the injection. At 9 months after the injection, mean visual acuity regressed significantly so that visual acuity at 9 months (p=0.83) and at 12 months after the injection (p=0.58) compared with baseline values did not differ significantly. Forty-seven (43%) eyes developed a rise in intraocular pressure (pressure >21 mmHg) for 6 to 8 months after the injection. No other severe complications were detected.

CONCLUSIONS

The duration of a visual acuity increase and intraocular pressure rise after high-dosage IVTA in diffuse diabetic macular edema is about 6 to 8 months. Compared with data in the literature, the high-dosage IVTA may not have a markedly higher profile of side effects than low-dosage IVTA.

Intravitreal triamcinolone versus laser photocoagulation as a primary treatment for diabetic macular oedema--a comparative pilot study

BACKGROUND

Diabetic macular oedema is the leading causes of blindness. Laser photocoagulation reduces the risk of visual loss. However recurrences are common and despite laser treatment, patients with diabetic macular oedema experienced progressive loss of vision. Stabilization of the blood retinal barrier introduces a rationale for intravitreal triamcinolone treatment in diabetic macular oedema. This study is intended to compare the best corrected visual acuity (BCVA) and the macular oedema index (MEI) at 3 month of primary treatment for diabetic macular oedema between intravitreal triamcinolone acetonide (IVTA) and laser photocoagulation.

METHODS

This comparative pilot study consists of 40 diabetic patients with diabetic macular oedema. The patients were randomized into two groups using envelope technique sampling procedure. Treatment for diabetic macular oedema was based on the printed envelope technique selected for every patient. Twenty patients were assigned for IVTA group (one injection of IVTA) and another 20 patients for LASER group (one laser session). Main outcome measures were mean BCVA and mean MEI at three months post treatment. The MEI was quantified using Heidelberg Retinal Tomography II.

RESULTS

The mean difference for BCVA at baseline [IVTA: 0.935 (0.223), LASER: 0.795 (0.315)] and at three months post treatment [IVTA: 0.405 (0.224), LASER: 0.525 (0.289)] between IVTA and LASER group was not statistically significant (p = 0.113 and p = 0.151 respectively). The mean difference for MEI at baseline [IVTA: 2.539 (0.914), LASER: 2.139 (0.577)] and at three months post treatment [IVTA: 1.753 (0.614), LASER: 1.711 (0.472)] between IVTA and LASER group was also not statistically significant (p = 0.106 and p = 0.811 respectively).

CONCLUSIONS

IVTA demonstrates good outcome comparable to laser photocoagulation as a primary treatment for diabetic macular oedema at three months post treatment.

TRIAL REGISTRATION

ISRCTN05040192 (http://www.controlled-trial.com).

Pattern electroretinogram changes after intravitreal bevacizumab injection for diabetic macular edema

We aimed at investigating the efficacy of intravitreal bevacizumab injection by evaluation of pattern electroretinogram (PERG) in diabetic patients with clinically significant macular edema (CSME). Thirty-five eyes of 35 patients with diabetes were treated with 2.5 mg of intravitreal bevacizumab injection as the primary therapy for CSME. The main outcome measures included best-corrected visual acuity, fundus fluorescein angiography, and P(50) amplitudes of pattern electroretinogram (PERG) before and after intravitreal injection. Mean visual acuity improved significantly from a mean LogMAR value of 1.1 +/- 0.2 at baseline to a maximum of 0.7 +/- 0.3 after a mean follow-up time of 6.4 months. The mean baseline P(50) and N(95) amplitudes of PERG before intravitreal injection were 1.4 +/- 0.7 and 2.4 +/- 0.8 microV, respectively. After the treatment, the mean P(50) amplitude of PERG was 2.4 +/- 0.9 microV at 1-month, 2.3 +/- 0.8 microV at 3-month, and 2.2 +/- 0.8 microV at the last visit, and the mean N(95) amplitude of PERG was 3.4 +/- 1.05 microV at 1-month, 3.3 +/- 0.9 microV at 3-month, and 3.2 +/- 0.9 microV at the last visit, and the mean P(50) and N(95) amplitudes were significantly higher when compared with baseline values (for each, P < .001). Mild anterior chamber inflammation in four eyes was controlled with topical corticosteroids. Eyes with diabetic macular edema treated with intravitreal bevacizumab showed improvement in visual acuity that was accompanied by improvement in PERG amplitudes. Further randomized trials are needed to investigate the role of PERG measurements in the evaluation of the efficacy of intravitreal bevacizumab injection.

Comparison of photocoagulation with combined intravitreal triamcinolone for diabetic macular edema

Purpose

To compare the efficacy between macular laser grid (MLG) photocoagulation and MLG plus intravitreal triamcinolone acetonide (IVTA; MLG+IVTA) therapy in diabetic macular edema (DME) patients.

Methods

A prospective, randomized, clinical trial was conducted of DME patients. A total of 60 eyes (54 patients) affected by DME were observed for a minimum of 6 months. Thirty eyes of 28 patients who received MLG treatment and 30 eyes of 26 patients who received the combined MLG+IVTA treatment were included in the study. Main outcome measures were BCVA and central macular thickness (CMT) as measured by optical coherence tomography (OCT) at 1, 3, and 6 months after treatment. Additionally, the authors examined retrospectively 20 eyes of 20 patients who were treated with only IVTA and compared with the 2 groups (MLG group and MLG+IVTA group).

Results

Baseline BCVA was 0.53±0.32 and CMT was 513.9±55.1 µm in the MLG group. At 1 and 3 months after treatment, the MLG group showed no significant improvement of BCVA and CMT, although there was significant improvement after 6 months. In the MLG+IVTA group, the baseline BCVA was 0.59±0.29 and CMT was 498.2±19.8 µm. After treatment, significant improvement of BCVA and CMT was observed at all follow-up time periods. When comparing the MLG group with the MLG+IVTA group, the latter had better results after 1 and 3 months, although at 6 months, there was no significant difference of BCVA and CMT between the 2 groups. Additionally, the IVTA group showed more improvement than the MLG group at 1 and 3 months but showed no significant difference at 6 months. In addition, the IVTA group showed no significant difference with the MLG+IVTA group at all follow-up time periods.

Conclusions

For DME patients, the combined MLG+IVTA treatment had a better therapeutic effect than the MLG treatment for improving BCVA and CMT at the early follow-up time periods. IVTA treatment alone could be an additional alternative therapeutic option to combined therapy.

Efficacy of intravitreal triamcinolone acetonide in long standing diabetic macular edema: a microperimetry and optical coherence tomography study

PURPOSE

To investigate the efficacy of intravitreal triamcinolone acetonide in patients suffering from diffuse long standing diabetic macular edema, by the assessment of retinal thickness and retinal function by means of optical coherence tomography (OCT) and microperimetry-1.

METHODS

Twenty eyes received 8 mg in 0.2 mL preservative free intravitreal triamcinolone injection delivered through the pars plana. The best corrected visual acuity (BCVA), foveal thickness, and the average retinal sensitivity of the 45 stimuli were considered in our study. Patients were instructed to attend for OCT and microperimetry-1 follow-up at baseline, 1, 3, and 6.

RESULTS

At the baseline, mean macular thickness was 692 micro +/- 70 micro; mean visual acuity was 0.13 +/- 0.09. Mean macular sensitivity determined with the microperimetry-1 was 6.85 dB +/- 2.1 dB. At the 1 month follow-up, mean OCT macular thickness decreased to 348.28 micro +/- 132.10 micro (P = 0.0001); mean BCVA improved to 0.23 +/- 0.15 (P = 0.019); mean retinal sensitivity improved to 8.71 dB +/- 2.79 dB (P = 0.03). At the 3 months follow-up, mean OCT macular thickness changed to 363.7 micro +/- 123.52 micro (P = 0.0002); mean BCVA was 0.23 +/- 0.15 (P = 0.0024); mean retinal sensitivity 8.54 dB +/- 2.78 dB (P = 0.048). Six months after the injection, mean OCT macular thickness was 460.61 micro +/- 104.9 micro (P > 0.05); mean BCVA was 0.15 (P > 0.05); mean retinal sensitivity 7.54 dB +/- 2.58 dB (P > 0.05).

CONCLUSION

In our study, we found intravitreal effective in improving BCVA, macular thickness, and retinal sensitivities during the first 3 months. At 6 months, follow-up of the data were not dissimilar to those obtained at baseline. Further investigation is warranted to asses the correlation among daily life visual performance, retinal sensitivities, and macular thickness.

Comparison of combination posterior sub-tenon triamcinolone and modified grid laser treatment with intravitreal triamcinolone treatment in patients with diffuse diabetic macular edema

PURPOSE

To compare the efficacy of posterior sub-Tenon's capsule triamcinolone acetonide injection combined with modified grid macular photocoagulation (PSTI + MP) with intravitreal triamcinolone acetonide (IVTA) injection in the treatment of diffuse diabetic macular edema (DME).

MATERIALS AND METHODS

Forty eyes of 33 patients with diffuse DME were randomly allocated into either PSTI + MP (20 eyes) or IVTA (20 eyes). Best corrected visual acuity (VA) and foveal thickness were measured.

RESULTS

The ETDRS scores at baseline were 25.2 +/- 13.6 (mean +/- SD) letters in the PSTI + MP group, whereas 21.7 +/- 16.3 letters in the IVTA group. The ETDRS scores improved by 33.2 +/- 15.9, 34.7 +/- 16.6 and 30.9 +/- 19.0 letters in the PSTI + MP group whereas by 30.9 +/- 15.4, 30.1 +/- 17.9 and 31.5 +/- 15.0 letters in the IVTA group at 1, 3, and 6 months after the treatments, respectively. The VA improved significantly at 1 month and 3 months after both treatments (all p < 0.02, paired t-test). The VA improvements were no longer significant at 6 months in either group. There were no statistically significant differences at any time points between the 2 groups (all p > 0.05, Student's t-test). The foveal thicknesses at baseline and 1, 3, and 6 months after the treatments were 382.8 +/- 148.3, 309.1 +/- 131.3, 319.3 +/- 93.3, 340.4 +/- 123.5 microm (mean +/- SD) in the PSTI + MP group vs. 369.1 +/- 123.1, 241.4 +/- 52.3, 277.5 +/- 137.4, 290.2 +/- 127.9microm in the IVTA group, respectively. Pairwise comparisons revealed significant decrease in foveal thickness at 1 month (p = 0.01, paired t-test) for the PSTI + MP group, and at both 1 month (p < 0.001) and 3 months (p = 0.016) for the IVTA group. There were no statistically significant differences at any time points between the 2 groups (all p > 0.05, Student's t-test). In contrast to the PSTI + MP group, where no complications were noted, the elevation of intra-ocular pressure in 3 of 20 eyes (15%) and a significant increase in average cataract grading were observed in the IVTA group.

CONCLUSION

PSTI + MP treatment provides significant improvement of vision in patients with diffuse DME over 3 months, and achieves outcomes comparable to those after IVTA treatment, however, with fewer complications.

Intravitreal triamcinolone for diabetic macular edema: comparison of 1, 2, and 4 mg

PURPOSE

To compare the efficacy and safety of different doses of intravitreal triamcinolone (IVTA) in treating eyes with refractory diffuse diabetic macular edema (DME) with cystic changes.

METHODS

Forty-five eyes of 45 patients with diffuse DME were randomized to receive 1, 2, or 4 mg IVTA. Patients were observed for 6 months and changes in best-corrected visual acuity (VA) in Early Treatment Diabetic Retinopathy Study (ETDRS) scores, retinal thickness analyzer (RTA) central macular thickness (CMT), intraocular pressure, and cataract progression were compared among the three groups.

RESULTS

Forty-two patients completed 6 months of follow-up and were included in the analysis. Following IVTA injection, the ETDRS score improved similarly, eight to nine letters, in all three groups at 4 weeks. The standardized CMT improved in all three groups at 4 weeks. This improvement was maintained through 12 and 24 weeks in the 1 and 2 mg groups, but not in the 4 mg group, which was significantly worse than the 1 and 2 mg groups at 12 and 24 weeks (P = 0.01, 0.03, 0.01, and 0.05).

CONCLUSIONS

Regarding eyes with refractory diffuse DME with cystic changes, 4 mg IVTA does not appear to be more effective than 1 or 2 mg IVTA.

Intravitreal bevacizumab (Avastin) for primary treatment of diabetic macular oedema

BACKGROUND

To evaluate the effectiveness of intravitreal bevacizumab injection as primary treatment of diabetic macular oedema.

MATERIAL AND METHODS

Thirty eyes of 30 diabetic patients were treated with 2.5 mg of intravitreal bevacizumab injection as the primary therapy for diabetic macular oedema. The main outcome measures included best-corrected visual acuity, fundus fluorescein angiography, and macular oedema map values of Heidelberg retinal tomograph II (HRT II) before and after intravitreal injection.

RESULTS

The visual acuity increased in 24 of 30 eyes (80%) during a mean follow-up time of 5.6 months. The mean baseline best-corrected LogMAR value for visual acuities of the patients before intravitreal bevacizumab injection was 1.09+/-0.23. After treatment, it was 0.90+/-0.17 at the 1-month, 0.81+/-0.24, at 3-month, and 0.77+/-0.26 at the last visit examinations and the differences were significant when compared with baseline values (for each, P<0.001). The mean oedema map values significantly decreased by 33.3% at the last visit examination when compared with preinjection values (P<0.001). Mild anterior chamber inflammation was observed in four eyes (13.3%), which resolved in a week with topical corticosteroid. No other injection- or drug-related complications were observed.

CONCLUSION

Intravitreal bevacizumab application provides significant improvement in visual acuity of diabetic patients and clinical course of macular oedema, and may therefore be a promising approach in the primary treatment of diabetic macular oedema.

Triamcinolone acetonide in ocular therapeutics

Triamcinolone acetonide has been effectively used in ocular therapeutics for over 50 years. Its use has increased dramatically in recent years for periocular and intraocular treatment of retinal vasculature disease and uveitis. This comprehensive review discusses the pharmacokinetics of triamcinolone acetonide and summarizes its uses in a number of diseases, both intraocular and extraocular. It discusses side effects and their management. Finally, it discusses the controversy over its use.

Long-term outcomes of pars plana vitrectomy with internal limiting membrane removal in diabetic macular edema

PURPOSE

To report the long-term visual results and anatomical outcome as assessed by optical coherence tomography (OCT) after pars plana vitrectomy (PPV) with removal of the internal limiting membrane (ILM) in diabetic macular edema (DME).

METHODS

Medical records of 27 eyes of 27 patients who underwent PPV with ILM removal for DME attributable to diffuse leakage were reviewed. This retrospective study included eyes that underwent PPV with ILM removal at our institution with preoperative and postoperative OCT assessment of DME. None of the eyes had OCT evidence of anteroposterior vitreomacular traction. Main outcome measures were foveal thickness and visual acuity changes.

RESULTS

Foveal thickness decreased by at least 20% in 22 eyes (81.4%) and increased by at least 20% in 3 eyes (11.1%) with PPV and ILM removal (mean follow-up +/- SD, 27.6 +/- 7.2 months; range, 12-38 months). Mean foveal thickness decrease +/- SD was 178 +/- 164 microm (43.6%), with a mean preoperative foveal thickness +/- SD of 408 +/- 121 microm compared with a mean postoperative foveal thickness +/- SD of 230 +/- 74 microm (P < 0.001). Recurrence of DME was observed at postoperative month 24 in 2 eyes and postoperative month 30 in 1 eye. Visual acuity improved by > or =2 lines in 10 eyes (37%) and decreased by > or =2 lines in 3 eyes (11.1%). Mean best-corrected logMAR (logarithm of the minimum angle of resolution) visual acuity +/- SD was 0.75 +/- 0.35 preoperatively and 0.63 +/- 0.33 postoperatively (P = 0.033).

CONCLUSION

PPV with ILM removal appears to be effective in reducing DME and improving visual acuity, and its effectiveness is maintained in the long term. Recurrence of DME may be observed in the late postoperative period.

Diabetic macular edema before and after intravitreal triamcinolone injection

PURPOSE

To compare intravitreal triamcinolone acetonide (IVT) versus natural course in refractory diabetic macular edema.

METHODS

In a prospective interventional case series, twenty five eyes with refractory DME which had been allocated to the sham group of a previous clinical trial underwent new examination and optical coherence tomography about 9 months after their first enrollment. Twenty eyes that met the inclusion criteria, visual acuity (VA) < 20/50 and central macular thickness (CMT) > 200 microm, were treated by 4 mg IVT. Evaluations were repeated at 2 and 4 months post-injection to imitate the similar examination intervals after sham injection. Corrected visual acuity and macular thickness changes following IVT were compared to the corresponding changes after sham injection (the natural course).

RESULTS

Visual acuity changes within and between each period were not statistically significant. Visual acuity decreased 0.08 & 0.09 logMAR by 2 months and 0.06 & 0.04 logMAR by 4 months after sham and IVT injections, respectively. The changes of macular thickness after IVT and sham intervention were not meaningful either. However, the difference between thickness changes by 4 months (52+/-50 microm increase after sham vs. 262+/-115 microm reduction after IVT) was significant (P=0.014).

CONCLUSIONS

Concerning macular thickness, IVT has beneficial effect on refractory diabetic macular edema as opposed to observation. However, considering visual acuity, it does not induce significant difference in comparison to the natural course of the disease.

Intravitreal steroids in the management of macular oedema

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

Intravitreal triamcinolone acetonide injection for the treatment of posterior uveitis

PURPOSE

To assess the efficacy and complications of intravitreal triamcinolone acetonide (IVTA) injection in the treatment of posterior uveitis and to compare the outcomes with patients who had received systemic corticosteroids.

METHODS

This prospective, interventional, clinical case series study included 11 eyes of 9 patients who received 8 mg/0.2 ml of IVTA injection for posterior uveitis that involved vitreous inflammation (group 1). Control group (group 2) consisted of 15 eyes of 12 patients who had received systemic corticosteroids for treatment of posterior uveitis with vitreous inflammation. The main outcome measures included best-corrected visual acuity, vitreous inflammation score and intraocular pressure.

RESULTS

In group 1, mean visual acuity improved significantly (P < 0.001) from a mean logarithm of the minimum angle of resolution (LogMAR) value of 2.05 +/- 0.82 at baseline to a maximum of 0.33 +/- 0.22 during the follow-up period of 5.0 +/- 2.8 months. In control group, mean LogMAR visual acuity before systemic corticosteroid therapy was 1.82 +/- 0.78, and it has reached a maximum of 0.40 +/- 0.22 after treatment (P < 0.001). The mean inflammatory scores decreased significantly in both groups when compared with preinjection values (for each, P < 0.05). There were no statistically significant differences between group 1 and group 2 when pre-and posttreatment visual acuities and inflammatory scores at 1-, 3-, and 5-month follow-up examinations were compared (for each, P > 0.05). In group 1, mean intraocular pressure (IOP) increased significantly from 13.4 +/- 2.6 mmHg to a mean maximal value of 19.3 +/- 4.3 mmHg (P < 0.001), but there was no statistically significant difference between mean IOP at 5-month after IVTA injection and pretreatment value (P = 0.06). Cataract progression was observed in one eye.

CONCLUSIONS

IVTA application may be an alternative therapeutic option for the treatment of acute posterior uveitis that involves vitreous inflammation, especially in patients who carry risks for systemic corticosteroid therapy.

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.

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.

Intravitreal triamcinolone will cause posterior subcapsular cataract in most eyes with diabetic maculopathy within 2 years

PURPOSE

To determine the incidence of cataract following intravitreal triamcinolone (IVTA) for diabetic macular oedema.

METHODS

Prospective, non-randomised, interventional cohort case series. A total of 27 eyes of 27 patients with diabetic macular oedema received an intravitreal injection of 4 mg (0.1 ml) of triamcinolone acetonide inferotemporally through the pars plana under direct vision. In 20 patients the fellow eye served as control, whereas seven patients had both eyes injected (not simultaneously). Seven patients had a repeat (second) injection in the same eye. The main outcome measures were cataract and intraocular pressure (IOP) rise of at least 5 mmHg (IOP responder).

RESULTS

The mean follow-up time was 18.9 months (range 13-29 months). A total of 22 (81%) of 27 eyes developed cataract during the follow-up period, of which 20 (74%) were posterior subcapsular in nature. None of the 20 uninjected fellow eyes developed posterior subcapsular cataract. Mean time to cataract formation was 16.2 months. In the seven patients who had both eyes injected, mean time to cataract formation was 16.5 and 17.1 months in the first and second eye, respectively. Mean time to cataract formation in seven eyes receiving a repeat second injection was 17.9 months. There was no significant difference in cataract formation between IOP responders (85%) and non-responders (79%) (P=1.00, Fisher's exact test). Uneventful cataract surgery was performed in six eyes of five patients.

CONCLUSION

This study demonstrates that given appropriate long-term follow-up, the majority of patients, even after a single IVTA injection, will go on to develop cataract, of which posterior subcapsular will be by far the most common.

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.

TIME COURSE OF CHANGES IN RETINAL THICKNESS AND VISUAL ACUITY AFTER INTRAVITREAL TRIAMCINOLONE ACETONIDE FOR DIFFUSE DIABETIC MACULAR EDEMA WITH AND WITHOUT PREVIOUS MACULAR LASER TREATMENT

PURPOSE

To describe the changes in retinal thickness (RT) and visual acuity over time in patients with clinically significant diffuse diabetic macular edema (DME) after intravitreal injection of triamcinolone acetonide (IVTA) and to compare patients with and without previous laser treatment.

METHODS

A total of 23 eyes with clinically significant DME received a 4-mg IVTA injection. Twelve eyes were refractory to macular laser treatment (group 1), and 11 eyes received IVTA as primary therapy (group 2). Visual acuity and changes in macular thickening shown by optical coherence tomography were evaluated 48 hours after injection, every 7 days for 1 month, and at 3 months and 6 months of follow-up.

RESULTS

RT decreased in all eyes in both groups. The reduction of edema was maximal in the first 7 days after IVTA and tended to remain stable for 3 months. The decrease in RT over time was significant in both groups (P < 0.001). At 6 months, RT had increased in almost all eyes. Visual acuity improved quickly, to a maximum at 2 weeks in both groups, after which it remained stable for 3 months and then decreased. Improvement in visual acuity over time was significant in both groups (P < 0.001). The temporal characteristics of the changes in RT and visual acuity were similar in the two groups (P < 0.05).

CONCLUSIONS

IVTA was effective in reducing clinically significant DME and improving visual acuity in eyes with and without previous laser treatment. Its action was maximal in the first week and lasted approximately 3 months in this study.

Intravitreal triamcinolone injection for chronic diabetic macular oedema with severe hard exudates

BACKGROUND

The purpose of the study was to determine the efficacy and safety of intravitreal triamcinolone acetonide (TA) in chronic diabetic macular oedema with severe hard exudates.

METHODS

This prospective, interventional consecutive case series study consisted of 33 eyes of 28 patients with chronic diabetic macular oedema and severe foveal hard exudates who received an intravitreal injection of 4 mg of TA. The patients were divided into two groups according to the type of foveal hard exudates: group I, plaque-like (17 eyes) and group II, dot-like scattered hard exudates (16 eyes). The results of both groups, evaluated by colour fundus photography and fluorescein angiography, were compared and complications were recorded.

RESULTS

All patients completed at least 6 months of follow-up. In all eyes, the hard exudates were completely resolved (24% in group I and 50% in group II) or decreased (76% in group I and 50% in group II). In group I, the mean diameter of the exudates plaques significantly decreased from 5.5+/-3.8 mm(2) in the pre-treatment period to 2.2+/-2.7 mm(2) at the end of the follow-up period. There was no recurrence of the hard exudates in either of the groups. The mean +/- SD visual acuity (VA) improved from 0.07+/-2.5 at the baseline to a maximum of 0.09+/-2.1 lines in group I (P<0.01) and from 0.13+/-3.9 to a maximum of 0.27+/-2.7 lines in group II (P<0.01). The mean VA improvement in group II was better than group I (3.2+/-2.5 vs. 1.4+/-1.0 lines, P<0.05). Intraocular pressure exceeded 21 mmHg in 10 eyes (30%), which was then controlled by topical medication. Three eyes (9%) exhibited signs of subcapsular cataract progression.

CONCLUSIONS

Intravitreal TA appears to be a valuable treatment in chronic diabetic macular oedema with severe foveal hard exudates. In all eyes in this study the hard exudates were completely resolved or decreased, and the mean VA improved significantly in both groups. However, the VA improvement was significantly worse in eyes with plaque-like exudates suggesting the possible value of earlier treatment. Further studies would enable the assessment of the universal effectiveness of this treatment.

Pattern electroretinogram for monitoring the efficacy of intravitreal triamcinolone injection in diabetic macular edema

PURPOSE

To investigate the efficacy of intravitreal triamcinolone (IVT) by evaluation of pattern electroretinogram (PERG) in diabetic patients with clinically significant macular edema (CSME).

METHODS

Forty eyes of 40 diabetic patients were treated with 8 mg of IVT injection as primary therapy for CSME. The main outcome measures included best-corrected visual acuity, fundus fluorescein angiography, P50 amplitudes of pattern electroretinogram (PERG) and intraocular pressures before and after injection.

RESULTS

The mean follow-up time was 6.1 months. Mean visual acuity improved significantly from a mean LogMAR value of 1.14 +/- 0.16 at baseline to a maximum of 0.73 +/- 0.30. The mean baseline P50 amplitude of PERG before intravitreal injection was 1.5 +/- 0.9 microV. After the treatment, it was 2.1 +/- 1.1 microV at 1-month, 2.4 +/- 1.0 microV at 3-month and 2.1 +/- 0.9 microV at last visit and the differences were significant when compared with baseline values (for each, p < 0.001). Temporary increases in intraocular pressures were controlled with topical antiglaucomatous medications, if required.

CONCLUSION

IVT injection provides rapid improvement in visual acuity of diabetic patients with CSME that has been supported by P50 amplitudes of PERG. P50 amplitudes of PERG may he used as novel predictive value in the evaluation of the effectiveness of IVT injection.

Intravitreal triamcinolone acetonide for treatment of persistent macular oedema in branch retinal vein occlusion

BACKGROUND

To evaluate the efficacy of intravitreal triamcinolone acetonide injection on persistent macular oedema in branch retinal vein occlusion that fails to respond to previous laser photocoagulation.

MATERIAL AND METHODS

A total of 19 eyes of 19 patients with persistent macular oedema due to branch retinal vein occlusion were treated with 8 mg/0.2 ml of intravitreal triamcinolone acetonide injection. The main outcome measures included best-corrected visual acuity, intraocular pressure, and macular oedema map values of Heidelberg Retinal Tomograph II (HRT II) before and after intravitreal triamcinolone injection.

RESULTS

The mean follow-up time was 6.2+/-1.0 months. The mean baseline best-corrected logarithm of minimal angle of resolution (LogMAR) value for visual acuities of the patients before intravitreal triamcinolone injection was 1.01+/-0.16. After treatment, it was 0.55+/-0.22 at the 1-month, 0.56+/-0.22 at 3-month, and 0.62+/-0.22 at the last visits and the differences were statistically significant when compared with baseline values (for each, P<0.001). The mean oedema map values on HRT II significantly decreased by 28.5% at 1-month, 23.8% at 3-month, and 23.8% at the last visit when compared with preinjection values (for each, P<0.001). Intraocular pressure elevation exceeding 21 mmHg was observed in 26.3% of eyes at 1-month, 15.7% at 3-month, and 5.2% at the last visit, but was controlled with topical anti-glaucomatous medications in all eyes.

CONCLUSION

Intravitreal triamcinolone acetonide application is a promising approach in the treatment of persistent macular oedema due to branch retinal vein occlusion non-respondent to laser photocoagulation.

Complications of intravitreal injection of triamcinolone acetonide

BACKGROUND

Intravitreal injection of triamcinolone acetonide appears to be a promising treatment for a variety of proliferative, edematous, neovascular and inflammatory ocular disorders. Reported complications include intraocular pressure (IOP) elevation, cataract formation, retinal detachment, vitreous hemorrhage and endophthalmitis. The purpose of this investigation was to report the complications of intravitreal triamcinolone injection that may be attributable to the injection procedure or to the corticosteroid suspension.

METHODS

A total of 212 eyes of 180 patients who underwent intravitreal triamcinolone acetonide injection for various indications were enrolled. All patients received 8 mg/0.2 mL of triamcinolone. A total of 270 injections were performed by the same surgeon under topical anesthesia. The patients were followed for a mean of 9.2 months. Complications related to the injection procedure and to the corticosteroid were recorded.

RESULTS

The most common complication encountered during follow-up was transient elevation of the IOP above 21 mm Hg (44 eyes [20.8%]). The average IOP rose by 28.5%, 38.2%, 16.7% and 4.2% from baseline at 1, 3, 6 and 9 months respectively. The mean IOP values at 1, 3 and 6 months were statistically significantly higher than the mean preinjection value (p < 0.001). Fourteen eyes (6.6%) had cataract progression and underwent cataract surgery with intraocular lens implantation. Endophthalmitis developed in one eye (0.5%); the patient underwent vitrectomy with silicone oil injection. Pseudoendophthalmitis occurred in one eye (0.5%), and pseudohypopyon was observed in two eyes (0.9%).

INTERPRETATION

Intravitreal triamcinolone injection was effective in a variety of ocular disorders. Patients should be monitored closely given the potential for complications of the injection procedure or the corticosteroid suspension.