[Intravitreal triamcinolone acetonide Complication of infectious and sterile endophthalmitis]. / Intravitreales Triamcinolonacetonid Komplikation von infektiöser und steriler Endophthalmitis.

PURPOSE: Intravitreal triamcinolone acetonide (TA), applied as treatment for various edematous and neovascular ocular diseases, was analyzed for infectious or sterile endophthalmitis and pseudoendophthalmitis. METHODS: In a prospective interventional study, 645 eyes were treated with approximately 20 mg intravitreal TA. The removal of the vehicle and the intravitreal injection were performed under sterile conditions. A total of 97 eyes received a second TA injection, 13 a third, 1 a fourth, 2 a fifth, and 1 a sixth injection. The mean follow-up was 7.5 months (median: 5.7 months). RESULTS: In the 1st week after 759 TA injections, 758 resulted in no hypopyon or Tyndall phenomenon >2(+), but in one eye a pseudoendophthalmitis with hypopyon was present. Anterior chamber lavage demonstrated TA crystals, and the culture was negative. In the 2nd week, one patient developed infectious endophthalmitis after a fall had caused ocular perforation. CONCLUSIONS: Intravitreal TA injections (approximately 20 mg) harbor a low risk of infectious or sterile endophthalmitis and pseudoendophthalmitis, if the injection and vehicle removal are performed under sterile conditions.

Intravitreal triamcinolone acetonide for treatment of central retinal vein occlusion.

PURPOSE: To evaluate the effect of intravitreal triamcinolone acetonide on visual acuity and intraocular pressure in patients with central retinal vein occlusion. METHODS: This prospective comparative non-randomized clinical interventional study included 32 patients (33 eyes) with central retinal vein occlusion. The study group (12 patients; 13 eyes) received an intravitreal injection of about 20 mg of triamcinolone acetonide. The control group (20 patients) did not receive any treatment. Mean follow-up was 10.1+/-8.6 months in the study group and 6.0+/-5.2 months in the control group. RESULTS: In the study group, mean visual acuity increased significantly (p=0.018) from 0.11+/-0.11 preoperatively to a best visual acuity during follow-up of 0.18+/-0.15. An improvement in visual acuity by at least 2 Snellen lines and 3 Snellen lines, respectively, was found for 8 (62%) eyes and 5 (38) eyes. Visual acuity measurements determined 1 month (p=0.038) and 3 months (p=0.046) after the injection were significantly higher than the baseline values. Increase in visual acuity was higher in the non-ischemic subgroup than in the ischemic subgroup. In the control group, baseline visual acuity and best visual acuity during the followup did not vary significantly (p=0.33). Visual acuity decreased significantly (p=0.007) towards the end of the follow-up. Comparing study group and control group, gain in visual acuity was significantly (p=0.01) higher in the study group. In the study group, intraocular pressure increased significantly (p=0.018) from 14.4+/-3.9 mmHg to a mean maximal value of 21.6+/-9.2 mmHg (range, 10-44 mmHg), and re-decreased (p=0.012) towards the end of follow-up to 15.3+/-5.1 mmHg (range, 10-21 mmHg). CONCLUSIONS: Intravitreal triamcinolone acetonide temporarily increases visual acuity in central retinal vein occlusion. It is accompanied by an increase in intraocular pressure.

Cataract surgery combined with intravitreal injection of triamcinolone acetonide.

PURPOSE: To evaluate whether the addition of cataract surgery to an intravitreal injection of triamcinolone acetonide markedly increases frequency and spectrum of complications. METHODS: The comparative nonrandomized clinical interventional investigation included a study group of 60 eyes (56 patients) undergoing cataract surgery and additionally receiving an intravitreal injection of about 20 mg of triamcinolone acetonide and a triamcinolone control group of 290 eyes (262 patients) that consecutively received an intravitreal injection of about 20 mg triamcinolone acetonide without cataract surgery. Reasons for intravitreal injection of triamcinolone acetonide were exudative age-related macular degeneration (n=228; 65%), diffuse diabetic macular edema (n=94; 27%), central retinal vein occlusion (n=17; 5%), and branch retinal vein occlusion (n=11; 3%). Mean follow-up was 8.6+/-6.8 months. A second control group included 1068 patients (1068 eyes) who consecutively underwent routine cataract surgery without intravitreal injection. RESULTS: Study group and triamcinolone control group did not vary significantly in best visual acuity during follow-up (p=0.08), final visual acuity at the end of follow-up (p=0.30), maximal intraocular pressure during follow-up (p=0.99), frequency of an intraocular pressure higher than 21 mmHg (p=0.66), and intraocular pressure at the end of follow-up (p=0.06). Postoperative infectious endophthalmitis, wound leakage or other corneal wound healing problems, persisting corneal endothelial decompensation, rhegmatogenous retinal detachment, marked postoperative pain, or a clinically significant decentration of the intraocular lens were not observed. Study group and the non-triamcinolone control group did not vary significantly in the rate of posterior lens capsule rupture (p=0.11), postoperative infectious endophthalmitis, and persisting postoperative corneal endothelial decompensation. CONCLUSIONS: The addition of cataract surgery to an intravitreal injection of triamcinolone acetonide may not markedly increase amount and frequency of side effects and complications of intravitreal triamcinolone acetonide. No safe conclusions can be reached regarding differences in frequency of postoperative infectious endophthalmitis.

Diffuse diabetic macular oedema treated by intravitreal triamcinolone acetonide: a comparative, non-randomised study.

AIM: To report on visual outcome of patients receiving an intravitreal injection of triamcinolone acetonide for treatment of diffuse diabetic macular oedema. METHODS: Prospective, comparative, non-randomised clinical interventional study included 136 patients with diffuse diabetic macular oedema. Patients of the study group (97 eyes) received an intravitreal injection of 20-25 mg of triamcinolone acetonide and no other retinal treatment. Patients of the control group (69 eyes) received focal or panretinal laser treatment if indicated. Mean (standard deviation) follow up was 8.4 (SD 6.0) months (range 1.03-25.2 months). RESULTS: Visual acuity (VA) increased significantly (p<0.001) in the study group with 66 (68%) eyes gaining in VA by at least two Snellen lines. In the control group, VA did not change significantly during the first 4 months of follow up, and decreased significantly (p<0.001) towards the end of the follow up. Difference in change of best VA was significant (p<0.001) between both groups. Correspondingly, the number of patients with VA improvement of two or more Snellen lines and visual loss of two or more Snellen lines, respectively, was significantly (p<0.001) higher and lower, respectively, in the study group. CONCLUSIONS: Intravitreal triamcinolone acetonide can temporarily increase VA in some patients with diffuse diabetic macular oedema.

Branch retinal vein occlusion treated by intravitreal triamcinolone acetonide.

PURPOSE: To evaluate the effect of intravitreal triamcinolone acetonide on visual acuity in branch retinal vein occlusion. METHODS: The prospective comparative nonrandomized clinical interventional study included 28 patients (28 eyes) with branch retinal vein occlusion. The study group consisting of 10 consecutive patients received an intravitreal injection of 20-25 mg of triamcinolone acetonide. The control group including 18 patients did not receive an intravitreal injection. The mean follow-up was 8.7+/-4.4 months. RESULTS: In the study group, mean visual acuity increased significantly (P=0.02) from 0.27+/-0.11 preoperatively to a best postoperative visual acuity of 0.45+/-0.27. Visual acuity measurements determined 1 month after the injection were significantly (P=0.027) higher than baseline values. Nine (90%) eyes gained in visual acuity, with six (60%) eyes showing an increase in visual acuity of at least two Snellen lines. In the ischaemic subgroup, visual acuity did not change significantly (0.18+/-0.18 to 0.13+/-0.04; P=0.66), while, in the nonischaemic subgroup, visual acuity increased significantly (P=0.012) from the baseline value to the best postoperative measurement (0.29+/-0.09 to 0.53+/-0.24). In the control group, baseline visual acuity and best visual acuity during the follow-up did not vary significantly (P=0.27). Comparing the study and control groups with each other, the gain in visual acuity was significantly higher in the study group at 1 month (P=0.016) and 2 months (P=0.012) after baseline. CONCLUSIONS: Intravitreal injection of triamcinolone acetonide can increase visual acuity in patients with branch retinal vein occlusion.

Exudative age-related macular degeneration treated by intravitreal triamcinolone acetonide. A prospective comparative nonrandomized study.

PURPOSE: To report on visual outcome of patients receiving an intravitreal injection of triamcinolone acetonide as treatment of progressive exudative age-related macular degeneration. METHODS: The prospective comparative nonrandomized clinical interventional study included 187 consecutive patients with progressive exudative age-related macular degeneration, divided into a study group of 115 patients receiving an intravitreal injection of 25 mg triamcinolone acetonide, and a control group of 72 patients without treatment. The mean follow-up was 6.0+/-4.2 months. RESULTS: Visual acuity increased significantly (P=0.03) in the study group, and decreased significantly (P=0.01) in the control group, at 1 month and 3 months after start of the study. Between the study group and control group, the differences in change of visual acuity were significant (P=0.001). In the study group, the number of patients with an increase in visual acuity of 2 or more Snellen lines was significantly (P=0.001) larger than in the control group. Correspondingly, the number of patients with a decrease of 2 or more Snellen lines was significantly (P=0.007) smaller in the study group. In all, 43 (37.4%) patients of the study group experienced an increase in best visual acuity by 2 or more Snellen lines. CONCLUSIONS: Visual acuity increased in patients with exudative age-related macular degeneration at 1 month and 3 months after an intravitreal injection of 25 mg triamcinolone acetonide.

[Diffuse diabetic macular edema. Intraocular pressure after intravitreal triamcinolone acetonide]. / Diffuses diabetisches Makulaödem Intraokularer Druck nach intravitrealem Triamcinolonacetonid.

BACKGROUND: Intraocular pressure (IOP) after intravitreal triamcinolone acetonide (TA) for diffuse diabetic macular edema will be analyzed. PATIENTS AND METHODS: This prospective, non-randomized interventional case-series study included 69 patients (n=81 eyes) with diffuse diabetic macular edema receiving intravitreal TA (about 20 mg); 4 eyes had re-injection. Follow-up was 7.66+/-7.36 months. RESULTS: IOP increased significantly (p<0.001, Wilcoxon) from mean preoperative 15.4+/-3.2 mmHg to mean maximum postoperative 20.4+/-4.7 mmHg. An increase of >21 mmHg in 31 eyes (38.3%) was noted. In eyes with secondary hypertension, IOP was controlled with antiglaucomatous drops; 6 months after injection IOP was normal without medication. CONCLUSION: After intravitreal TA, secondary ocular hypertension develops in 38.3% in eyes with diabetic diffuse macular edema after 1 month, which can be controlled by antiglaucomatous drops. Diffuse diabetic macular edema may not imply a contraindication for intravitreal TA.

Factors influencing visual acuity after intravitreal triamcinolone acetonide as treatment of exudative age related macular degeneration.

AIM: To evaluate factors influencing change in visual acuity (VA) after intravitreal injection of triamcinolone acetonide as treatment of exudative age related macular degeneration (AMD). METHODS: This prospective, interventional, comparative non-randomised clinical case series study included 94 patients (99 eyes) showing progressive exudative AMD with occult (n = 61 eyes), minimally classic (n = 18), predominantly classic (n = 1), or totally classic (n = 8) subfoveal neovascularisation. Mean follow up was 8.5 (SD 4.7) months (median, 7.3 months; range 3.1-24.5 months). All patients received an intravitreal injection of 20-25 mg of triamcinolone acetonide. RESULTS: An increase in best VA of at least one line on the Snellen charts was found in 63 (63.1%) eyes. Correspondingly, mean VA increased significantly (p<0.001) from 0.17 (SD 0.13) to 0.22 (SD 0.17) after the injection. Postoperative increase in VA was significantly (p<0.001) and negatively correlated with preoperative VA (correlation coefficient, -0.49). Gain in visual acuity was significantly (p = 0.009) higher if preoperative visual acuity was less than 0.08 (gain: 3.2 (SD 2.9) Snellen lines) than if preoperative VA ranged between 0.08 and 0.20 (gain: 1.2 (SD 2.2) Snellen lines). Change in VA was significantly (p = 0.016) less if preoperative VA was higher than 0.20 (change: -0.8 (SD 3.4) Snellen lines). Maximal gain in VA was significantly (p = 0.035) larger in eyes with retinal pigment epithelium detachment than in eyes with minimally classic subfoveal neovascularisation. This was statistically independent of age (p = 0.99), refractive error (p = 0.88), sex (p = 0.92), and duration of follow up (p = 0.46). CONCLUSIONS: Gain in VA after intravitreal injection of 20-25 mg of triamcinolone acetonide is significantly and negatively correlated with preoperative VA. It is significantly larger in eyes with retinal pigment epithelium detachment than in eyes with minimally classic subfoveal neovascularisation.

Cataract surgery after intravitreal injection of triamcinolone acetonide.

PURPOSE: To report the clinical outcome of patients undergoing cataract surgery after one or repeated intravitreal injections of triamcinolone acetonide as treatment of intraocular neovascular or oedematous diseases. METHODS: The interventional clinical case series study included all patients (n=22) who presented with cataract which had progressed after a single or repeated intravitreal injection of 25 mg of triamcinolone acetonide as treatment of exudative age-related macular degeneration (n=18) or diffuse diabetic macular oedema (n=4). Duration of the follow-up period was 3.76+/-4.99 months. With topical anaesthesia, the patients underwent standard cataract surgery including clear cornea incision, phakoemulsification and aspiration of the lens nucleus and cortex, and implantation of a foldable posterior chamber lens. The main outcome measures were frequencies of capsular rupture, vitreous loss, postoperative infectious endophthalmitis, secondary cataract, and decentration of the intraocular lens, visual acuity and intraocular pressure. RESULTS: Intraoperative dialysis of the lens zonules occurred in one (4.5%) eye and resulted in a loss of vitreous. Secondary cataract leading to Nd : YAG laser capsulotomy was observed in one (4.5%) eye. An optically significant decentration of the IOL or infectious endophthalmitis was not encountered in any patient. Visual acuity increased from 0.11+/-0.10 to 0.13+/-0.94 during the follow-up. Within 1 week after surgery, intraocular pressure was in the normal range in all the eyes. CONCLUSIONS: Cataract surgery after single or repeated intravitreal injection of 25 mg of triamcinolone acetonide does not harbour a markedly elevated frequency or a markedly changed profile of surgical complications.

[Intravitreal triamcinolone acetonide for the treatment of intraocular edematous and neovascular diseases]. / Intravitreales Triamcinolonacetonid zur Behandlung intraokulärer ödematöser und neovaskulärer Erkrankungen.

BACKGROUND: Within the last 2 years, intravitreal application of triamcinolone acetonide has exponentially increased as a treatment option for various intraocular neovascular and edematous proliferative disorders. METHODS AND RESULTS: The best response to intravitreal triamcinolone acetonide injection in terms of gain in visual acuity was obtained for 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 noninfectious uveitis including sympathetic ophthalmia. Intravitreal triamcinolone may be useful as angiostatic therapy in eyes with iris neovascularization and proliferative ischemic retinopathies. Possibly, intravitreal triamcinolone may be helpful for exudative age-related macular degeneration, alone or 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, such as secondary ocular hypertension in about 40% of the eyes injected, cataractogenesis, postoperative infectious and noninfectious endophthalmitis, and pseudo-endophthalmitis will be covered in another article. Intravitreal triamcinolone injection can be combined with other intraocular surgeries including 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, probably depending on the dosage used. CONCLUSIONS: Intravitreal triamcinolone acetonide may offer a possibility for adjunctive treatment of intraocular oedematous and neovascular disorders. One has to take into account the side effects and the lack of long-term follow-up observations.

[Intraocular triamcinolone for diffuse diabetic macular edema]. / Intraokulare Triamcinolongabe bei diffusem diabetischen Makulaödem.

BACKGROUND: The aim of the study was to evaluate the effect of an intravitreal injection of triamcinolone acetonide on the visual acuity of patients suffering from diffuse diabetic macular edema. PATIENTS AND METHODS: The prospective, clinically interventional, uncontrolled study included 32 eyes (26 patients) with diffuse diabetic macular edema and received an intravitreal injection of 25 mg triamcinolone acetonide. Visual acuity was 0.12+/-0.08 (min.-max. 0.03-0.3; median 0.1) at baseline. Mean follow-up was 6.8+/-4.3 months. RESULTS: Visual acuity increased to 0.17+/-0.11 (min.-max.: 0.03-0.4; median 0.125) after 4 weeks (p=0.009) and reached a mean maximum of 0.20+/-0.14 (min.-max.: 0.03-0.5; median 0.16) after 8 weeks (p=0.006). Later, visual acuity showed a slow decrease, but was significantly higher than at baseline up to 6 months postoperatively and 26 eyes (81.3%) gained in visual acuity. Ten eyes (31.2%) developed steroid-induced secondary ocular hypertension. CONCLUSION: An intravitreal injection of 25 mg of triamcinolone acetonide may be an option in the treatment of diffuse diabetic macular edema.

Intravitreal triamcinolone acetonide as treatment of ischemic ophthalmopathy.

PURPOSE: To describe the clinical course of a patient receiving repeated intravitreal injections of triamcinolone acetonide (25 mg) as treatment of ischemic ophthalmopathy. METHODS: A 70-year-old patient with Waldenström disease presented with progressive iris neovascularization, vitreous hemorrhage, and ocular hypotony due to ischemic ophthalmopathy. Visual acuity was 0.05. Within 2.5 years, he received three intravitreal injections of 25 mg of triamcinolone acetonide. Additionally, penetrating keratoplasty and synechiolysis were performed during the follow-up. RESULTS: After each intravitreal injection, visual acuity and intraocular pressure increased, iris neovascularization regressed, and vitreous haze cleared up. CONCLUSIONS: Intravitreal triamcinolone acetonide may induce regression of iris neovascularization, increase intraocular pressure, and improve visual acuity in eyes presenting with ocular hypotony, vitreous hemorrhage, and progressive intraocular neovascularization due to ischemic ophthalmopathy.

Intravitreal triamcinolone acetonide for exudative age related macular degeneration.

AIM: To evaluate the effect of intravitreal triamcinolone acetonide on the visual acuity of patients with exudative age related macular degeneration, to assess the duration of a possible effect, and to evaluate clinical side effects of the treatment. METHODS: The study included 67 patients (71 eyes) who presented with exudative age related macular degeneration of predominantly or total occult type (n = 68) or classic type (n = 3), and who received once, or repeatedly, an intravitreal injection of 25 mg of crystalline triamcinolone acetonide. Mean follow up time was 7.46 (SD 3.54) months (range 3.1-19.57 months). RESULTS: Visual acuity increased significantly (p <0.001) from 0.16 (0.11) to a mean maximum of 0.23 (0.17). Postoperative visual acuity was highest 1-3 months after the injection. 47 (66.2%) eyes gained in maximal visual acuity and 11 (15.5%) eyes lost in visual acuity. Intraocular pressure increased significantly (p <0.001) from 15.1 (3.1) mm Hg at baseline to a maximal value of 23.0 (8.25) mm Hg. At the end of follow up, intraocular pressure again decreased significantly (p<0.001) to 16.8 (4.9) mm Hg. No cases of postoperative infectious endophthalmitis, rhegmatogenous retinal detachment, or proliferative vitreoretinopathy occurred. Owing to a decrease in visual acuity after an initial increase, six patients received a second intravitreal triamcinolone acetonide injection after which visual acuity increased again in three eyes. CONCLUSIONS: Intravitreal injection of 25 mg of crystalline triamcinolone acetonide merits further study for the treatment of exudative age related macular degeneration.

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.

[Treatment of primary retinal detachment. Minimal extraocular or intraocular?]. / Die Behandlung der primären Ablatio retinae. Minimal extraokular oder intraokular?

The developments in treatment modalities for a primary retinal detachment over the last 70 years have been reviewed. There was a change from a surgery limited to the area of the break to a form of prophylactic surgery including the extent of the detachment. In between Rosengren had limited the treatment to the break with an intraocular gas bubble. A change was brought about by Custodis in 1953 who limited surgery to the break and omitted drainage. This procedure had serious postoperative complications which were eliminated by Lincoff by developing the cryosurgical detachment operation which was subsequently refined to extraocular minimal surgery. The ultimate realization of a minimal extraocular approach was the operation with a temporary balloon. Two additional intraocular procedures evolved, pneumatic retinopexy and primary vitrectomy, following one or the other pattern of treatment. With all four methods reattachment can result in 94-99% of the cases but differences can be seen in the morbidity and rate of reoperations.

Elevated concentration of intraocular cortisol obtained by sequential parabulbar injection in rabbit model.

BACKGROUND: Parabulbar injections of corticosteroids yield a high intraocular concentration, but the half-life is short. We determined the concentration of cortisol that might be obtained by sequential parabulbar infusions of hydrocortisone. MATERIALS AND METHODS: Single parabulbar injections of hydrocortisone sodium succinate were made in a rabbit model and the time of maximum concentration and half-life determined in the retina-choroid, vitreous, serum, and the tissues of the paired eye by radio-immune assay. Based upon the half-life, sequential injections were made at 3 hour intervals to obtain a steady concentration. RESULTS: The maximum concentration of cortisol in the ocular tissues occurred two hours after a single injection and was 98 times greater in the choroid-retina and 72 times greater in the optic nerve than in the paired eye and the serum. The half-life of cortisol was 15 minutes. Elevated levels could be sustained by sequential injections at 3 hour intervals. CONCLUSION: Sequential injections of hydrocortisone through a retained parabulbar catheter could make it possible to titrate and maintain a therapeutic level of cortisol in the eyes of patients with posterior uveitis or optic neuritis.

Retinal pigment epithelial tear after photodynamic therapy for choroidal neovascularization.

PURPOSE: To report a case of retinal pigment epithelial tear after photodynamic therapy for choroidal neovascularization. METHODS: Case report. A 74-year-old woman with exudative age-related macular degeneration and classic subfoveal choroidal neovascularization RE underwent photodynamic therapy with verteporfin. RESULTS: Ophthalmoscopy and fluorescein angiography RE disclosed a retinal pigment epithelial tear in the area of photodynamic therapy. CONCLUSION: This case presents the first report of a retinal pigment epithelial tear after photodynamic therapy with verteporfin for subfoveal choroidal neovascularization in age-related macular degeneration.