Efficacy of Intravitreal Anti-vascular Endothelial Growth Factor or Steroid Injection in Diabetic Macular Edema According to Fluid Turbidity in Optical Coherence Tomography

PURPOSE: To determine if short term effects of intravitreal anti-vascular endothelial growth factor or steroid injection are correlated with fluid turbidity, as detected by spectral domain optical coherence tomography (SD-OCT) in diabetic macular edema (DME) patients. METHODS: A total of 583 medical records were reviewed and 104 cases were enrolled. Sixty eyes received a single intravitreal bevacizumab injection (IVB) on the first attack of DME and 44 eyes received triamcinolone acetonide treatment (IVTA). Intraretinal fluid turbidity in DME patients was estimated with initialintravitreal SD-OCT and analyzed with color histograms from a Photoshop program. Central macular thickness and visual acuity using a logarithm from the minimum angle of resolution chart, were assessed at the initial period and 2 months after injections. RESULTS: Visual acuity and central macular thickness improved after injections in both groups. In the IVB group, visual acuity and central macular thickness changed less as the intraretinal fluid became more turbid. In the IVTA group, visual acuity underwent less change while central macular thickness had a greater reduction (r = -0.675, p = 0.001) as the intraretinal fluid was more turbid. CONCLUSIONS: IVB and IVTA injections were effective in reducing central macular thickness and improving visual acuity in DME patients. Further, fluid turbidity, which was detected by SD-OCT may be one of the indexes that highlight the influence of the steroid-dependent pathogenetic mechanism.

Prognostic Factors after Intravitreal Triamcinolone Injection for Macular Edema due to Branch Retinal Vein Occlusion

PURPOSE: To evaluate prognostic factors for improvement of visual acuity after intravitreal triamcinolone acetonide injection (IVTA) for treatment of macular edema (ME) secondary to branch retinal vein occlusion (BRVO). METHODS: Sixty-eight eyes of 68 consecutive patients treated with IVTA for ME due to BRVO were retrospectively reviewed. Patients were categorized into 2 groups according to the final visual acuity. The 'gainer group' consisted of eyes with a gain of 2 or more Snellen chart lines and the 'non-gainer group' consisted of eyes with less than 2 lines improvement or which had worsened at the last follow-up visit. Comparative clinical characteristics and ophthalmoscopic examinations were analyzed between the 2 groups. RESULTS: Out of the 68 eyes, 38 (56%) showed improved vision and were categorized as the gainer group; 30 eyes (44%) were categorized as the non-gainer group. The duration of symptoms in the non-gainer group was longer than the gainer group. Additionally, patients with a better baseline vision were expected to show greater improvement. The number of early visual acuity gainers who showed visual improvement at 1 month after IVTA was significantly higher in the gainer group. The number of eyes with angiographically documented macular ischemia was significantly higher in the non-gainer group. Existence of subretinal fluid has been identified as a positive factor for visual improvement. CONCLUSIONS: The cases with early treatment, good baseline visual acuity, case of favorable response to the initial IVTA, absence of macular ischemia, and baseline subretinal fluid are favorable prognostic factors for the outcome of visual acuity after IVTA for ME due to BRVO.

Presumed Necrotizing Viral Retinitis after Intravitreal Triamcinolone Injection: Case Report

A 56-year-old man presented with anterior chamber inflammation, increased intraocular pressure, peripheral retinal infiltration, and generalized retinal arterial obstruction suggesting acute retinal necrosis five months after intravitreal triamcinolone acetonide injection (IVTA). He was treated with intravenous antiviral agents and aspirin. Shortly after treatment, retinal infiltrations were resolved, and partial recanalization of the obstructed vessel was observed. Viral retinitis may occur as an opportunistic infection following IVTA due to the local immune modulatory effect of the steroid; hence, close observation following IVTA is necessary.

The Effectiveness of Selective Laser Trabeculoplasty in Steroid-Induced Ocular Hypertension

PURPOSE: To report the effectiveness of selective laser trabeculoplasty (SLT) in patients with intraocular hypertension refractory to maximum tolerated medical therapy after intravitreal triamcinolone acetonide (IVTA). CASE SUMMARY: The records of 3 patients with steroid-induced intraocular hypertension that did not respond to maximum tolerated medical therapy were retrospectively reviewed. The patients received SLT instead of filtering surgery or Argon laser trabeculoplasty. The mean intraocular pressure (IOP) of 13.7 mm Hg increased to 30.7 mm Hg within 13 days of IVTA. IOP was uncontrolled despite maximum tolerated medical therapy. Patients underwent SLT 15.3 weeks after IVTA. Mean IOP decreased to 16 +/- 3.0 mm Hg after 1 day, 19.7 +/- 8.0 mm Hg after 1 week, 17 +/- 8.0 mm Hg after 1 month, 12.3 +/- 2.9 mm Hg after 3 months and 12.3 +/- 0.6 mm Hg after 4 to 6 months. The number of IOP lowering drugs were decreased to 1 from 4.3 after 6 months of SLT. CONCLUSIONS: SLT may be effective and safe for the treatment of steroid-induced intraocular hypertension refractory to maximum tolerated medical therapy.

Comparison of Photocoagulation With Combined Intravitreal Triamcinolone for Diabetic Macular Edema

PURPOSE: To compare the efficacy between macular laser grid (MLG) photocoagulation and MLG plus intravitreal triamcinolone acetonide (IVTA; MLG+IVTA) therapy in diabetic macular edema (DME) patients. METHODS: A prospective, randomized, clinical trial was conducted of DME patients. A total of 60 eyes (54 patients) affected by DME were observed for a minimum of 6 months. Thirty eyes of 28 patients who received MLG treatment and 30 eyes of 26 patients who received the combined MLG+IVTA treatment were included in the study. Main outcome measures were BCVA and central macular thickness (CMT) as measured by optical coherence tomography (OCT) at 1, 3, and 6 months after treatment. Additionally, the authors examined retrospectively 20 eyes of 20 patients who were treated with only IVTA and compared with the 2 groups (MLG group and MLG+IVTA group). RESULTS: Baseline BCVA was 0.53+/-0.32 and CMT was 513.9+/-55.1 microm in the MLG group. At 1 and 3 months after treatment, the MLG group showed no significant improvement of BCVA and CMT, although there was significant improvement after 6 months. In the MLG+IVTA group, the baseline BCVA was 0.59+/-0.29 and CMT was 498.2+/-19.8 microm. After treatment, significant improvement of BCVA and CMT was observed at all follow-up time periods. When comparing the MLG group with the MLG+IVTA group, the latter had better results after 1 and 3 months, although at 6 months, there was no significant difference of BCVA and CMT between the 2 groups. Additionally, the IVTA group showed more improvement than the MLG group at 1 and 3 months but showed no significant difference at 6 months. In addition, the IVTA group showed no significant difference with the MLG+IVTA group at all follow-up time periods. CONCLUSIONS: For DME patients, the combined MLG+IVTA treatment had a better therapeutic effect than the MLG treatment for improving BCVA and CMT at the early follow-up time periods. IVTA treatment alone could be an additional alternative therapeutic option to combined therapy.

Dose Dependent Effects of Intravitreal Triamcinolone Acetonide on Diffuse Diabetic Macular Edema

PURPOSE: To evaluate the effect of different doses of intravitreal triamcinolone acetonide on diffuse diabetic macular edema. METHODS: In a retrospective study, 44 eyes with diffuse diabetic macular edema were treated with an intravitreal injection of 4 mg (n=12 eyes), 8 mg (n=17) or 25 mg (n=15) of triamcinolone acetonide (TA). Optical coherence tomography, best-corrected logMAR visual acuity and Goldmann tonometry were performed at baseline, 1 week, and 1, 3, 6, 9 and 12 months after treatment. Mean follow-up was 9.8 months (standard deviation=2.3) with a range of 5-12 months. RESULTS: The duration of intravitreal TA effects on macular thickness and visual acuity increased with increasing dosage. An observed increase in intraocular pressure induced by TA was not significantly associated with dosage. CONCLUSIONS: In patients with diffuse diabetic macular edema who receive intravitreal TA, effects may last longer after a dosage of 25 mg, than after lower doses of 8 mg or 4 mg.

The Effect of an Intravitreal Triamcinolone Acetonide Injection for Acute Nonarteritic Anterior Ischemic Optic Neuropathy

The purpose of this case report is to evaluate the visual outcome of an intravitreal triamcinolone acetonide injection (IVTA) as a treatment for a patient with acute nonarteritic anterior ischemic optic neuropathy (NAION). A 65-year-old male patient with severe visual loss due to acute NAION was treated with 4 mg/0.1mL IVTA. Fundus examination and measurements of the patient's best-corrected visual acuity and visual field were performed before and after the injection at 2 weeks, 1 month, 3 months, and 6 months. The best-corrected visual acuity changed from 0.05 before the injection to 0.16 at 2 weeks, 0.3 at 1 month, and 0.4 at 3 months and at the final visit. Optic disc swelling had markedly decreased at 1 week postoperatively and disappeared at 2 weeks after the injection. The clinical course of this patient suggests that an IVTA may be effective in increasing visual acuity following an acute NAION. A large randomized controlled trial is needed to assess the efficacy of IVTA as a treatment for NAION.

Intraocular Pressure Elevation After Intravitreal Triamcinolone Acetonide of Different Volumes: Comparing 0.1 ml vs 0.05 ml

PURPOSE: To assess whether a 4 mg/0.05 ml intravitreal triamcinolone acetonide injection can reduce the IOP elevation compared to conventional 4 mg/0.1 ml injection. METHODS: A retrospective case study was performed in 48 patients (48 eyes) who received intravitreal triamcinolone acetonide injection and who had a minimum follow-up time of six months. Patients were randomly assigned to receive 4 mg/0.1 ml or 4 mg/0.05 ml (24 patients in each group). RESULTS: Before injection, mean IOP was 13.8+/-2.2 mmHg and 13.9+/-2.4 mmHg in the 0.1 ml and 0.05 ml group. The difference in IOP elevation between the two groups was statistically significant immediately after injection (P=0.000), one hour after injection (P=0.001), and one day after injection (P=0.000). After injection, the central macular thickness decreased significantly the of two groups. The difference of the central macular thickness decrease between both groups was not statistically significant. CONCLUSIONS: An intravitreal triamcinolone acetonide 4 mg/0.05 ml injection will more quickly reduce the IOP elevation in the early phase compared to 4 mg/0.1 ml injection, while providing a similar effect on the change of central macular thickness.

Laser Photocoagulation Combined with Intravitreal Triamcinolone Acetonide Injection in Proliferative Diabetic Retinopathy with Macular Edema

PURPOSE: To evaluate therapeutic effects and usefulness of a combination treatment of intravitreal injection of triamcinolone acetonide (IVTA) and panretinal photocoagulation (PRP) in patients with clinically significant macular edema secondary to proliferative diabetic retinopathy (PDR). METHODS: Visual acuity test, fundoscopy, fluorescein angiography, and optical coherence tomography (OCT) were taken in 20 patients (20 eyes) of macular edema and PDR. A combination of intravitreal injection of triamcinolone acetonide and PRP was performed in 10 patients (10 eyes) and a combination of focal or grid laser photocoaqulation and PRP in the remaining 10 eyes. The postoperative outcomes were compared between the two combination treatments by best corrected visual acuity (BCVA), tonometry, fluorescein angiography, and OCT at 2 weeks, 1, 2, and 3 months. RESULTS: Average BCVA (log MAR) significantly improved from preoperative 0.56+/-0.20 to 0.43+/-0.08 at 1 month (P=0.042) and it was maintained until 3 months after a combination of IVTA and PRP in 10 eyes (P=0.007). The thickness of fovea decreased from average 433.3+/-114.9 micrometer to average 279.5+/-34.1 micrometer at 2 weeks after combined treatment of IVTA and PRP (P=0.005), which was significantly maintained until 3 months, but there was a transient visual disturbance and no significant difference in thickness of the fovea before and after treatment in the groups with PRP and focal or grid laser photocoagulation. CONCLUSIONS: A combination of IVTA and PRP might be an effective treatment modality in the treatment of macular edema and PDR and prevent the subsequent PRP-induced macular edema result in visual dysfunction. In combination with PRP, IVTA might be more effective than focal or grid laser photocoagulation and PRP for reducing diabetic macular edema and preventing aggravation of macular edema without transient visual disturbance in patients requiring immediate PRP.

Intraocular Pressure Change After Secondary Intravitreal Triamcinolone Acetonide Injection

PURPOSE: To evaluate the change of intraocular pressure (IOP) after first and second injection of intravitreal triamcinolone acetonide for the treatment of macular edema and the factors that influence these changes. METHODS: A prospective, non-comparative study was performed in 41 eyes at Kangnam Sacred Heart Hospital from October 2003 to November 2005. All of the patients received injection of intravitreal triamcinolone acetonide (4 mg) twice. The IOPs before and after triamcinolone injection were measured with non-contact tonometer and Goldmann applanation tonometer. RESULTS: Mean IOP after the first and second injections were elevated from the day after injection and peaked after 3 months. Younger age (p=0.042), male (p=0.050) and the history of IOP elevation after first injection (p=0.004) were a statistically significant predictive factor for IOP elevation after second injection. Younger age (p=0.000) and male (p=0.010) were a significant predictive factor for IOP elevation after first and second injection. CONCLUSIONS: Clinicians should consider checking IOP especially for the patients who with the history of IOP elevation after first injection, male and relatively younger age.