Sterile Endophthalmitis Following Intravitreal Injection of Triamcinolone Acetonide

Purpose: To investigate clinical findings and ocular characteristics of sterile endophthalmitis following intravitreal injection (IVI) of triamcinolone for the treatment of macular edema. Methods: IVI is an institutional practice at our hospital. From March 2002 to January 2003, a total of 21 IVIs of triamcinolone acetonide were performed on 19 patients with macular edema secondary to various retinal disorders. Cases diagnosed as sterile endophthalmitis after IVI of triamcinolone were selected for the study. Fisher's discriminant linear analysis was used to determine whether a significant correlation existed between specific ocular features and the occurrence of post-injection sterile endophthalmitis. Results: Five of 21 eyes (23.8%) had sterile endophthalmitis with hypopyon formation after the injection. Of the five sterile endophthalmitis patients, three were pseudophakic with impaired posterior capsule and four had a diagnosis of Irvine-Gass syndrome. The rate of sterile endophthalmitis was significantly higher in pseudophakic patients with impaired posterior capsule (p = 0.0075) and in patients with Irvine-Gass syndrome (p = 0.0008). The best-corrected visual acuity (BCVA) in these patients remained unchanged or even improved when the inflammation subsided. Conclusion: Pseudophakia with impaired posterior capsule and the diagnosis of cystoid macular edema due to Irvine-Gass syndrome are two risk factors of sterile endophthalmitis following IVI triamcinolone. No loss of BCVA was noted in the patients with post-injection sterile endophthalmitis.     

Combined Intravitreal Bevacizumab and Triamcinolone Acetonide Injection for Idiopathic Neuroretinitis

Purpose: To present a case with idiopathic neuroretinitis that was treated with combined intravitreal bevacizumab and triamcinolone. Design: Case report. Methods: Interventional case report. Results: A 31-year-old man presented with a visual acuity of 3/10 and afferent pupillary defect in the right eye. Ophthalmologic examination disclosed papillitis and macular edema. Neurology consultation with cranial computerized tomography scan revealed no abnormality. The patient was injected with bevacizumab and triamcinolone intravitreally. One week later, the vision increased to 10/10, macular edema disappeared. One month later, optic disc edema disappeared. Conclusions: Intravitreal injection of bevacizumab and triamcinolone effectively treated idiopathic neuroretinitis.     

Different Dosages of Intravitreal Triamcinolone Acetonide Injections for Macular Edema Secondary to Central Retinal Vein Occlusion

Purpose:.To study the effect of intravitreal injections of triamcinolone acetonide (TA) for the treatment of macular edema secondary to central retinal vein occlusion.(CRVO).in a sample of Chinese patients from Shaanxi province. Methods:.The 50 eyes from 50 patients were separated into three TA treatment groups:.17 patients were given 4 mg/0.1 ml,.19 patients were given 8 mg/0.2 ml,.and 14 patients were given 16 mg/0.4 ml. Patients were followed up for 12 months. Foveal thickness, intraocular pressure (IOP), and best-corrected visual acuity (BCVA) were measured. Results:.Macular edema responded well both anatomically and functionally to the TA injections. After the initial intravitreal injection,.macular edema recurred at 2-4 months in the low-dose group.(4 mg),.at 3-5 months in the medium-dose group (8 mg), and at 6-9 months in the high-dose group (16 mg)..No significant difference in BCVA or in foveal thickness were observed between the first intravitreal injection and the re-injection. There was no increase in IOP after re-injection of 16 mg TA,.if the patient did not have an elevated IOP after the initial intravitreal injection of 4/8 mg TA. Conclusion: A low dosage of TA (4 mg) administered via intravitreal injection might be useful as an initial treatment for macular edema secondary to CRVO..A higher dosage of TA (16mg) can be used if there is no IOP elevation with the initial TA injection.     

曲安奈德兔眼内注射治疗金黄色葡萄球菌眼内炎的有效性

目的:正确评价曲安奈德作为金黄色葡萄球菌性眼内炎辅助治疗的有效性。方法:30只健康青紫蓝兔所有右眼玻璃体腔注射ATCC25923标准金黄色葡萄菌104CFU/0.1mL混悬液,0.1mL建立眼内炎模型。建立眼内炎模型后24h,随机将实验动物分为3组,每组10眼进行不同干预,A(空白对照)组、B(玻璃体腔万古霉素)组、C(玻璃体腔万古霉素 曲安奈德混悬剂)组。干预后每日间接眼底镜观察结膜、角膜、前房、虹膜、玻璃体的变化并按照规定的时间进行临床炎症评分;注射细菌后24h及干预后14d所有实验动物行B超检查;干预后5d进行玻璃体腔细菌学培养;干预14d后处死所有动物行光镜检查并进行病理评分。结果:B,C组较A组炎症明显减轻。不同时间3组进行临床炎症评分,A组评分明显高于B,C2组,A,B,C3组间评分均有显著性差异(P<0.05),5,7,14d验证评分B,C2组间均无显著性差异(P=0.717,0.694,0.543);7,14d前房闪辉分级B,C组间无显著性差异(P=0.796,0.562);A,B,C3组间细菌学培养检出率无统计学意义;B超显示A,B,C3组视网膜脱离发生率无显著性差异(P=0.830);光镜下见A组各组织结构均失去正常形态不易辨认;B、C组组织结构能够辨认。对角膜、前房、玻璃体、视网膜进行病理评分,A,B,C3组间有显著性差异(P=0.000),组间比较B,C视网膜分级有显著性差异(P=0.011),其余均无显著性差异。结论:金黄色葡萄球菌性眼内炎治疗中玻璃体腔注射曲安奈德对眼组织的保护作用具有局限性。     

小剂量曲安奈德玻璃体腔内注射治疗黄斑水肿

目的评价小剂量曲安奈德玻璃体腔内注射治疗黄斑水肿的效果和安全性。方法31例(31眼)黄斑水肿患者,其中糖尿病性黄斑水肿19例、视网膜中央静脉阻塞性黄斑水肿8例、白内障术后黄斑水肿4例,所有患者均行6mg曲安奈德玻璃体腔内注射。在注射后1周、1个月、2个月、3个月对患者视力、眼压进行检查并行黄斑部光相干断层扫描检查黄斑区视网膜厚度和黄斑区视网膜总容积。结果所有患者的视力在注射后均有一定升高,经LogMAR转换后注射前和注射后3个月视力分别为0.620±0.334和0·455±0·313(P<0.05);黄斑区视网膜厚度和容积下降,注射后3个月分别为(312±146)μm和(2.61±0.27)mm3,与注射前相比[(484±216)μm和(3.76±0.56)mm3]差异有显著性意义(P<0.05)。随访1周、1个月、2个月时的平均眼压[(18.1±6.4)mmHg、(18.9±6.3)mmHg、(17.6±5.8)mmHg,1kPa=7.5mmHg]较注射前平均水平[(14.2±4.6)mmHg]显著升高(P<0.05)。随访期内1例患者因白内障进展而需手术治疗。结论至少3个月随访期内,小剂量曲安奈德玻璃体腔内注射治疗黄斑水肿安全有效,没有严重并发症。     

Complications of Intravitreal Injections in Patients with Diabetes

Abstract

Intravitreal injections for the treatment of retinal disorders and intraocular infection have become a common ophthalmic procedure, and injections of anti-vascular endothelial growth factor agents or steroids are frequently performed for the treatment of diabetic macular edema or other diabetic vascular pathology. Diabetic patients may be at higher risk of adverse events than non-diabetic individuals given frequent systemic co-morbidities, such as cardiovascular and renal disease, susceptibility to infection, and unique ocular pathology that includes fibrovascular proliferation. Fortunately, many associated complications, including endophthalmitis, are related to the injection procedure and can therefore be circumvented by careful attention to injection techniques. This review highlights the safety profile of intravitreal injections in patients with diabetes. Although diabetic patients may theoretically be at higher risk than non-diabetic patients for complications, a comprehensive review of the literature does not demonstrate substantial increased risk of intravitreal injections in patients with diabetes.     

Intravitreal injections: a review of the evidence for best practice

Intravitreal injection is a common procedure performed by ophthalmologists. It is a quick and targeted treatment for a number of ophthalmic conditions. Despite this, the potential to cause serious complications and patient discomfort cannot be ignored. This article presents the level of evidence in the scientific literature supporting common practices such as location of the procedure, anaesthetic choice, sterile procedure techniques, comparison of some common pharmaceutical agents and the use of antibiotics.     

Bacterial Contamination of Needles Used for Intravitreal Injections: Comparison between 27-gauge and 30-gauge Needles

Abstract

Purpose: To compare the contamination rate between 27-gauge and 30-guage needles used for intravitreal injection (IVT).

Methods: Patients undergoing IVT injections were enrolled prospectively. Injections were performed with 27- or 30-gauge needles. All needle tips were collected and placed in brain–heart infusion broth. The contamination rates of needles were compared.

Results: A total of 109 patients participated in the study and a total of 126 IVT injections were performed. Injections were performed by 27-gauge (49%) and 30-gauge (51%) needle. No patient developed endophthalmitis. The overall contamination rate of the used needles were 13% for 27-guage and 29% for 30-guage (p?=?0.022). However, this difference was nonsignificant after Bonferroni's correction was applied. The most common bacteria isolated from the used needles are coagulase-negative Staphylococcus (CNS).

Conclusion: The results suggest that the needle bore size seems not to be a risk factor for contamination during IVT injection.     

Examination of Purification Methods and Development of Intravitreal Injection of Triamcinolone Acetonide

Purpose

Intravitreal injection of triamcinolone acetonide (TA) is used in ophthalmic treatment, but the reliability of commercially available TA preparations has still not been established. We evaluated two previously reported purification methods, and developed a more reliable TA injection which can be prepared in a hospital pharmacy.

Methods

We tested the two methods previously reported for purifying commercial TA preparations, the sedimentation and the filtration and backflushing methods. We developed a new TA injection made of pure TA suspended in 0.5% sodium hyaluronate. We measured the TA content in each preparation by high-performance liquid chromatography to evaluate the three methods.

Results

In the sedimentation purification method, the TA content of a nominal 4-mg preparation varied from 1.43 to 7.37?mg, and the average recovery rate was 91.6%. In the filtration and backflushing method, TA content was 0.10–10.33?mg and recovery was 59.5%. In the TA injection we developed, the mean TA content was 102.5% (SD, 0.24; CV, 2.9%). The stability of this preparation was 99% after sterilization, and 97% after 3 months of storage.

Conclusions

The results of our investigation showed that the purification methods used for commercial preparations are simple and easy but not precise enough for an intravitreal injection. In contrast, the TA injection prepared by our method is reliable, stable, and safe enough for clinical use. Jpn J Ophthalmol 2005;49:384–387 © Japanese Ophthalmological Society 2005     

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.     

Safety of intravitreal triamcinolone acetonide:an electrophysiologic and histopathological study in rabbits

AIM

To evaluate the retinal safety of various doses of intravitreal triamcinolone acetonide (TA) in rabbits.

Methods

Thirty New Zealand albino rabbits were divided into five groups (six animals each). In group 1 (control group), each animal received a single intravitreal injection of 0.1mL phosphate buffered saline. In groups 2, 3, 4 and 5, each rabbit received a single intravitreal injection of 4, 8, 16 and 32mg of TA, respectively. Each dose was contained in 0.1mL phosphate buffered saline. Clinical ocular examinations were performed before the injection and on the 1st, 3rd, 10th and 17th post-injection days. A standard dark adapted electroretinogram (ERG) was obtained before injection and on the 3rd, 10th and 17th post-injection days. After 17d, animals were sacrificed and their eyes prepared for pathological examination.

RESULTS

By monitoring ERG as a functional index for the retina, intravitreal injection of 4mg TA showed no significant ERG changes. At doses of 8, 16 and 32, hyper-abnormal responses in a- and b- waves of ERG were detected on the 3rd post-injection day. These changes gradually returned back to normal limits after 17d. Histopathological examination of the retina of all animals showed no pathological changes.

CONCLUSION

High doses of intravitreal TA seemed to have enhancing effects on the retinal function with gradual return to normal limits with no pathological changes detected in examined eyes.     

Triamcinolone Intravitreal Injection and Intraocular Pressure in Macular Edema Associated with Retinal Vein Occlusion

 Purpose: To study the risk factors of increased intraocular pressure (IOP) response to triamcinolone acetonide intravitreal (IVTA) injection in eyes with macular edema associated with retinal vein occlusion. Methods: Eighty-nine eyes with macular edema associated with retinal vein occlusion first received periocular injection of 40 mg triamcinolone acetonide (TA) and were followed for one month. According to the diversity of IOP after periocular TA (PTA) injection, they were divided into the elevation IOP group (group A, 26 eyes) and the normal IOP group (group B, 63 eyes). They then received 4 mg TA intravitreal injection. IOP measurements were recorded after PTA and IVTA injections, and were followed for six months. Results: Both PTA and IVTA injections caused a rise in IOP, but it was higher in the IVTA injection (40.45%) than in the PTA injection (29.21%). The mean rise in IOP was more significant in eyes with IVTA injection (28.08 ± 8.24 mmHg) than in eyes with PTA injection (20.87 ± 4.07 mmHg). Patients with an elevation IOP above 6 mmHg after PTA injection had a 73.08% chance of developing a pressure of 24 mmHg or higher, whereas only 12.70% of those with an elevation IOP below 6 mmHg after PTA injection experienced pressure elevation. Conclusion: IOP response to PTA injection is a good way to judge IOP response to IVTA. If the patient is highly sensitive to corticosteroid, treatments other than IVTA injection are used to avoid the increased risks associated with intravitreal corticosteroid injection.     

Safety of intravitreal triamcinolone acetonide:an electrophysiologic and histopathological study in rabbits

AIM: To evaluate the retinal safety of various doses of intravitreal triamcinolone acetonide (TA) in rabbits.Methods: Thirty New Zealand albino rabbits were divided into five groups (six animals each). In group 1 (control group), each animal received a single intravitreal injection of 0.1mL phosphate buffered saline. In groups 2, 3, 4 and 5, each rabbit received a single intravitreal injection of 4, 8, 16 and 32mg of TA, respectively. Each dose was contained in 0.1mL phosphate buffered saline. Clinical ocular examinations were performed before the injection and on the 1st, 3rd, 10th and 17th post-injection days. A standard dark adapted electroretinogram (ERG) was obtained before injection and on the 3rd, 10th and 17th post-injection days. After 17d, animals were sacrificed and their eyes prepared for pathological examination.RESULTS:By monitoring ERG as a functional index for the retina, intravitreal injection of 4mg TA showed no significant ERG changes. At doses of 8, 16 and 32, hyper-abnormal responses in a- and b- waves of ERG were detected on the 3rd post-injection day. These changes gradually returned back to normal limits after 17d. Histopathological examination of the retina of all animals showed no pathological changes.CONCLUSION: High doses of intravitreal TA seemed to have enhancing effects on the retinal function with gradual return to normal limits with no pathological changes detected in examined eyes.     

曲安奈得:用于玻璃体内注射的配制法

目的：具有抗增生、抗水肿、抗炎和血管稳定作用的曲安奈得（TA）混悬液在眼水肿、新生血管和增生性疾病,特别是黄斑疾病的应用正在不断增加.本文描述玻璃体内注射用的TA的配制法并分析赋形剂（苯甲基乙醇）过滤后的实际剂量.方法：从40mg Volon A瓶中,相当于Kenalog40mg,抽取0.625mL结晶混悬液,相当于TA25mg.在无菌条件下,过滤混悬液以去除溶剂苯甲基乙醇,结晶体用9g/L氯化钠洗涤4次,进行TA玻璃体注射.需要密切随访,监测在头2wk内的眼内炎和1～2mo的高眼压.结果：预期25mg TA的浓度在溶剂过滤后测量为23.8mg.在另一个药学实验室,同样过滤后结果是12.8mg,均不是预期的剂量25mg TA.结论：还没有玻璃体内注射TA的标准剂量.手术医生应该知道过滤后玻璃体内注射TA的剂量将比预期的要少.需要在注射后密切随访：在第1wk监测无菌性眼内炎或假性眼内炎,在第2wk要识别感染性眼内炎,它可能出现在无痛和不充血的眼,但必须立即治疗.继发性高眼压可能在注射后1～2mo发生;一般可用抗青光眼药物控制.     

The Pros and Cons of Intravitreal Triamcinolone Injections for Uveitis and Inflammatory Cystoid Macular Edema

Intravitreal triamcinolone acetonide (IVTA) injections are gaining in popularity and are regularly administered nowadays for various ocular diseases. This paper presents a literature review on the use, efficacy, and complications of IVTA application in non-infectious uveitis and inflammatory cystoid macular edema (CME). In addition, we describe the experiences of our own institute. IVTA applications brought about a quick improvement in vision in the majority of cases. Drawbacks included the temporary duration of the effect with the need for repeated injections which re-exposed patients to the risk of complications. The risk of bacterial endophthalmitis was 0.5% and was further influenced by the specific IVTA preparation. Based on the literature review, we chose ready-for-use IVTA injections prepared by our pharmacy department, in which 90% of the toxic additives were removed and the dispensed dose of triamcinolone acetonide was validated to diminish the risk of endophthalmitis. Elevated intraocular pressure (IOP) was seen in 30–43% of the eyes and cataract developed in 29% of the eyes of patients, who were usually of advanced age. In conclusion, the rapid effect of IVTA might be of value in severe presentations of non-infectious uveitis and CME and might shorten the time interval needed for the improvement.     

Intravitreal injection of triamcinolone acetonide in nonarteritic anterior ischemic optic neuropathy

BackgroundSystemic corticosteroid may play a vital role in treating nonarteritic ischemic optic neuropathy (NAION). An intravitreal route provides the advantage of avoiding systemic side effects. In this study, we investigated the treatment result of intravitreal injection of acetonide (IVITA).MethodsWe retrospectively reviewed six patients with NAION who were treated with a single IVITA. The patients were followed monthly for 6 months.ResultsVisual acuity improved in three patients. One patient also had a better visual field at the 6^th month follow up. Two patients with more severe swelling of the optic disc initially did not gain better visual acuity. One patient with a pre-existing epiretinal membrane maintained stable visual acuity.ConclusionSome patients with NAION may improve with IVITA treatment. Further randomized controlled clinical trials are needed.     

Endophthalmitis: A review of recent trends

Endophthalmitis is a feared complication of trauma, surgical procedures and septicemia. Although uncommon, its potential for significant visual loss is well recognized. Especially over the past decade, complicated surgeries and medical techniques have increased and seriously ill patients are being sustained in ever increasing numbers. New pathogens are being recognized and known ones reclassified thanks to advances in molecular analysis. Continuously evolving PCR methodologies also add a new dimension to the diagnosis of infectious endophthalmitis. As well, medical literature is now truly international, encompassing studies from around the world that expand our understanding of ocular infectious disease. This report reviews some of these changes as they relate to endophthalmitis and particularly to the spectrum of organisms involved.     

Postoperative Endophthalmitis: A Review of Risk Factors,Prophylaxis, Incidence,Microbiology, Treatment,and Outcomes

ABSTRACT

Postoperative endophthalmitis is one of the most feared complications of intraocular surgery. The most common types of intraocular surgeries performed worldwide are cataract extraction, glaucoma drainage implants/trabeculectomy, and pars plana vitrectomy. This review will focus on the clinical features, risk factors, prophylaxis, and treatment of endophthalmitis in these three main intraocular surgeries.