Combined phacoemulsification surgery and intravitreal triamcinolone injection versus stand-alone surgery in patients with type 2 diabetes: a prospective randomized trial.

BACKGROUND: We would assess the efficacy of intravitreal injection of triamcinolone acetonide IVTA combined with standard phacoemulsification on the central subfield macular thickness (CSMT), the progression of diabetic retinopathy (DR), and the corrected distant visual acuity (CDVA) in type 2 diabetic patients. METHODS: In this prospective single-blinded randomized clinical trial we recruited patients with type 2 diabetes who were eligible for cataract surgery. The patients were randomly assigned to two groups. The case group received an intravitreal IVTA at the end of phacoemulsification, and the control group had routine surgery. CSMT, progression of DR, CDVA, IOP, and adverse events including endophthalmitis were compared between the groups preoperatively and at 1, 3, and 6 months postoperatively. RESULTS: Among a total of 66 patients that were treated within the study period, 50 patients were included in the final analysis. The case group comprised 21 eyes, and the control group included 29 eyes. Regression models and corrected ANOVA test for repeated measures showed a significant reduction in CSMT at 3 and 6 months postoperatively, which was most significant when the preoperative CSMT was ≥300 µm, with a cut-off value of 347.3 µm in the case group (p < 0.000). DR progression was halted in the case group at 6 months with 52.38% of patients having their DR classified as moderate (P = 0.012). CDVA was significantly improved from baseline 6/60 (logMAR 1.0) pre-op to 6/6 (logMAR 0.00) at 6 months post-op in the case group, and from baseline 6/120 (logMAR 1.3) pre-op to 6/12 (logMAR 0.3) at 6 months post-op in the control group. The gain in visual acuity was significantly higher in the case group at all study points (p < 0.001). No significant rise in IOP was observed at any study point in both groups (p = 0.23 > 0.05). No endophthalmitis was recorded. CONCLUSIONS: Diabetic patients benefit significantly from cataract surgery. This study supports IVTA injection at the end of phacoemulsification in diabetic patients. Triamcinolone is an affordable (which is of particular importance in low-income countries as per our setting), and relatively safe "phaco-enhancer". TRIAL REGISTRATION: NCT05413330. Initial release 10/06/2022. Unique Protocol ID: UDMS-Opthal-01-2022.

Severe intraocular pressure response to periocular or intravitreal steroid treatment in Australia and New Zealand: data from the Australian and New Zealand Ophthalmic Surveillance Unit.

BACKGROUND: Increase in intraocular pressure is a recognized complication of corticosteroid treatment via intravitreal or periocular injections for treatment of a range of conditions including macular oedema and retinal neovascularization. DESIGN: This surveillance study was designed to determine the incidence and nature of severe intraocular pressure elevation as a complication of intravitreal or periocular corticosteroid injections in Australia and New Zealand. PARTICIPANTS: Seventeen cases meeting the defined criteria of severe intraocular pressure elevation, above 35 mmHg, following an intravitreal or periocular corticosteroid injection were included in the study. METHODS: Over an 18-month period, ophthalmologists were invited to report cases to the Australian and New Zealand Ophthalmic Surveillance Unit. After reporting, further demographic and clinical information was sought via a follow-up questionnaire. MAIN OUTCOME MEASURES: Intraocular pressure elevation above 35 mmHg. RESULTS: Follow-up questionnaires were received for 20 cases of 34 initially reported to the unit. Seventeen met the defined criteria. Triamcinolone acetonide was used in all 17 cases, with 16 delivered as a 4-mg intravitreal injection. There was an absence of identified underlying risk factors in the majority of cases with personal history of glaucoma in 2 of 17 cases. No cases reported a positive family history of glaucoma. Trabeculectomy was performed in 8 of 17 patients (47%) for intraocular pressure management. CONCLUSIONS: Severe intraocular pressure elevation following intravitreal or periocular corticosteroid injection can occur in the absence of risk factors such as personal and family history of glaucoma. The severe intraocular pressure elevation may ultimately require trabeculectomy.

Sterile endophthalmitis after intravitreal triamcinolone acetonide injection: A case report series.

Corticosteroids have proven their effectiveness in the treatment of cystoid macular edema. Especially after an intravitreal injection. Triamcinolone acetonide is the most commonly used in the treatment of macular edema. Noninfectious endophthalmitis is a form of endophthalmitis that can occur in the absence of a defined germ after an intravitreal injection of triamcinolone acetonide. We report here the case of three diabetic patients, who presented with visual blur, three days after an intra vitreal triamcinolone acetonide injection performed in the right eye. The vitreous inflammation resolved spontaneously in the first two cases after three weeks, and after four weeks for the third. The diagnosis of sterile endophthalmitis was made in view of the spontaneous resolution of the inflammation without the use of intravitreal injection of antibiotics and/or vitreoretinal surgery.

Efficacy and safety of triamcinolone acetonide injection combined with laser photocoagulation in the treatment of diabetic macular edema: a systematic review and meta-analysis.

BACKGROUND: Diabetic macular edema (DME) is a type of retinopathy caused by diabetes, and the 2 main clinical treatment modalities are drug therapy intravitreal triamcinolone acetonide injection (IVTA) and laser photocoagulation. This meta-analysis investigated the efficacy of combining both the 2 treatment modalities. METHODS: The Embase, Cochrane library, PubMed, and Ovid databases were searched for English literatures. The literatures were screened and assessed for the risk of bias, after that the Revman 5.4 software was used to conduct the meta-analysis. RESULTS: A total of 8 articles, including 549 patients, were included in this study. Meta-analysis showed that the effect of (IVTA + laser) on early central macular thickness (CMT) was not significantly different with IVTA alone [mean difference (MD) =-5.13, 95% confidence interval (CI): -17.06 to 6.80, P=0.40], however, significantly different with laser alone (MD =-94.31, 95% CI: -135.04 to -53.58, P<0.00001). Similarly, the effect of (IVTA + laser) on early best corrected visual acuity (BCVA) was not significantly different with IVTA alone (MD =0.02, 95% CI: -0.03 to 0.07, Z=0.79, P=0.43). but different with laser alone [MD =-0.20, 95% CI: -0.24 to -0.16, Z=10.16, P<0.00001). The effect of (IVTA + laser) on long-term CMT was not significantly different with IVTA alone (MD =-66.90, 95% CI: -132.66 to -1.15, Z=1.99, P=0.05) nor with laser alone (MD =-15.86, 95% CI: -31.37 to -0.35, Z=2.00, P=0.05). Similarly, the effect of combined intervention (IVTA + laser) on long-term BCVA was not significantly different with IVTA alone (MD =-0.18, 95% CI: -0.39 to 0.03, Z=1.71, P=0.09) nor with laser alone (MD =-0.11, 95% CI: -0.23 to 0.01, Z=1.74, P=0.08). Administration of IVTA before laser was superior to laser alone (MD =-0.19, 95% CI: -0.31 to -0.07, Z=3.09, P=0.002). DISCUSSION: The effect of IVTA + laser therapy is similar to IVTA alone, but superior to laser alone for the early treatment of DME. However, the long-term effect is similar to IVTA alone or laser alone, a better therapeutic effect can be achieved if IVTA is administered before laser treatment.

The effects of intravitreal triamcinolone acetonide in diabetic macular edema refractory to anti-VEGF treatment.

PURPOSE: To investigate the efficacy and safety of primary intravitreal triamcinolone acetonide (IVTA) in eyes affected by diabetic macular edema (DME) refractory to anti-vascular endothelial growth factor (VEGF) therapy. STUDY DESIGN: Retrospective observational study METHODS: The medical records of patients who attended our clinic from March 2013 to September 2018 with refractory macular were reviewed. We included the patients who were injected at least one IVTA and completed 6 months of observation. Best-corrected Snellen visual acuity (VA), central macular thickness (CMT), intraocular pressure (IOP), and adverse events (AEs) were examined at baseline and at 1 month, 2 months, 3 months, and 6 months. RESULTS: Sixty-four eyes of 54 subjects were included. The mean VA was improved significantly at all time points compared to pre-treatment (P < 0.0001), with the greatest mean improvement at 1 month (0.3 logMAR). The reduction in mean CMT was also significant at all follow-up examinations compared to baseline (P < 0.0001), with the greatest decrease at 1 month (113.68 ± 53.78 µm). A poorer VA before injection was a factor that influenced visual gain 1 month post treatment (0.247 logMAR units/unit increase in baseline VA, P = 0.006). The most common AE associated with IVTA treatment was elevated IOP (11 eyes), observed significantly more often after IVTA injections containing a preservative (25.8%) than after those that were preservative-free (9.1%) (P = 0.033). CONCLUSION: IVTA injection can be an alternative steroid treatment for DME refractory to anti-VEGF therapy.

Intravitreal dexamethasone implant versus triamcinolone acetonide for macular oedema of central retinal vein occlusion: quantifying efficacy and safety.

PURPOSE: Among the retinal vascular diseases, burden of retinal vein occlusion is most common immediately after diabetic retinopathy. Intravitreal corticosteroids are gaining popularity in managing macular edema (ME) of RVO. Our study compares efficacy and safety of intravitreal triamcinolone (IVTA) and dexamethasone implant (IVD) over 6 months. METHODS: This comparative, prospective, randomized study on 40 patients of non-ischemic central RVO with significant ME (> 330 µm) of < 3 months duration. Study was done at Army Research Hospital between Sep-2012 and May-2014 in accordance to Helsinki Declaration. IVD group (n = 20) received Ozurdex® while IVTA group (n = 20) received triamcinolone-acetonide (4 mg/0.1 ml), followed up at day-1 and weeks 4, 8, 12, 24. RESULTS: At 6 months, mean improvement in best corrected visual acuity and retinal thickness (CMT) in the IVD group was 0.43 logmar and 323 µm and in IVTA group was 0.49 logmar and 322 µm respectively. Proportion of patients achieving ≥ 15 letters was about 40% in both groups. IOP rise was significantly higher in IVTA group at 12 and 24 weeks. In IVTA group ≥ 10 mmHg IOP rise was seen in 60% of patients, 41.6% among them had > 35 mmHg and 66% needed combination treatment and failed to reach baseline line IOP at 6 months. In IVD group, 5 pts had IOP rise with all being < 26 mmHg and were easily managed with single agent with IOP reaching baseline by 6th month in all pts. Relative risk of IOP rise with IVTA is 2.4 times higher compared to IVD. Cataract progression and cataract surgeries were required at significantly higher rates in IVTA group. In IVTA group, cataract progression was seen in 35% patients, with 71.5% requiring cataract surgery at 6 months. IVD group, 10% patients had cataract progression while none required surgery at 6 months. Relative risk of cataract progression with IVTA is 3.5 times higher compared to IVD. CONCLUSION: Intravitreal steroids are effective in managing macular edema of retinal vein occlusion, while newer formulation of sustained release dexamethasone implant is significantly safer than IVTA.

Safety of high-dose intravitreal triamcinolone acetonide as low-cost alternative to anti-vascular endothelial growth factor agents in lower-middle-income countries.

PURPOSE: The purpose of this study was to evaluate the safety of high-dose intravitreal triamcinolone acetonide (IVTA) as affordable low-cost alternative to anti-vascular endothelial growth factor (anti-vascular endothelial growth factor [anti-VEGF] agents) in lower-middle-income countries. PATIENTS AND METHODS: This was a retrospective interventional non-comparative case series. The study recruited patients who received 20 mg IVTA for treating various retinal and optic nerve diseases over the past 5 years. Main outcome measure was assessment of complications secondary to high-dose IVTA. The crosstabs procedure was used to display the interaction between the variables tested. The ANOVA test was used to analyze the differences among group means. RESULTS: The study included 207 eyes of 168 patients. The main indication for high-dose IVTA were diabetic macular edema 64%, and macular edema secondary to retinal vein occlusion 19%. The mean follow-up period post-injection was 22 months. Mean number of injections was 1.3. Cataract developed in 54% of eyes. Glaucoma developed in 18.5% of eyes. Glaucoma surgery for intractable glaucoma attributed to high-dose IVTA was needed in 1% of eyes. Endophthalmitis and retinal detachment developed in one patient each. CONCLUSION: High-dose IVTA is a safe and cost-effective alternative to anti-VEGF agents. Cataract formation and intraocular pressure rise do not pose major adverse effects when weighed against the risk of vision loss due to inability to afford anti-VEGF treatment.

Photodynamic therapy for polypoidal choroidal vasculopathy.

The first effective therapy for exudative macular degeneration (AMD) was Photodynamic Therapy (PDT). Diagnosis of the disease was to a large extent by fluorescein angiography (FA). Distinguishing between the leaky choroidal neovessels (CNV) associated with exudative AMD, and the polypoidal structures associated with Polypoidal Choroidal Vasculopathy (PCV) is not always easy using FA alone. The switch to Indocyanine Green angiography helped to pinpoint PCV, and thus to study the efficacy of photodynamic therapy of this particular form of retinal disease, which is more frequently encountered among pigmented individuals. The results appear to be quite promising, and in the year following treatment only a small fraction of the patients had to be retreated. Alternatively, treating PCV with repeated intravitreal VEGF blocking agents was not as successful as it was in the treatment of wet AMD. However, combining PDT-induced angio-occlusion of the polypoidal lesions with anti-vascular endothelial growth factor therapy was shown to be quite effective, and the combination of PDT with an anti-angiogenic agent as well as a steroid, in a triple therapy, was recently also shown to be a quite promising option. In the present article we review the data on PDT of PCV, including combination therapies and alternative treatments. We also report on similarities and differences between AMD and PCV.

Comparison of intravitreal triamcinolone treatment and intravitreal triamcinolone with grid laser treatment in patients with diffuse diabetic macular edema.

OBJECTIVE: To compare the efficacy of intravitreal triamcinolone acetonide (IVTA) and IVTA plus macular laser grid photocoagulation therapy in diffuse diabetic macular edema (DME). MATERIAL AND METHODS: Sixteen patients affected by diffuse DME were retrospectively evaulated. Patients were divided into two groups: control group (IVTA injection) and laser group (IVTA plus grid laser). Main outcomes were best corrected visual aquity (BCVA) and central macular thickness (CMT) at the 3(rd) and 6(th) months of treatment. IVTA associated complications and reinjection necessity were assessed. RESULTS: Our study comprised 18 eyes of 16 patients. The baseline BCVA and CMT were 0.93±0.45 and 530±136µm for the control and 1.02±0.52 and 509±177µm for the laser group respectively. Posttreatment BCVA at the 3(rd) and 6(th) month were 0.73±0.4 and 0.75±0.45 for control and 0.98±0.44 and 1.04±0.4 for laser group respectively (p>0.05 for all). CMT values at the 3(rd) and 6(th) months were 260±174µm (p=0.008) and 362±163 µm (p=0.05) for control and 331±161µm (p=0.05) and 388±215 µm (p>0.05) for laser groups. 55% of control and 66% of laser groups needed reinjection with an avarage of 7±4 months after the first injection. 22% cataract progression and 33% intraocular pressure elevation were noted. CONCLUSION: Macular grid laser photocoagulation after IVTA does not have beneficial effects for diffuse DME.

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/0.1 mL 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.