Loss of visual function after repeated intravitreal injections of triamcinolone acetonide in refractory uveitic macular oedema

Purpose The effects of intravitreal triamcinolone acetonide on macular oedema have been evaluated in many studies. Good short-time effects are usually reported on visual function and macular oedema. However, adverse events like intraocular hypertension and cataract formation have been described in humans, and retinal toxicity is found in experimental studies. Case report We report on a 56-year-old male patient with a bilateral macular oedema in idiopathic intermediate uveitis, treated with two and six intravitreal injections of triamcinolone acetonide, respectively, and followed for 6 years. Results The macular oedema disappeared after each intravitreal injection, but each time it recidivated some months later. Visual acuity improved only after the first injections. After six intravitreal injections, visual acuity was limited to counting fingers in the absence of macular oedema. OCT and ERG results show central and peripheral retinal damage that could be a consequence of a retinotoxic property of triamcinolone acetonide. Conclusion Repeated intravitreal injection of triamcinolone acetonide does not show any long-term efficacy on uveitic macular oedema and can even lead to irreversible global retinal damage.     

Subconjunctival injections of triamcinolone acetonide to treat uveitic macular edema

AIM: To evaluate the efficacy and safety of subconjunctival triamcinolone acetonide (TA) injections for treating uveitic macular edema (UME). METHODS: This retrospective case series study included patients with UME who received subconjunctival TA injections with a minimum follow-up period of 6mo. The main outcome measure was central macular thickness (CMT). The secondary outcome measures included best-corrected visual acuity (BCVA), recurrence rate and intraocular pressure (IOP). RESULTS: In total, 65 patients (80 eyes), mainly including idiopathic uveitis in 33 patients (50.77%) and Vogt-Koyanagi-Harada (VKH) syndrome in 19 patients (29.23%), were enrolled in this study. The mean CMT decreased from 457.6±173.0 μm at baseline to 325.9±176.8, 302.7±148.2, 332.2±177.3 and 270.6±121.6 μm at 1-, 2-, 3- and 6-months postinjection, respectively (all P<0.001). BCVA increased from logMAR 0.5±0.3 at baseline to logMAR 0.4±0.3, 0.4±0.3, 0.4±0.4 and 0.4±0.3 at the 1-, 2-, 3- and 6-months postinjection visits, respectively (all P<0.001). Twenty-one (21/80, 26.25%) eyes underwent relapse of UME within 6mo. A total of 20/80 (25%) eyes exhibited elevated IOPs, of which 13 eyes were controlled with topical IOP-lowering agents and 7 eyes underwent surgical removal of subconjunctival TA deposit. CONCLUSION: Subconjunctival TA injections appear to be safe and effective for UME.     

Safety and efficacy of intravitreal triamcinolone acetonide for uveitic macular edema

BACKGROUND: To evaluate the safety and efficacy of intravitreal triamcinolone acetonide (TA) for treating macular edema secondary to non-infectious uveitis. METHODS: Retrospective review of sixteen patients (20 eyes) with chronic cystoid macular edema (CME) as a consequence of controlled intermediate uveitis, posterior uveitis, or panuveitis who received at least one intravitreal injection of TA. Main outcome measures were visual acuity (VA), intraocular pressure (IOP), formation or progression of an existing cataract, and CME resolution during the follow-up period. RESULTS: At last follow-up, VA showed improvement (compared to baseline) in 11 eyes (55%), deterioration in three eyes (15%), remained completely unchanged in one eye (5%), and showed improvement initially but returned to baseline levels in five eyes (25%). At last follow-up, CME had relapsed or was still present in 10 of the eyes (50%). The remaining eyes showed complete resolution of the CME, without evidence of recurrence during the follow-up time. Mean VA at last follow-up showed statistically significant improvement (p = 0.02) in nonvitrectomized eyes (mean baseline VA: 1.14 +/- 0.58; mean final VA: 0.96 +/- 0.66) compared to the almost unaltered mean visual acuity for vitrectomized eyes (mean baseline VA: 0.76 +/- 0.41; mean final VA: 0.71 +/- 0.48)(p = 0.40, paired samples t-test). Elevation of IOP was transient in all cases and responded well to topical medications, except for one patient who required placement of an Ahmed valve. Preexisting cataract progressed in three of the 15 phakic eyes (20%). One patient developed a retinal detachment and required additional surgery to reattach it. Patients were followed for a mean of 34 weeks (median: 32 weeks; range: 19-56 weeks). CONCLUSIONS: Intravitreal TA may play a role in the treatment of uveitis-related CME. Further controlled studies are necessary to test this hypothesis.     

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.     

Macular function after intravitreal triamcinolone acetonide injection for diabetic macular oedema

Purpose: We aimed to evaluate the effect of intravitreal triamcinolone acetonide (IVTA) on macular function in patients with diabetic macular oedema (DMO). Methods: Eleven eyes in 11 patients with DMO were enrolled. In each eye, at baseline and at 30 days after IVTA injection, logMAR visual acuity (VA), macular sensitivity, fixation stability and fixation location by MP‐1 microperimetry and optical coherence tomography (OCT) foveal thickness were assessed. Results: Thirty days after IVTA injection, eyes with DMO showed a significant (p < 0.001) reduction in foveal thickness and significant (p < 0.01) increases in logMAR VA and MP‐1 retinal sensitivity (p < 0.001). There was also significant (p = 0.046) improvement in fixation location and some improvement in fixation stability, although the latter was not significant (p = 0.08). Conclusions: In eyes with DMO, short‐term improvement in retinal sensitivity and fixation properties can be achieved by IVTA injection.     

Decreasing efficacy of repeated intravitreal triamcinolone injections in diabetic macular oedema

BACKGROUND/AIM: Intravitreal triamcinolone (IVTA) results in transient improvements in diabetic macular oedema (DMO), necessitating repeated injections. The authors report a case series of 10 eyes of 10 patients with DMO, who received a repeat injection of 4 mg IVTA, at least 26 weeks after the first injection of the same dose. METHOD: Pre-injection and at 2, 4, 9, and 17 weeks post-injection, best corrected visual acuity (BCVA) and central foveal thickness (CFT) on optical coherence tomography, after the first and repeat injections, were compared using paired t test. Side effects were monitored. RESULTS: BCVA, CFT, intraocular pressure (IOP), and cataract scores were not significantly different before initial and repeat injections (given at 32.5 (SD 3.5) weeks after the first injection). Transient improvements of BCVA and CFT were achieved after both injections. However, after the repeat injection, the BCVA was significantly worse at all time points (p<0.05) and so were the best achieved CFT and the CFT at 4 weeks post-injection (p = 0.034 and 0.011 respectively), compared with the initial injection. Post-injection maximum IOPs and increase in cataract scores were not significantly different between the two injections. CONCLUSION: A repeat injection of 4 mg of IVTA may not be as effective as an initial injection for the treatment of DMO.     

Dosage dependency of intravitreal triamcinolone acetonide as treatment for diabetic macular oedema

AIM: To evaluate the effect of different doses of intravitreal triamcinolone acetonide on diffuse diabetic macular oedema. METHODS: The prospective, randomised, double masked, clinical interventional study included 27 eyes (27 patients) with diffuse diabetic macular oedema. They were randomly divided into three study groups receiving an intravitreal injection of filtered triamcinolone acetonide of about 2 mg (n = 8 eyes), 5 mg (n = 10), or 13 mg (n = 9), respectively. Dosage measurement was performed before filtration. Mean follow up was 6.6 (SD 2.4) months (3-12 months). Main outcome measures were visual acuity and intraocular pressure. RESULTS: Maximal increase in visual acuity was significantly (p = 0.046; 95% CI: 0.032 to 2.99; r = 0.38) correlated with the dosage of intravitreal triamcinolone acetonide. Additionally, the duration of the effect of intravitreal triamcinolone acetonide increased significantly with the dosage of intravitreal triamcinolone acetonide (r = 0.45; p = 0.014). Increase in intraocular pressure during follow up was statistically not significantly associated with the dosage used (p = 0.77). CONCLUSIONS: In patients with diffuse diabetic macular oedema receiving intravitreal triamcinolone acetonide, treatment response may last longer and be more pronounced with a dosage of 13 mg than in lower doses of 5 mg or 2 mg. Triamcinolone acetonide induced increase in intraocular pressure may not be markedly associated with the dosage used.     

Resolution of severe macular oedema in adult Coat's syndrome with high-dose intravitreal triamcinolone acetonide

OBJECTIVE: To report the clinical outcome of a patient who received high-dose intravitreal triamcinolone acetonide as treatment for severe macular oedema secondary to adult Coat's syndrome. METHOD: Case report. RESULTS: A 74-year-old Indian man complaining of chronic gradual blurring of vision in the left eye was found to have adult Coat's syndrome with severe macular oedema. He received 25 mg of intravitreal triamcinolone acetonide following unsuccessful resolution with grid laser. Optical coherence tomography (OCT) demonstrated up to 75% decrease in macular oedema that was evident even after 9 months follow-up. However, there was no significant improvement in visual acuity. CONCLUSION: Intravitreal triamcinolone is a reasonable option in reducing severe macular oedema in cases of adult Coat's syndrome.     

Intravitreal triamcinolone acetonide versus combined intravitreal bevacizumab and dexamethasone in diffuse diabetic macular oedema

Background: To compare the efficacy of a single injection of combined intravitreal dexamethasone and bevacizumab (Avastin) with that of intravitreal triamcinolone acetonide in eyes with diffuse cystoid diabetic macular oedema. Design: Prospective, non‐randomized, masked, interventional case series. Participants: Twenty‐four eyes of 24 subjects with centre‐involved diabetic macular oedema extending over two disc‐areas with predominant cystic changes on spectral domain optical coherence tomography were selected. Methods: Ten phakic and two pseudophakic, ocular hypertensive eyes received intravitreal dexamethasone and bevacizumab as against 12 pseudophakic, normotensive eyes that received intravitreal triamcinolone acetonide. Main Outcome Measures: Change in central macular volume on spectral domain optical coherence tomography and best‐corrected visual acuity were measured at 6‐week follow‐up. Results: Baseline data were matched in both groups. Post‐injection central macular volume (7.46 ± 0.73 mm³) was significantly lower (P < 0.001) in the intravitreal triamcinolone acetonide group when compared with its pre‐injection central macular volume (9.11 ± 1.0 mm³) or when compared with the post‐injection central macular volume (P = 0.02) of the intravitreal dexamethasone and bevacizumab group (8.42 ± 1.18 mm³). However, post‐injection best‐corrected visual acuity between the intravitreal triamcinolone acetonide (0.65 ± 0.15 logMAR) and the intravitreal dexamethasone and bevacizumab groups (0.685 ± 0.15 logMAR) was not significantly different (P = 0.06) at 6 weeks. No significant correlation was noted between change in central macular volume and change in best‐corrected visual acuity (r = 0.35, P = 0.07) from the pooled data of both the groups. A fair correlation was noted between change in central macular volume and pre‐injection central macular volume (r = 0.55, P = 0.005). Conclusions: Intravitreal triamcinolone acetonide may be more effective than intravitreal dexamethasone and bevacizumab in reducing macular volume in patients with diffuse cystoid diabetic macular oedema. A significant reduction in macular volume does not necessarily translate into a correspondingly significant improvement in best‐corrected visual acuity.     

Prospective comparisons of intravitreal injections of triamcinolone acetonide and bevacizumab for macular oedema due to branch retinal vein occlusion

Purpose: To compare the efficacy of intravitreal injections of triamcinolone acetonide (TA) and that of bevacizumab for macular oedema because of branch retinal vein occlusion (BRVO). Design: Prospective, comparative, randomized, interventional clinical trial. Methods: Forty‐three eyes of 43 patients with macular oedema because of BRVO were randomly assigned to 4‐mg intravitreal injections of TA (IVTA)(21 patients, IVTA group) or 1.25‐mg intravitreal injections of bevacizumab (IVB) (22 patients, IVB group) and followed for 12 months. No additional treatments were administered for 3 months after the initial injection; additional injections were administered when macular oedema recurred between 3 and 12 months after the initial injection. The best‐corrected visual acuity (BCVA) and the central retinal thickness (CRT) were measured at baseline and monthly. The main outcome measures were changes in the logarithm of the minimal angle of resolution BCVA and CRT from baseline to 12 months. Results: Eighteen eyes of 18 patients in the IVTA group and 18 eyes of 18 patients in the IVB group completed follow‐up at 12 months. The mean improvements in BCVA from baseline to 12 months were 0.12 in the IVTA group and 0.33 in the IVB group, which was significantly (p = 0.032) higher than in the IVTA group. There was no significant difference between the two groups in the mean reduction in CRT from baseline to 12 months after the initial injection. Two eyes in the IVTA group required intraocular pressure–lowering medications. Conclusion: Intravitreal injection of bevacizumab may be of greater benefit than that of TA for macular oedema because of BRVO.     

Full-thickness macular hole in a patient with diabetic cystoid macular oedema treated by intravitreal triamcinolone injections

PURPOSE: Full-thickness macular hole associated with diabetic macular oedema is a rare feature and its pathogenesis remains incompletely elucidated. We report the occurrence of a full-thickness macular hole, documented with optical coherence tomography (OCT), in a patient with diabetic cystoid macular oedema treated by intravitreal triamcinolone injections. CASE REPORT: A 48-year-old woman with refractory diabetic cystoid macular oedema underwent successive intravitreal triamcinolone injections, which were followed by a progressive thinning of the neurosensory retina at the fovea, and then by a full-thickness macular hole, associated with a perifoveal posterior hyaloid detachment, visible on OCT. During pars plana vitrectomy, a thin epiretinal macular membrane was diagnosed and removed. DISCUSSION: Pathogenesis of the present full-thickness macular hole associated with diabetic macular oedema is different from that of idiopathic macular holes because anteroposterior vitreous tractions were not involved in its formation. Recurrent intravitreal triamcinolone injections may have had an indirect role in the development of the macular hole, by favouring the rupture of distended Muller cells and intraretinal pseudocysts.     

Efficacy and safety of multiple intravitreal triamcinolone injections for refractory diabetic macular oedema

AIM: The efficacy and safety of repeated injections of intravitreal triamcinolone (IVTA) for diabetic macular oedema is unclear, with results of previous reports conflicting. METHODS: This is a prospective, observational case series of 27 eyes receiving IVTA for diabetic macular oedema. LogMAR visual acuity (VA) and central macular thickness (CMT) were measured at baseline and in 3 to 6 monthly intervals for up to 24 months, then correlated with the number of IVTA injections given. RESULTS: One IVTA injection was required in 6 (18%) eyes, 2 in 8 (24%) eyes, 3 in 13 (39%) eyes and 4-5 in 6 (18%) eyes. VA improved in all patients, but neither the final improvement in VA nor the absolute improvement in CMT from baseline to 24 months correlated with the number of injections received (p = 0.44 and 0.84, respectively). Cataract surgery was more frequent in eyes receiving more injections (p = 0.01). CONCLUSIONS: This study suggests that repeated injections of IVTA continue to be as effective as the first over a 2-year period. The probability of cataract surgery increases with an increasing number of injections.     

Pars plana vitrectomy with intravitreal triamcinolone: effect on uveitic cystoid macular oedema and treatment limitations

OBJECTIVE: To investigate the effect of pars plana vitrectomy (PPV) in combination with intraoperative intravitreal triamcinolone acetonide injection on the course of cystoid macular oedema (CME) in patients with uveitis. METHODS: Patients with uveitis with CME (n = 19) not responding to systemic corticosteroids and/or immunosuppression combined with acetazolamide were retrospectively studied after PPV with additional intravitreal injection of 4 mg triamcinolone acetonide. Patients had chronic anterior uveitis (n = 4), intermediate uveitis (n = 9), posterior uveitis (n = 3) or panuveitis (n = 3). Visual acuity tests, tonometry, fluorescein angiographic appearance and postoperative complications were analysed. Mean follow-up was 14 months (SD 4.6). RESULTS: CME improved in 58% of the patients within the first 6 weeks postoperatively. After 12 months, CME was further improved in 44% and worsened in another 12%. Improvement of visual acuity was noted in 42% after 3 months and in 28% after 12 months. Cataract progressed in 85% of the phacic patients postoperatively. Increased intraocular pressure was detected in 27% at 2 weeks and in 11% at 12 months after surgery. CONCLUSION: Uveitic CME that is unresponsive to systemic immunosuppression and acetazolamide may improve after PPV with additional intravitreal triamcinolone application. The effect seems to be transient in many of the patients. Frequent complications were cataract formation and ocular hypertension.