|Year : 2014 | Volume
| Issue : 3 | Page : 148-152
Role of triamcinolone acetonide in the treatment of secondary macular edema
Tamer H El-Sersy
Departmenet of ophthalmology faculty of medicine october 6 university, cairo, Egypt
|Date of Submission||03-Mar-2014|
|Date of Acceptance||10-Jun-2014|
|Date of Web Publication||30-Dec-2014|
Tamer H El-Sersy
11 Montazah Street, Heliopolis, 11311 Cairo
Source of Support: None, Conflict of Interest: None
Aim of the work
The aim of the work is to evaluate the efficacy of an intravitreal injection of triamcinolone acetonide in cases with secondary macular edema.
Patients and methods
A total of 24 eyes with secondary macular edema were included in this study. Patients were classified into three groups. Group A included 10 patients with macular edema secondary to nonproliferative diabetic retinopathy, group B included eight patients with macular edema secondary to branch vein occlusion, and group C included six patients with macular edema secondary to central retinal vein occlusion. Further classification of the three groups was performed according to the nature of macular edema, whether perfused or ischemic. All groups received a single intravitreal injection dose of 4 mg of triamcinolone acetonide. Ophthalmological assessments performed were best-corrected visual acuity, intraocular pressure measurement using applanation tonometry, and fundus biomicroscopy. Also, optical coherence tomography and fundus fluorescein angiography were performed to evaluate the progression of macular edema. All examinations and investigations were performed regularly during follow-up visits. All data were analyzed and recorded.
There was significantly greater improvement in macular edema in group B than in groups A and C. Perfused macular edema showed better results than ischemic edema in the three groups.
An intravitreal injection of triamcinolone acetonide seems to be an effective and harmless treatment for macular edema, especially following branch vein occlusion.
Keywords: diabetic retinopathy, intravitreal injection, macular edema, retinal vein occlusion, triamcinolone acetonide
|How to cite this article:|
El-Sersy TH. Role of triamcinolone acetonide in the treatment of secondary macular edema. J Egypt Ophthalmol Soc 2014;107:148-52
| Introduction|| |
Diabetic retinopathy, followed by occlusive disorders are the most frequent causes of blindness. Panretinal photocoagulation has been considered the mainstay for the treatment of diabetic retinopathy; recently, vascular endothelial growth factor inhibitors have been also been found to play an important role in the management of diabetic retinopathy .
Occlusive disorders affect men and women equally. These disorders occur most frequently between 60 and 70 years of age and most commonly occur at the arteriovenous crossing, where the artery and the vein share a common adventitial sheath .
Macular edema is the most common cause of central visual loss in branch vein occlusion, central retinal vein occlusion, and diabetic retinopathy. Ischemic macular edema occurs when a segment of the macular circulation is nonperfused and there is no late leakage observed on the fluorescein angiogram. Nevertheless, prominent cystoid macular edema may be clinically evident .
| The aim of the study|| |
The aim of the study is to evaluate the efficacy of an intravitreal injection of triamcinolone acetonide in patients with secondary macular edema.
| Patients and methods|| |
A total of 24 eyes of patients of both sexes and of different age groups were included in this study; all patients had been diagnosed with secondary macular edema. All patients were from the October 6th University Hospital outpatient's clinic. These eyes were classified into three groups: group A included 10 patients with nonproliferative diabetic retinopathy as a precipitating cause of macular edema, group B included eight eyes with upper (five cases) and lower (three cases) temporal branch vein occlusion as the causative primary disease for macular edema, and group C included six eyes with central retinal vein occlusion causing secondary macular edema.
Further classification was performed according to the type of macular edema, whether perfused or ischemic.
After the diagnosis of secondary macular edema in all the eyes was established, a single intravitreal injection dose of 4 mg of triamcinolone acetonide was administered to all the eyes under a completely sterile condition.
Follow-up was performed regularly by determining the best-corrected visual acuity (BCVA), intraocular pressure (IOP) measurement using applanation tonometry, and fundus biomicroscopy. Also, optical coherence tomography (Zeiss model; Hymphrey system, San leandro, California, USA) and fundus fluorescein angiography (TOPCON CORPORATION, 75-1, Hasunuma-cho, Itabashi-ku, Tokyo 174-8580 Japan so IX fundus camera with image net 2000) were performed to evaluate the prognosis of macular edema after an injection of triamcinolone acetonide. Follow-up was performed regularly for 9 months; all data were analyzed and reported.
Eyes with glaucoma or ocular hypertension or any disease that could affect the vision or any other retinal diseases were excluded from this study.
| Results|| |
This study included 24 eyes of 24 patients with an established diagnosis of cystoid macular edema resulting from nonproliferative diabetic retinopathy (10 eyes), branch vein occlusion (eight eyes), and central vein occlusion (six eyes); 15 eyes of 15 patients had perfused macular edema (six eyes from group A, five eyes from group B, and four eyes from group C and nine eyes of nine patients had ischemic macular edema (the resultant eyes). A single dose of intravitreal injection of 4 mg triamcinolone acetonide was administered to all eyes.
[Table 1] shows the age distribution among the three groups. There was no statistically significant difference among the three groups in age.
The duration of diabetic retinopathy ranged from 11 to 15 years (mean 11+/185 years), in branch retinal vein occlusion, the duration ranged from 1 to 18 months (mean 8+/1.75 months), and finally the duration of central retinal vein occlusion ranged from 3 to 6 months (mean 3+/1.33 months). All patients completed the 9-month follow-up period ([Table 2], [Figure 1] and [Figure 2]).
|Figure 2: OCT tomograms in case with perfused macular edema after 3 months, receiving IVTA: (a) before the injection (CMT = 576 μm), (b) first month after the injection (CMT = 382 μm), (c) third month after the injection CMT = 200μm, (d) sixth month after the injection (CMT = 255 μm). CMT, central macular thickness; IVTA, intravitreal triamcinolone acetonide; OCT, optical coherence tomography.|
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BCVA changed significantly in the three groups, with no statistically significant difference in its progression among the three groups in etiological aspects. However, there was a statistically significant difference in the progression of BCVA among patients with perfused and ischemic macular edema. The final BCVA was significantly higher than the baseline in cases with perfused macular edema; the median BCVA improved significantly from 0.083 to 0.25 at 3-month intervals in patients with perfused macular edema, whereas in ischemic macular edema, the BCVA was the same as the baseline during the entire follow-up period.
Fundus fluorescein angiography showed decreased vascular leakage postoperatively in 95% of cases. Cystoid macular edema had decreased significantly in cases with perfused macular edema after 1 week of injection and then increased again slightly at 6 months, but was still significantly lower than the baseline. There was a statistically significant difference between progression of macular edema after injection among patients with perfused and ischemic macular edema.
Optical coherence tomography showed statistically significant changes in central macular thickness (CMT) postoperatively among the three groups as shown in [Table 3].
|Table 3 Progression in central macular thickness among the three groups during the follow-up period |
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There was a marked improvement in perfused macular edema in group A at the 3-month follow-up time point. At the sixth month of the follow-up period, there was similar thickness among perfused cases in groups A and B, and this was not statistically significant.
Changes in the IOP were studied in the 24 patients as a whole. The mean IOP at the start of the study was controlled (12.3 ± 1.80 mmHg), reaching the maximum elevation on the 40th day of the follow-up period: 20.11 ± 6.60 mmHg in group C, 16.99 ± 3.20 mmHg in group A at the third month, and 18.90 ± 2.08 mmHg in group B. The increase in IOP could be normalized by topical antiglaucomatous medication. No glaucomatous damage occurred in the optic nerve in our study. No complications were encountered in any of our patients who received an intravitreal injection of triamcinolone acetonide.
| Discussion|| |
Macular edema is one of the leading causes of decreased vision in diabetic patients. Macular edema is defined as thickening of the retina within one disc diameter of the center of the macula and/or hard exudates .
The prevalence of macular edema increases with increasing severity of retinopathy and duration of the diabetes. Ischemic macular edema occurs when a segment of the macular circulation is nonperfused. No late leakage is observed on the fluorescein angiogram. Nevertheless, prominent cystoid macular edema may be clinically evident .
Recently, an intravitreal injection of the corticosteroid suspension triamcinolone acetonide has been shown to be relatively safe and effective in the treatment of secondary macular edema.
Macular edema has a variable visual prognosis, with only 37% of eyes gaining two or more lines of visual acuity (VA). In eyes with intact foveal capillary perfusion, the Branch Vein Occlusion Study Group showed a significant benefit of argon laser grid photocoagulation in the treatment of branch retinal vein occlusion and macular edema, reducing VA to 20/40 or worse. However, 12% of the eyes treated with laser will still have VA 20/200 or worse after 3 years .
Laser treatment has not been shown to be beneficial in eyes with foveal capillary nonperfusion. The majority of cases showed a good visual outcome; patients presented with a VA of 20/100 or better. Poor presenting VA is correlated with a poor visual prognosis.
The lack of any proven effective treatment for eyes with foveal capillary nonperfusion has led to interest in other treatment methods including surgical treatment with pars plana vitrectomy with or without internal limiting membrane removal, which has been proposed to reduce the macular edema in some cases. Arteriovenous sheathotomy has also been reported to be beneficial in some early cases. The majority of the investigators have reported some increase in BCVA following those procedures, but the results have been quite variable .
Corticosteroids have been used in the treatment of macular edema because of their ability to inhibit the arachidonic acid pathway. They have also been proposed to downregulate the production of vascular endothelial growth factor. They modulate the expression of intercellular adhesion molecule-I and reduce breakdown of the blood-retinal barrier. In addition, corticosteroids are proposed to exert further edema-controlling effect by influencing the cellular permeability and improving the barrier function of the retinal pigment epithelium .
In the present study, intravitreal triamcinolone acetonide (IVTA) treatment produced a statistically significant median BCVA during the follow-up period among the three groups that remained significantly higher than the baseline. This is in agreement with Cakir et al. , who treated 25 eyes with secondary macular edema with a 0.1 ml suspension containing 4 mg triamcinolone acetonide (Kenacort-A) injected intravitreally using a 30-G needle. They found that BCVA increased following IVTA during the first month, and remained statistically better than preinjection values at all time points during follow-up. Also, Roth et al.  reported an improvement in VA in patients with branch retinal vein occlusion after an IVTA injection and this was maintained over a 12-month period.
Jonas et al.  have reported an improvement in VA and macular edema following IVTA for the treatment of secondary macular edema. They treated 10 eyes with 20-25 mg IVTA for secondary macular edema. They reported a significant improvement in the mean VA from baseline at the first month after injection, but not at subsequent time points.
However, Chen et al.  reported a favorable response to IVTA in a patient with ischemic secondary macular edema. They found that eight of 17 eyes examined in the first month following an IVTA injection gained VA; five of those showed an improvement in VA by at least two Snellen lines, thus providing further confirmation that resolution of macular edema may be associated with improved VA despite the presence of foveal ischemia.
In the current study, a significant decrease in CMT was found after an intravitreal injection of triamcinolone acetonide, with a statistically significant difference in the results. There was a marked improvement in CMT in perfused macular edema, especially in groups A and B.
Chen et al.  evaluated 18 eyes of 18 patients with secondary macular edema and foveal ischemia. They reported that CMT improved by ~40%.
Thus, there was no strong correlation between BCVA and CMT at presentation or during follow-up. Subsequently, macular edema may only be a partial cause for VA reduction in our study.
In the present study, treatment of cystoid macular edema with intravitreal triamcinolone showed many potential benefits including prompt resolution of macular edema, resulting in a marked early improvement in VA. These results are in agreement with those of Oh et al. , who reported that in patients with secondary macular edema who received triamcinolone acetonide intravitreal injection (4 mgl/0.1 ml), VA and CMT improved significantly from baseline over 6 months of follow-up.
The safety of IVTA has been supported by animal studies and human trials. Potential complications such as retinal detachment, vitreous hemorrhage, and endophthalmitis have been reported by Vasconcelos-Santos et al. . No such complications were encountered in the current study. The major ocular side effects attributed to corticosteroids include elevated IOP and cataract . In the current study, no ocular complications were recorded.
Vasconcelos-Santos and colleagues found that a 4 mg IVTA injection was associated with secondary ocular hypertension in 32% of treated eyes.
The findings from the present study suggest that IVTA offers the possibility of reduction in CMT and improvement in VA in eyes with secondary macular edema, particularly in patients with perfused macular edema.
| Acknowledgements|| |
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]