Application of subtenon injection of triamcinolone acetonide combined with vitrectomy in the treatment of retinal detachment with choroidal detachment / 中华实验眼科杂志

Background The introvitreal injection of triamcinolone acetonide (TA) before vitrectomy for retinal with choroidal detachment (RD/CD) can alleviate inflammatory response,but it easily lead to complications under the low intraocular pressure.The study on the efficiency and safety of subtenon injection of TA for treatment of RD/CD is lack.Objective This study was to evaluate the efficiency and safety of subtenant injection of TA with vitrectomy for treatment of RD/CD.Methods A retrospective study was adopted.The data of 22 eyes of 22patients who received subtenon injection of TA with vitrectomy for RD/CD were collected and analyzed in Affiliated Eye Hospital of Wenzhou Medical University from May 2010 to June 2014.TA of 40 mg in 0.4 ml was administered subtenantly 5 days before RD repair surgery.After initiating the treatment,the therapeutic effects on uvitis were analyzed.Intraocular pressure was monitored and CD height and range were determined by B type ultrasonography before injection and 5 days after injection respectively.In addition,blood glucose and blood pressure of the patients were evaluated.Results Ocular inflammation alleviated to some degree after TA injection in all 22 eyes.The mean intraocular pressure was (5.4±2.9) mmHg (1 mmHg =0.133 kPa) in pre-injection and (8.2±4.3) mmHg in postinjection,showing a significant difference between them (t =3.430,P ＜ 0.01).The mean maximum CD height was 5.2 (3.1,6.6)mm in pre-injection and 0.9 (0,3.8)mm in post-injection,with a significant difference between the before and after injection (Z=-4.198,P＜0.01).The mean CD range was 12 (10,12) clock before injection and 3(0,6) clock after injection,and no significant difference was found between before and after injection (all at P＞0.05) (Z=-4.124,P＜0.01).There were no statistically significant difference in the changes of blood glucose and blood pressure between before and after injection.The LogMAR visual acuities were 2.14±0.46,1.29±0.57 and 1.17±0.55 before injection and 1 month,3 months after injection,respectively,with a siginificant difference among them (F =22.060,P＜0.001).The retinal reattachment rate was 95.5 ％.Conclusions Subtenon injection of TA seems to be a good option for perisurgical management of RD/CD patients,which can alleviate uvitis,increase intraocular pressure,reduce CD height and CD range.

Effect of Posterior Subtenon Triamcinolone Acetonide Injection on Diabetic Macular Edema Refractory to Intravitreal Bevacizumab Injection

PURPOSE: To evaluate the effects of posterior subtenon triamcinolone acetonide injection on refractory diabetic macular edema (DME) after intravitreal bevacizumab (IVB) injection failure. METHODS: Patients with DME and central subfield thickness (CST) >300 microm who did not respond to IVB injections were retrospectively included. Specifically, we enrolled patients who were diagnosed with refractory DME and who experienced an increase in CST after 1 to 2 IVB injections or no decrease after > or =3 consecutive IVB injections. One clinician injected 20 mg of triamcinolone acetonide into the posterior subtenon space. All patients received ophthalmic examinations at baseline and at 2, 4, and 6 months post-baseline. Examinations included Snellen visual acuity, intraocular pressure, and spectral-domain optical coherence tomography. RESULTS: Forty eyes of 34 patients were included. The average baseline CST was 476 microm. The average CST decreased to 368 microm at 2 months, 374 microm at 4 months, and 427 microm at 6 months (p < 0.001 for all results, Wilcoxon signed-rank test). The average intraocular pressure increased from 15.50 to 16.92 mmHg at 2 months but decreased to 16.30 mmHg at 4 months and 15.65 mmHg at 6 months. Logarithm of the minimum angle of resolution visual acuity improved from 0.56 to 0.50 at 2 months (p = 0.023), 0.50 at 4 months (p = 0.083), and 0.48 at 6 months (p = 0.133, Wilcoxon signed-rank test). No complications were detected. CONCLUSIONS: Posterior subtenon triamcinolone acetonide is an effective and safe treatment for reducing CST in DME refractory to IVB.

Posterior Subtenon Triamcinolone Acetonide in Gas-filled Eyes as an Adjunctive Treatment for Complicated Proliferative Diabetic Retinopathy

PURPOSE: To evaluate the effect of adjunctive subtenon injection of triamcinolone acetonide (TA) in gas-filled eyes after vitrectomy for complicated proliferative diabetic retinopathy (PDR). METHODS: This nonrandomized comparative study included 27 patients (27 eyes) who underwent pars plana vitrectomy and gas tamponade for treatment of PDR with tractional or combined tractional-rhegmatogenous retinal detachment and who received subtenon injection of TA (40 mg) at the end of surgery. The study group was compared with the control group (29 eyes), which was matched with the study group for preoperative and intraoperative parameters, but underwent pars plana vitrectomy and gas tamponade without a subtenon injection of TA. RESULTS: Retinal reattachments without reoperation were achieved in 25 eyes (92.6%) and 26 eyes (89.7%) at 6 months (p = 1.000) in the study and control groups, respectively. The study group and the control group did not differ significantly in the frequency of postoperative proliferative vitreoretinopathy, retinal redetachment rate, reoperation rate, macular pucker formation, postoperative vitreous hemorrhage, gain in visual acuity, intraocular pressure, and intraocular inflammation (p > 0.05). CONCLUSIONS: The clinical results of pars plana vitrectomy for complicated PDR are not improved significantly by an adjunctive subtenon TA injection in gas-filled eyes.

Posterior Subtenon Triamcinolone Acetonide Injection for Refractory Diabetic Macular Edema in Vitrectomized Eye

PURPOSE: To evaluate the effect of posterior subtenon injection of triamcinolone acetonide (TA) in patients with refractory diabetic macular edema (DME) after vitrectomy. METHODS: Seventeen vitrectomized eyes in 16 patients with DME underwent a posterior subtenon injection of TA (40 mg/1.0 ml) and were followed-up for more than six months. Visual acuity (VA, logMAR) and central subfield macular thickness (CSMT, microm) according to optical coherent tomography were assessed at baseline and 1, 3, and 6 months after an injection of TA. RESULTS: The patients included four men and 12 women with an average age of 56.9 years. VA improved significantly from 0.70 +/- 0.33 (mean +/- SD) before injection to 0.56 +/- 0.24 one month and 0.54 +/- 0.21 three months after an injection of TA. Visual acuity at six months was 0.61 +/- 0.24 and had no significance (p = 0.17). CSMT decreased significantly from 469 +/- 145 before injection to 323 +/- 58, 343 +/- 100, and 389 +/- 156 one, three, and six months after an injection of TA, respectively. CONCLUSIONS: Posterior subtenon injection of TA is effective in the short-term for improving VA and CMT in patients with refractory diabetic macular edema after vitrectomy.

Treatment of Diabetic Macular Edema: A Comparative Study

PURPOSE: To compare the effect and complications of treatments for diabetic macular edema. METHODS: Literature review using the Korean medical database and the Korean Ophthalmological Society database was performed. Studies used consisted of patients with diabetic macular edema, comparing intravitreal triamcinolone acetonide (IVTA) injection with posterior subtenon triamcinolone acetonide (STTA) injection or intravitreal bevacizumab (IVB) injection, according to visual acuity (VA) outcomes, central macular thickness (CMT), and intraocular pressure (IOP) at 1, 3, and 6 months. RESULTS: In the three studies comparing IVTA injection with STTA injection, IVTA injection demonstrated greater improvement in VA at 1 month and CMT at 6 months. The patients who received IVTA injection had significantly higher IOP at 3 months. In the three studies comparing IVTA injection with IVB injection, IVTA injection demonstrated greater improvement in VA at 3 months and CMT at 6 months. CONCLUSIONS: The functional and anatomical improvements are achieved by IVTA injection, STTA injection, and IVB injection for diabetic macular edema, and the effect of IVTA injection is more prominent than other injection types with longer duration.

Combined Therapy of Intravitreal Bevacizumab and Posterior Subtenon Triamcinolone Acetonide Injection in Diabetic Macular Edema

PURPOSE: To investigate the outcomes of the combined therapy of intravitreal bevacizumab (IVB) and posterior sutbtenon triamconolone acetonide (STTA) injections as compared to single injections of each in patients with diabetic macular edema (DME). METHODS: IVB injection (IVB group), STTA injection (STTA group) and combined therapy injection (combined group) were performed randomly for 90 eyes (83 patients) diagnosed with DME. Changes in central macular thickness (CMT), best corrected visual acuity (BCVA) and intraocular pressure (IOP) were compared among groups prospectively at pre-injection and one, three and six months after injection. RESULTS: Reduction of CMT and improvement of BCVA were maintained for three months after treatment in all groups, but CMT and BCVA deteriorated at six months after treatment. The combined therapy group revealed significant reductions in CMT and improvement of BCVA (p=0.003, p=0.021, respectively) for the first month compared to the single treatment group. Elevated IOPs were found in three cases and there was no endophthalmitis or retinal detachment. CONCLUSIONS: The combined therapy injection showed significant early improvements in CMT and BCVA for one month. Additionally, the combined therapy revealed similar outcomes as compared with each single treatment after three months.

The Effects of a Subtenoncapsular Injection of Bevacizumab for Ocular Surface Disease With Corneal Neovascularization

PURPOSE: To investigate the effect of an injection of bevacizumab into the sub-Tenon's capsule on ocular surface neovascularization disease including pterygium and corneal neovascularization. METHODS: Twenty-five eyes of 21 patients with pterygium and 19 eyes of 15 patients with corneal neovascularization were given an injection of 5 mg bevacizumab into the sub-Tenon's capsule. The clinical effects and complications were evaluated by analyzing the changes in anterior segment photo, visual acuity, and intraocular pressure at week one, week two, week four, and every month thereafter. RESULTS: After injections of bevacizumab, partial remission of corneal neovascularized lesion was observed in five eyes (20%) of the pterygium group, and there were no significant changes in the visual acuity and no complications. In the corneal neovascularization group, corneal neovascularized lesions of 18 eyes (95%: 2 eyes, complete remission 16 eyes, partial remission) improved after injections of the bevacizumab and the scores of extent and severity of corneal neovascularized lesion improved significantly, unlike the pterygium group. The visual acuity of two eyes (11%) improved more than two lines of Yong-Han Jin's distance visual acuity test and there were no systemic side effects. Localized side effects included four eyes (21%) with punctate epithelial erosions and two eyes (11%) with temporary, elevated intraocular pressure in the corneal neovascularization group. The side effects improved without any additional treatment. CONCLUSIONS: An injection of bevacizumab into the sub-Tenon's capsule is more effective in fresh lesions of corneal neovascularization disease than in old and stable lesions of pterygium. Therefore, it could be used as a prominent treatment of various corneal neovascularization diseases.

Intravitreal Versus Subtenon Injections of Triamcinolone Acetonide for Diabetic Macular Edema

PURPOSE: To retrospectively evaluate the clinical effect of intravitreal (IVT) and posterior subtenon (PSTT) triamcinolone acetonide (TA) injection in diabetic macular edema. METHODS: Fifty eyes of 43 patients with diabetic macular edema (DME) were included. Twenty-two eyes in the IVT group received 4 mg/0.1 ml intravitreal TA injections and 26 eyes in the PSTT group received 40 mg/1.0 ml subtenon TA injections. LogMAR visual acuity and intraocular pressure (IOP) were measured and, using OCT, central macular thickness (CMT) and total macular volume (TMV) were also measured before and 1, 3, and 6 months postoperatively. RESULTS: Both groups showed significant decreases in the mean CMT and TMV. The mean CMT in the IVT group was significantly thinner than that of the PSTT group 1 month postoperatively. The percentage reduction in CMT and TMV were also greater in the IVT group than the PSTT group 1 month postoperatively. Both groups showed significant improvements in mean visual acuity, with no significant difference between the two groups. However, at 1-month postoperative improvement in visual acuity was significantly greater in the IVT group than the PSTT group. The mean IOP in the IVT group was also greater than that in the PSTT 1 month postoperatively. CONCLUSIONS: Both injections caused a significant increase in visual acuity and a decrease in CMT and TMV. The effect was more pronounced in the IVT group. However, the PSTT injection also appeared to be a safe and effective technique for the treatment of DME.

The Intraocular Pressure Rise Secondary to Subtenon's Injection of Triamcinolone After Intravitreal Injection

PURPOSE: To evaluate the safety of posterior subtenon's injection of triamcinolone acetonide (PSTA) after intravitreal triamcinolone acetonide injection (IVTA). METHODS: We reviewed the charts of 34 patients who had previously treated with IVTA. Patients were categorized as steroid responder or non-responder. Responders were defined as having a relative intraocular pressure increase of 5 mmHg and absolute intraocular pressure greater than 24 mmHg. Relative risk of intraocular pressure was prospectively evaluated after PSTA. RESULT: Eighteen eyes were categorized as steroid responders after IVTA injection and sixteen eyes were categorized as non-responders. For the actual amount of increase in the intraocular pressures, the steroid responder group (39%) was shown to be statistically higher than the non-responder group (6%) (P=0.044). However, the mean pressure values did not show a significant difference (P>0.05). Only one eye required the use of glaucoma medications and the intraocular pressure remained normal after treatment. CONCLUSIONS: PSTA is a relatively safe treatment method after IVTA injection regardless of steroid responsiveness.

Ocular Concentration after Subtenon and Intravitreal Injection of Triamcinolone Acetonide in Rabbits

PURPOSE: To improve our understanding of the pharmacokinetics of triamcinolone acetonide (TA) and TA concentration in ocular tissue, TA concentration was measured in ocular tissue after intravitreal and subtenon injection. METHODS: Fifteen rabbit eyes underwent subtenon TA injection (40 mg/1 ml), and another 15 rabbit eyes underwent intravitreal TA (4 mg/0.1 ml) injection. All eyes were enucleated at 1, 2, 4, 8, and 12 weeks after subtenon and intravitreal injection, and TA concentration in the aqueous and vitreous humor and the retina-choroid were measured by high performance liquid chromatography (HPLC). RESULTS: In cases of subtenon's TA injection, TA concentrations were 0 ng/ml, 136.7 ng/ml, 178.7 ng/ml, 0 ng/ml, and 0 ng/ml in the aqueous humor; 99.1 ng/ml, 125.7 ng/ml, 726.8 ng/ml, 0 ng/ml, and 0 ng/ml in the vitreous humor; 72.7 ng/ml, 304.6 ng/ml, 459.0 ng/ml, 0 ng/ml, and 0 ng/ml in the retina-choroid after 1, 2, 4, 8, and 12 weeks, respectively. In cases of intravitreal TA injection, the measured values were 0 ng/ml, 0 ng/ml, 0 ng/ml, 654.1 ng/ml, and 0 ng/ml in the aqueous humor; 28152.2 ng/ml, 13646.4 ng/ml, 11388.8 ng/ml, 10297.2 ng/ml, and 183.0 ng/ml in the vitreous humor; and 0 ng/ml, 27.9 ng/ml, 108.3 ng/ml, 0 ng/ml, and 0 ng/ml in the retina-choroid at each time point. CONCLUSIONS: Intravitreal TA injection may be more effective for drug delivery than subtenon TA injection, but subtenon TA injection seems to be an effective and safe technique.

Intravitreal and Additional Posterior Subtenon Triamcinolone Injection in Diabetic Macular Edema

PURPOSE: To compare the effect of triamcinolone acetonide injection between intravitreal injection alone group and intravitreal injection in combintaion with posterior subtenon injection group in diabetic macular edema. METHODS: Twenty-nine eyes of 29 patients with diabetic macular edema were randomly classified into two groups. Intravitreal injection of triamcinolone acetonide 4 mg was administered to 15 eyes and posterior subtenon injection of triamcinolone acetonide 20 mg in combination with intravitreal injection was administered to 14 eyes. Best corrected visual acuity (BCVA), macular thickness measured by optical coherence tomography were assessed 1, 3, 6, and 12 months after the procedure. RESULTS: Baseline BCVA and macular thickness showed no differences between two groups. BCVA and macular thickness 1, 3, and 6 months after the procedure revealed significant improvement, but no significant differences between two groups were observed. CONCLUSIONS: Intravitreal injection of triamcinolone acetonide alone and intravitreal inejction in combination with posterior subtenon injection were equally effective, but had no significant differences.

Intravitreal versus Posterior Subtenon Injection of Triamcinolone Acetonide for Diabetic Macular Edema

PURPOSE: To compare the short-term effects of intravitreal versus posterior subtenon injection of triamcinolone acetonide for diabetic macular edema. METHODS: This is a prospective and interventional study. Sixty eyes of 60 patients who had diffuse diabetic macular edema were assigned to receive a single intravitreal injection (4 mg) or a single posterior subtenon injection (40 mg) of triamcinolone acetonide. The central retinal thickness was measured using optical coherent tomography before injection and at 1 and 3 months after injection. Visual acuity and intraocular pressure (IOP) were also measured. RESULTS: Both intravitreal and posterior subtenon injections of triamcinolone acetonide resulted in significant improvements in visual acuity at 1 month and 3 months after injection. Both groups resulted in a significant decrease in central macular thickness (CMT) at 1 month and 3 months post-injection. IOP in the intravitreal injection group was significantly higher than in the posterior subtenon injection group at 3 months after injection. CONCLUSIONS: The posterior subtenon injection of triamcinolone acetonide had a comparable effect to the intravitreal triamcinolone injection and showed a lower risk of elevated IOP. Posterior subtenon injection of triamcinolone acetonide may be a good alternative for the treatment of diffuse diabetic macular edema.

Triamcinolone-Induced Intraocular Pressure Elevation: Intravitreal Injection for Macular Edema and Posterior Subtenon Injection for Uveitis

PURPOSE: To assess the effect of intravitreal and posterior subtenon injections of triamcinolone acetonide (TA) on intraocular pressure (IOP). METHODS: we reviewed 42 consecutive eyes after intravitreal TA injection (IVTA) and 43 eyes following posterior subtenon TA injection (PSTA). All cases had a minimum follow-up time of three months. After injection, the value and time of the maximal IOP, the amount of IOP elevation and the needs of the medication were assessed. RESULTS: The IOP increased significantly (p<0.001) from 16.3+/-2.5 mmHg preoperatively to a mean maximum of 21.7+/-5.3 mmHg in the IVTA group, and from 15.3+/-4.5 mmHg to 20.6+/-3.0 mmHg in the PSTA group. An elevation in the IOP of more than 5 mmHg from the baseline IOP was seen in 52.4% of the IVTA group at a mean time of 3.1 weeks postoperatively, and 44.2% of the PSTA group displayed an IOP elevation at 5.9 weeks. CONCLUSIONS: Both developed significant elevations of IOP, but this appeared at a later date in the PSTA group. Careful follow-up after local injection of steroids is necessary.

Morphological Changes in Extraocular Muscle of Rabbit Eye Produced by Subtenon's Botulinum A Toxin Chemodenervation

PURPOSE: Currently, when injecting botulinum a toxin into the extraocular muscle, EMG (Electromyography) is used for accurate location. In this study, we examined the effects of subtenon botulinum toxin injection without EMG guidance by quantifying the morphological changes of the extraocular muscle fibers in rabbits. METHODS: Using 10 New Zealand white rabbits, 10 units of botulinum a toxin in 0.1 ml of normal saline was injected into the subtenon space of the superior rectus muscles, 5 mm from the muscle insertion in right eyes. As a control, 0.1 ml of normal saline was injected into the subtenon space of the superior rectus muscles in left eyes. At 3 weeks after injections, the bilateral superior rectus muscles of each rabbit were carefully dissected from the globe. Cross-sections of 5 micrometer thickness were obtained at the site, 5 mm from the insertion of each superior rectus muscle. Sections were stained with Masson's trichrome and observed by light microscopy. Using Image-Pro Plus software, the diameter of the orbital layer myofibers was measured and statistical analysis was done using the Kruskal-Wallis test. RESULTS: The average diameter of the orbital layer fiber cells after botulinum toxin injection was 11.5+/-2.26 micrometer at 3 weeks, whereas that of the control was 14.4+/-3.77 micrometer. The difference was statistically significant (p<0.01). CONCLUSIONS: The diameter of myofibers in the orbital layer was reduced after subtenon botulinum a toxin injection. Further studies on the duration of botulium toxin in subtenon space and the change in the size of myofibers depending on the dosage of botulinum toxin will be necessary.