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Hamidi NA, Güneş İB, Baykara M. Evaluation of intraocular pressure change and anterior segment parameters after intravitreal bevacizumab injection - Cannula size matters. Saudi J Ophthalmol 2021; 34:247-250. [PMID: 34527866 PMCID: PMC8409356 DOI: 10.4103/1319-4534.322606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 09/24/2019] [Accepted: 07/06/2020] [Indexed: 12/02/2022] Open
Abstract
PURPOSE: To determine the changes in intraocular pressure (IOP) and anterior chamber parameters following intravitreal bevacizumab injection with different sizes of cannulas. METHODS: This clinical trial was conducted with 70 eyes of 70 patients who received an intravitreal injection of bevacizumab with 26 G (Group 1) or 30 G (Group 2) needle. Preinjection and postinjection 30th-min IOP and pentacam measurements were obtained. Anterior chamber depth (ACD), anterior chamber volume (ACV), central corneal thickness (CCT), corneal volume (CV), and iridocorneal angle (ICA) measurements were evaluated in pentacam. RESULTS: Preinjection mean IOP values in Group 1 and 2 were 14.7 ± 3.29 mm Hg and 15.1 ± 2.87 mm Hg, respectively. Postinjection mean IOP in Group 1 was 16.8 ± 6.24 mm Hg and in Group 2 was 20.3 ± 3.66 mm Hg. Postinjection mean IOP values were significantly higher than preinjection values in both groups (Group 1 P < 0.005 and Group 2 P < 0.001). IOP change was significantly higher in Group 2 after injection (P < 0.05). In both groups, the change in IOP found to be more significant in phakic eyes than pseudophakic eyes (Group 1 P < 0.001, Group 2 P < 0.001). CCT and CV were significantly higher in both groups 30 min after the injection than preinjection (Group 1 and Group 2; P < 0.01). In Group 2 ACD, ACV and ICA values were significantly lower than preinjection values (P < 0.05). CONCLUSION: Needle bore size is an important parameter that influences anterior segment parameters and IOP change in the intravitreal injection. IOP rise and anterior segment changes are more prominent with a thinner cannula.
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Affiliation(s)
| | - İrfan B Güneş
- Kocaeli Medicalpark Hospital Eye Clinic, Kocaeli, Turkey
| | - Mehmet Baykara
- Department of Ophthalmology, Uludağ University Hospital, Bursa, Turkey
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Nourinia R, Borna F, Rahimi A, Jabbarpoor Bonyadi MH, Amizadeh Y, Daneshtalab A, Kheiri B, Ahmadieh H. Repeated Injection of Methotrexate into Silicone Oil-Filled Eyes for Grade C Proliferative Vitreoretinopathy: A Pilot Study. Ophthalmologica 2019; 242:113-117. [PMID: 31163427 DOI: 10.1159/000500271] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 04/10/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate the effects of repeated intra-silicone oil (SO) injections of methotrexate (MTX) on the outcomes of surgery for rhegmatogenous retinal detachment (RRD) with grade C proliferative vitreoretinopathy (PVR-C). METHODS In this prospective pilot case series, eyes with RRD and PVR-C underwent pars plana vitrectomy and intraocular injection of SO. At the conclusion of the procedure, 250 µg of MTX was injected into the SO-filled vitreous cavity. Intra-SO injection was repeated at weeks 3 and 6; the minimum follow-up period was 6 months. The main outcome measure was retinal reattachment rate. RESULTS Eleven eyes of 11 patients (mean age, 52.73 ± 18.01 years) were included. The mean follow-up period was 9 ± 3 months (range, 6-15 months). Total retinal detachment with anterior and/or posterior PVR-C was present in all eyes before surgery. Mean preoperative best-corrected visual acuity (BCVA) was 2.62 ± 0.04 logMAR. All operated eyes exhibited retinal reattachment posterior to the equator during the follow-up period. Mean postoperative BCVA was significantly improved to 1.02 ± 0.51 logMAR (p = 0.003). No ocular or systemic side effects were observed. CONCLUSION Repeated intra-SO injection of MTX as an adjunctive therapy for RRD complicated by PVR showed promising results and was not associated with adverse effects. Further studies are needed to confirm its possible beneficial effects on the final anatomic and functional outcomes in these cases.
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Affiliation(s)
- Ramin Nourinia
- Ocular Tissue Engineering Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farinaz Borna
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | | | - Yashar Amizadeh
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arash Daneshtalab
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Bahareh Kheiri
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Ahmadieh
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran,
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Jeong JS, Lee DW, Kim BS, Yoo WS, Chung IY, Park JM. Comparison of Short-term Effects of Intravitreal Injection of Three Modalities on Central Retinal Vein Occlusion. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2019. [DOI: 10.3341/jkos.2019.60.11.1072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Ji-Seong Jeong
- Department of Ophthalmology, Gyeongsang National University College of Medicine, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea
| | - Dong-Woo Lee
- Department of Ophthalmology, Gyeongsang National University College of Medicine, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea
| | - Byoung-Seon Kim
- Department of Ophthalmology, Gyeongsang National University College of Medicine, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea
| | - Woong-Sun Yoo
- Department of Ophthalmology, Gyeongsang National University College of Medicine, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
| | - In Young Chung
- Department of Ophthalmology, Gyeongsang National University College of Medicine, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
| | - Jong-Moon Park
- Department of Ophthalmology, Gyeongsang National University College of Medicine, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
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Marullo M, Scupola A, Pasqua R, Agostini N, Balestrazzi E. Iris Diaphragm Implantation in Post-Traumatic Aniridia and Tractional Retinal Detachment. Eur J Ophthalmol 2018; 7:171-3. [PMID: 9243222 DOI: 10.1177/112067219700700209] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The implantation of an artificial iris diaphragm is described in a case of aniridia and traumatic aphakia with a relapsed, tractional retinal detachment. The addition of heparin and dexamethasone to the infusion liquid is useful to reduce the fibrinous exudation which seems to be the main cause of diaphragm obliteration.
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Affiliation(s)
- M Marullo
- Department of Ophthalmology, University of L'Aquila, Italy
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Kuo HK, Chen YH, Kuo YH, Ke MC, Tseng YC, Wu PC. Evaluation of the Effect of Everolimus on Retinal Pigment Epithelial Cells and Experimental Proliferative Vitreoretinopathy. Curr Eye Res 2017; 43:333-339. [PMID: 29182404 DOI: 10.1080/02713683.2017.1396618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Failure of retinal detachment surgery is most commonly due to the development of proliferative vitreoretinopathy (PVR). Everolimus is an inhibitor of mammalian target of rapamycin (mTOR), and is available as oral tablets. In this study, we investigated the effect of everolimus on retinal pigment epithelial cells and modification of the severity of experimental PVR. METHODS In our in vitro studies, primary culture of retinal pigment epithelium (RPE) cells was obtained from pigmented Rex rabbits. Cell proliferation was assayed with the tetrazolium dye cytotoxicity test, and cell migration assay was performed in 24-well transwell units with 8-μm filters. In the in vivo study, pigmented Rex rabbits weighing between 2 and 2.5 kg were used. Each rabbit eye underwent gas compression; one week later, 5 × 104 RPE cells were injected into the vitreous cavity to induce PVR, and each eye was graded with indirect ophthalmoscopy on days 1, 3, 7, 14, 21, and 28. The rabbits were administered everolimus (0.5 mg/day orally) from the day of PVR induction. Total proteins extracted from RPE cells and dissected retinal samples were processed for Western blotting analysis of mTOR and ribosomal protein S6 (RPS6). RESULTS The in vitro studies showed that everolimus significantly inhibited the proliferation of RPE cells at 0.1 μg/ml; additionally, at 10 μg/ml, it suppressed the migration of RPE cells and significantly suppressed the expression of mTOR and RPS6 in RPE cells. The in vivo study did not show any benefit of oral everolimus (0.5 mg/day) in suppressing experimental PVR. Thus, everolimus significantly suppressed the expression of mTOR and RPS6 in PVR. CONCLUSIONS Everolimus suppressed the proliferation and migration of RPE cells in vitro. Oral everolimus (0.5 mg/day) suppressed the expression of mTOR and RPS6 in the retina, but showed no effect in suppressing experimental PVR.
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Affiliation(s)
- Hsi-Kung Kuo
- a Department of Ophthalmology , Kaohsiung Chang-Gung Memorial Hospital , Kaohsiung , Taiwan.,b Chang-Gung University College of Medicine , Kaohsiung , Taiwan
| | - Yi-Hao Chen
- a Department of Ophthalmology , Kaohsiung Chang-Gung Memorial Hospital , Kaohsiung , Taiwan.,b Chang-Gung University College of Medicine , Kaohsiung , Taiwan
| | - Yu-Hsia Kuo
- a Department of Ophthalmology , Kaohsiung Chang-Gung Memorial Hospital , Kaohsiung , Taiwan
| | - Mu-Chan Ke
- a Department of Ophthalmology , Kaohsiung Chang-Gung Memorial Hospital , Kaohsiung , Taiwan
| | - Ya-Chi Tseng
- a Department of Ophthalmology , Kaohsiung Chang-Gung Memorial Hospital , Kaohsiung , Taiwan
| | - Pei-Chang Wu
- a Department of Ophthalmology , Kaohsiung Chang-Gung Memorial Hospital , Kaohsiung , Taiwan.,b Chang-Gung University College of Medicine , Kaohsiung , Taiwan
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Khoroshilova-Maslova IP, Leparskaya NL, Vorotelyak EA, Vasiliev AV. [The significance of fibroblasts in experimental modeling of proliferative vitreoretinopathy]. Vestn Oftalmol 2017; 133:4-10. [PMID: 29165406 DOI: 10.17116/oftalma201713354-10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM to investigate the role of heterogeneous fibroblasts in the development of epiretinal membrane in eyes with modeled proliferative vitreoretinopathy. MATERIAL AND METHODS The material for investigation were 6 eyes of 3 Chinchilla rabbits. Suspended fibroblasts (fibroblasts of the human skin - 200000 cells in 0.1 ml) were injected into the vitreous cavity via the pars plana. The animals were followed up for 1 month and then made out of the experiment. The eyes were enucleated and fixed in 10% neutral buffered formalin for routine histological examination. Microscopy was performed on the Leica system. RESULTS The main clinical and morphological criteria for a rabbit model of PVR induced by intravitreal injection of heterogenic fibroblasts have been established: epiretinal membrane formation, changes in intraocular structures (the retinal pigment epithelium and retina), and inflammation (due to transplantation immunity). Particularities of the epiretinal membrane development and the role of different intraocular structures have been described. CONCLUSION The experimental fibroblastic model of PVR reproduces the final, fibrous, stage of PVR, which is significant for efficacy evaluation of antiproliferative drugs.
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Affiliation(s)
- I P Khoroshilova-Maslova
- Moscow Helmholtz Research Institute of Eye Diseases, Ministry of Health of the Russian Federation, 14/19 Sadovaya-Chernogriazskaya St., Moscow, Russian Federation, 105062
| | - N L Leparskaya
- Moscow Helmholtz Research Institute of Eye Diseases, Ministry of Health of the Russian Federation, 14/19 Sadovaya-Chernogriazskaya St., Moscow, Russian Federation, 105062
| | - E A Vorotelyak
- Koltzov Institute of Developmental Biology, Russian Academy of Sciences, 26 Vavilova St., Moscow, Russian Federation, 119334
| | - A V Vasiliev
- Koltzov Institute of Developmental Biology, Russian Academy of Sciences, 26 Vavilova St., Moscow, Russian Federation, 119334
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Pastor JC, Rojas J, Pastor-Idoate S, Di Lauro S, Gonzalez-Buendia L, Delgado-Tirado S. Proliferative vitreoretinopathy: A new concept of disease pathogenesis and practical consequences. Prog Retin Eye Res 2015. [PMID: 26209346 DOI: 10.1016/j.preteyeres.2015.07.005] [Citation(s) in RCA: 199] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
During the last four decades, proliferative vitreoretinopathy (PVR) has defied the efforts of many researchers to prevent its occurrence or development. Thus, PVR is still the major complication following retinal detachment (RD) surgery and a bottle-neck for advances in cell therapy that require intraocular surgery. In this review we tried to combine basic and clinical knowledge, as an example of translational research, providing new and practical information for clinicians. PVR was defined as the proliferation of cells after RD. This idea was used for classifying PVR and also for designing experimental models used for testing many drugs, none of which were successful in humans. We summarize current information regarding the pathogenic events that follow any RD because this information may be the key for understanding and treating the earliest stages of PVR. A major focus is made on the intraretinal changes derived mainly from retinal glial cell reactivity. These responses can lead to intraretinal PVR, an entity that has not been clearly recognized. Inflammation is one of the major components of PVR, and we describe new genetic biomarkers that have the potential to predict its development. New treatment approaches are analyzed, especially those directed towards neuroprotection, which can also be useful for preventing visual loss after any RD. We also summarize the results of different surgical techniques and clinical information that is oriented toward the identification of high risk patients. Finally, we provide some recommendations for future classification of PVR and for designing comparable protocols for testing new drugs or techniques.
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Affiliation(s)
- J Carlos Pastor
- Retina Group, IOBA (Eye Institute), University of Valladolid, Valladolid, Spain; Department of Ophthalmology, Hospital Clinico Universitario de Valladolid, Valladolid, Spain.
| | - Jimena Rojas
- Retina Group, IOBA (Eye Institute), University of Valladolid, Valladolid, Spain; Department of Ophthalmology, Hospital Universitario Austral, Universidad Austral, Buenos Aires, Argentina
| | - Salvador Pastor-Idoate
- Retina Group, IOBA (Eye Institute), University of Valladolid, Valladolid, Spain; Manchester Royal Eye Hospital, Manchester Vision Regeneration (MVR) Lab at NIHR/Wellcome Trust, Manchester, United Kingdom
| | - Salvatore Di Lauro
- Retina Group, IOBA (Eye Institute), University of Valladolid, Valladolid, Spain; Department of Ophthalmology, Hospital Clinico Universitario de Valladolid, Valladolid, Spain
| | - Lucia Gonzalez-Buendia
- Retina Group, IOBA (Eye Institute), University of Valladolid, Valladolid, Spain; Department of Ophthalmology, Hospital Clinico Universitario de Valladolid, Valladolid, Spain
| | - Santiago Delgado-Tirado
- Retina Group, IOBA (Eye Institute), University of Valladolid, Valladolid, Spain; Department of Ophthalmology, Hospital Clinico Universitario de Valladolid, Valladolid, Spain
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Kuo HK, Chen YH, Wu PC, Kuo YH. The Effects of Ozurdex® (Dexamethasone Intravitreal Implant) on Experimental Proliferative Vitreoretinopathy. Ophthalmologica 2015; 233:198-203. [DOI: 10.1159/000371901] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 12/29/2014] [Indexed: 11/19/2022]
Abstract
Purpose: To investigate a new sustained-release formulation of dexamethasone (Ozurdex®) for inhibiting proliferative vitreoretinopathy (PVR) and its effect on the expression of retinal glial reaction and inflammation in experimental PVR eyes. Methods: We used 30 pigmented rabbits for this study. One week after gas compression, the eyes were injected with 5 × 104 retinal pigment epithelial cells into the vitreous cavity to induce PVR. Concurrently, one eye also received an intravitreal injection of Ozurdex; the other eye was used as a control. PVR was graded by indirect ophthalmoscopy on days 1, 3, 7, 14, 21, and 28. The expression of the retinal glial reaction and inflammation in experimental PVR eyes were evaluated by Western blot analysis. Results: PVR severity increased gradually and peaked after 14 days, and no differences in PVR severity between the study and control groups were observed at any time point. The expression of glial fibrillary acid protein (GFAP) increased on days 7 and 14 in both the PVR control and study groups. While the use of Ozurdex in the study group showed less GFAP expression, this difference was not significant. The expression of tumor necrosis factor (TNF)-α and interleukin (IL)-6 significantly increased on days 7 and 14 in PVR control eyes. There was a significant difference in TNF-α between PVR control eyes and Ozurdex-treated eyes on days 7 (p < 0.001) and 14 (p = 0.019). Ozurdex in the study group showed lower IL-6 expression; however, this difference was not significant on days 7 (p = 0.063) and 14 (p = 0.052). Conclusions: The intravitreal injection of Ozurdex suppressed the expression of inflammatory markers; however, it did not mitigate the severity of experimental PVR in this animal model.
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Maturi RK, Chen V, Raghinaru D, Bleau L, Stewart MW. A 6-month, subject-masked, randomized controlled study to assess efficacy of dexamethasone as an adjunct to bevacizumab compared with bevacizumab alone in the treatment of patients with macular edema due to central or branch retinal vein occlusion. Clin Ophthalmol 2014; 8:1057-64. [PMID: 24940042 PMCID: PMC4051812 DOI: 10.2147/opth.s60159] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims To determine if intravitreal bevacizumab combined with the dexamethasone intravitreal implant 0.7 mg improves visual acuity and macular thickness more than bevacizumab monotherapy in eyes with macular edema due to branch and central retinal vein occlusions. Methods Thirty eyes were randomly assigned to receive either combination therapy or bevacizumab monotherapy. All patients received intravitreal bevacizumab at baseline, followed by dexamethasone implants or sham injections 1 week later. Monthly bevacizumab injections were given if the central subfield thickness (CST) was >250 μm, and the combined group received a second implant at month 4 or 5 if CST was >250 μm. Results At 6 months, several secondary endpoints were met. Patients receiving combined therapy required fewer bevacizumab reinjections compared to those receiving monotherapy (two versus three; P=0.02), experienced greater mean reductions in CST from randomization (−56 μm versus +45 μm; P=0.01), and were more likely to have resolved all edema (CST <250 μm) (7/11 versus 2/14; P=0.02). The primary endpoint was not met since mean visual acuity changes from baseline were similar in the two groups (P=0.75). Conclusion In patients with macular edema due to vein occlusions, bevacizumab with dexamethasone implants produces greater improvements in macular thickness compared to bevacizumab monotherapy, despite fewer bevacizumab injections.
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Affiliation(s)
- Raj K Maturi
- Midwest Eye Institute, Indianapolis, IN, USA ; Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, USA
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Traumatic endophthalmitis, retinal detachment, and metallosis after intraocular foreign body injuries. Int Ophthalmol Clin 2014; 53:93-104. [PMID: 24088936 DOI: 10.1097/iio.0b013e31829ceee1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sundaram V, Barsam A, Virgili G. Intravitreal low molecular weight heparin and 5-Fluorouracil for the prevention of proliferative vitreoretinopathy following retinal reattachment surgery. Cochrane Database Syst Rev 2013:CD006421. [PMID: 23440808 DOI: 10.1002/14651858.cd006421.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Proliferative vitreoretinopathy (PVR) is a significant cause of failure in retinal reattachment surgery. Various pharmacological agents have shown potential benefit in reducing postoperative PVR risk. OBJECTIVES This review aimed to compare the use of intravitreal low molecular weight heparin (LMWH) alone or with 5-Fluorouracil (5-FU) versus placebo, as an adjunct in the prevention of PVR following retinal reattachment surgery. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 9), MEDLINE (January 1950 to October 2012), EMBASE (January 1980 to October 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 15 October 2012. SELECTION CRITERIA We only included randomised controlled trials (RCTs) that compared intravitreal LMWH alone or with 5-FU, versus placebo for the prevention of postoperative PVR in patients undergoing primary vitrectomy for rhegmatogenous retinal detachment repair. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. The review authors contacted study authors for additional information. MAIN RESULTS We included two RCTs (with a total of 789 participants) comparing LMWH with 5-FU infusion and placebo. However, we did not perform a meta-analysis because of significant heterogeneity between these studies. One study found a significant beneficial effect of LMWH with 5-FU in reducing postoperative PVR compared to placebo (RR: 0.48, 95% confidence interval: 0.25 to 0.92), in 174 patients who were viewed at high-risk of developing postoperative PVR. The other study included 615 unselected cases of rhegmatogenous retinal detachment and could not show a difference between LMWH with 5-FU infusion and placebo in reducing PVR rates (RR:1.45, 95% confidence interval: 0.76 to 2.76). AUTHORS' CONCLUSIONS Results from this review indicate that there is inconsistent evidence from two studies on patients at different risk of PVR on the effect of LMWH and 5-FU used during vitrectomy to prevent PVR. Future research should be conducted on high risk patients only, until a benefit is confirmed at least in this patient subgroup.
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Affiliation(s)
- Venki Sundaram
- c/o Cochrane Eyes and Vision Group, ICEH, London School of Hygiene & Tropical Medicine, London, UK.
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Uniform suspension of the clustered triamcinolone acetonide particle. J Ophthalmol 2013; 2013:315658. [PMID: 23431418 PMCID: PMC3568888 DOI: 10.1155/2013/315658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Accepted: 12/30/2012] [Indexed: 11/17/2022] Open
Abstract
Purpose. MaQaid (MaQ) is a new triamcinolone acetonide commercialised in Japan to visualize the vitreous. Because MaQ is preservative-free, it has a lower risk of ocular toxicities. However, since MaQ is only available as a powder, it needs suspenssion. Suspension does not always result uniformally, which causes poor visibility. This study reports a new MaQ suspension for better visibility. Methods. After medium addition to a MaQ vial, various methods were used. These included the use of (1) vortex mixer, (2) two syringes and a three-way stopcock, and (3) ultrasonic washer. We calculated suspended MaQ concentration (n = 5). To evaluate the reproducibility, we estimated the coefficient of variance (CV, n = 3). We used this MaQ for pig eyes, and vitreous visualization was simulated. Subsequently, we used this MaQ suspension for humans.
Results.
MaQ suspensions were sucessfull, and the concentrations of single particles increased significantly (P < 0.01). The CV was 36.1% for the routine method and 9.03% ffor the new method. Administration of a suspended MaQ made it possible to clearly visualize the vitreous in both pig and human eyes. Conclusions.
We devised new techniques for uniformal MaQ suspension. These new methods can compensate for the MaQ disadvantages and ensure a safety surgery.
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Lee SY, Ryan SJ. Pathophysiology of Ocular Trauma. Retina 2013. [DOI: 10.1016/b978-1-4557-0737-9.00098-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Diabetic retinopathy is the leading cause of blindness in working age individuals in developed countries. Most cases of diabetes related vision loss result from breakdown of the blood-retinal barrier with resultant diabetic macular edema (DME). For over 30 years, laser photocoagulation has been the standard therapy for DME, but most eyes do not experience significant improvements in visual acuity. Intravitreal injections of drugs that inhibit the action of vascular endothelial growth factor (VEGF) lead to gains in vision, but can be expensive and need to be repeated frequently. In addition to VEGF-mediated breakdown of the blood-retinal barrier, recent evidence suggests that inflammation plays an important role in the development of DME. Recognizing this, physicians have injected steroids into the vitreous and developers have created sustained release implants. Intravitreal injections of triamcinolone acetonide lead to rapid resolution of macular edema and significant short-term improvements in visual acuity, but unfortunately, visual acuities diminish when treatment is continued through 2 years. However, intravitreal triamcinolone remains an attractive treatment option for eyes that are pseudophakic, scheduled to undergo cataract surgery, resistant to laser photocoagulation, or require urgent panretinal photocoagulation for proliferative retinopathy. In controlled trials, intraocular implants that slowly release dexamethasone and fluocinolone show promise in reducing macular edema and improving visual acuity. The high incidences of drug related cataracts and glaucoma, however, require that corticosteroids be used cautiously and that patients be selected carefully. The increasing number of patients with DME, the burgeoning cost of medical care and the continuing development of intravitreal steroids suggest that the use of these agents will likely increase in coming years.
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Vadlapudi AD, Patel A, Cholkar K, Mitra AK. Recent Patents on Emerging Therapeutics for the Treatment of Glaucoma, Age Related Macular Degeneration and Uveitis. RECENT PATENTS ON BIOMEDICAL ENGINEERING 2012; 5:83-101. [PMID: 25414810 PMCID: PMC4235159 DOI: 10.2174/1874764711205010083] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Advancements in the field and rising interest among pharmaceutical researchers have led to the development of new molecules with enhanced therapeutic activity. Design of new drugs which can target a particular pathway and/or explore novel targets is of immense interest to ocular pharmacologists worldwide. Delivery of suitable pharmacologically active agents at proper dose (within the therapeutic window) to the target tissues without any toxicity to the healthy ocular tissues still remain an elusive task. Moreover, the presence of static and dynamic barriers to drug absorption including the corneal epithelium (lipophilic), corneal and scleral stroma (hydrophilic), conjunctival lymphatics, choroidal vasculature and the blood-ocular barriers also pose a significant challenge for achieving therapeutic drug concentrations at the target site. Although many agents are currently available, new compounds are being introduced for treating various ocular diseases. Deeper understanding of the etiology and complex mechanisms associated with the disease condition would aid in the development of potential therapeutic candidates. Novel small molecules as well as complex biotechnology derived macromolecules with superior efficacy, safety and tolerability are being developed. Therefore, this review article provides an overview of existing drugs, treatment options, advances in emerging therapeutics and related recent patents for the treatment of ocular disorders such as glaucoma, age related macular degeneration (AMD) and uveitis.
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Affiliation(s)
- Aswani Dutt Vadlapudi
- Division of Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, 2464 Charlotte Street, Kansas City, MO 64108-2718, USA
| | - Ashaben Patel
- Division of Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, 2464 Charlotte Street, Kansas City, MO 64108-2718, USA
| | - Kishore Cholkar
- Division of Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, 2464 Charlotte Street, Kansas City, MO 64108-2718, USA
| | - Ashim K. Mitra
- Division of Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, 2464 Charlotte Street, Kansas City, MO 64108-2718, USA
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Abstract
INTRODUCTION The Ozurdex(®) (Allergan Inc., Irvine, CA, USA) dexamethasone drug delivery system (DDS) was recently developed as a biodegradable intravitreal implant to provide sustained delivery of 700 μg of preservativefree dexamethasone to the retina and vitreous, and is approved by the United States Food and Drug Administration (FDA) for the treatment of macular edema associated with retinal vein occlusion, as well as for noninfectious posterior uveitis. This review summarizes the rationale behind the development of the dexamethasone DDS, evidence for its use in various clinical scenarios, and compares its efficacy to other available treatment options. METHODS Published data regarding the dexamethasone DDS as well as unpublished data that has been presented at national meetings were reviewed. RESULTS The dexamethasone DDS has evidence for efficacy in multiple clinical situations, including macular edema associated with retinal vein occlusion (RVO), macular edema associated with uveitis or Irvine-Gass syndrome, diabetic macular edema in vitrectomized eyes, persistent macular edema, noninfectious vitritis, and as adjunctive therapy for age-related macular degeneration. Safety concerns include cataract formation and intraocular pressure elevation that is most often temporary and amenable to medical management. CONCLUSIONS The dexamethasone DDS is one of the most recent additions to the armamentarium against macular edema, and is intriguing for its potency, dose consistency, potential for extended duration of action, and favorable safety profile. Early evidence shows clinical utility for several conditions, the most well established being for macular edema associated with RVO. Future studies and, in particular, head-to-head comparisons with other treatment modalities will elucidate the precise role for the dexamethasone DDS in clinical practice.
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Dehghan MH, Ahmadieh H, Soheilian M, Azarmina M, Moradian S, Ramezani AR, Tavallal A, Naghibozakerin J. Effect of oral prednisolone on visual outcomes and complications after scleral buckling. Eur J Ophthalmol 2010; 20:419-23. [PMID: 19924670 DOI: 10.1177/112067211002000224] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate the effect of oral prednisolone on visual outcomes and complications of scleral buckling (SB) in phakic eyes with acute rhegmatogenous retinal detachment (RRD). METHODS In a randomized double-blind placebo-controlled trial, patients with acute RRD underwent SB. The treatment group received 1 mg/kg oral prednisolone for 10 days while the control group received placebo. Outcome measures included visual acuity (VA), retinal redetachment (re-RD), cystoid macular edema (CME), proliferative vitreoretinopathy (PVR), and other possible postoperative complications. Outcome measures were compared between groups with McNemar test. RESULTS Overall, 52 eyes of 52 subjects were enrolled into the study, which included 25 and 27 eyes in the treatment and placebo groups, respectively. Preoperatively, the extent and location of RD and rate of hypotony was comparable between the study groups. VA improvement (logMAR) was 0.75+/-0.61 overall: 0.85+/-0.62 in the treatment group versus 0.65+/-0.61 in the placebo group (p=0.36). Postoperative complications in the treatment and placebo groups included choroidal detachment, 3 versus 4 eyes (p=0.45), significant PVR, 1 versus 3 (p=0.33), and CME, 3 versus 5 eyes (p=0.39), respectively. CONCLUSIONS Postoperative oral prednisolone does not seem to improve the visual outcomes and complications of scleral buckling in simple phakic RRD.
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Affiliation(s)
- Mohammad H Dehghan
- Department of Ophthalmology and Ophthalmic Research Center, Labbafinejad Medical Center, Shaheed Beheshti University (MC), Tehran, Iran.
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Sundaram V, Barsam A, Virgili G. Intravitreal low molecular weight heparin and 5-Fluorouracil for the prevention of proliferative vitreoretinopathy following retinal reattachment surgery. Cochrane Database Syst Rev 2010:CD006421. [PMID: 20614445 DOI: 10.1002/14651858.cd006421.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Proliferative vitreoretinopathy (PVR) is a significant cause of failure in retinal reattachment surgery. Various pharmacological agents have shown potential benefit in reducing postoperative PVR risk. OBJECTIVES This review aimed to compare the use of intravitreal low molecular weight heparin (LMWH) alone or with 5-Fluorouracil (5-FU) versus placebo, as an adjunct in the prevention of PVR following retinal reattachment surgery. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2010, Issue 5), MEDLINE (January 1950 to May 2010), EMBASE (January 1980 to May 2010), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) and ClinicalTrials.gov (http://clinicaltrials.gov). There were no language or date restrictions in the search for trials. The electronic databases were last searched on 24 May 2010. SELECTION CRITERIA We only included randomised controlled trials (RCTs) that compared intravitreal LMWH alone or with 5-FU, versus placebo for the prevention of postoperative PVR in patients undergoing primary vitrectomy for rhegmatogenous retinal detachment repair. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. The review authors contacted study authors for additional information. MAIN RESULTS We included two RCTs (with a total of 789 participants) comparing LMWH with 5-FU infusion and placebo. However, we did not perform a meta-analysis because of significant heterogeneity between these studies. One study found a significant beneficial effect of LMWH with 5-FU in reducing postoperative PVR compared to placebo (RR: 0.48, 95% confidence interval: 0.25 to 0.92), in 174 patients who were viewed at high-risk of developing postoperative PVR. The other study included 615 unselected cases of rhegmatogenous retinal detachment and could not show a difference between LMWH with 5-FU infusion and placebo in reducing PVR rates (RR:1.45, 95% confidence interval: 0.76 to 2.76). AUTHORS' CONCLUSIONS Results from this review indicate that there is inconsistent evidence from two studies on patients at different risk of PVR on the effect of LMWH and 5-FU used during vitrectomy to prevent PVR. Future research should be conducted on high risk patients only, until a benefit is confirmed at least in this patient subgroup.
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Affiliation(s)
- Venki Sundaram
- c/o Cochrane Eyes and Vision Group, ICEH, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK, WC1E 7HT
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Kim BK, Kweon EY, Lee DW, Ahn M, Cho NC. The Results of a Combination of Cataract Surgery and Intravitreal Bevacizumab Injection for Diabetic Macular Edema. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2010. [DOI: 10.3341/jkos.2010.51.7.954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Bu Ki Kim
- Department of Ophthalmology, Chonbuk National University Medical School, Jeonju, Korea
| | - Eui Yong Kweon
- Department of Ophthalmology, Chonbuk National University Medical School, Jeonju, Korea
| | - Dong Wook Lee
- Department of Ophthalmology, Chonbuk National University Medical School, Jeonju, Korea
| | - Min Ahn
- Department of Ophthalmology, Chonbuk National University Medical School, Jeonju, Korea
| | - Nam Chun Cho
- Department of Ophthalmology, Chonbuk National University Medical School, Jeonju, Korea
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Abstract
BACKGROUND Intravitreal injection (IVI) with administration of various pharmacological agents is a mainstay of treatment in ophthalmology for endopthalmitis, viral retinitis, age-related macular degeneration, cystoid macular edema, diabetic retinopathy, uveitis, vascular occlusions, and retinal detachment. The indications and therapeutic agents are reviewed in this study. METHODS A search of the English, German, and Spanish language MEDLINE database was conducted. A total of 654 references spanning the period through early 2008 were individually evaluated. RESULTS The advantage of the IVI technique is the ability to maximize intraocular levels of medications and to avoid the toxicities associated with systemic treatment. Intravitreal injection has been used to deliver several types of pharmacological agents into the vitreous cavity: antiinfective and antiinflammatory medications, immunomodulators, anticancer agents, gas, antivascular endothelial growth factor, and several others. The goal of this review is to provide a detailed description of the properties of numerous therapeutic agents that can be delivered through IVI, potential complications of the technique, and recommendations to avoid side effects. CONCLUSION The IVI technique is a valuable tool that can be tailored to the disease process of interest based on the pharmacological agent selected. This review provides the reader with a comprehensive summary of the IVI technique and its multitude of uses.
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Affiliation(s)
- Gholam A Peyman
- Department of Ophthalmology and Vision Science, College of Medicine, University of Arizona, Tucson, Arizona 85351, USA.
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Citirik M, Dilsiz N, Batman C, Zilelioglu O. Comparative toxicity of 4 commonly used intravitreal corticosteroids on rat retina. Can J Ophthalmol 2009; 44:e3-8. [PMID: 19506592 DOI: 10.3129/i09-059] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To investigate the effects of 4 commonly used steroids (dexamethasone, triamcinolone, betamethasone, and methylprednisolone) on 50 retinas of 25 adult pigmented rats. STUDY DESIGN Experimental animal study. PARTICIPANTS Twenty-five pigmented Long-Evans male rats. METHODS Each steroid drug with 2 different doses (0.025 mL and 0.050 mL) was injected into the vitreous of each eye of 5 rats. The low drug dose was injected into the right eye and the high dose was injected into the left eye. Ten eyes of 5 randomly selected rats were used as a control group and intravitreal saline was injected into these eyes. Oxidative damage and intrinsic antioxidative capacity were determined by measuring retinal malondialdehyde (MDA) and glutathione (GSH) levels, respectively. RESULTS No statistically meaningful difference was observed in retinal GSH and MDA measurements in the low- and high-dose triamcinolone (1 and 2 mg), low-dose betamethasone (0.075 mg), and low-dose dexamethasone (0.1 mg) groups, compared with the control group. Both doses of methylprednisolone (1.6 mg and 3.2 mg), high-dose betamethasone (0.15 mg), and high-dose dexamethasone (0.2 mg) markedly altered retinal GSH and MDA levels. CONCLUSIONS The results of our study show that the toxicity of triamcinolone is not evident even in high doses. It may be used safely. We also suggest that intravitreal use of low doses of betamethasone and dexamethasone is safer than higher doses of these drugs and both doses of methylprednisolone.
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Affiliation(s)
- Mehmet Citirik
- SB Ankara Ulucanlar Eye Education and Research Hospital, Ankara, Turkey.
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Propes B, Poon D, Do DV. Role of intraocular steroids for the treatment of diabetic macular edema. EXPERT REVIEW OF OPHTHALMOLOGY 2009. [DOI: 10.1586/eop.09.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Theodossiadis PG, Liarakos VS, Sfikakis PP, Vergados IA, Theodossiadis GP. Intravitreal administration of the anti-tumor necrosis factor agent infliximab for neovascular age-related macular degeneration. Am J Ophthalmol 2009; 147:825-30, 830.e1. [PMID: 19211094 DOI: 10.1016/j.ajo.2008.12.004] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Revised: 11/14/2008] [Accepted: 12/02/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE To present our preliminary experience on intravitreal administration of an anti-tumor necrosis factor (TNF) monoclonal antibody for neovascular age-related macular degeneration (AMD). DESIGN Prospective, noncomparative series of 3 patients previously treated with an anti-vascular endothelial growth factor agent. METHODS Two intravitreal injections of 0.05 ml containing infliximab were administered in the first (1 and 2 mg, 2 months apart), second (2 mg each, 2 months apart), and third patient (2 mg each, 3 months apart). Best-corrected visual acuity (BCVA) and central foveal thickness (CFT) were monthly assessed for up to 7 months. RESULTS In the first patient, BCVA increased from 20/200 to 20/100 and CFT decreased from 462 to 386 microm, 2 months after the first injection. The condition was further improved after the second injection (BCVA, 20/40; CFT, 210 microm), but recurrence occurred 7 months post-baseline. In the second patient, BCVA increased from 20/200 to 20/70 and CFT decreased from 512 to 420 and 184 microm, 2 and 4 months post-baseline, respectively. In the third patient, clinical improvement was documented after the first injection. A second injection attributable to recurrence resulted in improvement of BCVA from 20/100 to 20/30 and decrease of CFT from 388 to 282 microm, 2 months after the second injection. CONCLUSIONS These findings, although insufficient to consider "off-label" treatment with intravitreal infliximab, provide in vivo evidence of a pathogenetic link of locally produced and/or acting TNF to neovascular AMD. A randomized study of consecutive intravitreal injections of infliximab for AMD may be warranted.
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FAGHIHI HOOSHANG, TAHERI ARASH, FARAHVASH MOHAMMADSADEGH, ESFAHANI MOHAMMADRIAZI, RAJABI MOHAMMADTAHER. INTRAVITREAL TRIAMCINOLONE ACETONIDE INJECTION AT THE END OF VITRECTOMY FOR DIABETIC VITREOUS HEMORRHAGE. Retina 2008; 28:1241-6. [DOI: 10.1097/iae.0b013e31817d5be3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Affiliation(s)
- Clifford A. Silverman
- Retina Division Jules Steine Eye Institute Department of Ophthamology, UCLA School of Medicine Los Angeles, California
| | - Marc O. Yoshizumi
- Retina Division Jules Steine Eye Institute Department of Ophthamology, UCLA School of Medicine Los Angeles, California
- UCLA School of Medicine, Los Angeles, California
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Chang YC, Hu DN, Wu WC. Effect of oral 13-cis-retinoic acid treatment on postoperative clinical outcome of eyes with proliferative vitreoretinopathy. Am J Ophthalmol 2008; 146:440-446. [PMID: 18599016 DOI: 10.1016/j.ajo.2008.05.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Revised: 05/02/2008] [Accepted: 05/05/2008] [Indexed: 11/28/2022]
Abstract
PURPOSE To determine whether postoperative oral 13-cis-retinoic acid (RA) treatment could improve the outcome of vitreoretinal surgery with silicone oil for the management of proliferative vitreoretinopathy (PVR). DESIGN Prospective controlled randomized interventional case series. METHODS This study included 35 eyes of 35 patients with primary rhegmatogenous retinal detachment and PVR. All patients underwent surgical repair by similar procedures. The RA group consisted of 16 patients who received 10 mg oral RA twice daily for eight weeks postoperatively. The control group included 19 patients without taking RA. The outcome measure included the rate of retinal attachment, macular pucker formation, ambulatory vision, and RA-related side effects. RESULTS At last follow-up (at least one year postoperatively), 15 of 16 eyes (93.8%) in the RA group and 12 of 19 eyes (63.2%) in the control group maintained retinal attachment (P = .047). The rate of macular pucker formation was significantly lower in the RA group (18.8% vs 78.9% in the control group; P = .001). A higher rate of ambulatory vision was achieved in the RA group as compared to the control group (56.3% vs 10.5%; P = .009). CONCLUSIONS Postoperative administration with oral moderate dosage of RA for eight weeks appears to maintain retinal attachment, decrease the macular pucker, and improve vision after surgical repair for eyes with PVR.
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Affiliation(s)
- Yo-Chen Chang
- Department of Ophthalmology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, No. 100 Zihyou 1st Road, Kaohsiung, Taiwan
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Vasconcelos-Santos DV, Nehemy MB, Rich RM, Negrao S, Flynn HW. Intravitreal triamcinolone acetonide: potential complications. EXPERT REVIEW OF OPHTHALMOLOGY 2007. [DOI: 10.1586/17469899.2.6.987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
PURPOSE OF REVIEW To provide a current update on the use of intravitreal corticosteroids as a treatment for a variety of retinal diseases. RECENT FINDINGS Pharmacokinetic studies demonstrate that a single 4 mg injection of intravitreal triamcinolone acetonide is present in the vitreous for up to 3 months. Many recent studies demonstrate a significant reduction in macular edema often with a significant improvement in vision for up to several months followed by a waning of treatment effect and recurrence of macular edema. Retreatments have been shown to be efficacious. Intravitreal triamcinolone acetonide may help lead to a reduction in subfoveal hard exudates in diffuse diabetic macular edema. It has been shown to be a more potent treatment than sub-Tenon's and retrobulbar triamcinolone acetonide for persistent macular edema. It may also be a significant adjunctive treatment for choroidal neovascularization treated with photodynamic therapy. Intravitreal corticosteroid implants have also been shown to be beneficial in early trials for persistent macular edema. SUMMARY Intravitreal triamcinolone acetonide provides a potent short-term treatment for persistent macular edema and may be a useful adjunctive treatment for choroidal neovascularization. It remains to be determined whether intravitreal corticosteroids can provide long-term visual gain or stabilization. The side-effect profile of intravitreal corticosteroids is significant with corticosteroid-induced intraocular pressure rises. With longer-term studies, the rate of posterior subcapsular cataract formation is higher than previously reported, and there is a small but potential risk of endophthalmitis.
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Affiliation(s)
- Stephen M Conti
- Department of Ophthalmology, University of Toronto, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada
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Abstract
PURPOSE To review current treatment approaches in diabetic macular edema (DME). METHODS The underlying pathopathology, classifications and diagnostic examination techniques including fluorescein angiography, optical coherence tomography and stereoscopic biomicroscopy. Treatment modalities with focal or grid argon laser photocoagulation, pars plana vitrectomy with and without peeling of the inner limiting membrane (ILM), as well as intravitreal injections using triamcinolone acetonide or novel vascular endothelial growth factor (VEGF) inhibitors are described. RESULTS DME results from a series of biochemical and cellular changes, causing progressive leakage and exudation. Focal and grid photocoagulation remains the standard care for diabetic maculopathy. However, the availability of new agents raises the possibility of improvements if significant benefits can be validated in randomized clinical trials. Posterior vitreous attachments play a critical role through several mechanical or physiological mechanisms. Vitrectomy without ILM removal seems to be effective in reducing the retinal thickness and improving visual acuity. CONCLUSION A proper evaluation of the vitreous and retina is fundamental to select the most appropriate treatment approach in DME. While small microaneurysms with focal DME may be treated by conventional focal photocoagulation, diffuse DME which do not respond to grid photocoagulation may benefit from intravitreal injections using triamcinolone acetonide or novel VEGF inhibitors. Eyes with DME and additional vitreous traction may benefit from pars plana vitrectomy without ILM peeling. A combination of laser, pharmacological and surgical treatment modalities may be necessary to maintain central vision in eyes with DME.
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Affiliation(s)
- Carsten H Meyer
- Department of Ophthalmology, Philipps University, Marburg, Germany.
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Agrawal RN, He S, Spee C, Cui JZ, Ryan SJ, Hinton DR. In vivo models of proliferative vitreoretinopathy. Nat Protoc 2007; 2:67-77. [PMID: 17401340 DOI: 10.1038/nprot.2007.4] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We outline current in vitro and in vivo models for experimental proliferative vitreoretinopathy (PVR) and provide a detailed protocol of our standardized in vivo PVR model. PVR is the leading cause of failed surgical procedures for the correction of rhegmatogenous retinal detachment. The pathogenesis of this multifactorial condition is still not completely understood. Experimental models for PVR help us understand the factors that play a role in the pathogenesis of the disease process in a controlled manner and allow for reproducible preclinical assessment of novel therapeutic interventions. We describe a cell injection model in detail that uses homologous retinal pigment epithelial (RPE) cell cultures to induce PVR over a 2-8 week period.
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Affiliation(s)
- Rajat N Agrawal
- Department of Ophthalmology, Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033, USA
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Jonas JB, Schlichtenbrede F. Visual acuity and intraocular pressure after high-dose intravitreal triamcinolone acetonide in selected ocular diseases. Eye (Lond) 2007; 22:869-73. [PMID: 17304257 DOI: 10.1038/sj.eye.6702734] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
PURPOSE Within 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. SCOPE Comparing 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. CONCLUSIONS Improvement 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.
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Affiliation(s)
- J B Jonas
- Department of Ophthalmology, Faculty of Clinical Medicine Mannheim of the University, Heidelberg, Germany.
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Garcia RA, Sanchez JG, Arevalo JF. Combined 5-Fluorouracil, Low-Molecular–Weight Heparin, and Silicone Oil in the Management of Complicated Retinal Detachment With Proliferative Vitreoretinopathy Grade C. Ophthalmic Surg Lasers Imaging Retina 2007; 38:276-82. [PMID: 17674917 DOI: 10.3928/15428877-20070701-02] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE To determine whether combined 5-fluorouracil (5-FU) and low-molecular-weight heparin (LMWH) could improve the outcome of vitreoretinal surgery with silicone oil for the management of complicated retinal detachment with proliferative vitreoretinopathy (PVR) grade C. PATIENTS AND METHODS In an interventional, controlled, nonrandomized clinical trial, 33 eyes with complicated retinal detachment and PVR underwent vitrectomy with silicone oil and perioperative infusion of 5-FU and LMWH (study group) and 31 eyes underwent vitrectomy with silicone oil without adjunctive medication (control group). RESULTS In the study group, 24 eyes (72.7%) had the retina attached and 9 had a retinal redetachment (27.3%) at 6 months. In the control group, 25 eyes (80.6%) had the retina attached and 6 eyes (19.4%) had a retinal redetachment at 6 months (chi-square: 0.53, P > .05). One-year postoperative data were available for 17 eyes in the study group and 19 eyes in the control group. Four eyes in each group (23.5% and 21%, respectively) developed retinal redetachment (chi-square: 0.03, P > .05). CONCLUSIONS Combined 5-FU and LMWH does not seem to improve the outcome of vitreoretinal surgery with silicone oil for the management of complicated retinal detachment with PVR grade C.
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Affiliation(s)
- Reinaldo A Garcia
- Retina and Vitreous Service, Clinica Oftalmológica Centro Caracas, Caracas, Venezuela
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Cheema RA, Peyman GA, Fang T, Jones A, Lukaris AD, Lim K. Triamcinolone Acetonide as an Adjuvant in the Surgical Treatment of Retinal Detachment With Proliferative Vitreoretinopathy. Ophthalmic Surg Lasers Imaging Retina 2007; 38:365-70. [DOI: 10.3928/15428877-20070901-02] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Jonas JB, Strueven V, Kamppeter BA, Harder B, Spandau UH, Schlichtenbrede F. Visual Acuity Change After Intravitreal Triamcinolone in Various Types of Exudative Age-Related Macular Degeneration. J Ocul Pharmacol Ther 2006; 22:370-6. [PMID: 17076632 DOI: 10.1089/jop.2006.22.370] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The aim of this study was to compare the visual acuity change after an intravitreal high-dose injection of triamcinolone acetonide (TA) in various types of exudative age-related macular degeneration (AMD). PARTICIPANTS The interventional comparative case series study included 142 patients (146 eyes) with progressive exudative AMD differentiated into the occult type (n = 78; 53.4%), minimal classic type (n = 45; 30.8%), predominantly classic type (n = 17; 11.6%), and the purely classic type (n = 6; 4.1%). Mean follow-up was 9.7 +/- 7.0 months (3-35.7 months). METHODS Single intravitreal injection of approximately 20 mg of TA. OUTCOME MEASURES Visual acuity, intraocular pressure (IOP). RESULTS Gain in visual acuity measured at 1 month (P = 0.20), 2 months (P = 0.43), and at 3 months (P = 0.38) after the intravitreal injection of triamcinolone and maximal gain in visual acuity during the whole follow-up (P = 0.81) did not vary significantly between the 4 study groups. Correspondingly, the size of a retinal pigment epithelium detachment was not significantly associated with the change in visual acuity at 1 month (P = 0.62), 2 months (P = 0.24), 3 months (P = 0.96), or the maximal gain in visual acuity during follow-up (P = 0.93). The amount of rise in IOP, compared with the baseline value (6.5 +/- 7.4 mmHg), was statistically not associated with the type of subfoveal membrane (P = 0.20; 95% confidence interval: -0.52, 2.45). CONCLUSIONS The change in visual acuity and the rise in IOP in patients with exudative AMD receiving an intravitreal triamcinolone monotherapy is statistically independent of the type of subfoveal membrane, including the size of a retinal epithelium detachment.
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Affiliation(s)
- Jost B Jonas
- Department of Ophthalmology, Faculty of Clinical Medicine Mannheim of the University of Heidelberg, Heidelberg, Germany.
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Jonas JB. Intravitreal triamcinolone acetonide: a change in a paradigm. Ophthalmic Res 2006; 38:218-45. [PMID: 16763379 DOI: 10.1159/000093796] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2005] [Accepted: 05/09/2006] [Indexed: 12/20/2022]
Abstract
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-Behçet'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.
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Affiliation(s)
- Jost B Jonas
- Department of Ophthalmology, Faculty of Clinical Medicine Mannheim, Ruprecht Karls University of Heidelberg, Heidelberg, Germany.
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Jonas JB, Spandau UHM, Kamppeter BA, Degenring RF, Kreissig I, Akkoyun I, Vossmerbaeumer U. Duration of the Effect of Intravitreal Triamcinolone Acetonide in Eyes with Exudative Age-Related Macular Degeneration. J Ocul Pharmacol Ther 2006; 22:194-9. [PMID: 16808681 DOI: 10.1089/jop.2006.22.194] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the duration of the effect of an intravitreal injection of approximately 20 mg of triamcinolone acetonide (TA) on visual acuity and intraocular pressure (IOP) in patients with exudative age-related macular degeneration (AMD) with subfoveal choroidal neovascularization. PARTICIPANTS The prospective, clinical, interventional, case series study included 69 patients (71 eyes) with exudative AMD who showed an increase in visual acuity by at least 2 Snellen lines after an intravitreal injection of approximately 20 mg TA. Mean follow-up was 11.5 +/- 7.4 months (3.3-35.7 months). The main outcome measure was visual acuity. RESULTS Within the first week after the injection, visual acuity and IOP started to increase significantly (P < 0.001) by reaching a plateau-like maximum at 1-6 months after the injection. Visual acuity and IOP returned to baseline values 7-9 months after the injection. Increase of IOP was statistically (P = 0.72) independent of the change in visual acuity. CONCLUSIONS In patients with exudative AMD, who have shown an increase of at least 2 Snellen lines in visual acuity, the effect of intravitreal TA (dosage approximately 20 mg) lasts 7-9 months with respect to an increase in visual acuity and IOP.
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Affiliation(s)
- Jost B Jonas
- Department of Ophthalmology, Faculty of Clinical Medicine Mannheim of the Ruprecht-Karls-University of Heidelberg, Germany
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Zein WM, Noureddin BN, Jurdi FA, Schakal A, Bashshur ZF. Panretinal photocoagulation and intravitreal triamcinolone acetonide for the management of proliferative diabetic retinopathy with macular edema. Retina 2006; 26:137-42. [PMID: 16467667 DOI: 10.1097/00006982-200602000-00002] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate intravitreal triamcinolone acetonide (IVTA) as an adjunctive therapy to panretinal photocoagulation (PRP) in patients with both high-risk proliferative diabetic retinopathy (PDR) and clinically significant macular edema (CSME). METHODS Thirty-five eyes diagnosed with both high-risk PDR and CSME underwent PRP and a single injection of 4 mg of IVTA (IVTA group). Visual, anatomic, and fluorescein angiographic changes were documented. Any complications resulting from the combined procedure were noted. These data were compared retrospectively to 35 eyes that underwent grid laser treatment to the macula followed 2 weeks later by PRP (laser group). Main outcome measures included change in best-corrected visual acuity, improvement in macular edema (clinical or angiographic), and control of the neovascular disease. RESULTS Mean follow-up was 9.6 months for the IVTA group and 11.9 months for the laser group. Mean pretreatment best-corrected visual acuity was 20/286 in the IVTA group and 20/282 in the laser group (P = 0.80). After 9 months of follow-up, visual acuity was 20/80 in the IVTA group versus 20/156 in the laser group (P = 0.007). Thirty-four percent of eyes in the IVTA group had final vision of 20/40 or better versus 11% in the laser group (P = 0.044). At 9 months follow-up, 84% of IVTA eyes had complete resolution of macular edema versus 46% of laser eyes (P = 0.002). Three eyes in the IVTA group had recurrence of macular edema after 6 months and required reinjection of IVTA. Elevation in intraocular pressure occurred in eight eyes in the IVTA group and responded to topical therapy. Cataract progression was observed in nine eyes in the IVTA group. CONCLUSIONS The addition of intravitreal triamcinolone acetonide to PRP in the management of patients with both PDR and CSME seems promising. Further study is needed to assess the effect of this combined treatment.
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Affiliation(s)
- Wadih M Zein
- Department of Ophthalmology, American University of Beirut, Medical Center, Beirut, Lebanon
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Thompson JT. Cataract formation and other complications of intravitreal triamcinolone for macular edema. Am J Ophthalmol 2006; 141:629-37. [PMID: 16564796 DOI: 10.1016/j.ajo.2005.11.050] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2005] [Revised: 11/04/2005] [Accepted: 11/28/2005] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate complications and results of intravitreal triamcinolone acetonide for treatment of macular edema. DESIGN Interventional, consecutive, retrospective case series. METHODS Ninety-three eyes with macular edema arising from retinovascular etiologies were treated with 4 mg intravitreal triamcinolone. Eyes were monitored after injection for visual acuity changes and complications, including cataract formation and increase in intraocular pressure (IOP). Cataract progression was analyzed by linear regression analysis of lens scores from lens opacity standards. RESULTS The mean visual acuity improved from 20/125 to -1 to 20/100 + 2 by one to two months after injection (P < .001) and was 20/100 at the final examination (P = .006) at a mean of 1.2 years after injection. Complications included a severe, culture-negative inflammatory reaction in one eye (1.1%). IOP increased to 30 mm Hg or more in nine (9.7%) of 93 eyes between 1 and 140 days after injection and was more frequent in eyes receiving one or more preinjection glaucoma drops (two of 13 eyes, 15.4%, vs seven of 80 eyes, 8.75%, without preinjection glaucoma drops). Nuclear sclerosis increased at a rate of 0.175 U per year, posterior subcapsular cataracts at 0.423 U per year, and cortical cataracts at 0.045 U per year. Posterior subcapsular cataract increased by > or = 1 U or required cataract surgery in 45.2% of eyes followed at least one year. CONCLUSIONS Intravitreal triamcinolone improves visual acuity in most eyes but eyes must be monitored carefully for increase in IOP. Posterior subcapsular cataract formation becomes visually significant in almost half of eyes by one year after injection.
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Munir WM, Pulido JS, Sharma MC, Buerk BM. Intravitreal triamcinolone for treatment of complicated proliferative diabetic retinopathy and proliferative vitreoretinopathy. Can J Ophthalmol 2006; 40:598-604. [PMID: 16391623 DOI: 10.1016/s0008-4182(05)80052-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND We present a retrospective evaluation of the clinical outcome and complications associated with intravitreal injection of unaltered triamcinolone acetonide in conjunction with pars plana vitrectomy and silicone oil injection for the treatment of complicated proliferative diabetic retinopathy with tractional retinal detachment and severe proliferative vitreoretinopathy. METHODS Thirteen eyes of 12 consecutive patients were identified from a computerized patient database. All eyes were operated on by the same surgeon and received 4 mg of unaltered, commercially available triamcinolone acetonide intravitreally, before silicone oil injection. The patients were followed for a mean of 4.7 months (range 1-15 months), and demographic as well as pertinent preoperative and postoperative clinical information was gathered. RESULTS At the last follow-up visit, vision had improved in 4 eyes, remained stable in 5 eyes, and worsened in 4 eyes. The retina was attached at the end of follow-up in 10 of the 13 eyes. Eight of the 13 eyes did not show any clinical signs of re-roliferation or redetachment during the course of follow-up. The mean intra-ocular pressure did not increase (preoperative value was 10.8+/- 6.22 mm Hg with a range of 0-22 mm Hg; at last follow-up, mean pressure was 9.6 +/-3.86 mm Hg with a cumulative postoperative range of 0-26 mm Hg). Steroid crystals were visible at 1 month postoperatively in 3 eyes and did not hinder fundus examination significantly. INTERPRETATION The intravitreal injection of low-dose, unaltered triamcinolone acetonide in the setting of pars plana vitrectomy and silicone oil injection for the treatment of proliferative vitreoretinopathy and complicated proliferative diabetic retinopathy appears to be well tolerated. Further controlled study is needed to clearly define the potential beneficial effects of intravitreal steroids in these 2 disease processes.
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Affiliation(s)
- Wuqaas M Munir
- Department of Opthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois, USA
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Jonas JB. Intravitreal triamcinolone acetonide for treatment of intraocular oedematous and neovascular diseases. ACTA ACUST UNITED AC 2006; 83:645-63. [PMID: 16396641 DOI: 10.1111/j.1600-0420.2005.00592.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Intravitreal triamcinolone acetonide (IVTA) has increasingly been applied as treatment for various intraocular neovascular and oedematous 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 (VA) has been achieved for intraretinal oedematous diseases such as diffuse diabetic macular oedema, branch retinal vein occlusion, central retinal vein occlusion and pseudophakic cystoid macular oedema. In eyes with various types of non-infectious uveitis, including acute or chronic sympathetic ophthalmia and Adamantiadis-Behcet's disease, VA increased and the degree of intraocular inflammation decreased. Some studies have suggested that intravitreal triamcinolone may be useful as angiostatic therapy in eyes with iris neovascularization and proliferative ischaemic retinopathies. Intravitreal triamcinolone may possibly be helpful as adjunct therapy for exudative age-related macular degeneration (AMD), particularly in combination with photodynamic therapy. In eyes with chronic, therapy-resistant ocular hypotony, intravitreal triamcinolone can induce an increase in intraocular pressure (IOP) 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 IOP 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% of elderly patients within 1 year of injection; postoperative infectious endophthalmitis occurring at a rate of about one per 1000; non-infectious endophthalmitis, perhaps due to a reaction to the solvent agent, and pseudo-endophthalmitis with triamcinolone acetonide crystals appearing in the anterior chamber. Intravitreal triamcinolone injection can be combined with other intraocular surgeries, 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 the resultant benefits decrease after the initial IVTA injection. In non-vitrectomized 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. So far, it has remained unclear whether the solvent agent should be removed, and if so, how.
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Affiliation(s)
- Jost B Jonas
- Department of Ophthalmology, Faculty of Clinical Medicine Mannheim, Ruprecht-Karls-University of Heidelberg, Germany.
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Kampougeris G, Cheema R, McPherson R, Gorman C. Safety of Triamcinolone acetonide (TA)-assisted pars plana vitrectomy in macular hole surgery. Eye (Lond) 2006; 21:591-4. [PMID: 16456587 DOI: 10.1038/sj.eye.6702265] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
AIM To evaluate whether Triamcinolone acetonide (TA)-assisted pars plana vitrectomy for visualisation of posterior hyaloid during macular hole surgery has any adverse effects on macular hole closure rate and intraocular pressure (IOP). METHODS Case series comparing outcomes and adverse effects in patients who had surgery for macular holes with ILM peel, with and without the use of TA-assisted vitrectomy. RESULTS During the study period, 29 patients had vitrectomy for macular holes. In 18 patients (group 1), TA was used intraoperatively to facilitate visualisation of the posterior hyaloid and in 11 patients (group 2) no TA was used. There was no statistically significant difference in the macular hole closure rates and the improvement in visual acuity between the two groups. No long-term increase in IOP was recorded in any of the 29 patients. The total anatomical success rate in both groups was 85.6% and the average improvement in visual acuity in both groups was two Snellen lines. CONCLUSIONS TA is safe and there is no contraindication for its use as an intraoperative aid to facilitate vitreous visualisation in macular hole surgery.
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Affiliation(s)
- G Kampougeris
- Vitreoretinal Service, Cardiff Eye Unit, University Hospital of Wales, Cardiff, UK
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Jonas JB, Spandau UH, Kamppeter BA, Harder B. Follow-up after intravitreal triamcinolone acetonide for exudative age-related macular degeneration. Eye (Lond) 2006; 21:387-94. [PMID: 16410809 DOI: 10.1038/sj.eye.6702222] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To report on the follow-up of patients who received an intravitreal triamcinolone acetonide injection (IVTA) as treatment of exudative age-related macular degeneration. METHODS The clinical interventional case-series study included 205 patients (222 eyes) with progressive exudative age-related macular degeneration with subfoveal neovascularization who consecutively received an IVTA of about 20 mg as only therapeutic procedure and for whom follow-up was at least 3 months. Mean follow-up was 10.4+/-7.1 months (range, 3-35.7 months). RESULTS Visual acuity improved significantly (P<0.001) from baseline (0.90+/-0.45 logarithm of the minimum angle of resolution (LogMar)) to a mean minimum of 0.79+/-0.42 LogMar during follow-up. In 86 (38.7%) eyes and in 55 (24.8%) eyes, best visual acuity increased by at least two and three Snellen lines, respectively. Comparing the measurements at specific postinjection examination dates showed that visual acuity measurements taken at 1, 2, and 3 months after injection were not significantly different from the baseline value. Measurements taken at 6, 9, and 12 months after the injection were significantly (P<0.001) lower than the measurements at baseline. Mean loss at 6 months was 1.4+/-3.8 Snellen lines, at 9 months, 2.5+/-4.6 lines, and at 12 months after the injection, 2.6+/-4.0 lines. Intraocular pressure increased significantly (P<0.001) during the first 6 months, and returned to baseline at 9 months after injection. CONCLUSIONS Single injection high-dosage IVTA did not show an apparent benefit at 12 months after injection in patients with neovascular age-related macular degeneration.
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Affiliation(s)
- J B Jonas
- Department of Ophthalmology, Faculty of Clinical Medicine Mannheim of the University Heidelberg, Mannheim, Germany.
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Ryan SJ, Yoon YH. Posterior Segment Trauma: Open Globe. Retina 2006. [DOI: 10.1016/b978-0-323-02598-0.50144-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Steroids in Macular Disease. Retina 2006. [DOI: 10.1016/b978-0-323-02598-0.50061-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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The Mechanism of Action of Drugs for the Treatment of Vitreoretinal Scarring. Retina 2006. [DOI: 10.1016/b978-0-323-02598-0.50138-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Angunawela RI, Heatley CJ, Williamson TH, Spalton DJ, Graham EM, Antcliffe RJ, Stanford MR. Intravitreal triamcinalone acetonide for refractory uveitic cystoid macular oedema: longterm management and outcome. ACTA ACUST UNITED AC 2005; 83:595-9. [PMID: 16187999 DOI: 10.1111/j.1600-0420.2005.00438.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE To establish the role of intravitreal triamcinalone acetonide (TA) in the long term management of refractory uveitic cystoid macular oedema (CMO) and to determine the long term visual outcome in these patients. METHOD This is a retrospective observational case series. All patients had resistant CMO and active inflammation. The primary outcome measure was complete resolution of CMO on ocular coherence tomography. Visual acuity and intraocular pressure were also monitored. Twelve eyes of twelve patients received 2 (n = 10) to 4 (n = 2) mg of intravitreal TA. All had previously been unresponsive to orbital floor steroids. Fluorescein angiography was performed where indicated. RESULTS There was complete resolution of CMO in all patients. Nine patients had improvement in acuity at there final follow up (mean follow up 40.5 months). Seven had improved by 2 lines (58%). In 3 patients there was no visual improvement. These 3 failed to respond to re-treatment. Five other patients were re-treated because of recurring CMO and deteriorating VA (median time to re-treatment 4 mths). The mean number of re-treatments for this group with orbital floor TA was three. 41.6% of patients developed ocular hypertension (33.8 mhg mean). One required a trabeculectomy. CONCLUSIONS 2 mg of intravitreal TA is effective even in cases of resistant uveitic CMO. Although re-treatment is often required, the initial response to treatment can be maintained by subsequent orbital floor steroid injections.
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Affiliation(s)
- R I Angunawela
- GKT Department of Ophthalmology, Rayne Institute, St Thomas' Hospital, London, UK
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Cruysberg LPJ, Nuijts RMMA, Gilbert JA, Geroski DH, Hendrikse F, Edelhauser HF. In vitro sustained human transscleral drug delivery of fluorescein-labeled dexamethasone and methotrexate with fibrin sealant. Curr Eye Res 2005; 30:653-60. [PMID: 16109645 DOI: 10.1080/02713680590968600] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To study the use of fibrin sealant as a drug delivery system for the sustained transscleral delivery of dexamethasone and methotrexate. METHODS Scleral sections excised from moist-chamber-stored human globes were mounted in a perfusion chamber. Dexamethasone-fluorescein or methotrexate-fluorescein in either fibrin sealant or balanced salt solution (BSS) was applied to the episcleral surface. BSS was perfused to the choroidal side, fluorescence was measured in perfusate fractions, and an apparent scleral permeability P(A) was calculated for each solute-vehicle combination. RESULTS P(A) for both compounds was significantly lower with fibrin sealant delivery compared to delivery in BSS (p < 0.001). However, the fibrin sealant vehicle provided a more sustained release of both drugs through 24 hr. CONCLUSIONS Incorporating dexamethasone and methotrexate into a fibrin sealant provided a more gradual drug delivery and a more uniform delivery compared to dissolving these drugs in BSS. Fibrin sealant could be useful for transscleral delivery for posterior segment disease.
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Affiliation(s)
- Lars P J Cruysberg
- Department of Ophthalmology, University Hospital of Maastricht, The Netherlands
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Patelli F, Fasolino G, Radice P, Russo S, Zumbo G, DI Tizio FM, Frisone G, Marchi S. TIME COURSE OF CHANGES IN RETINAL THICKNESS AND VISUAL ACUITY AFTER INTRAVITREAL TRIAMCINOLONE ACETONIDE FOR DIFFUSE DIABETIC MACULAR EDEMA WITH AND WITHOUT PREVIOUS MACULAR LASER TREATMENT. Retina 2005; 25:840-5. [PMID: 16205561 DOI: 10.1097/00006982-200510000-00004] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe the changes in retinal thickness (RT) and visual acuity over time in patients with clinically significant diffuse diabetic macular edema (DME) after intravitreal injection of triamcinolone acetonide (IVTA) and to compare patients with and without previous laser treatment. METHODS A total of 23 eyes with clinically significant DME received a 4-mg IVTA injection. Twelve eyes were refractory to macular laser treatment (group 1), and 11 eyes received IVTA as primary therapy (group 2). Visual acuity and changes in macular thickening shown by optical coherence tomography were evaluated 48 hours after injection, every 7 days for 1 month, and at 3 months and 6 months of follow-up. RESULTS RT decreased in all eyes in both groups. The reduction of edema was maximal in the first 7 days after IVTA and tended to remain stable for 3 months. The decrease in RT over time was significant in both groups (P < 0.001). At 6 months, RT had increased in almost all eyes. Visual acuity improved quickly, to a maximum at 2 weeks in both groups, after which it remained stable for 3 months and then decreased. Improvement in visual acuity over time was significant in both groups (P < 0.001). The temporal characteristics of the changes in RT and visual acuity were similar in the two groups (P < 0.05). CONCLUSIONS IVTA was effective in reducing clinically significant DME and improving visual acuity in eyes with and without previous laser treatment. Its action was maximal in the first week and lasted approximately 3 months in this study.
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Affiliation(s)
- Fabio Patelli
- Department of Ophthalmology, "Villa Tiberia" Clinic, Rome, Italy.
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