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

AIMTo 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).

Complications of intravitreal triamcinolone acetonide for macular edema and predictive factors for intraocular pressure elevation

AIM: To investigate the complications of intravitreal triamcinolone acetonide (IVTA) for the treatment of macular edema, and to determine the risk factors for intraocular pressure (IOP) elevation. METHODS: Charts of patients with macular edema secondary to branch retinal vein occlusion (BRVO), diabetic retinopathy and uveitis who had received IVTA injections were reviewed to document its complications. IOP elevation was defined as a pressure of ≥24mmHg at some point during follow-up. Multivariate logistic regression analysis was performed to characterize baseline risk factors for this elevation. RESULTS: The study included 111 eyes of 65 female and 46 male patients with a mean follow-up of (11.6±5.1) months. Of the 111 eyes, 52 (46.8%) had macular edema secondary to BRVO, 44 (39.6%) had clinically significant diabetic macular edema (CSDME) and 15 (13.5%) had non-infectious uveitis with macular edema. IOP was recorded ≥24mmHg in 38 eyes (34.2%) during the follow-up. Higher baseline IOP (P =0.022), younger age (P =0.003), and male gender (P = 0.014) were significant risk factors for IOP elevation after IVTA injection. Eyes with prior vitrectomy were less likely to have IOP elevation (P =0.054). Two eyes (5.2% of eyes with increased IOP) underwent trabeculectomy, and 9 eyes (16.3% of the phakic eyes) necessitated cataract surgery. Other complications included branch vein occlusion (1.8%), sterile endophthalmitis (0.9%) and pseudohypopyon (0.9%). CONCLUSION: IVTA has side effects with IOP elevation and cataract formation being the two most common. A subset of patients is more prone to developing increased IOP following IVTA, namely, younger male patients with higher baseline IOP.

Short-term effects of intravitreal triamcinolone acetonide injection on ocular blood flow evaluated with color Doppler ultrasonography

AIM:To evaluate the changes in ocular blood flow with color Doppler ultrasonography(CDU) after intravitreal triamcinolone acetonide(IVTA) injection.METHODS:A total of 46 patients who underwent IVTA(4 mg/0.1 mL) injection for diabetic macular edema(DME)(n =22), central retinal vein occlusion(CRVO)(n =12) and choroidal neovascular membrane(CNVM)(n =12) were included in the study. Peak systolic velocity(PSV), end diastolic velocity(EDV) and resistivity index(RI) were measured from the ophthalmic artery(OA), the central retinal artery(CRA) and the posterior ciliary artery(PCA)of each patient with CDU before, at the end of the first week and at the end of the first month following IVTA injection.RESULTS:In the DME group, PSV of OA at the first of the first month(mean ±SD)(37.48 ±10.87 cm/s) increased compared to pre-injection value(31.39 ±10.84 cm/s)(P =0.048). There was a statistically significant decrease(P =0.049) in PSV of CRA at the end of the first month(7.97±2.67 cm/s) compared to the pre-injection(9.47±3.37 cm/s).There was not any statistically significant difference onthe other parameters in the DME group. Also, there was not any statistically significant difference on the ocular blood flow values in the CRVO and CNVM groups.CONCLUSION:We observed that 4 mg/0.1 mL IVTA increased PSV of OA and decreased PSV of CRA in DME patients and did not have any effect on ocular blood flow values of CRVO and CNVM patients.

Triamcinolone as an adjunct to the combination of anti-VEGF for the management of diabetic macular edema

AIM:To assess the efficacy of intravitreal triamcinolone(IVTA)as an adjunct to the combination of anti-vascular endothelial growth factor(VEGF)for the management of diabetic macular edema(DME).METHODS:A total of 51 patients with visual disabilities causing by DME from two sites were retrospectively collected and assigned to two groups according to the therapeutic method:intravitreal conbercept(IVC)combined with focal laser(24 eyes)and IVC combined with focal laser and IVTA(27 eyes).Best-corrected visual acuity(BCVA),the required number of IVCs,central retinal thickness(CRT),the mean costs of treatment burden and safety were compared over 12 mo.RESULTS:From baseline to month 1 through month 12,IVC combined with focal laser and IVTA improved the mean average change in BCVA superior to IVC combined with focal laser(+5.20 vs+2.71 letters).At month 12,20.83%of the IVC combined with focal laser and 37.04%of IVC combined with focal laser and IVTA arms gained more than 10 BCVA letters.During the period,the mean CRT decreased significantly in the IVC combined with focal laser and IVTA arm(-245.9μm)compared to the IVC combined with focal laser arm(-98.45μm).The average of 6.45 and 1.25 conbercept injections performed in the IVC combined with focal laser and IVC combined with focal laser and IVTA arms,respectively.The mean cost of treatment burden for 12 mo was$6247.44±4069.18 in the IVC combined with focal laser arm and$1679.19±542.73 in the IVC combined with focal laser and IVTA arm,with a statistically significant difference.Apart from occasional minor subconjunctival hemorrhage,no other significant ocular adverse events(AEs)were observed in either group during the 12-month period.CONCLUSION:It is effective and cost-effective to treat DME by utilizing triamcinolone as an adjunct to the combination of anti-VEGF.

Intravitreal triamcinolone acetonide： a ＂real world＂ analysis of visual acuity, pressure and outcomes

Dear Sir,Triamcinolone acetonide（TA）is worldwide available therapeutic agent that is commonly used throughout medicine.TA remains a safe and important ophthalmic therapeutic agent even after the advent of angiogenesis inhibitors[1-2].

Clinical trials on corticosteroids for diabetic macular edema

Diabetic macular edema(DME)is a common cause of visual impairment in diabetic patients.It is caused by an increase in the permeability of the perifoveal capillaries and a disruption of the blood retinal-barrier.The pathogenesis of DME is multifactorial.Several therapeutic modalities have been proposed for the treatment of DME.Corticosteroid treatments have emerged as an alternative therapy for persistent DME or refractory to conventional laser photocoagulation and other modalities,due to anti-inflammatory,anti-vascular endothelial growth factor and anti-proliferative effects.Many studies have demonstrated the beneficial therapeutic effect of corticosteroids with improvement to both retinal thickness and visual acuity in short-term on the treatment of DME.Peribulbar and intravitreal injections have been used to deliver steroids for DME with frequent injections due to the chronic and recurrent nature of the disease.Steroid-related side effects include elevated intraocular pressure,cataract,and injection related complications such as endophthalmitis,vitreous hemorrhage,and retinal detachment particularly with intravitreal steroid injections.In order to reduce the risks,complications and frequent dosing of intravitreal steroids,intravitreal implants have been developed recently to provide sustained release of corticosteroids and reduce repeated intravitreal injections for the management of DME.

Update on treatments of diabetic macular edema

Objective To review the update research progress about the treatment of diabetic macular edema and to give helpful guidelines in the treatment of diabetic macular edema based on available evidence to date. Data sources A literature search of all English articles was performed on the online electronic PubMed database dated 1984 to 2009. The keywords searched included： macular edema, therapy, laser coagulation, intravitreal triamcinolone acetonide, vascular endothelial growth factor inhibitor, protein kinase C inhibitor and Pars plana vitrectomy. After finding relevant articles within these search limits, a manual search was conducted through the references from these articles. Study selection Original articles and critical reviews were reviewed and selected to address the stated purpose. Results To date, demonstrated means to reduce the risk of vision loss from diabetic macular edema include focal/grid laser photocoagulation and improved metabolic control. Emerging pharmacologic therapies （intravitreal triamcinolone acetonide, vascular endothelial growth factor inhibitors and protein kinase C beta-isoform inhibitors） and Pars plana vitrectomy have shown early promise in the treatment of diabetic macular edema. Conclusions As there has been extensive development in multiple treatments of diabetic macular edema, choice of the most suitable treatment for specific patients becomes important. Combination therapy of laser, pharmacological and surqical treatment modalities mav offer an alternative to treatment of diabetic macular edema.