Intravitreal Triamcinolone Acetonide in Refractory Pseudophakic Cystoid Macular Edema: Functional and Anatomic Results

Efficacy and Safety of 0.19-mg Fluocinolone Acetonide Implant in Postoperative Cystoid Macular Edema after Pars Plana Vitrectomy: the ILUCYD study

PURPOSE

To assess the efficacy and safety of 0.19-mg fluocinolone acetonide (FAc) intravitreal implant (Iluvien®) in treating chronic postoperative cystoid macular edema (PCME) after pars plana vitrectomy.

DESIGN

Retrospective multicentric case series in clinical settings.

SUBJECTS

Patients with chronic PCME who underwent vitrectomy in tertiary care centers in France. All eyes had a documented good response to the DEX implant prior to FAc implantation.

METHODS

Review of charts and OCT scans of patients treated with a FAc intravitreal implant.

MAIN OUTCOME MEASURES

The primary endpoints were the best-corrected visual acuity (BCVA) and central retinal thickness (CRT). Secondary endpoints were the intraocular pressure (IOP); proportion of patients maintaining a BCVA ≥20/40; need for additional non-study treatment; differences between eyes that underwent a single and multiple surgeries and OCT biomarkers of better BCVA.

RESULTS

Forty-nine eyes of 49 patients with a mean follow-up of 24.5 ± 3.9 months were included. The mean BCVA increased from 0.40 ± 0.26 logMAR at baseline to 0.32 ± 0.24 logMAR at month 24 (M24) (p=0.0035). The mean CRT decreased from 409.37 ± 139.43 μm at baseline to 340 ± 91 μm at M24 (p=0.0001). The mean IOP was 14.0 ± 4 mmHg at baseline and remained stable at 14.03 ± 4.1 mmHg at M24 (p=0.99). During the follow-up, the IOP exceeded 21 mmHg in 9 eyes. The IOP rise was controlled with topical therapy in all eyes except one, which required cyclophotocoagulation. The BCVA was ≥20/40 in 47% of eyes (95% CI: 34%-61%) at baseline and in 58% of eyes at M24 (95% CI: 41%-73%). At M18, the likelihood of achieving a BCVA ≥20/40 was higher in eyes with intact external limiting membrane and ellipsoid zone. Additional dexamethasone implant (DEXi) was injected in 14 eyes (28.57%). The treatment burden of 2.45 ± 1.35 DEXi/year was decreased to 0.57 ± 0.60 DEXi/year after FAc implantation (p=0.001).

CONCLUSION

FAc implant improved the BCVA and reduced the CRT in eyes with chronic PCME after vitrectomy. The IOP rise could be anticipated by the previous response to corticosteroids. FAc implant in eyes with chronic PCME also allowed reducing the treatment burden.

Current management options for the treatment of refractory postoperative cystoid macular edema: A systematic review

Post-operative cystoid macular edema (PCME) is an important complication following intraocular surgery that often resolves spontaneously without treatment. In some cases, PCME may persist despite initial medical therapy, which can adversely impact visual outcomes. Various topical, intraocular and systemic treatments exist for the prevention and management of cystoid macular edema; however, there is no consensus on treatment of refractory cases in the postoperative setting. In accordance with the PRISMA guidelines, we systematically reviewed 68 articles describing management options and their outcomes for treatment-resistant cases of PCME. The most commonly reported treatments included steroid (39 studies) and biological-based (17 studies) therapies. We provide an overview of the treatment options for refractory PCME.

Intravitreal Fluocinolone Acetonide Implant (FAc, 0.19 mg, ILUVIEN®) in the Treatment of Patients with Recurrent Cystoid Macular Edema After Pars Plana Vitrectomy

INTRODUCTION

Postoperative cystoid macular edema (PCME) is a complication of several ocular procedures, including pars plana vitrectomy (PPV), due to the activation of the inflammatory cascade. The purpose of this case series is to evaluate the effectiveness and safety of fluocinolone acetonide intravitreal implant (FAc, 0.2 μg/day; ILUVIEN®) in the treatment of refractory PCME after successful PPV.

METHODS

This retrospective observational case series includes consecutive eyes of patients with recurrent PCME after PPV and treated with a single FAc implant at Centro Hospitalar Universitário de São João, Porto, Portugal. Previous treatments, best-corrected visual acuity (BCVA, ETDRS letters), central macular thickness (CMT, μm), intraocular pressure (IOP, mmHg), and IOP-lowering medication needed were recorded at baseline and during follow-up. Total macular edema resolution was defined as CMT less than 300 μm or a reduction of greater than 20%, and partial macular edema resolution was defined as a reduction of greater than 10%.

RESULTS

Nine eyes from nine patients were included. Before FAc implant, all eyes received intravitreal short-action corticosteroids (triamcinolone and dexamethasone implant), with a good response but relapse 1-5 months later. At baseline, BCVA was 55.0 ± 10.6 letters, CMT was 514.9 ± 165.6 μm, and IOP was 15.4 ± 2.4 mmHg with four eyes under IOP-lowering medication. After FAc implant, all eyes achieved edema resolution (eight total and one partial) with a peak gain of 17.2 letters and a maximum decrease of 208.2 μm in CMT. During follow-up (44.0 ± 14.8 months), 66.7% of the eyes kept their macula dry and three showed recurrence after 11, 14, and 28 months, respectively. The maximum IOP registered was 17.0 ± 6.0 mmHg. IOP-lowering regimen was increased in one eye and two additional eyes started hypotensive drops.

CONCLUSION

FAc implant can be considered a therapeutic alternative in PCME refractory to other therapies in vitrectomized eyes, reducing the need for repeated treatments.

Intravitreal fluocinolone acetonide implant for chronic postoperative cystoid macular edema - two years results

PURPOSE

We report visual and anatomical outcomes of chronic postoperative macular edema treated with a fluocinolone acetonide intravitreal implant.

METHOD

Retrospective study of chronic, post-surgical CME treated with a fluocinolone acetonide intravitreal implant. Best registered visual acuity (BRVA), central retinal thickness (CRT), and Goldmann tonometry intraocular pressure (IOP) were assessed over 24 months. The need for IOP lowering treatment, top-up therapy during follow-up, and complications were also assessed.

RESULTS

We analyzed 16 consecutive eyes of 16 patients with chronic, post-surgical CME treated with fluocinolone acetonide intravitreal implant. Surgical indications included cataract surgery, vitrectomy plus membrane peeling and combined phaco-vitrectomy. Baseline mean BRVA of 0.8 ± 0.65 logMAR improved to 0.60 ± 0.4 logMAR (p = 0.02) at 12 months and to 0.7 ± 0.5 logMAR (p = 0.32) at 24 months. At month 12, BRVA improved in 11 eyes, stabilized in 4 eyes, and decreased in 1 eye. At month 24, VA remained improved in 5 eyes, remained stabilized in 5 eyes, and decreased in 1 eye. Mean CRT decreased from 524 ± 132 μm at baseline to 389 μm at month 3, 347 μm at month 6, 355 ± 106 μm (p = 0.0003) at month 12, and 313 ± 83 μm (p = 0.0001) at month 24. At 12 months, CRT improved in 13 eyes and remained unchanged in 2 eyes. At 24 months, CRT improved further in 8 eyes, and stabilized in 3 eyes. Increased IOP (≥21 mmHg) was observed only in 4 eyes, all successfully managed with topical medication. No further side effects were observed in any patient.

CONCLUSION

Visual and anatomic improvements were achieved by a single fluocinolone acetonide implant with few side effects up to 24 months in CME eyes with a long and heavy prior treatment history.

Efficacy of Intravitreal Injection of Filtered Modified Low-Dose Triamcinolone Acetonide and Ranibizumab on Pseudophakic Cystoid Macular Edema

Purpose

To compare the visual and morphological effects between intravitreal injection of filtered modified 2 mg triamcinolone acetonide (TA) and 0. 5 mg ranibizumab in patients with pseudophakic cystoid macular edema (PCME).

Methods

A retrospective, interventional study was conducted from January 2015 to February 2020 involving patients with PCME after uneventful cataract surgery. A total of 25 patients (25 eyes) with PCME received an intravitreal injection of 0.22 μm filtered modified 2 mg TA, while 15 patients (15 eyes) received 0.5 mg ranibizumab injection. Central macular thickness (CMT), best-corrected visual acuity (BCVA), intraocular pressure (IOP), times of repeated injections, and other side effects were observed at 2 weeks, 1 month, 3 months, and 6 months after injection; then, the data were compared with preinjection information in each group and between the two groups.

Results

Both the TA and ranibizumab intravitreal injection can achieve improved BCVA and reduced CMT in patients with PCME (P < 0.05), with a trend toward greater improvement in the TA group, but the difference was only significant at 3 months (P < 0.05). IOP was in the normal range without any significant difference (P > 0.05). Thirty-three percent of patients in the ranibizumab group required repeated intravitreal injection compared to 4% in the TA group. Further stratified analysis showed that the better therapeutic effect of the TA group at 3 months after injection only existed in patients with diabetes mellitus (DM), while not in patients without DM. There was no repeat injection in the TA group and 12.5% in the ranibizumab group for patients without DM, while 16.7% in the TA group and 57.1% in the ranibizumab group required repeated injection for patients with DM, which had a significant difference (P < 0.05).

Conclusion

Intravitreal injection of filtered modified 2 mg TA is safe, effective, and an inexpensive alternative to antivascular endothelial growth factor (anti-VEGF) agents for patients with PCME, especially for patients concurrently with DM. A large number of clinical randomized controlled studies along with long-term follow-up observations are needed.

Current Management Options in Irvine-Gass Syndrome: A Systemized Review

Irvine-Gass syndrome (IGS) remains one of the most common complications following uneventful cataract surgery. In most cases, macular edema (ME) in IGS is benign, self-limiting, and resolves spontaneously without visual impairment; however, persistent edema and refractory cases may occur and potentially deteriorate visual function. Despite the relatively high prevalence of IGS, no solid management guidelines exist. We searched the PUBMED database for randomized clinical trials (RCT) or case series of at least 10 cases published since 2000 evaluating different treatment strategies in patients with cystoid macular edema (CME). The search revealed 28 papers that fulfilled the inclusion criteria with only seven RCTs. The scarceness of material makes it impossible to formulate strong recommendations for the treatment of IGS. Clinical practice and theoretical background support topical non-steroidal anti-inflammatory drugs (NSAIDs) as the first-line therapy. Invasive procedures, such as periocular steroids, intravitreal corticosteroids, and anti-vascular endothelial growth factor (anti-VEGF), are usually applied in prolonged or refractory cases. Results of novel applications of subthreshold micropulse laser (SML) are also promising and should be studied carefully in terms of the safety profile and cost effectiveness. Early initiation of invasive treatment for providing better functional results must be examined in further research.

Clinical Course of Pseudophakic Cystoid Macular Edema Treated with Nepafenac

Background: To evaluate the clinical course of pseudophakic cystoid macular edema (PCME) treated with topical non-steroidal anti-inflammatory drugs (NSAIDs). Methods: An analysis of the clinical course of PCME consisting of 536 eyes of 536 patients from five consecutive randomized clinical trials aimed at the optimization of anti-inflammatory medication in patients undergoing routine cataract surgery. PCME was classified as (i) grade 0a; no macular thickening, (ii) grade 0b; macular thickening (central subfield macular thickness (CSMT) increase of at least 10%) without signs of macular edema, (iii) grade I; subclinical PCME, (iv) grade II; acute PCME, (v) grade III; long-standing PCME. Eyes with PCME classification from grade I onwards were treated with nepafenac 1 mg/mL t.i.d. for two months. Results: CSMT increase of at least 10% at any postoperative timepoint with cystoid changes—a criterion for PCME—was found in 19 of 536 eyes (total incidence 3.5%). Of these 19 eyes, 13 eyes (total incidence 2.4%) had clinically significant PCME. PCME was considered clinically significant when both of the following visual acuity criteria were fulfilled. At any timepoint after the cataract surgery both the corrected distance visual acuity (CDVA) gain was less than 0.4 decimals from that of preoperative CDVA, and the absolute CDVA level remained below 0.8 decimals. Only one of the 19 eyes with criteria for PCME (total incidence 0.2%, incidence of PCME eyes 5.3%) showed no macular edema resolution within 2 months after topical nepafenac administration. Conclusions: PCME in most cases is self-limiting using topical nepafenac without any further need for intravitreal treatment.

Cystoid macular edema related to cataract surgery and topical prostaglandin analogs: Mechanism, diagnosis, and management

Cystoid macular edema (CME) is a form of macular retina thickening that is characterized by the appearance of cystic fluid-filled intraretinal spaces. It has classically been diagnosed upon investigation after a decrease in visual acuity; however, improvements in imaging technology make it possible to noninvasively detect CME even before a clinically significant decrease in central vision. Risk factors for the development of CME include diabetic retinopathy, retinal vein occlusion, uveitis, and cataract surgery. It has been proposed that eyes with elevated intraocular pressure after cataract surgery, including those treated with prostaglandin analog eye drops, may be at higher risk for the development of CME. We summarize the current knowledge of the molecular mechanisms underlying CME, the potential role of ocular surgery and topical glaucoma medication in increasing the risk of CME, the newly developed imaging methods for diagnosing CME, and the clinical management of CME.

Novel Triamcinolone Acetonide-Loaded Liposomal Topical Formulation Improves Contrast Sensitivity Outcome After Femtosecond Laser-Assisted Cataract Surgery

Purpose: To assess visual results, macular modifications, and the incidence of clinically significant macular edema (CSME) in patients using a topical triamcinolone acetonide-loaded liposomal formulation (TA-LF) after femtosecond laser-assisted cataract surgery (FLACS). Methods: Fifty-six eyes after FLACS were selected. Twenty-eight eyes in the combined therapy group (P + N) were treated with prednisolone 1% and nepafenac 0.1% for 21 days postoperatively, whereas 28 eyes in the TA-LF group received a liposomal formulation containing 2 mg/mL of TA (0.2%) for the same period of time. Follow-up visits at 1 day, 6 weeks, and 12 weeks after surgery consisted of visual acuity, contrast sensitivity (CS), central foveal thickness (CFT), total macular volume (TMV) measurements, and the detection of CSME. Results: CS improved in the TA-LF group (basal value: 1.087 ± 0.339 vs. 1.276 ± 0.147 at week 12, P = 0.0346), whereas in the P + N group, CS was not different from the baseline (basal value: 1.130 ± 0.331 vs. 1.274 ± 0.133 at week 12, P = 0.1276). There were similar increases in postoperative CFT and TMV in both groups. CFT and TMV significantly correlate with CS only in the TA-LF group. The r² for CFT and CS was 0.1963 (P = 0.0206), whereas the r² for TMV and CS was 0.3615 (P = 0.0007) at 12 weeks. No difference was observed in the incidence of CSME between the groups. Conclusion: TA-LF is associated with better CS outcomes compared to combined therapy after FLACS.

Novel Triamcinolone Acetonide-Loaded Liposomes Topical Formulation for the Treatment of Cystoid Macular Edema After Cataract Surgery: A Pilot Study

Purpose: To report tolerability, safety, and efficacy of a topical triamcinolone acetonide-loaded liposomes formulation (TA-LF) in targeting the macular area in patients with refractory pseudophakic cystoid macular edema (PCME).

Methods: For tolerability, safety and efficacy evaluation, 12 eyes of 12 patients with refractory PCME were exposed to one drop of TA-LF (TA at 0.2%) every 2 h for 90 days or until best-corrected visual acuity (BCVA) was achieved. Intraocular pressure (IOP), slit lamp examination, and central foveal thickness (CFT) were analyzed at every visit.

Results: Patients with refractory PCME under TA-LF therapy showed a significant improvement in BVCA and CFT without significant IOP modification (P = 0.94). On average CFT decreased to 206.75 ± 135.72 μm and BCVA improved to 20.08 ± 10.35 letters (P < 0.0005). BCVA was achieved at 10.58 ± 6.70 weeks (range 2–18). TA-LF was well tolerated in all cases. Neither ocular surface abnormalities nor adverse events were recorded.

Conclusion: TA-LF was well tolerated and improved BCVA and CFT on patients with refractory PCME.

A systematic review and economic evaluation of adalimumab and dexamethasone for treating non-infectious intermediate uveitis, posterior uveitis or panuveitis in adults

BACKGROUND

Non-infectious intermediate uveitis, posterior uveitis and panuveitis are a heterogeneous group of inflammatory eye disorders. Management includes local and systemic corticosteroids, immunosuppressants and biological drugs.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of subcutaneous adalimumab (Humira^®; AbbVie Ltd, Maidenhead, UK) and a dexamethasone intravitreal implant (Ozurdex^®; Allergan Ltd, Marlow, UK) in adults with non-infectious intermediate uveitis, posterior uveitis or panuveitis.

DATA SOURCES

Electronic databases and clinical trials registries including MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and the World Health Organization's International Clinical Trials Registry Platform were searched to June 2016, with an update search carried out in October 2016.

REVIEW METHODS

Review methods followed published guidelines. A Markov model was developed to assess the cost-effectiveness of dexamethasone and adalimumab, each compared with current practice, from a NHS and Personal Social Services (PSS) perspective over a lifetime horizon, parameterised with published evidence. Costs and benefits were discounted at 3.5%. Substantial sensitivity analyses were undertaken.

RESULTS

Of the 134 full-text articles screened, three studies (four articles) were included in the clinical effectiveness review. Two randomised controlled trials (RCTs) [VISUAL I (active uveitis) and VISUAL II (inactive uveitis)] compared adalimumab with placebo, with limited standard care also provided in both arms. Time to treatment failure (reduced visual acuity, intraocular inflammation, new vascular lesions) was longer in the adalimumab group than in the placebo group, with a hazard ratio of 0.50 [95% confidence interval (CI) 0.36 to 0.70; p < 0.001] in the VISUAL I trial and 0.57 (95% CI 0.39 to 0.84; p = 0.004) in the VISUAL II trial. The adalimumab group showed a significantly greater improvement than the placebo group in the 25-item Visual Function Questionnaire (VFQ-25) composite score in the VISUAL I trial (mean difference 4.20; p = 0.010) but not the VISUAL II trial (mean difference 2.12; p = 0.16). Some systemic adverse effects occurred more frequently with adalimumab than with placebo. One RCT [HURON (active uveitis)] compared a single 0.7-mg dexamethasone implant against a sham procedure, with limited standard care also provided in both arms. Dexamethasone provided significant benefits over the sham procedure at 8 and 26 weeks in the percentage of patients with a vitreous haze score of zero (p < 0.014), the mean best corrected visual acuity improvement (p ≤ 0.002) and the percentage of patients with a ≥ 5-point improvement in VFQ-25 score (p < 0.05). Raised intraocular pressure and cataracts occurred more frequently with dexamethasone than with the sham procedure. The incremental cost-effectiveness ratio (ICER) for one dexamethasone implant in one eye for a combination of patients with unilateral and bilateral uveitis compared with limited current practice, as per the HURON trial, was estimated to be £19,509 per quality-adjusted life-year (QALY) gained. The ICER of adalimumab for patients with mainly bilateral uveitis compared with limited current practice, as per the VISUAL trials, was estimated to be £94,523 and £317,547 per QALY gained in active and inactive uveitis respectively. Sensitivity analyses suggested that the rate of blindness has the biggest impact on the model results. The interventions may be more cost-effective in populations in which there is a greater risk of blindness.

LIMITATIONS

The clinical trials did not fully reflect clinical practice. Thirteen additional studies of clinically relevant comparator treatments were identified; however, network meta-analysis was not feasible. The model results are highly uncertain because of the limited evidence base.

CONCLUSIONS

Two RCTs of systemic adalimumab and one RCT of a unilateral, single dexamethasone implant showed significant benefits over placebo or a sham procedure. The ICERs for adalimumab were estimated to be above generally accepted thresholds for cost-effectiveness. The cost-effectiveness of dexamethasone was estimated to fall below standard thresholds. However, there is substantial uncertainty around the model assumptions. In future work, primary research should compare dexamethasone and adalimumab with current treatments over the long term and in important subgroups and consider how short-term improvements relate to long-term effects on vision.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016041799.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

EFFECT OF AN INTRAVITREAL DEXAMETHASONE IMPLANT ON DIABETIC MACULAR EDEMA AFTER CATARACT SURGERY

PURPOSE

To analyze the effects of a dexamethasone intravitreal implant (DEX; Ozurdex 700 μg; Allergan) administered immediately after cataract surgery in diabetic patients.

METHODS

This prospective, single-arm, open label study (NCT01748487 at ClinicalTrials.gov) involved Type 2 diabetic patients with at least mild diabetic retinopathy (DR) who underwent cataract surgery and DEX insertion after phacoemulsification, and intraocular lens implantation were enrolled. Best-corrected visual acuity and central retinal thickness (CRT) measured by spectral-domain optical coherence tomography were recorded at 1 week preoperatively, and 1 week, 1 month, and 3 months after surgery. Adverse events were also recorded.

RESULTS

Twenty-four eyes of 24 patients (17 [70.8%] men; mean age 63.7 ± 8.7 years) with mild nonproliferative DR (41.7%), moderate nonproliferative DR (33.3%), severe nonproliferative DR (16.7%), or treated proliferative DR (8.3%) were selected. After DEX treatment, mean CRT changed from 241.1 μm (95% confidence interval, 227.5-254.6 μm) at baseline to 236.9 μm (95% confidence interval, 223.9-249.9 μm) at 1 week (P = 0.09), 238.9 μm (95% confidence interval, 225.5-252.3 μm) at 1 month (P = 0.44), and 248 μm (95% confidence interval, 232.4-260.8 μm) at 3 months (P = 0.15). No eyes showed a postoperative increase >50 μm in the CRT at any visit. A 10% increase in CRT was found in 8.3% of eyes. Mean best-corrected visual acuity significantly improved from 0.37 (20/50) at baseline to 0.19 (20/30) at 1 week, 0.12 (20/25) at 1 month, and 0.12 (20/25) at 3 months (P < 0.001 for each comparison). Mean intraocular pressure before surgery was 13.8 mmHg, and none of the patients developed an intraocular pressure ≥22 mmHg at any visit. None of the patients developed any serious adverse events during the follow-up.

CONCLUSION

These short-term results suggest that a single DEX injection intraoperatively after phacoemulsification could avoid an increase in CRT after cataract surgery in diabetic patients.

USE OF AFLIBERCEPT FOR THE MANAGEMENT OF REFRACTORY PSEUDOPHAKIC MACULAR EDEMA IN IRVINE-GASS SYNDROME AND LITERATURE REVIEW

BACKGROUND/PURPOSE

To present the patient treated for pseudophakic cystoid macular edema with intravitreal aflibercept.

METHODS

Interventional case report.

CASE

An 83-year-old woman presented with decreased vision 1 month after uneventful cataract surgery. After failure to respond to posterior subtenons triamcinolone and three Ranibizumab injections, the patient responded to one intravitreal aflibercept injection. Recurrence occurred two months later, and therefore three monthly injections were then given. Again the patient responded although recurrence occurred two months after treatment. The patient refused further treatment.

CONCLUSION

Intravitreal aflibercept may be effective for the treatment of pseudophakic cystoid macular edema.

Role of Concomitant Triamcinolone Acetonide Injection in Small-Gauge Vitrectomy for Idiopathic Epiretinal Membrane Peel

PURPOSE

The concomitant use of triamcinolone acetonide (TA) at the completion of pars plana vitrectomy for the treatment of epiretinal membrane may speed up the anatomical and functional outcomes of surgery. We report the outcome of patients undergoing small-gauge vitrectomy for idiopathic epiretinal membrane peel with or without adjuvant TA therapy.

DESIGN

This is a retrospective, single-center case series.

METHODS

We included 75 eyes of 75 individual patients. Twenty-six patients (group A) had an adjuvant TA injection during surgery, whereas 49 patients (group B) were not injected. We assessed the patients for change in visual acuity (VA) and central macular thickness before and after surgery.

RESULTS

Group A had a mean logarithm of the minimum angle of resolution VA of 0.63 ± 0.33 and 0.51 ± 0.31 preoperatively and 3 months after surgery, respectively. Group B had a mean logarithm of the minimum angle of resolution VA of 0.47 ± 0.17 and 0.36 ± 0.17 preoperatively and 3 months after surgery, respectively. No significant difference was found between the groups in change of VA. The mean central macular thickness for groups A and B patients before surgery was 474.12 ± 120 μm and 445 ± 85 μm, decreasing to 369 ± 70 μm and 386 ± 60 μm at the final visit, respectively. The difference in macular thickness reduction between the groups was statistically significant.

CONCLUSIONS

Anatomical and functional improvement was found in both groups after surgery. Macular thickness was further reduced in the group of patients treated with adjuvant TA.

Management of pseudophakic cystoid macular edema

Pseudophakic cystoid macular edema (PCME) is a common complication following cataract surgery. Acute PCME may resolve spontaneously, but some patients will develop chronic macular edema that affects vision and is difficult to treat. This disease was described more than 50 years ago, and there are multiple options for clinical management. We discuss mechanisms, clinical efficacy, and adverse effects of these treatment modalities. Topical non-steroidal anti-inflammatory agents and corticosteroids are widely used and, when combined, may have a synergistic effect. Intravitreal corticosteroids and anti-vascular endothelial growth factor (anti-VEGF) agents have shown promise when topical medications either fail or have had limited effects. Randomized clinical studies evaluating anti-VEGF agents are needed to fully evaluate benefits and risks. When PCME is either refractory to medical therapy or is associated with significant vitreous involvement, pars plana vitrectomy has been shown to improve outcomes, though it is associated with additional risks.

Migration of intravitreal dexamethasone implant to anterior chamber

PURPOSE

To describe two cases of migration of intravitreally injected dexamethasone implant into the anterior chamber.

METHODS

Charts were reviewed of two patients who received sustained-release dexamethasone implant intravitreally for chronic intractable cystoid macular edema.

RESULTS

Both patients had pseudophakic cystoid macular edema and a complicated clinical course before receiving the implant. Treatments before intravitreal injection of implant included topical nonsteroidal anti-inflammatory drugs, sub-Tenon triamcinolone injections, vitrectomy, and, in one case, intravitreal bevacizumab. Both patients responded well to triamcinolone injections but required repeated injections. This led to the decision to inject the implant. Within 2 weeks of injection, the implant was noted in the anterior chamber causing pain and decreased vision from corneal edema. Both patients underwent successful removal of the implant.

CONCLUSION

Sustained-release intravitreal injectable implants can migrate freely in vitrectomized pseudophakic or aphakic eyes. Selection of a scleral-fixated steroid implant might be safer in such cases.

Influence of drug lipophilicity on drug release from sclera after iontophoretic delivery of mixed micellar carrier system to human sclera

Mixed micelles prepared using sodium taurocholate (TA) and egg lecithin (LE) were previously found to be an effective carrier for sustained release of a poorly water-soluble drug in transscleral iontophoretic delivery. The objectives of the present study were to investigate the effects of drug lipophilicity upon micellar carrier solubilization potential and drug release profiles from the sclera after iontophoretic delivery of model lipophilic drugs dexamethasone (DEX), triamcinolone acetonide (TRIAM), and β-estradiol (E2β) with a mixed micellar carrier system of TA-LE (1:1 mole ratio). In this study, the micellar carrier system was characterized for drug solubilization. The micelles encapsulating these drugs were evaluated for transscleral passive and 2-mA iontophoretic delivery (both cathodal and anodal) and drug release from excised human sclera in vitro. The results show that drug solubility enhancement of the micellar carrier system increased with increasing drug lipophilicity. The more lipophilic drugs E2β and TRIAM displayed slower drug release from the sclera compared with the less lipophilic drug DEX after iontophoretic drug delivery with the mixed micelles. These results suggest that the combination of transscleral iontophoresis and micellar carriers is more effective in sustaining transscleral delivery of the more lipophilic drugs studied in this investigation.

Intraocular corticosteroids for posterior segment disease: 2012 update

INTRODUCTION

Diabetic macular edema (DME), cystoid macular edema (CME), age-related macular degeneration (AMD), retinal vascular occlusion (RVO) and uveitis are responsible for severe visual impairment worldwide. In some patients with these conditions, treatment with intraocular corticosteroids may be beneficial. Although off-label use of these agents has occurred for many years, novel agents including preservative-free and sustained-release intravitreal implants are currently being studied in clinical trials (CTs).

AREAS COVERED

This paper reviews the use of CTs for vitreoretinal (VR) diseases including choroidal neovascularization, CME, DME, RVO and posterior uveitis. It also discusses the use of corticosteroids for treating VR disease, including dexamethasone, fluocinolone acetonide, intravitreal implants and triamcinolone acetonide.

EXPERT OPINION

Used alone, intravitreal corticosteroids may benefit disorders such as DME, RVO and uveitis compared with standard therapy. Cases of exudative AMD non-responsive to standard treatment may benefit from combination therapy, including usage of intravitreal corticosteroid injections. Intraoperative use of these agents may aid visualization of retinal structures. Sustained-release intraocular implants have been approved for posterior uveitis and RVO associated with macular edema. In spite of this, most intraocular corticosteroids have a limited duration of action along with significant side effects, including cataract and glaucoma. Currently, intravitreal corticosteroid usage for DME is considered off-label.

Macular atrophy after combined intravitreal triamcinolone and photodynamic therapy to treat choroidal neovascularization

AIM

To report the appearance of choriocapillaris atrophy after combined high dose intravitreal triamcinolone acetonide (TA) and photodynamic therapy (PDT) to treat choroidal neovascularization (CNV) associated with age related macular degeneration (AMD).

METHODS

The present study was retrospective about non-randomized interventional case series. Fifty-one consecutive eyes with subfoveal (all types) CNV associated with AMD were treated by PDT and intravitreal (19.4±2.1)mg per 0.1mL TA at the Alicante Institute of Ophthalmology. The appearance of macular choriocapillaris and retinal pigment epithelium (RPE) atrophy was considered at two years follow-up. Thirty consecutive eyes treated by PDT alone, matched for age, sex, and type and size of CNV were considered as control group.

RESULTS

Twenty-one of 47 eyes in the study group (45%) and 7 of 30 eyes in the control group (23%) developed macular RPE and choriocapillaris atrophy in the treated area at month 24 (P=0.04, Chi-square test). The greatest diameter of the atrophic areas averaged (5044±1666)µm in the study group vs (4345±1550)µm in the control group. Mean final best corrected visual acuity (logarithm of minimal angle of resolution) was (0.87±0.33) in the cases with RPE atrophy vs (0.66±0.26) in the cases with no RPE atrophy in the study group (P=0.11, Mann-Whitney U test).

CONCLUSION

The association of high doses of intravitreal TA and PDT may increase the risk for RPE and choriocapillaris atrophy.

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.

The use of intraocular corticosteroids

BACKGROUND

Diabetic macular edema (DME), cystoid macular edema (CME), age-related macular degeneration (AMD), retinal vascular occlusion (RVO) and uveitis are responsible for severe visual impairment worldwide. In some patients with these conditions, treatment with intraocular corticosteroids may be beneficial. Although off-label use of these agents has occurred for many years, novel agents including preservative-free and sustained-release intravitreal implants are currently being studied in clinical trials (CTs).

OBJECTIVE

To review the use of intraocular corticosteroids.

METHODS

Literature review.

RESULTS

Used alone, intravitreal corticosteroids may benefit disorders such as DME, RVO and uveitis compared with standard therapy or observation. Patients with AMD may benefit more from combination treatment with photodynamic therapy, intravitreal corticosteroid and intravitreal anti-VEGF injections. Intraoperative use of these agents may assist in visualization and manipulation of fine retinal structures. Sustained-release intraocular implants have been approved for severe posterior uveitis, and have shown benefits in ongoing CTs.

CONCLUSION

Although intraocular corticosteroid injections have a limited duration of action requiring frequent re-treatment, and significant side effects including cataract and glaucoma development, intraocular injections may be of benefit in certain ocular disorders. Corticosteroid implants are emerging as potential treatments for macular edema due to uveitis, DME or RVO.

Efficacy of intravitreal triamcinolone after or concomitant with laser photocoagulation in nonproliferative diabetic retinopathy with macular edema

PURPOSE

To investigate the clinical effects and outcomes of intravitreal injection of 4 mg of triamcinolone acetonide (IVTA) after or concomitant with macular laser photocoagulation (MP) for clinically significant macular edema (CSME).

METHODS

Forty-nine eyes of 49 patients with nonproliferative diabetic retinopathy and CSME were randomized into three groups. The eyes in the laser group (n=17), group 1, were subjected to MP 3 weeks after IVTA; the eyes in the IVTA group (n=13), group 2, were subjected to MP, concomitant with IVTA; the eyes in the control group (n=19), group 3, underwent only IVTA application. Visual acuity (VA), fundus fluorescein angiography, and photography were performed in each group.

RESULTS

In the first group, the mean VA improved from 0.17-/+0.09 at baseline to 0.28-/+0.15 (p=0.114) and in the second group, deteriorated from 0.19-/+0.08 at baseline to 0.14-/+0.08 at the sixth month (p=0.141), respectively. In Group 3, the mean VA improved from 0.16-/+0.08 at baseline to 0.28-/+0.18 (p=0.118) at the end of the follow-up. When VA was compared between the control and study groups, significant difference was detected at the sixth month (p=0.038).

CONCLUSIONS

MP after IVTA improved VA, rather than MP concomitant with IVTA, and only IVTA application for CSME. MP after IVTA may reduce the recurrence of CSME and needs further investigations in a longer period.

Intravitreal triamcinolone for intraocular inflammation and associated macular edema

Triamcinolone acetonide (TA) is a corticosteroid that has many uses in the treatment of ocular diseases because of its potent anti-inflammatory and anti-permeability actions. Intraocular inflammation broadly referred to as uveitis can result from several causes, including the immune system and after ophthalmic surgery. One of the most common reasons for vision loss with uveitis is macular edema. TA has been used for many years as an intravitreal injection for the treatment of ocular diseases. Several case control studies have been reported showing the efficacy of TA in the treatment of intraocular inflammation and associated macular edema caused by Behcet's disease, Vogt-Koyanagi-Harada syndrome, sympathetic ophthalmia and white dot syndromes. It has also been shown efficacious in cases of pars planitis and idiopathic posterior uveitis. Some authors have reported its use in postoperative cystoid macular edema. Many of the studies on the use of TA in controlling intraocular inflammation and concomitant macular edema showed its effect to be transient in many patients requiring reinjection. Complications can arise from intravitreal injection of TA including elevated intraocular pressure and cataract. Rarely, it can be associated with infectious and non-infectious endophthalmitis. TA may be useful as an adjuvant in the treatment of uveitis and its associated macular edema, especially in patients resistant or intolerant to standard treatment.

Triamcinolone-assisted neodymium:YAG laser vitreolysis

Triamcinolone acetonide was injected into the vitreous cavity to treat a case of cystoid macular edema. After the injection, slit-lamp examination was performed and the vitreous strands adhered to the remaining edge of the posterior capsule were clearly visualized. The strands were dissected with neodymium:YAG (Nd:YAG) laser shots. A technique that can be used to facilitate diagnosis and Nd:YAG laser dissection of vitreous strands in cases with complications of adhesion of vitreous strands into anterior segment structures is described.

Intravitreal pegaptanib sodium for refractory pseudophakic macular oedema

PURPOSE

Evaluate the efficacy of intravitreal pegaptanib sodium (Macugen) in refractory pseudophakic cystoid macular oedema (CME).

DESIGN AND METHODS

Prospective, nonrandomized, interventional case series. Four eyes of four patients with refractory pseudophakic CME to pars plana vitrectomy and intravitreal bevacizumab and triamcinolone, were treated with pegaptanib sodium, with a mean follow up of 4 months. Pre- and postinfection examinations included assessment of best-corrected visual acuity (BCVA) using the Early Treatment Diabetic Retinopathy Study chart (ETDRS), fluorescein angiography (FA), and optical coherence tomography (OCT).

RESULTS

Visual acuity increased in all patients after intravitreal pegaptanib sodium. OCT showed improvement of the retinal thickness in the macular area.

CONCLUSION

Intravitreal pegaptanib sodium (Macugen) is a promising treatment for pseudophakic cystoid macular oedema resistant to other medical treatment strategies. However, further study is needed to assess the treatment's long term efficacy and the need for retreatment.

Safety and pharmokinetics of triamcinolone hexacetonide in rabbit eyes

PURPOSE

The aim of this study was to evaluate whether intravitreal triamcinolone hexacetonide (TH) is a safe, longer lasting alternative to intravitreal triamcinolone acetonide (TA) in the rabbit eye.

METHODS

Three groups, each comprising of 15 Dutch-belted rabbits, received a unilateral injection of 0.1 mL of drug and 0.1 mL of physiologic salt solution in the fellow eye. Group I received TA, group II received commercially available TH, and group III received reformulated iso-osmolar triamcinolone hexacetonide (rTH). Simultaneous bilateral dark-adapted electroretinography was performed following the injection. Retinal morphology was assessed by using histopathology in each group enucleated 12 weeks after injection. High-performance liquid chromatography of vitreous isolated from the enucleated eyes was used to determine drug concentrations.

RESULTS

A significant reduction in saturated a-wave and maximal scotopic b-wave was observed in the group II eyes relative to the fellow control eyes at both 2 and 12 weeks postinjection (P < 0.001 for each comparison) but not in the other groups. Histopathology showed no differences between drug-injected eyes and fellow control eyes in groups I and III, but in group II there was severe degeneration of all retina layers. In group I, the drug half-life was 17.7 +/- 1.7 days, group II 44 +/- 13 days, and group III 12.8 +/- 2.3 days.

CONCLUSIONS

The half-life of commercially available TH in the vitreous is double that of TA, but the former is toxic to the retina in this rabbit model. Reformulated iso-osmolar TH showed no evidence of deleterious effects to retina function or structure but had a similar half-life to TA.

Intravitreal and posterior subtenon triamcinolone acetonide in idiopathic bilateral uveitic macular oedema

PURPOSE

To study the efficacy of intravitreal triamcinolone acetonide (IVTA) versus posterior subtenon triamcinolone acetonide (PSTA) in bilateral macular oedema secondary to idiopathic intermediate uveitis.

METHODS

In a prospective, interventional case series, 10 patients (20 eyes) with bilateral uveitic macular oedema were included. Patients underwent fundus fluorescein angiography, record of visual acuity and intraocular pressure (IOP). Patients received IVTA 4 mg/0.1 mL in one eye and PSTA 20 mg/0.5 mL in the fellow eye at an interval of > or =4 weeks. The outcome measures were record of IOP, best corrected visual acuity and angiographic resolution of cystoid macular oedema at 3 and 6 months.

RESULTS

The mean pre-intervention IOP at baseline between the IVTA and the PSTA group was comparable. At 1 week, the mean IOP recorded was greater in the eyes that received IVTA than those that received PSTA (P < 0.001). However, at 1- and 3-month follow up, the mean IOP between the two groups was similar. Best corrected visual acuity of > or =6/12 achieved at 3 and 6 months in the IVTA and PSTA group was comparable (77.8% vs. 44.4% [P = 0.14] and 88.9% vs. 77.8% [P = 0.53]). There was also no significant difference in angiographic resolution of cystoid macular oedema at 3 (P = 0.32) and 6 months (P = 0.53) between the two groups. Recurrence of macular oedema was seen in one and two eyes that received IVTA and PSTA, respectively, at 6 months.

CONCLUSION

Triamcinolone acetonide injection, whether administered intravitreally or via posterior subtenon route, is an effective treatment option in achieving complete anatomic and functional improvement in cases treated for macular oedema secondary to idiopathic intermediate uveitis.

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.

Adverse events after intravitreal triamcinolone in patients with and without uveitis

PURPOSE

To evaluate the rates of adverse ocular events after intravitreal triamcinolone acetonide (IVTA) injection in patients with and without uveitis.

DESIGN

Retrospective observational case series.

PARTICIPANTS

Two hundred twenty-two eyes of 173 patients were included in the study: 45 eyes of 31 patients with macular edema (ME) due to uveitis and 177 eyes of 142 patients with ME secondary to other etiologies.

METHODS

Retrospective review of patients who received IVTA at the Cole Eye Institute for ME attributable to various causes between the years 2001 and 2005. Data review of clinical records included patient demographics, etiology of ME, and adverse outcomes after injection. Rates of adverse outcomes in patients with and without uveitis were compared.

MAIN OUTCOME MEASURES

Intraocular pressure (IOP) elevation and posterior subcapsular cataract (PSC) progression.

RESULTS

Uveitis patients were significantly younger, more likely to be female, and more likely to have had prior posterior sub-Tenon's capsule steroid injection and/or glaucoma therapy than their nonuveitis counterparts. In a multivariate analysis adjusting for the differences in these factors, the presence of uveitis was the strongest risk factor for an adverse IOP event (odds ratio, 2.5; 95% confidence interval [CI], 1.0-6.1; P = 0.05). The odds of having a documented increase in PSC after IVTA injection were 5.6 times greater in uveitis eyes (P = 0.007; 95% CI, 1.6-19.6).

CONCLUSIONS

Intraocular pressure elevation and PSC progression occurred with greater frequency in uveitis patients receiving IVTA. Patients with uveitis treated with IVTA should be counseled about these risks and monitored closely.

Steroidal and Nonsteroidal Antiinflammatory Medications Can Improve Photoreceptor Survival after Laser Retinal Photocoagulation

OBJECTIVE

To determine whether methylprednisolone or indomethacin can enhance photoreceptor survival after laser retinal injury in an animal model.

DESIGN

Experimental study.

PARTICIPANTS

Twenty rhesus monkeys.

METHODS

Twenty rhesus monkeys (Macaca mulatta) received a grid of argon green (514.5 nm, 10 ms) laser lesions in the macula of the right eye and a grid of neodymium:yttrium-aluminum-garnet (Nd:YAG; 1064 nm, 10 ns) lesions in the macula of the left eye, followed by randomization to 2 weeks of treatment in 1 of 4 treatment groups: high-dose methylprednisolone, moderate-dose methylprednisolone, indomethacin, or control. The lesions were assessed at day 1, day 14, 2 months, and 4 months. The authors were masked to the treatment group. This report discusses the histologic results of ocular tissue harvested at 4 months.

MAIN OUTCOME MEASURE

The number of surviving photoreceptor cell nuclei within each lesion was compared with the number of photoreceptor nuclei in surrounding unaffected retina. The proportion of surviving photoreceptor nuclei was compared between each treatment group.

RESULTS

Argon retinal lesions in the high-dose steroid treatment group and the indomethacin treatment group demonstrated improved photoreceptor survival compared with the control group (P = 0.004). Hemorrhagic Nd:YAG lesions demonstrated improved survivability with indomethacin treatment compared with controls (P = 0.003). In nonhemorrhagic Nd:YAG laser retinal lesions, the lesions treated with moderate-dose steroids demonstrated improved photoreceptor survival compared with the control group (P = 0.004).

CONCLUSIONS

Based on histologic samples of retinal laser lesions 4 months after injury, treatment with indomethacin resulted in improved photoreceptor survival in argon laser lesions and hemorrhagic Nd:YAG laser lesions. Treatment with systemic methylprednisolone demonstrated improved photoreceptor survival in argon retinal lesions and in nonhemorrhagic Nd:YAG lesions.

INTRAOCULAR TRIAMCINOLONE ACETONIDE FOR PSEUDOPHAKIC CYSTOID MACULAR EDEMA

PURPOSE

To evaluate pseudophakic cystoid macular edema (CME) by optical coherence tomography (OCT) and multifocal electroretinography (mf-ERG) and determine the efficacy of intravitreal triamcinolone acetonide injections.

METHODS

In this nonrandomized retrospective study, 14 eyes of 14 patients with persistent pseudophakic CME were treated with triamcinolone acetonide injection and were followed up for 1 year. All patients underwent complete ophthalmologic examination including determination of best-corrected visual acuity, slit-lamp examination, tonometry, and funduscopy. Results of OCT and mf-ERG were also recorded before and after the injection.

RESULTS

Visual acuity and mf-ERG values increased in all patients after intravitreal triamcinolone acetonide injections. OCT showed improvement of the retinal thickness in the macular area. Temporary increase of intraocular pressure was controlled with topical use of antiglaucoma drops.

CONCLUSION

Intravitreal triamcinolone acetonide injection is a promising therapeutic tool for chronic pseudophakic edema resistant to other medical treatment. However, further study is needed to assess the treatment's long-term efficacy, its safety, and the need for retreatment.

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.

Retinal toxicity of intravitreal triamcinolone acetonide at high doses in the rabbit

In order to study acute retinal toxicity of intravitreal triamcinolone acetonide (TA) at high doses in an animal model, thirty New Zealand albino rabbits were injected with intravitreal TA. The animals were divided in five groups: Group 1 received an intravitreal injection of 0.1 mL balanced salt solution; Group 2, 0.1 mL of the solvent (0.99 mg of benzyl alcohol); Group 3, received 4 mg/0.1 mL TA; Group 4, 20mg/0.1 mL TA; and Group 5, 30 mg/0.1 mL TA. A standard light and dark adapted electroretinogram (ERG) was obtained prior and 28 days after the injection. The animals were sacrificed 28 days after the injection and the eyes were enucleated and examined by electron (EM) and light microscopy (LM) using hematoxylin-eosin, Nissl fluorescent, and immunohistochemistry (glial fibrillary acidic protein). No statistically significant differences in ERG before and 28 days after the injection were found. LM and EM did not show retinal damage in any animal. One eye developed bacterial endophthalmitis 14 days after the injection. Intravitreal TA up to 30 mg does not seem to have acute toxic effects on the function (ERG) or the structure (LM, EM) of the retina of albino rabbits.

Retinal toxicity of triamcinolone’s vehicle (benzyl alcohol): an electrophysiologic and electron microscopic study

PURPOSE

To assess retinal toxicity of the vehicle of triamcinolone, benzyl alcohol (BA), when injected into the vitreous cavity of rabbits.

METHODS

This prospective comparative experimental study included 24 pigmented rabbits assigned into two groups: group 1 (experimental, n = 12) received intravitreal 0.1 ml of BA, and group 2 (control, n = 12) received intravitreal 0.1 ml of balanced salt solution (BSS); all injections were done in the right eyes. Clinical examinations [slit lamp biomicroscopy, indirect ophthalmoloscopy, and three intraocular pressure (IOP) measurements] were done on both eyes before injection, at 1 and 3 h post injection, together with electroretinograms (ERGs) at 3 days, 1, 2, 4, and 6 weeks following injections. Three rabbits from each group were euthanased at 1, 2, 4, or 6 weeks and eyes were sent for light and electron microscopic examination for quantitative morphometric measurements.

RESULTS

The mean amplitudes of the a and b waves of the BA-injected eyes were 6.42 +/- 9.02 microv and 11.18 +/- 15.18 microv at 3 days, respectively, which were significantly reduced compared with the BSS-injected eyes (30.87 +/- 8.22 microv and 57.90 +/- 13.38 microv, respectively; P < 0.01 t-test) and the non-injected contralateral eyes (36.20 +/- 7.85 microv and 64.10 +/- 9.36 microv, respectively; P < 0.01 t-test). These ERG responses continued to be significantly reduced in the BA-injected eyes (P < 0.01 t-test) throughout the study period. The mean ganglion cell count was significantly reduced (P < 0.005 t-test) in the BA-injected eyes (8.42 +/- 2.4) compared with the BSS- and non-injected eyes (16.42 +/- 3.9 and 16.5 +/- 4.2, respectively). The mean thicknesses of the inner nuclear layer (INL) and outer nuclear layer (ONL) were significantly reduced (P < 0.005 t-test) in the BA-injected eyes (3.78 +/- 0.96 microm and 11.77 +/- 1.29 microm, respectively) compared with the BSS- (6.1 +/- 0.92 microm and 21.82 +/- 0.95 microm, respectively) and non-injected eyes (7.05 +/- 1.9 microm and 22.49 +/- 1.01 microm, respectively). Electron microscopy showed moderate to severe intracellular changes in the ganglion cell layer, INL, ONL, and photoreceptor layer at 6 weeks in BA-injected eyes, with no significant changes in BSS-injected eye. There was no significant rise in the IOP or clinical evidence of increased lens density during the study period in any of the eyes.

CONCLUSIONS

Triamcinolone acetonide's vehicle, BA, produced severe ERG and structural damage to the retina when injected intravitreally.

Outcome of intravitreal triamcinolone acetonide in postoperative cystoid macular oedema

AIMS

To assess the efficacy and safety of intravitreal triamcinolone in the treatment of postoperative cystoid macular oedema (CMO).

METHODS

A retrospective case series review of 21 eyes (20 patients) that had an intravitreal injection of triamcinolone 4 mg for postoperative CMO. Diagnosis was confirmed by fundus fluorescein angiography and/or optical coherence tomography in all eyes.

RESULTS

Mean age of patients was 71.1 years. CMO had developed following routine phacoemulsification cataract extraction (13 eyes), phacoemulsification cataract extraction complicated by posterior capsule tear and vitreous loss (two eyes), vitrectomy (three eyes), or planned combined phacoemulsification and vitrectomy (three eyes). Mean duration of CMO before triamcinolone injection was 4.9 months. Mean duration of follow-up was 7.4 months. Two eyes required a repeat injection. Mean logarithm of minimum angle of resolution (LogMAR) visual acuity (VA) before treatment was 0.53; at 1 month post injection, this increased significantly to 0.33 (P<0.001). Improvement in VA was maintained throughout follow-up; at 6 months or later, mean LogMAR VA was significantly better than baseline (0.33 vs 0.53, P=0.02). At the latest review, 43% of eyes had improved Snellen VA by two or more lines and 86% by one or more lines compared to baseline. The remaining 14% had reduced Snellen VA compared to baseline. In the post-injection period, 33% of eyes developed an intraocular pressure of 22 mm Hg or higher and all responded well to short-term topical agents. There were no other post-injection complications.

CONCLUSION

Intravitreal triamcinolone results in a rapid improvement in VA that may be sustained for more than 6 months.

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 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.