J Korean Ophthalmol Soc.  2011 Sep;52(9):1063-1070.

Posterior Sub-Tenon Triamcinolone Acetonide Injection for Recurrent Diabetic Macular Edema after Repeated Intravitreal Bevacizumab Injections

Affiliations
  • 1Department of Ophthalmology, Kyungpook National University School of Medicine, Daegu, Korea.
  • 2Nune Eye Hospital, Daegu, Korea. kimsy@knu.ac.kr

Abstract

PURPOSE
To evaluate posterior sub-Tenon injection of triamcinolone acetonide (TA) for recurrent diabetic macular edema (DME) after repeated intravitreal bevacizumab (IVB).
METHODS
This is a retrospective interventional case series comprised of 35 eyes (32 patients) with recurrent clinically significant DME after two or more IVB treatments. All patients were administered TA 40 mg injections. Best-corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP) were reevaluated at months 1, 3, and 6.
RESULTS
The baseline OCT showed five eyes with diffuse retinal thickening, 18 eyes with cystoid macular edema, and 12 eyes with serous retinal detachment. Mean BCVA improved at months 1 and 3, and mean CMT decreased at months 1 and 3. However, mean BCVA and CMT at six months was not different from baseline. Each DME pattern showed significant improvements in BCVA and CMT at three months. Mean IOP at months 1, 3, and 6 did not show any significant difference from baseline. No eyes showed complications including cataract progression or endophthalmitis.
CONCLUSIONS
Posterior sub-Tenon injection of TA should be considered for patients with recurrent DME after repeated IVB. The studied eyes showed improvements in BCVA and CMT during three months in all of the three patterns of DME.

Keyword

Bevacizumab; Diabetic macular edema; Posterior sub-Tenon injection; Triamcinolone acetonide

MeSH Terms

Antibodies, Monoclonal, Humanized
Cataract
Endophthalmitis
Eye
Humans
Intraocular Pressure
Macular Edema
Retinal Detachment
Retinaldehyde
Retrospective Studies
Triamcinolone
Triamcinolone Acetonide
Visual Acuity
Bevacizumab
Antibodies, Monoclonal, Humanized
Retinaldehyde
Triamcinolone
Triamcinolone Acetonide

Figure

  • Figure 1. Changes in central macular thickness (CMT) and best-corrected visual acuity (BCVA) of eyes with diabetic macular edema (DME) after posterior sub-Tenon triamcinolone acetonide (TA) 40 mg (1 ml) injection. (A, B, C) Horizontal optical coherence tomography (OCT) scan of a 67-year-old patient with recurrent DME despite 3 repeated intravitreal bevacizumab (IVB) injections. (A) At baseline, OCT showed cystoid macular edema with intraretinal cystoid spaces with 735 μ m of CMT and BCVA was 20/200. (B) Three months after TA injection, OCT showed complete resolution of intraretinal cystoid spaces with 244 μ m of CMT and BCVA improved to 20/50. (C) Six months after TA injection, CMT increased to 560 μ m and BCVA decreased to 20/100.

  • Figure 2. Changes in central macular thickness (CMT) and best-corrected visual acuity (BCVA) of eyes with diabetic macular edema (DME) after posterior sub-Tenon triamcinolone acetonide (TA) 40 mg (1 ml) injection. (A, B C) Horizontal optical coherence tomography (OCT) scan of a 64-year-old patient with recurrent DME despite 3 repeated intravitreal bevacizumab (IVB) injections. (A) At baseline, OCT showed serous retinal detachment with low subretinal reflectivity with 545 μ m of CMT and BCVA was 20/125. (B) Three months after TA injection, OCT showed nearly complete resolution of subretinal fluid with 242 μ m of CMT and BCVA improved to 20/80. (C) Six months after TA injection, CMT increased to 431 μ m and BCVA decreased to 20/125.


Reference

References

1. Early Treatment Diabetic Retinopathy Study Research Group. Photocoagulation for diabetic macular edema. Early Treatment Diabetic Retinopathy Study report number 1. Early Treatment Diabetic Retinopathy Study research group. Arch Ophthalmol. 1985; 103:1796–806.
2. Nguyen QD, Tatlipinar S, Shah SM, et al. Vascular endothelial growth factor is a critical stimulus for diabetic macular edema. Am J Ophthalmol. 2006; 142:961–9.
Article
3. Lee CM, Olk RJ. Modified grid laser photocoagulation for diffuse diabetic macular edema. Long-term visual results. Ophthalmology. 1991; 98:1594–602.
4. Isaac DL, Abud MB, Frantz KA, et al. Comparing intravitreal triamcinolone acetonide and bevacizumab injections for the treatment of diabetic macular oedema: a randomized double-blind study. Acta Ophthalmol. 2009 Dec 16. [Epub ahead of print].
Article
5. Paccola L, Costa RA, Folgosa MS, et al. Intravitreal triamcinolone versus bevacizumab for treatment of refractory diabetic macular oedema (IBEME study). Br J Ophthalmol. 2008; 92:76–80.
Article
6. Shimura M, Nakazawa T, Yasuda K, et al. Comparative therapy evaluation of intravitreal bevacizumab and triamcinolone acetonide on persistent diffuse diabetic macular edema. Am J Ophthalmol. 2008; 145:854–61.
Article
7. Oh SB, Moon JW, Kim HC. Comparison of effects of intravitreal triamcinolone and bevacizumab in the treatment of diabetic macular edema. J Korean Ophthalmol Soc. 2009; 50:1190–6.
Article
8. Gillies MC, Sutter FK, Simpson JM, et al. Intravitreal triamcinolone for refractory diabetic macular edema: two-year results of a double-masked, placebo-controlled, randomized clinical trial. Ophthalmology. 2006; 113:1533–8.
9. Bhavsar AR, Ip MS, Glassman AR. The risk of endophthalmitis following intravitreal triamcinolone injection in the DRCRnet and SCORE clinical trials. Am J Ophthalmol. 2007; 144:454–6.
Article
10. Ozdek S, Bahceci UA, Gurelik G, Hasanreisoglu B. Posterior subtenon and intravitreal triamcinolone acetonide for diabetic macular edema. J Diabetes Complications. 2006; 20:246–51.
11. Cellini M, Pazzaglia A, Zamparini E, et al. Intravitreal vs. subtenon triamcinolone acetonide for the treatment of diabetic cystoid macular edema. BMC Ophthalmol. 2008; 8:5–12.
Article
12. Otani T, Kishi S, Maruyama Y. Patterns of diabetic macular edema with optical coherence tomography. Am J Ophthalmol. 1999; 127:688–93.
Article
13. Chylack LT Jr, Wolfe JK, Singer DM, et al. The Lens Opacities Classification System III. The Longitudinal Study of Cataract Study Group. Arch Ophthalmol. 1993; 111:831–6.
14. Kang SW, Park CY, Ham DI. The correlation between fluorescein angiographic and optical coherence tomographic features in clinically significant diabetic macular edema. Am J Ophthalmol. 2004; 137:313–22.
Article
15. Kim BY, Smith SD, Kaiser PK. Optical coherence tomographic patterns of diabetic macular edema. Am J Ophthalmol. 2006; 142:405–12.
Article
16. Kim NR, Kim YJ, Chin HS, Moon YS. Optical coherence tomographic patterns in diabetic macular oedema: prediction of visual outcome after focal laser photocoagulation. Br J Ophthalmol. 2009; 93:901–5.
Article
17. Funatsu H, Yamashita H, Sakata K, et al. Vitreous levels of vascular endothelial growth factor and intercellular adhesion molecule 1 are related to diabetic macular edema. Ophthalmology. 2005; 112:806–16.
Article
18. Arevalo JF, Fromow-Guerra J, Quiroz-Mercado H, et al. Primary intravitreal bevacizumab (Avastin) for diabetic macular edema: results from the Pan-American Collaborative Retina Study Group at 6-month follow-up. Ophthalmology. 2007; 114:743–50.
19. Arevalo JF, Sanchez JG, Wu L, et al. Primary intravitreal bevacizumab for diffuse diabetic macular edema: the Pan-American Collaborative Retina Study Group at 24 months. Ophthalmology. 2009; 116:1488–97.
20. Kook D, Wolf A, Kreutzer T, et al. Long-term effect of intravitreal bevacizumab (avastin) in patients with chronic diffuse diabetic macular edema. Retina. 2008; 28:1053–60.
Article
21. Roh MI, Byeon SH, Kwon OW. Repeated intravitreal injection of bevacizumab for clinically significant diabetic macular edema. Retina. 2008; 28:1314–8.
Article
22. Bakri SJ, Snyder MR, Reid JM, et al. Pharmacokinetics of intravitreal bevacizumab (Avastin). Ophthalmology. 2007; 114:855–9.
Article
23. Stewart MW. Predicted biologic activity of intravitreal bevacizumab. Retina. 2007; 27:1196–200.
Article
24. Artunay O, Yuzbasioglu E, Rasier R, et al. Incidence and management of acute endophthalmitis after intravitreal bevacizumab (Avastin) injection. Eye (Lond). 2009; 23:2187–93.
Article
25. Biester S, Ziemssen F, Ulrich Bartz-Schmidt K, Gelisken F. Is intravitreal bevacizumab treatment effective in diffuse diabetic macular edema? Graefes Arch Clin Exp Ophthalmol. 2009; 247:1575–7.
Article
26. Shima C, Sakaguchi H, Gomi F, et al. Complications in patients after intravitreal injection of bevacizumab. Acta Ophthalmol. 2008; 86:372–6.
Article
27. Huang ZL, Lin KH, Lee YC, et al. Acute vision loss after intravitreal injection of bevacizumab (Avastin) associated with ocular ischemic syndrome. Ophthalmologica. 2009; 224:86–9.
Article
28. Chen E, Hsu J, Park CH. Acute visual acuity loss following intravitreal bevacizumab for diabetic macular edema. Ophthalmic Surg Lasers Imaging. 2009; 40:68–70.
Article
29. Song HJ, Sohn HJ, Lee DY, Nam DH. Tractional retinal detachment after intravitreal bevacizumab (Avastin®) injection in proliferative diabetic retinopathy. J Korean Ophthalmol Soc. 2009; 50:1751–4.
Article
30. Funatsu H, Yamashita H, Ikeda T, et al. Vitreous levels of inter-leukin-6 and vascular endothelial growth factor are related to diabetic macular edema. Ophthalmology. 2003; 110:1690–6.
Article
31. Aiello LP. The potential role of PKC beta in diabetic retinopathy and macular edema. Surv Ophthalmol. 2002; 47(Suppl 2):S263–9.
32. Kent D, Vinores SA, Campochiaro PA. Macular oedema: the role of soluble mediators. Br J Ophthalmol. 2000; 84:542–5.
Article
33. Sander B, Larsen M, Moldow B, Lund-Andersen H. Diabetic macular edema: passive and active transport of fluorescein through the blood-retina barrier. Invest Ophthalmol Vis Sci. 2001; 42:433–8.
34. Bandi N, Kompella UB. Budesonide reduces vascular endothelial growth factor secretion and expression in airway (Calu-1) and alveolar (A549) epithelial cells. Eur J Pharmacol. 2001; 425:109–16.
Article
35. Fischer S, Renz D, Schaper W, Karliczek GF. In vitro effects of dexamethasone on hypoxia-induced hyperpermeability and expression of vascular endothelial growth factor. Eur J Pharmacol. 2001; 411:231–43.
Article
36. Tong JP, Lam DS, Chan WM, et al. Effects of triamcinolone on the expression of VEGF and PEDF in human retinal pigment epithelial and human umbilical vein endothelial cells. Mol Vis. 2006; 12:1490–5.
37. Floman N, Zor U. Mechanism of steroid action in ocular inflammation: Inhibition of prostaglandin production. Invest Ophthalmol Vis Sci. 1977; 16:69–73.
38. Kang BS, Chung EY, Yun YP, et al. Inhibitory effects of anti-inflammatory drugs on interleukin-6 bioactivity. Biol Pharm Bull. 2001; 24:701–3.
Article
39. Umland SP, Nahrebne DK, Razac S, et al. The inhibitory effects of topically active glucocorticoids on IL-4, IL-5, and interferon-gamma production by cultured primary CD4+ T cells. J Allergy Clin Immunol. 1997; 100:511–9.
40. Wilson CA, Berkowitz BA, Sato Y, et al. Treatment with intravitreal steroid reduces blood-retinal barrier breakdown due to retinal photocoagulation. Arch Ophthalmol. 1992; 110:1155–9.
Article
41. Bonini-Filho MA, Jorge R, Barbosa JC, et al. Intravitreal injection versus sub-Tenon's infusion of triamcinolone acetonide for refractory diabetic macular edema: a randomized clinical trial. Invest Ophthalmol Vis Sci. 2005; 46:3845–9.
Article
42. Chung EJ, Roh MI, Kwon OW, Koh HJ. Effects of macular ischemia on the outcome of intravitreal bevacizumab therapy for diabetic macular edema. Retina. 2008; 28:957–63.
Article
43. Kim HD, Choi KS, Lee SJ. Combined therapy of intravitreal bevacizumab and posterior subtenon triamcinolone acetonide injection in diabetic macular edema. J Korean Ophthalmol Soc. 2009; 50:1652–6.
Article
44. Inoue M, Takeda K, Morita K, et al. Vitreous concentrations of triamcinolone acetonide in human eyes after intravitreal or subtenon injection. Am J Ophthalmol. 2004; 138:1046–8.
Article
45. Audren F, Tod M, Massin P, et al. Pharmacokinetic-pharmacody-namic modeling of the effect of triamcinolone acetonide on central macular thickness in patients with diabetic macular edema. Invest Ophthalmol Vis Sci. 2004; 45:3435–41.
Article
46. Kim YG, Yu SY, Kwak HW. The effect of intravitreal triamcinolone acetonide injection according to the diabetic macular edema. J Korean Ophthalmol Soc. 2006; 46:84–9.
47. Yoon SC, Lee DY, Nam DH. The effect of intravitreal triamcinolone injection according to the OCT patterns of diabetic macular edema. J Korean Ophthalmol Soc. 2008; 49:1611–8.
Article
48. Jonas JB, Kreissig I, Degenring R. Intraocular pressure after intravitreal injection of triamcinolone acetonide. Br J Ophthalmol. 2003; 87:24–7.
Article
49. Smithen LM, Ober MD, Maranan L, Spaide RF. Intravitreal triamcinolone acetonide and intraocular pressure. Am J Ophthalmol. 2004; 138:740–3.
Article
50. Beck RW, Edwards AR, Aiello LP, et al. Three-year follow-up of a randomized trial comparing focal/grid photocoagulation and intravitreal triamcinolone for diabetic macular edema. Arch Ophthalmol. 2009; 127:245–51.
Article
51. Moshfeghi DM, Kaiser PK, Scott IU, et al. Acute endophthalmitis following intravitreal triamcinolone acetonide injection. Am J Ophthalmol. 2003; 136:791–6.
Article
52. Sohn HJ, Nam DH. Infectious endophthalmitis after intravitreal injection of triamcinolone acetonide. J Korean Ophthalmol Soc. 2006; 47:1865–70.
53. Ikewaki J, Imaizumi M, Nakamuro T, et al. Peribulbar fungal abscess and endophthalmitis following posterior subtenon injection of triamcinolone acetonide. Acta Ophthalmol. 2009; 87:102–4.
Article
Full Text Links
  • JKOS
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr