小剂量曲安奈德玻璃体腔重复注射的安全性观察

目的评价小剂量曲安奈德玻璃体腔内重复注射的安全性。设计前瞻性、非对照干预研究。研究对象31例(31眼),包括黄斑水肿16例、糖尿病性黄斑水肿6例、渗出型老年黄斑变性4例、中央或分支视网膜静脉阻塞3例和非感染性葡萄膜炎2例。方法4mg曲安奈德玻璃体腔内重复注射,在距首次注射分别(2.9±1.1)个月和(4.5±2.5)个月时,分别进行了第2次(31眼)和第3次(9眼)注射,每次注射后监测视力和眼内压等。平均随访(8.4±1.6)个月。主要指标眼压、视力。结果相对于曲安奈德玻璃体腔内单次注射,重复注射并未导致特殊并发症发生。在第1、2、3次注射后分别有23(74.2%)、24(77.4%)和7(77.8%)眼眼压保持正常。3次注射后(每次)眼压的平均值之间比较无显著统计学差异。2眼(6.5%)白内障进展迅速需手术治疗。结论短期随访,小剂量曲安奈德玻璃体腔内重复注射对眼压等无明显影响。     

Safety profile of intravitreal triamcinolone acetonide.

BACKGROUND: There is currently a widespread use of intravitreal triamcinolone acetonide (IVTA) for age-related macular degeneration, diabetic macular edema, cystoid macular edema secondary to retinal vein occlusions, and uveitis. The aim of this investigation was to assess the rates of various complications associated with this treatment and to determine which factors are associated with the development of these complications. METHODS: A retrospective interventional case series of all patients from one retina specialist undergoing IVTA was conducted in a clinical setting from 2002 to 2005. All disease entities were included. Patients were followed for a mean of 9.5 months after receiving 4 mg (0.1 mL) of nonfiltered triamcinolone acetonide (TA). All complications associated with the injection procedure or with the TA were noted. RESULTS: Two hundred and twenty-three (223) eyes of 192 patients received a total of 336 IVTA injections between 2002 and 2005. The mean age was 73.3 years and mean follow-up was 9.5 months. A single injection was performed in 144 eyes (64.6%); 2 IVTAs in 55 eyes (24.7%); 3 IVTAs in 16 eyes (7.2%), and 3.6% of eyes had more than 3 injections at a minimal interval of 3 months. The only immediate complication was a single injection (0.3%) associated with a temporary occlusion of the central retinal artery, which opened immediately following anterior paracentesis. Late complications included endophthalmitis in 1 of 336 (0.3%) injections and a steroid response requiring glaucoma medication in 60 of 192 patients (31.3%). In patients with preexisting glaucoma, 58.8% required additional glaucoma medication. Glaucoma-filtering surgery was required in 2 of 192 patients (1.0%). CONCLUSIONS: In the study center, the IVTA is extremely safe in patients without a history of glaucoma. However, patients with preexisting glaucoma with progressive optic neuropathy must be treated with great caution.     

Management of iatrogenic intravitreal triamcinolone acetonide

Intravitreal corticossteroids have been used for therapeutic purposes in optimum doses and adverse reports have not been described. To best of our knowledge, this entity has never been reported as a problem. We report a case of successful management of iatrogenic intravitreal triamcinolone acetonide for intermediate uveitis. This case study highlights the strategy of appropriate and timely surgical management.     

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.     

Pseudohypopyon following intravitreal triamcinolone acetonide injection

OBJECTIVE: To report a case of a pseudohypopyon that developed after intravitreal injection of triamcinolone acetonide for choroidal neovascularization from age-related macular degeneration. METHODS: Observational case report. RESULTS: A 62-year-old woman received an intravitreal injection of triamcinolone acetonide for the treatment of a choroidal neovascular membrane that developed as a result of age-related macular degeneration. A layer of yellowish deposits was observed in the anterior chamber 1 day after the injection. The patient denied any pain or reduced vision, and there was no redness noted on examination. The deposits cleared spontaneously on the fourth postoperative day. CONCLUSIONS: Pseudohypopyon may develop after intravitreal injection of triamcinolone acetonide. Distinguishing this from a true hypopyon is important because the treatment and prognosis are very different for the two conditions.     

Complications of intravitreal injection of triamcinolone acetonide

BACKGROUND: Intravitreal injection of triamcinolone acetonide appears to be a promising treatment for a variety of proliferative, edematous, neovascular and inflammatory ocular disorders. Reported complications include intraocular pressure (IOP) elevation, cataract formation, retinal detachment, vitreous hemorrhage and endophthalmitis. The purpose of this investigation was to report the complications of intravitreal triamcinolone injection that may be attributable to the injection procedure or to the corticosteroid suspension. METHODS: A total of 212 eyes of 180 patients who underwent intravitreal triamcinolone acetonide injection for various indications were enrolled. All patients received 8 mg/0.2 mL of triamcinolone. A total of 270 injections were performed by the same surgeon under topical anesthesia. The patients were followed for a mean of 9.2 months. Complications related to the injection procedure and to the corticosteroid were recorded. RESULTS: The most common complication encountered during follow-up was transient elevation of the IOP above 21 mm Hg (44 eyes [20.8%]). The average IOP rose by 28.5%, 38.2%, 16.7% and 4.2% from baseline at 1, 3, 6 and 9 months respectively. The mean IOP values at 1, 3 and 6 months were statistically significantly higher than the mean preinjection value (p < 0.001). Fourteen eyes (6.6%) had cataract progression and underwent cataract surgery with intraocular lens implantation. Endophthalmitis developed in one eye (0.5%); the patient underwent vitrectomy with silicone oil injection. Pseudoendophthalmitis occurred in one eye (0.5%), and pseudohypopyon was observed in two eyes (0.9%). INTERPRETATION: Intravitreal triamcinolone injection was effective in a variety of ocular disorders. Patients should be monitored closely given the potential for complications of the injection procedure or the corticosteroid suspension.     

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.     

Safety and pharmacokinetics of a preservative-free triamcinolone acetonide formulation for intravitreal administration

PURPOSE: The safety and pharmacokinetics of a triamcinolone acetonide (TA) preservative-free (TA-PF) formulation were investigated after intravitreal administration in rabbits. METHODS: A TA-PF formulation was prepared as a sterile 40-mg/mL or 160-mg/mL suspension in single-use vials by adding TA powder to 0.5% hydroxypropyl methylcellulose in normal saline. TA-PF (4-mg and 16-mg doses) and Kenalog (Bristol-Myers-Squibb, Princeton, NJ) (4-mg dose) were injected into the vitreous of separate groups of rabbits, and drug levels were measured in the vitreous over time with HPLC. Ocular toxicology (clinical examination, serial electroretinography, and histopathologic analysis) was evaluated in a separate group of animals after intravitreal TA-PF injection. RESULTS: The half-lives of the injection amount in the vitreous, 4-mg TA-PF, 16-mg TA-PF, and 4-mg Kenalog, were found to be 24 days, 39 days, and 23 days, respectively. There were no signs of toxicities by clinical examination after TA-PF injection. Serial electroretinograms of rabbits receiving either 4-mg or 16-mg intravitreal TA-PF injections remained normal over time. Histopathologic analysis showed normal ocular tissues in animals receiving either 4-mg or 16-mg intravitreal TA-PF injections. CONCLUSION: The half-life of TA in the vitreous after a 4-mg injection of either TA-PF or Kenalog was comparable. A 16-mg dose of TA-PF produced a long vitreous half-life, and this may be of clinical benefit in patients requiring 6 months of drug exposure in the eye for a chronic disease.     

Visual acuity and intraocular pressure after high-dose intravitreal triamcinolone acetonide in selected ocular diseases

PURPOSE: Within the last 5 years, intravitreal injections of triamcinolone acetonide have been for a wide variety of ocular diseases with intraocular oedema and neovascularization. With clinical experience accumulating, the question arises for which indication the side effects outweigh the therapeutic efficacy of intravitreal triamcinolone monotherapy. SCOPE: Comparing different diseases, increase in visual acuity was lower in patients receiving intravitreal triamcinolone monotherapy for exudative age-related macular degeneration than in patients with diabetic macular oedema, branch retinal vein occlusion, central retinal vein occlusion, uveitis, and pseudophakic cystoid macular oedema. Rise in intraocular pressure was significantly higher in relatively young patients with uveitis than in any other patient group. CONCLUSIONS: Improvement in vision after intravitreal triamcinolone monotherapy is highest in non-ischaemic diseases with an intraretinal macular oedema such as pseudophakic cystoid macular oedema; it is lower in partially ischaemic diseases with intraretinal macular oedema such as diabetic macular oedema or retinal vein occlusions; and it is lowest in diseases with a primarily subretinal location of the disease such as exudative age-related macular degeneration. For the latter diseases, intravitreal triamcinolone monotherapy is, therefore, no longer up-to-date, particularly with the upcoming intravitreal application of vascular endothelial growth factor blocking drugs. For diseases with intraretinal oedema, the rule of thumb may be that intravitreal triamcinolone increases vision as much as retinal ischaemia and tissue destruction by the underlying disease allow it. The rise in intraocular pressure is higher in relatively young patients with uveitis than in elderly patients with other reasons for macular oedema.     

Retinal angiomatous proliferation reactivation 6 months after high-dose intravitreal acetonide triamcinolone and photodynamic therapy

PURPOSE: To describe the incidence of retinal angiomatous proliferation (RAP) reactivation after combined treatment with a high-dose intravitreal triamcinolone acetonide (IVTA) and photodynamic therapy (PDT) at 1-year follow-up. METHODS: All patients had undergone a full ophthalmic examination. High-dose IVTA (20 mg) was injected via pars plana. Four to 7 days later, PDT was delivered. RESULTS: Fourteen eyes of 13 patients were included. Eight lesions (57%) reopened and needed retreatment with combined therapy at 6 months follow-up. At 1-year follow up, the lesion was obliterated in nine cases (64.2%) and best-corrected visual acuity improved from 0.87 logMar (range, 0.7-1) to 0.79 logMar (range, 0.5-1). CONCLUSIONS: Combined therapy using high-dose IVTA and PDT is beneficial in stabilizing RAP. However, a high incidence of RAP reactivation has been observed at 6 months, even with a high-dose IVTA injection.     

Intraocular pressure alterations following intravitreal triamcinolone acetonide

AIMS: To determine the prevalence of intraocular pressure (IOP) alterations following intravitreal injection of triamcinolone acetonide (IVTA) and to assess possible risk factors of IOP elevation in eyes receiving single and/or repeat injections. METHODS: Retrospective, consecutive case series. 570 consecutive eyes of 536 patients who received a single IVTA injection (4 mg/0.1 ml) and a second set of 43 eyes of 40 patients who received a second injection. Retrospective review of all IVTA cases performed by three vitreoretinal surgeons over a 42 month period beginning in 2000. The main outcome measure was change in IOP defined as absolute value of IOP elevation (5 mm Hg or higher, 10 mm Hg or higher), and percentage of baseline (30% or higher increase from baseline IOP). RESULTS: Of the 528 eyes receiving single injections, 281 (53.2%) had an IOP elevation; 267 eyes (50.6%) experienced an elevation of IOP of at least 30%, and 245 (45.8%) and 75 (14.2%) eyes had an increase of 5 mm Hg or 10 mm Hg or more, respectively. Baseline IOP greater than 16 mm Hg is a risk factor for post-injection IOP elevation. Of the 43 eyes which received a second injection, 28 (65.1%) experienced an increase in IOP of at least 30% of baseline. Filtering surgery was required in five (0.094%) of the single and one (2.3%) of repeat injection eyes. CONCLUSIONS: Elevated IOP after IVTA is common and patients should be monitored beyond 6 months post-injection. Patients with a baseline IOP more than 16 mm Hg or receiving a second injection should be carefully monitored for an elevated IOP.     

Herpes simplex keratitis after intravitreal triamcinolone acetonide

PURPOSE: To report a case of recurrent herpes simplex virus (HSV) epithelial keratitis after intravitreal triamcinolone acetonide injection for the treatment of diabetic macular edema. METHODS: Case report. RESULTS: We describe a case of a 59-year-old woman with a history of ocular HSV disease and severe proliferative diabetic retinopathy. She received an intravitreal injection of triamcinolone acetonide for macular edema in the right eye. One week later, she developed foreign body sensation, redness, and photophobia in the same eye. Slit-lamp examination revealed a corneal epithelial dendritic lesion. She was diagnosed with a recurrence of HSV epithelial keratitis and was treated with oral acyclovir 400 mg, 5 times a day, with good resolution of HSV signs and symptoms. CONCLUSIONS: Intravitreal triamcinolone acetonide injection may result in reactivation of HSV keratitis.     

Acute endophthalmitis following intravitreal triamcinolone acetonide injection

PURPOSE: To report the clinical features, causative organisms, management, and visual acuity outcomes of eight eyes of eight patients who developed acute postoperative endophthalmitis following intravitreal injection of triamcinolone acetonide (IVTA). DESIGN: Retrospective, multicenter, interventional, case series. METHODS: A retrospective, interventional, case series of all patients with acute postoperative endophthalmitis following IVTA at seven academic clinical centers between March 2001 and July 2002. RESULTS: A total of 922 IVTAs were performed. Eight eyes of eight patients with acute postoperative endophthalmitis were identified in the 6 weeks following IVTA for an incidence of 0.87% (95% confidence interval of 0.38% to 1.70%). The median time to presentation was 7.5 days (range, 1-15 days) after IVTA. The most common clinical findings were iritis (n = 8), vitritis (n = 8), hypopyon (n = 8), pain (n = 7), red eye (n = 6), and decreased vision (n = 5). The median presenting visual acuity was 20/1127 (range, 20/60 to light perception). Initial treatment consisted of vitreous tap and injection of antibiotics (n = 6) or pars plana vitrectomy and injection of intravitreal antibiotics (n = 2). Intraocular cultures yielded identification in seven patients. One demonstrated intracellular gram-positive cocci in chains with numerous polymorphonuclear cells on gram stain. The median postinfection vision was 20/400 (range, 20/40 to no light perception). Three patients ended up with no light perception visual acuity, including enucleation (n = 1) and phthisis (n = 1). CONCLUSIONS: Acute postoperative endophthalmitis following IVTA occurs rapidly and can result in severe loss of vision.