Regression of Optic Nerve Head Neovascularization in Proliferative Diabetic Retinopathy After Intravitreal Triamcinolone: Regression of Diabetic Optic Disc Neovascularization After Intravitreal Triamcinolone

The aim of this study is to report the clinical outcome of a diabetic patient with optic nerve head neovascularization treated with an intravitreal injection of triamcinolone acetonide. A 52-year-old patient presented with clinically significant diffuse macular edema and optic nerve head neovascularization due to proliferative diabetic retinopathy in her right eye. Despite grid laser photocoagulation in the macular region macular edema progressed and visual acuity declined. The patient received a single intravitreal injection of 4 mg triamcinolone acetonide with topical anesthesia. After injection of triamcinolone acetonide visual acuity increased and macular edema decreased. Furthermore optic nerve head neovascularization had markedly regressed. No complication was observed during follow-up period. Intravitreal injection of triamcinolone acetonide may be useful for treatment of optic nerve head neovascularization in patients with proliferative diabetic retinopathy.     

Intravitreal triamcinolone acetonide for treatment of intraocular proliferative, exudative, and neovascular diseases

Within the last three years, triamcinolone acetonide has increasingly been applied intravitreally as treatment option for various intraocular neovascular edematous and proliferative disorders. The best response in terms of gain in visual acuity after the intravitreal injection of triamcinolone acetonide was found in eyes with intraretinal edematous diseases such as diffuse diabetic macular edema, branch retinal vein occlusion, central retinal vein occlusion, and pseudophakic cystoid macular edema. Visual acuity increased and degree of intraocular inflammation decreased in eyes with various types of non-infectious uveitis including acute or chronic sympathetic ophthalmia and Adamantiadis-Behcet's disease. Intravitreal triamcinolone may be useful as angiostatic therapy in eyes with iris neovascularization and proliferative ischemic retinopathies. Possibly, intravitreal triamcinolone may be helpful as adjunct therapy for exudative age-related macular degeneration, possibly in combination with photodynamic therapy. In eyes with chronic, therapy resistant, ocular hypotony, intravitreal triamcinolone can induce an increase in intraocular pressure and may stabilize the eye. The complications of intravitreal triamcinolone therapy include secondary ocular hypertension in about 40% of the eyes injected, cataractogenesis, postoperative infectious and non-infectious endophthalmitis, and pseudo-endophthalmitis. Intravitreal triamcinolone injection can be combined with other intraocular surgeries including cataract surgery. Cataract surgery performed some months after the injection does not show a markedly elevated rate of complications. If vision increases and eventually decreases again after an intravitreal triamcinolone acetonide injection, the injection can be repeated. The duration of the effect of a single intravitreal injection of triamcinolone depended on the dosage given. Given in a dosage of about 20mg to non-vitrectomized eyes, the duration of the effect and of the side-effects was 6-9 months. Intravitreal triamcinolone acetonide may offer a possibility for adjunctive treatment of intraocular edematous and neovascular disorders. One has to take into account the side-effects and the lack of long-term follow-up observations.     

Treatment of oedematous,proliferative and neovascular diseases by intravitreal triamcinolone acetonide

BACKGROUND: Recent studies have suggested that intravitreal triamcinolone acetonide may be a therapeutical possibility for treating of various intraocular neovascular, oedematous and proliferative diseases. METHODS AND RESULTS: Gain in visual acuity was relatively highest for eyes with intraretinal oedematous diseases such as diffuse diabetic macular oedema and various types of cystoid macular oedema due to reasons such as retinal venous occlusions and uveitis. Intravitreal triamcinolone may be useful as angiostatic therapy in eyes with iris neovascularisation and proliferative ischaemic retinopathies. Possibly, intravitreal triamcinolone may be helpful for exudative age-related macular degeneration. In eyes with chronic therapy resistant ocular hypotony, intravitreal triamcinolone can induce an increase in intraocular pressure. The role of intravitreal triamcinolone as adjunctive treatment of proliferative vitreoretinopathy has not been determined so far. Complications of intravitreal triamcinolone include secondary ocular hypertension in about 50 % of the eyes injected, with one per cent of the eyes necessitating antiglaucomatous filtrating surgery; a cataractogenic effect; and postoperative infectious endophthalmitis. Long-term studies of more than 3 years follow-up have been missing so far, so that there is no reliable information on long-term complications. The injection can be combined with cataract surgery. Cataract surgery performed some months after the injection did not show a markedly elevated rate of complications. If vision increases after the intravitreal triamcinolone injection, the injection can be repeated. The duration of the effect of a single intravitreal injection of triamcinolone ranges between 2 and 9 months. Triamcinolone acetonide was detected in the aqueous humour nine months after an intravitreal injection of 25 mg. CONCLUSIONS: Intravitreal triamcinolone acetonide may offer a possibility for adjunctive treatment of intraocular oedematous, neovascular and proliferative diseases.     

Intravitreal triamcinolone acetonide for persisting cystoid macular edema after penetrating keratoplasty

PURPOSE: The intravitreal application of triamcinolone acetonide as treatment of long-standing, therapy-resistant cystoid macular edema after penetrating keratoplasty is reported. METHODS: A 44-year-old patient showed therapy-resistant cystoid macular edema for 2 years after repeated penetrating keratoplasty was performed as treatment of keratoconus. The crystalline lens was clear. The patient received an intravitreal injection of approximately 20 mg of triamcinolone acetonide. Preinjection visual acuity measured 20/80. RESULTS: Within the first 4 weeks after the injection, dense cataract developed necessitating cataract surgery. After phakoemulsification, visual acuity improved to 20/50. Optical coherent tomography and fluorescein angiography showed an almost complete resolution of cystoid macular edema. Ten months after the injection, visual acuity remained at 20/50, and intraocular pressure measured 15 mm Hg without antiglaucomatous therapy taken. CONCLUSIONS: Intravitreal injection of triamcinolone acetonide may be an additional tool in the treatment of therapy-resistant cystoid macular edema after penetrating keratoplasty. After intravitreal injection of triamcinolone acetonide, cataract may rapidly develop in eyes that have been intensively treated, topically and systemically, by corticosteroids for several years.     

Intraocular injection of crystalline cortisone as adjunctive treatment of diabetic macular edema

PURPOSE: To report the clinical outcome of a diabetic patient with macular edema treated with an intravitreal injection of crystalline cortisone. METHODS: Interventional case report. A 73-year-old patient with diabetes mellitus presented with clinically significant diffuse macular edema caused by nonproliferative diabetic retinopathy. Despite grid laser coagulation in the macular region, cystoid macular edema progressed, and within 6 months before the cortisone injection, visual acuity declined from 0.25 to 0.16 and, finally, to 0.10. The patient received a single intravitreal injection of triamcinolone acetonide with topical anesthesia. RESULTS: After the intravitreal injection of triamcinolone acetonide, visual acuity improved from 0.10 to 0.40 during the follow-up period spanning 5 months. Intraocular pressure increased to values up to 30 mm Hg before antiglaucomatous treatment. CONCLUSION: Intravitreal injection of triamcinolone acetonide may be useful for treatment of diabetic macular edema resistant to conventional therapy.     

Intravitreal steroids for macular edema: the past, the present, and the future

Macular edema, a condition usually associated with an underlying disease process, is a common cause of severe visual loss. There have been a variety of approaches to the treatment of macular edema; within the past few years, however, intravitreal corticosteroid treatments have emerged as an increasingly used treatment option for patients with macular edema. Intravitreal delivery allows the steroid to bypass the blood–retinal barrier, leading to a more concentrated dose of steroid for a prolonged period of time. Corticosteroids have likely been successful in the treatment of various forms of macular edema, due to their known anti-angiogenic, anti-edematous, anti-inflammatory, anti-apoptotic, and anti-proliferative effects. Intravitreal triamcinolone acetonide has been repeatedly successful in reducing macular edema and improving visual acuity, although the duration of action is typically short-term. Due to the recurrent and chronic nature of macular edema, biodegradable implants may be the future of intravitreal steroids. Intravitreal corticosteroids are not without risks. Steroid-related side effects include cataract formation and elevated intraocular pressure. Injection-related side effects include retinal detachment, vitreous hemorrhage, bacterial endophthalmitis, and sterile endophthalmitis. This article reviews the evolving role of intravitreal corticosteroids in the treatment of macular edema secondary to uveitis, diabetes, and retinal vascular disorders.     

Intravitreal triamcinolone acetonide for diabetic macular edema

PURPOSE: Intravitreal injection of triamcinolone acetonide has been advocated to treat exudative diabetic macular edema. The purpose of the study was to evaluate the clinical outcome of an intravitreal injection of triamcinolone acetonide as treatment for diffuse diabetic macular edema. METHODS: This study was a retrospective, interventional, clinical case series examining 210 eyes of 174 patients who received an intravitreal injection of 1 or 4 mg of triamcinolone acetonide for treatment of diffuse diabetic macular edema. Inclusion criteria were clinically significant macular edema, visual acuity loss, and leakage shown by fluorescein angiography. Main outcome measures were visual acuity and intraocular pressure. Mean follow-up time +/- SD was 6.6 +/- 3.1 months. RESULTS: In the study group, visual acuity improved significantly (P < 0.001) from a median of 20/200 (mean logMAR, 0.92) at baseline to 20/80 (mean logMAR, 0.82) at 6 months. Mean intraocular pressure +/- SD increased from 15.4 +/- 3.4 mmHg (median, 16 mmHg; range, 6-26 mmHg) to a maximal value of 20.4 +/- 6.2 mmHg (median, 19 mmHg; range, 12-51 mmHg) during the follow-up period. Complications included culture-negative sterile endophthalmitis in six cases and cataract extraction in five eyes. CONCLUSIONS: Intravitreal injection of 1 to 4 mg of triamcinolone acetonide may benefit patients by improving visual acuity in eyes with clinically significant diabetic macular edema. This study did not provide significant evidence to justify its routine use in clinical practice for all patients with diabetic macular edema. A randomized clinical trial on this issue would provide more conclusive evidence and help identify those patients most likely to benefit from intravitreal triamcinolone acetonide.     

玻璃体腔注射曲安奈德治疗葡萄膜炎致黄斑水肿临床研究

目的观察玻璃体腔注射曲安奈德(TA)治疗葡萄膜炎致黄斑水肿的疗效及安全性。方法回顾性分析我院眼科门诊于2008年10月至2010年4月明确诊断为葡萄膜炎致黄斑水肿病例共56例(64只眼),均给予玻璃体腔注射TA注射液,联合散瞳药物等治疗,随访1~2个月,观察视力、眼压、眼前后节情况进行疗效分析。结果 TA治疗后与治疗前比较,视力明显提高(P<0.001),相干光断层扫描(OCT)示黄斑中心视网膜厚度(CMT)明显变薄,由术前的平均(568±94)μm降至约(238±41)μm(P<0.001),黄斑水肿减轻,未见与药物有关的眼部和全身不良反应。结论葡萄膜炎并发黄斑水肿患者给予玻璃体腔注射TA可安全、有效提高视力、控制炎症及预防并发症。     

Toxoplasmosis retinochoroiditis after photodynamic therapy and intravitreal triamcinolone for a supposed choroidal neovascularization: a case report

The purpose is to report a complication after photodynamic therapy (PDT) and intravitreal triamcinolone for a presumed choroidal neovascularization in age-related macular degeneration. Photodynamic therapy and intravitreal triamcinolone were used in an 84-year-old man with choroidal neovascularization in the left eye. Forty-five days after therapy, the patient returned with a severe necrotizing uveitis in the posterior pole and vitritis. Laboratory investigation disclosed a high anti-Toxoplasma IgG titer. Therapy with pyrimethamine, sulfadiazine and folinic acid resulted in total lesion healing although central vision was lost. Intravitreal triamcinolone may have had an influence on the exacerbation of retinochoroiditis in the posterior pole of the patient. Although rare, this complication may not be disregarded in the cases that require intraocular corticosteroids for treatment of several conditions, especially in patients who had previously suffered from toxoplasmosis infection.     

Intravitreal triamcinolone acetonide for pseudophakic cystoid macular edema

PURPOSE: To report the clinical outcome of patients undergoing intravitreal injection of triamcinolone acetonide as treatment of long-standing cystoid macular edema after phacoemulsification. DESIGN: Prospective clinical interventional cases series studies. METHODS: The study included five patients suffering from cystoid macular edema after cataract surgery. They received an intravitreal injection of 25-mg crystalline triamcinolone acetonide transconjunctivally with topical anesthesia. RESULTS: In the follow-up period of 6.6 +/- 4.1 months, visual acuity increased from 0.26 +/- 0.13 to a mean maximal visual acuity of 0.60 +/- 0.19. For all patients, visual acuity improved during the follow-up by at least 0.20. Two (40%) patients developed intraocular pressure values higher than 21 mm Hg, which could be controlled by topical antiglaucomatous treatment. CONCLUSIONS: Intravitreal triamcinolone acetonide may be a therapeutic option for long-standing cystoid macular edema after cataract surgery.     

Ischemic maculopathy following intravitreal bevacizumab for refractory diabetic macular edema

A 58-year-old male presented with decreased visual acuity from persistent diffuse diabetic macular edema despite multiple interventions including laser photocoagulation and intravitreal triamcinolone acetonide injections. Following treatment with 1.25 mg of intravitreal bevacizumab, reduction in macular leakage was shown by fluorescein angiography and resolution of edema was shown by optical coherence tomography (OCT); however, visual acuity deteriorated and fluorescein angiograms demonstrated progressive enlargement of the foveal avascular zone (FAZ), which had shown no abnormalities before the injection. Despite normalisation of macular thickness on OCT and cessation of leakage on angiography, visual acuity remained at the same level until 6 months of follow-up. Intravitreal bevacizumab must be used with caution in patients with chronic, persistent diabetic macular edema. Disruption of the fragile fine foveal network of capillaries with induction of macular ischemia may result following treatment even if there are no pre-existing defects in the FAZ and may be responsible for non-improvement or decrease in visual acuity.     

Drug delivery options for the treatment of ocular inflammation

Treatments available for ocular inflammatory diseases and their associated complications have expanded significantly over the course of the last ten years. While corticosteroids are a mainstay of therapy for uveitis and macular edema, the methods of delivering corticosteroids have evolved. Intravitreal triamcinolone acetonide provides a local therapy for persistent cystoid macular edema (CME) and posterior uveitis. Other intravitreal therapies, such as bevacizumab and methotrexate, have also been used successfully in uveitic CME. Sustained release intravitreal implants, including the fluocinolone acetonide implant and the dexamethasone drug delivery system, offer an alternative therapy for chronic, recalcitrant posterior uveitis and CME. Their design was inspired by the ganciclovir implant, which prevented the progression of CMV retinitis in AIDS patients. Technological advances in drug delivery have supplied new treatments for patients with ocular inflammatory disease.     

Drug Delivery Options for the Treatment of Ocular Inflammation

Treatments available for ocular inflammatory diseases and their associated complications have expanded significantly over the course of the last ten years. While corticosteroids are a mainstay of therapy for uveitis and macular edema, the methods of delivering corticosteroids have evolved. Intravitreal triamcinolone acetonide provides a local therapy for persistent cystoid macular edema (CME) and posterior uveitis. Other intravitreal therapies, such as bevacizumab and methotrexate, have also been used successfully in uveitic CME. Sustained release intravitreal implants, including the fluocinolone acetonide implant and the dexamethasone drug delivery system, offer an alternative therapy for chronic, recalcitrant posterior uveitis and CME. Their design was inspired by the ganciclovir implant, which prevented the progression of CMV retinitis in AIDS patients. Technological advances in drug delivery have supplied new treatments for patients with ocular inflammatory disease.     

Intravitreal triamcinolone acetonide: a change in a paradigm

BACKGROUND: Based on experimental studies and clinical observations by Robert Machemer, Gholam Peyman and others, the vitreous cavity has increasingly been used as a reservoir of drugs for the direct treatment of intraocular diseases. METHODS AND RESULTS: The most widely injected drug so far has been triamcinolone acetonide for various intraocular neovascular and edematous diseases. Comparing the various diseases with respect to effect and side effects of the treatment, the best response in terms of gain in visual acuity has been achieved for intraretinal edematous diseases such as diffuse diabetic macular edema, branch retinal vein occlusion, central retinal vein occlusion, and pseudophakic cystoid macular edema. In eyes with various types of noninfectious uveitis including acute or chronic sympathetic ophthalmia and Adamantiadis-Beh?et's disease, visual acuity increased and the degree of intraocular inflammation decreased. Some studies have suggested that intra- vitreal triamcinolone may be useful as an angiostatic agent in eyes with iris neovascularization and proliferative ischemic retinopathies. Intravitreal triamcinolone may possibly be helpful as adjunct therapy for exudative age-related macular degeneration, particularly in combination with photodynamic therapy. In eyes with chronic, therapy-resistant ocular hypotony, intravitreal triamcinolone can induce an increase in intraocular pressure and may stabilize the eye. The complications of intravitreal triamcinolone therapy include secondary ocular hypertension in about 40% of the eyes injected; medically uncontrollable high intraocular pressure leading to antiglaucomatous surgery in about 1-2% of the eyes; posterior subcapsular cataract and nuclear cataract leading to cataract surgery in about 15-20% in elderly patients within 1 year after injection; postoperative infectious endophthalmitis with a rate of about 1:1,000; noninfectious endophthalmitis, perhaps due to a reaction to the solvent agent, and pseudoendophthalmitis with triamcinolone acetonide crystals appearing in the anterior chamber. Intravitreal triamcinolone injection can be combined with other types of intraocular surgery including cataract surgery, particularly in eyes with iris neovascularization. Cataract surgery performed some months after the injection does not show a markedly elevated complication rate. The injection may be repeated, if vision redecreases. In nonvitrectomized eyes, the duration of the effect and side effects of a single intravitreal injection of triamcinolone is about 6-9 months for a dosage of about 20 mg, and about 2-4 months for a dosage of 4 mg. It has remained unclear so far, whether and how to remove the solvent agent. In the future, intravitreal triamcinolone may be combined with other antiangiogenic drugs for the treatment of exudative age-related macular degeneration or with neuroprotective drugs for treatment of diabetic retinopathy. CONCLUSIONS: Despite an exponentially increasing number of mostly case-series studies, the intravitreal injection of triamcinolone may still be considered an experimental procedure until randomized studies have been presented.     

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.     

Intravitreal triamcinolone acetonide for idiopathic cystoid macular edema

PURPOSE: To report intravitreal triamcinolone acetonide for idiopathic cystoid macular edema (ICME). DESIGN: Interventional case series. METHODS:Two patients with ICME were treated with intravitreal triamcinolone. RESULTS: In one patient, best-corrected acuity was 20/70 before treatment and 20/30 6 months posttreatment in both eyes. Foveal thickness was 606 microm before and 197 microm posttreatment in the right eye and 542 microm before and 190 microm posttreatment in the left eye. In another patient, best-corrected acuity was 20/200 before treatment and 20/50 5 months posttreatment; foveal thickness was 580 microm before and 208 microm posttreatment. Recurrence of macular edema responded to repeat intravitreal triamcinolone acetonide in both patients. CONCLUSIONS: Intravitreal triamcinolone may be associated with reduced edema and improved vision in patients with ICME; however, these changes may be transient.     

Intravitreal triamcinolone acetonide as treatment of macular edema in central retinal vein occlusion

PURPOSE: To report the clinical outcome of a patient receiving an intravitreal injection of triamcinolone acetonide as treatment of bilateral, long-standing, cystoid macular edema due to central retinal vein occlusion. METHODS: A 70-years-old patient suffering from bilateral central retinal vein occlusion for 2 years and 1.5 years, respectively, received transconjunctivally an intravitreal injection of 25 mg of crystalline triamcinolone acetonide in each eye, with 10 weeks between injections. RESULTS: During the follow-up period of 4 months (OD) and 6 weeks (OS), respectively, visual acuity increased from 0.05 to 0.25 in his right eye and from 0.125 to 0.25 in his left eye. Fluorescein angiography showed a decrease of fluorescein leakage in the macular area. CONCLUSIONS: Intravitreal injection of triamcinolone acetonide may be a therapeutic option for long-standing cystoid macular edema due to central retinal vein occlusion.     

Treatment of radiation maculopathy and radiation-induced macular edema: A systematic review

Radiation maculopathy and radiation-induced macular edema are common, sight-threatening complications after radiotherapy, especially that used for uveal melanoma. While many treatment and preventive strategies have been proposed, management of these conditions is still challenging. Initially, treatments were based on the use of retinal laser, but the outcomes were poor. Subsequently, management has shifted toward injection of intravitreal antivascular endothelial growth factor or corticosteroids. We reviewed current clinical evidence, which mostly relies on small sample-sized and retrospective studies, for the management of radiation maculopathy and, in particular, radiation-induced macular edema. At present, the first-line approach is usually intravitreal antivascular endothelial growth factor. Intravitreal dexamethasone implantation may be an option for those with suboptimal response or contraindications to antivascular endothelial growth factor agents. Possible preventive treatments that require future study are intravitreal bevacizumab and ranibizumab, peripheral laser photocoagulation, and subtenon triamcinolone acetonide.     

感染性葡萄膜炎玻璃体注射疗法研究进展

非感染性葡萄膜炎（non-infectious uveitis，NIU）治疗目的是控制炎症，减少并发症，保护视力。NIU玻璃体注射疗法可减少全身副作用和药物频繁使用的问题，已成为全身用药的有效替代方案，且玻璃体注射途径的靶向治疗可实现NIU患者个性化精准治疗。玻璃体注射糖皮质激素（Ozurdex、Retisert、Iluvien、Yutiq、曲安奈德）、抗血管内皮生长因子（贝伐单抗、雷珠单抗、阿柏西普）、抗肿瘤坏死因子-α（阿达木单抗、英夫利昔单抗）、免疫抑制剂（西罗莫司、甲氨蝶呤、环孢素A）等可有效治疗NIU的炎症、黄斑水肿及炎性脉络膜新生血管的相关并发症。但由于缺乏对照研究，很难比较这些药物，且部分药物价格昂贵、临床试验经验较少。（国际眼科纵览，2021, 45： 425-430）     

Intraocular triamcinolone acetonide for pseudophakic cystoid macular edema: optical coherence tomography and multifocal electroretinography study

PURPOSE: To evaluate pseudophakic cystoid macular edema (CME) by optical coherence tomography (OCT) and multifocal electroretinography (mf-ERG) and determine the efficacy of intravitreal triamcinolone acetonide injections. METHODS: In this nonrandomized retrospective study, 14 eyes of 14 patients with persistent pseudophakic CME were treated with triamcinolone acetonide injection and were followed up for 1 year. All patients underwent complete ophthalmologic examination including determination of best-corrected visual acuity, slit-lamp examination, tonometry, and funduscopy. Results of OCT and mf-ERG were also recorded before and after the injection. RESULTS: Visual acuity and mf-ERG values increased in all patients after intravitreal triamcinolone acetonide injections. OCT showed improvement of the retinal thickness in the macular area. Temporary increase of intraocular pressure was controlled with topical use of antiglaucoma drops. CONCLUSION: Intravitreal triamcinolone acetonide injection is a promising therapeutic tool for chronic pseudophakic edema resistant to other medical treatment. However, further study is needed to assess the treatment's long-term efficacy, its safety, and the need for retreatment.