Intraocular pressure elevation after intravitreal triamcinolone acetonide injection: a Meta-analysis

AIM: To report on intraocular pressure (IOP) after intravitreal injections of triamcinolone acetonide. METHODS: Systematic literature review of studies that investigated the effects of an injection of triamcinolone intravitreal triamcinolone acetonide on IOP was conducted according to the Cochrane Collaboration methodology and the reported effects have been analyzed with Meta-analysis. RESULTS: We found that the IOP follows an inverted-U shape pattern over time starting with an average value of 14.81±1.22 mm Hg before the injection, rising to a maximum of 19.48±2.15 mm Hg after one month of injection and falling down to 16.16±1.92 mm Hg after 6mo. Moreover, country of study, age, previous history of glaucoma and gender compositions matter for cross-study were different in reported IOP changes. CONCLUSION: Our findings may be helpful in determining pressure elevation risk of intravitreal triamcinolone acetonide therapy as well as comparing it with those of more recent therapies such as the anti-vascular endothelial growth factor agents.     

Intraocular pressure elevation after intravitreal or posterior sub-Tenon triamcinolone acetonide injection

BACKGROUND: Despite the benefits of intraocular steroids for the treatment of inflammatory, neovascular, proliferative, and edematous diseases, one of the side effects is raised intraocular pressure (IOP). In this study, we attempted to identify when IOP elevates, peaks, and returns to the preinjection baseline IOP after intravitreal or posterior sub-Tenon administration of triamcinolone acetonide, as well as the factors that might affect IOP. METHODS: Retrospective case review was undertaken of 69 patients (82 eyes), who received either a 4 mg intravitreal (16 eyes) or a 20 mg posterior sub-Tenon (66 eyes) triamcinolone acetonide injection. IOP assessment for each eye was completed at the preinjection baseline and at the first, third, and sixth month of follow-up. RESULTS: The mean IOP of all eyes increased significantly at each follow-up. The mean maximum elevation ratio from the baseline was 4.0 (SD 5.2) mm Hg. An elevation of 5 mm Hg or greater occurred in 28 eyes (34.1%). The maximum elevation correlated significantly with age (p < 0.01). The incidence of an elevation of 5 mm Hg or greater was significantly higher among patients younger than 60 years (p < 0.01) and relatively higher among female patients (p = 0.051). The mean IOP increased significantly at the first month after intravitreal injection but at all follow-up periods after posterior sub-Tenon injection. There was no significant difference in IOP elevation according to disease type, although eyes with diabetic retinopathy tended to be at higher risk of IOP elevation. Two eyes of two female patients, who had received posterior sub-Tenon injections for the treatment of diabetic retinopathy, required glaucoma surgery. INTERPRETATION: The IOP elevation of 5 mm Hg or greater observed in 34.1% of the eyes was consistent with past reports. IOP elevation was associated with patients of less than 60 years of age and with female sex, and it lasted longer after posterior sub-Tenon injection than after intravitreal injection. Careful assessment of IOP during a follow-up period of at least 6 months is paramount, especially in younger female patients after posterior sub-Tenon injection.     

Intraocular pressure after intravitreal injection of triamcinolone acetonide

AIM: To investigate the intraocular pressure (IOP) response after intravitreal injections of triamcinolone acetonide as treatment of intraocular neovascular or oedematous diseases. METHODS: The prospective consecutive non-comparative interventional case series study included 71 patients (75 eyes) with progressive exudative age related macular degeneration (n = 64 eyes) or diffuse diabetic macular oedema (n = 11 eyes), who received an intravitreal injection of 25 mg triamcinolone acetonide. Mean follow up time was 6.86 (SD 2.52) months (range 3.1-14.47 months). RESULTS: IOP increased significantly (p<0.001) from 15.43 (3.26) mm Hg preoperatively to a mean maximum of 23.38 (8.37) mm Hg (range 13-64 mm Hg) postoperatively. An IOP rise to values higher than 21 mm Hg was observed in 39 (52%) eyes. Elevation of IOP occurred about 2 months after the injection. Preoperative predictive factor for the rise in IOP was younger age (p=0.013). It was statistically independent of refractive error, presence of diabetes mellitus, and indication for the injection. In all but one eye, IOP could be lowered to the normal range with topical medication, without development of glaucomatous optic nerve head changes. In the eyes with an elevation of IOP, IOP normalised about 6 months after the injection, without further medication. Eyes undergoing repeatedly intravitreal injections of triamcinolone acetonide showed only an elevation of IOP, if after the first injection a rise of IOP had occurred. CONCLUSIONS: After intravitreal injections of 25 mg of triamcinolone acetonide, an IOP elevation can develop in about 50% of eyes, starting about 1-2 months after the injection. In the vast majority, IOP can be normalised by topical medication, and returns to normal values without further medication about 6 months after the injection.     

Intraocular availability of triamcinolone acetonide after intravitreal injection

BACKGROUND: To evaluate the intraocular concentration of triamcinolone acetonide after intravitreal injection. METHODS: The prospective clinical interventional case series study included 17 patients who had received a 20 to 25-mg intravitreal injection of triamcinolone acetonide as treatment for exudative age-related macular degeneration, diffuse diabetic macular edema, or retinal vein occlusions. During a secondary intraocular surgery taking place 4.1 weeks to 25.7 months after the intravitreal injection, aqueous humor samples were obtained. None of the eyes were vitrectomized. RESULTS: In the aqueous humor samples, triamcinolone acetonide was in low, but measurable, concentrations detected up to 1.5 years after the intravitreal injection. Concentrations found in samples obtained during the first 6 months, or 7 to 12 months, respectively, after the injection ranged between 3.0 microg/l and 436 microg/l, and between 0.0 microg/l and 11.2 microg/l, respectively. CONCLUSIONS: After injection of triamcinolone acetonide, triamcinolone can be present in measurable concentrations up to 1.5 years after the application.     

Intraocular pressure elevation after subtenon injection of triamcinolone acetonide during uveitis

INTRODUCTION: New therapeutic concepts in the management of ocular inflammation have led to the development of periocular and intravitreal injections. Such treatment modalities can induce intraocular pressure elevation. PATIENTS AND METHODS: Periocular injections have been given to patients suffering from strictly unilateral or bilateral but asymmetrical and noninfectious posterior uveitis. A history of corticosteroid-induced glaucoma was a contraindication to such treatment. A retrospective review of cases who were given subtenon triamcinolone acetonide injection between May and October 2001 was undertaken to evaluate the efficacy of the treatment and the risk of intraocular pressure elevation. Ocular pressure was measured before and after the injection and the efficacy of the treatment was evaluated by measurements of visual acuity and fluorescein angiography. RESULTS: One or several injections were given to 61 patients. Intraocular pressure rose in 13 patients (21.3%). Medical treatment was unsuccessful in three cases and surgical excision of periocular corticosteroid deposit was required. Therefore, intraocular pressure was controlled with no other medication. Treatment was considered effective in 32 patients (52.45%): improvement of visual acuity (more than two lines) or control of inflammation on fluorescein angiography. DISCUSSION: and conclusions: Periocular subtenon injection of triamcinolone acetonide in posterior noninfectious uveitis is a safe procedure. Intraocular pressure elevation is not frequent and can be controlled through medical treatment or surgical excision of a residual deposit, in which pharmacologically active triamcinolone can be present several months after the 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.     

Intraocular pressure after intravitreal injection of triamcinolone acetonide following vitrectomy for macular edema

PURPOSE: To evaluate long-term intraocular pressure (IOP) response after intravitreal injections of different doses of triamcinolone acetonide (TA) upon completion of pars plana vitrectomy (PPV) for macular edema secondary to diabetic retinopathy or retinal vein occlusion. PATIENTS AND METHODS: Retrospective, consecutive, comparative, interventional case series. Twenty-seven eyes of 25 consecutive patients with macular edema associated with diabetic retinopathy (n=18) or retinal vein occlusion (n=9), who underwent PPV for the treatment of macular edema between January 2003 and December 2003, were included. Upon completion of vitrectomy, different doses of TA were injected into the vitreous cavity: 14 eyes with 5 mg of TA (group 1) and 13 eyes with 10 mg of TA (group 2). The main outcome measure was IOP. RESULTS: All patients were followed up for at least 12 months. Preoperative IOP was 12.6+/-2.6 mm Hg (mean+/-standard deviation) in group 1 and 13.2+/-2.1 mm Hg in group 2. Postoperatively, IOP increased to a mean maximum of 20.6+/-5.5 mm Hg in group 1 and 31.5+/-3.5 mm Hg in group 2 (P<0.01 for both groups). The difference between groups was also significant (P<0.05). Five of 14 eyes (36%) in group 1 and 10 of 13 eyes (77%) in group 2 had an elevation of IOP exceeding 21 mm Hg (P=0.03). The median interval from surgery to reach maximal IOP was 7 days in both groups. The significant IOP elevation lasted for 3 months in group 1 and 6 months in group 2. CONCLUSIONS: After injecting of TA into the vitreous cavity upon completion of PPV for macular edema, a dose-dependent IOP elevation was observed, starting from early postoperative days and returning to normal values after several months. These results show that intravitreal TA injection in the vitrectomized eyes might have different IOP changes from in the nonvitrectomized eyes.     

Selective laser trabeculoplasty for intraocular pressure elevation after intravitreal triamcinolone acetonide injection.

PURPOSE: Intravitreal injection of triamcinolone acetonide has increasingly become a therapeutic option for neovascular, inflammatory, and edematous intraocular diseases. A common side effect of this treatment is a steroid-induced elevation of intraocular pressure. In most of these patients, the rise in intraocular pressure can be treated topically. Those cases that cannot be treated medically have been treated with filtering surgery. This report presents a case of intraocular pressure elevation after intravitreal triamcinolone acetonide injection that was successfully treated with selective laser trabeculoplasty. CASE REPORT: A 63-year-old white man presented with brow ache on the right side approximately 3 months after undergoing intravitreal injection of triamcinolone acetonide for diabetic macular edema in the right eye. Applanation tonometry revealed an intraocular pressure of 45 mm Hg in the involved eye. After initial treatment with topical medications, the patient underwent selective laser trabeculoplasty. Now, 6 months postlaser treatment, the intraocular pressure in the involved eye is stable at 15 mm Hg without topical medications. CONCLUSIONS: A steroid-induced elevation of intraocular pressure is a common and widely reported side effect of treatment with intravitreal triamcinolone acetonide. This case report suggests that selective laser trabeculoplasty has potential as first- or second-line therapy for intraocular pressure elevation after intravitreal triamcinolone acetonide injection.     

Intraocular pressure elevation after injection of triamcinolone acetonide: a multicenter retrospective case-control study

PURPOSE: To determine the risk factors for intraocular pressure (IOP) elevation after the injection of triamcinolone acetonide (TA). DESIGN: Retrospective interventional case-control study. METHODS: SETTING: Multicenter. PATIENT POPULATION: Four hundred and twenty-seven patients. OBSERVATION PROCEDURES: Intraocular pressure levels after TA treatment by the sub-Tenon capsule injection (STI; 12 mg, 20 mg, or 40 mg), intravitreal injection (IVI; 4 mg or 8 mg), or the combination of STI (20 mg) and IVI (4 mg), and IOP levels after two TA treatments. MAIN OUTCOME MEASURE: Risk factors for IOP levels of 24 mm Hg or higher. RESULTS: Younger age (hazards ratio [HR], 0.96/year; P < .0001), IVI (HR, 1.89/year; P < .0001), and higher baseline IOP (HR, 1.15/mm Hg; P = .003) were identified as risk factors. Dose dependency was shown in STI-treated eyes (HR, 1.07/mg; P = .0006), as well as after IVI (HR, 1.64/mg; P = .013). The combination of STI and IVI was a significant risk factor (HR, 2.27; P = .003) compared with STI alone. In eyes receiving two TA treatments, IVI (HR, 2.60; P = .010), higher IOP elevation after the first injection (HR, 1.18/mm Hg; P = .011), and increased dosage of STI (HR, 1.07/mm Hg; P = .033) were risk factors. CONCLUSIONS: Younger age, higher baseline IOP, IVI, and increased TA dosage were associated with TA-induced IOP elevation. IOP elevation after repeated TA injection was frequently associated with eyes treated with IVI, high IOP elevation after the first injection, and high doses of STI.     

Intraocular concentration and pharmacokinetics of triamcinolone acetonide after a single intravitreal injection

PURPOSE: To describe the pharmacokinetics occurring after the direct injection of triamcinolone acetonide into the vitreous humor of humans. DESIGN: Interventional case series. PARTICIPANTS: Five patients who received a single 4-mg intravitreal injection of triamcinolone acetonide. METHODS: An aqueous humor sample was obtained from 5 eyes via an anterior chamber paracentesis at days 1, 3, 10, 17, and 31 after injection. At each visit, visual acuity and intraocular pressure were measured and indirect ophthalmoscopy was performed. A fluorescein angiogram was carried out at day 10. Concentrations were determined using high performance liquid chromatography; pharmacokinetic analysis was carried out using PK Analyst, an iterative, nonlinear, weighted, least-squares regression program. MAIN OUTCOME MEASURES: Intraocular concentrations of triamcinolone were measured and population pharmacokinetic parameters were calculated. RESULTS: Pharmacokinetic data followed a two-compartment model. Peak aqueous humor concentrations ranged from 2151 to 7202 ng/ml, half-lives from 76 to 635 hours, and the integral of the area under the concentration-time curve (AUC(0-t)) from 231 to 1911 ng/h per milliliter. After a single intravitreal injection of triamcinolone, the mean elimination half-life was 18.6 days in nonvitrectomized patients. The half-life in a patient who had undergone a vitrectomy was shorter at 3.2 days. CONCLUSIONS: There was considerable intrasubject variation among peak concentration, AUC(0-t) values, and elimination half-lives. After intravitreal injection, measurable concentrations of triamcinolone would be expected to last for approximately 3 months (93 +/- 28 days) in the absence of a vitrectomy. Because triamcinolone pharmacokinetics were characterized only in elderly patients with macular edema, the results cannot be extrapolated to other patient populations.     

Early rapid rise in intraocular pressure after intravitreal triamcinolone acetonide injection

PURPOSE: To report the occurrences of early rapid increases in intraocular (IOP) after intravitreal glucocorticoid injection. DESIGN: Observational case series. METHODS: We retrospectively reviewed the records of three patients seen and treated at Duke Eye Center. RESULTS: In all three cases, a significant rise in IOP occurred within 1 week of intravitreal triamcinolone injection for refractory macular edema. In one patient, a white material was found in the angle on gonioscopy. All three cases required surgical intervention to reduce the IOP. CONCLUSIONS: Considering the early rapid rise in IOP in these three cases, we suggest that clinicians closely monitor patients after intravitreal triamcinolone injections for the development of acute glaucoma. Additionally, it may be advisable to perform gonioscopic examinations to look for any abnormal accumulation of material in the angle.     

Filtering bleb rupture after intravitreal triamcinolone acetonide injection

Intravitreal triamcinolone acetonide is effective in treating various ocular disorders associated with inflammation and swelling of the retina. Unfortunately, the use of intraocular steroids is also associated with several side effects, including increased intraocular pressure and the development of cataracts. This article describes a case of intravitreal steroid injection resulting in filtering bleb rupture due to an acute rise of intraocular pressure, expands on the mechanism, and provides possible ways to avoid such an occurrence in thin, cystic filtering blebs.