1: Eye. 2007 Feb 16; [Epub ahead of print]
Links
Visual acuity and intraocular pressure after high-dose
intravitreal triamcinolone acetonide in selected ocular
diseases.


Jonas JB,
Schlichtenbrede F.
1Department of Ophthalmology, Faculty of Clinical Medicine Mannheim
of the University, Heidelberg, Germany.
PurposeWithin the last 5 years, intravitreal injections of triamcinolone
acetonide have been for a wide variety of ocular diseases with
intraocular oedema and neovascularization. With clinical experience
accumulating, the question arises for which indication the side effects
outweigh the therapeutic efficacy of intravitreal triamcinolone
monotherapy.ScopeComparing different diseases, increase in visual
acuity was lower in patients receiving intravitreal triamcinolone
monotherapy for exudative age-related macular degeneration than in
patients with diabetic macular oedema, branch retinal vein occlusion,
central retinal vein occlusion, uveitis, and pseudophakic cystoid
macular oedema. Rise in intraocular pressure was significantly higher
in relatively young patients with uveitis than in any other patient
group.ConclusionsImprovement in vision after intravitreal
triamcinolone monotherapy is highest in non-ischaemic diseases with
an intraretinal macular oedema such as pseudophakic cystoid macular
oedema; it is lower in partially ischaemic diseases with intraretinal
macular oedema such as diabetic macular oedema or retinal vein
occlusions; and it is lowest in diseases with a primarily subretinal
location of the disease such as exudative age-related macular
degeneration. For the latter diseases, intravitreal triamcinolone
monotherapy is, therefore, no longer up-to-date, particularly with the
upcoming intravitreal application of vascular endothelial growth factor
blocking drugs. For diseases with intraretinal oedema, the rule of
thumb may be that intravitreal triamcinolone increases vision as much
as retinal ischaemia and tissue destruction by the underlying disease
allow it. The rise in intraocular pressure is higher in relatively young
patients with uveitis than in elderly patients with other reasons for
macular oedema.Eye advance online publication, 16 February 2007;
doi:10.1038/sj.eye.6702734.
1: Ophthalmic Res. 2006;38(4):218-45. Epub 2006 Jun 6.
Links
Intravitreal triamcinolone acetonide: a change in a paradigm.

Jonas JB.
Department of Ophthalmology, Faculty of Clinical Medicine Mannheim,
Ruprecht Karls University of Heidelberg, Heidelberg, Germany.
Jost.Jonas@augen.ma.uni-heidelberg.de
BACKGROUND: Based on experimental studies and clinical
observations by Robert Machemer, Gholam Peyman and others, the
vitreous cavity has increasingly been used as a reservoir of drugs for
the direct treatment of intraocular diseases. METHODS AND RESULTS:
The most widely injected drug so far has been triamcinolone acetonide
for various intraocular neovascular and edematous diseases.
Comparing the various diseases with respect to effect and side effects
of the treatment, the best response in terms of gain in visual acuity
has been achieved for intraretinal edematous diseases such as diffuse
diabetic macular edema, branch retinal vein occlusion, central retinal
vein occlusion, and pseudophakic cystoid macular edema. In eyes with
various types of noninfectious uveitis including acute or chronic
sympathetic ophthalmia and Adamantiadis-Behcet's disease, visual
acuity increased and the degree of intraocular inflammation decreased.
Some studies have suggested that intra- vitreal triamcinolone may be
useful as an angiostatic agent in eyes with iris neovascularization and
proliferative ischemic retinopathies. Intravitreal triamcinolone may
possibly be helpful as adjunct therapy for exudative age-related
macular degeneration, particularly 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 include secondary ocular hypertension in about
40% of the eyes injected; medically uncontrollable high intraocular
pressure leading to antiglaucomatous surgery in about 1-2% of the
eyes; posterior subcapsular cataract and nuclear cataract leading to
cataract surgery in about 15-20% in elderly patients within 1 year after
injection; postoperative infectious endophthalmitis with a rate of about
1:1,000; noninfectious endophthalmitis, perhaps due to a reaction to
the solvent agent, and pseudoendophthalmitis with triamcinolone
acetonide crystals appearing in the anterior chamber. Intravitreal
triamcinolone injection can be combined with other types of intraocular
surgery including cataract surgery, particularly in eyes with iris
neovascularization. Cataract surgery performed some months after the
injection does not show a markedly elevated complication rate. The
injection may be repeated, if vision redecreases. In nonvitrectomized
eyes, the duration of the effect and side effects of a single intravitreal
injection of triamcinolone is about 6-9 months for a dosage of about 20
mg, and about 2-4 months for a dosage of 4 mg. It has remained
unclear so far, whether and how to remove the solvent agent. In the
future, intravitreal triamcinolone may be combined with other
antiangiogenic drugs for the treatment of exudative age-related
macular degeneration or with neuroprotective drugs for treatment of
diabetic retinopathy. CONCLUSIONS: Despite an exponentially
increasing number of mostly case-series studies, the intravitreal
injection of triamcinolone may still be considered an experimental
procedure until randomized studies have been presented. Copyright (c)
2006 S. Karger AG, Basel.
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