Evaluation of Intravitreal Kenalog Toxicity in Humans

Reduced Electroretinogram Responses in Morphologically Normal Retina in Patients with Primary Hyperoxaluria Type 1

Purpose

To describe ocular findings in individuals with primary hyperoxaluria type 1 (PH1), focusing on the correlations between retinal anatomy and retinal function. To characterize the retinal alterations that occur at different disease stages by evaluating individuals with diverse degrees of renal impairment associated with PH1.

Design

A cross-sectional study.

Participants

Patients diagnosed with PH1 based on clinical criteria and genetic testing, treated in the Pediatric Nephrology Unit of the Ruth Children's Hospital, Rambam Health Care Campus, Haifa, Israel between 2013 and 2021.

Methods

The ophthalmological assessment included a slit-lamp biomicroscopy of the anterior and posterior segment or indirect ophthalmoscopy. Electroretinography was employed for assessment of the retinal function, and retinal imaging included spectral-domain OCT and fundus autofluorescence. A systematic evaluation of the disease stage was based on clinical criteria including physical examination, purposeful imaging (X-ray, echocardiography, and US abdomen), and laboratory tests as needed.

Main Outcome Measures

Anatomical and functional assessment of the retina in patients with PH1, and the relationship between retinal dysfunction and kidney impairment.

Results

A total of 16 eyes were examined in the study of 8 children ranging in age from 4 to 19 years. Four eyes (25%) showed normal structural and functional retinal findings, 8 eyes (50%) presented functional impairment in the absence of pathological structural findings, and 4 eyes (25%) had advanced retinal damage that manifested as significant morphological and functional impairment. There was no direct relationship between the severity of the renal disease and the severity of the retinal phenotype.

Conclusions

Subjects with PH1 present varying severity levels of the retinal phenotype, with possible discrepancy between the clinical retinal morphology and the retinal function noted on electroretinography. These findings raise questions about the molecular basis of the retinal manifestations in PH1. The presence of functional impairment in the absence of evident crystal deposition in the retina suggests that, in addition to oxalate crystal accumulation, other biomolecular processes may play a role in the development of retinopathy.

Biologic Therapy and Treatment Options in Diabetic Retinopathy with Diabetic Macular Edema

Proliferative diabetic retinopathy and diabetic macular edema can be a potentially sightthreatening disease if not treated correctly. It is directly correlated to the duration of diabetes and how well managed the patients' diabetes is. In the last 15 years, the treatment of diabetic eye disease has taken a quantum leap in methodology due to the group of biological agents named antivascular endothelial growth factor (anti-VEGF). The introduction of the first biological agent has revolutionized the treatment, not only in diabetic eye disease but also across most inflammatory eye diseases, causing leakage of fluid from the blood vessels i.e., in age-related macular degeneration. The availability of these biological agents, despite their considerable costs, have significantly improved the outcomes measured in visual acuity compared to more traditional treatments of diabetic retinopathy in the form of sole laser treatment and glycemic control. The agents demonstrate a favorable safety profile, but if the rarest and most severe side effects occur, there is a potential total loss of vision. This review aims to make an overview of the current pharmaceutical therapeutic options in the treatment of diabetic macular edema. This includes laser therapy, intravitreal steroids, and a primary focus on intravitreal antivascular endothelial growth factors.

Noninfectious endophthalmitis following intravitreal triamcinolone acetonide: clinical case and literature review

OBJECTIVE

To review the literature on noninfectious endophthalmitis (NIE) following intravitreal triamcinolone acetonide (IVTA).

DESIGN

A literature review and case report.

PARTICIPANTS

Individuals who developed NIE after IVTA injection.

METHODS

A review of the literature was undertaken using Ovid MEDLINE and EMBASE databases, and articles available up to and including December 30, 2019, were included. A total of 518 articles were identified, of which 27 were selected. We also present an illustrative case report.

RESULTS

The incidence rate of NIE lies between 0.1% and 7.3% in most studies. Although the etiology of NIE is still the subject of investigation, proposed mechanisms include excipients and rheologic stress caused by small crystals. The time to presentation of NIE is often 1-3 days after IVTA injection, with symptoms of moderate to marked reduction in visual acuity along with signs of anterior chamber inflammatory reaction, hypopyon, and vitritis. Resolution occurs in 1-3 weeks in the majority of patients, and almost all return to their pre-injection visual acuity. Differences in the presentations of NIE, infectious endophthalmitis, and pseudo-endophthalmitis are discussed. We also present an illustrative case report of an 80-year-old woman who developed NIE after an IVTA injection for cystoid macular edema.

CONCLUSIONS

It is important to distinguish NIE from other forms of endophthalmitis because they have different natural histories and require different interventions and follow-up. NIE is rarely accompanied by significant pain or conjunctival erythema. Visual acuity is inconsistently affected and is therefore not a good criterion for identifying the type of presenting endophthalmitis.

Diabetic Retinopathy Clinical Practice Guidelines: Customized for Iranian Population

PURPOSE

To customize clinical practice guidelines (CPGs) for management of diabetic retinopathy (DR) in the Iranian population.

METHODS

Three DR CPGs (The Royal College of Ophthalmologists 2013, American Academy of Ophthalmology [Preferred Practice Pattern 2012], and Australian Diabetes Society 2008) were selected from the literature using the AGREE tool. Clinical questions were designed and summarized into four tables by the customization team. The components of the clinical questions along with pertinent recommendations extracted from the above-mentioned CPGs; details of the supporting articles and their levels of evidence; clinical recommendations considering clinical benefits, cost and side effects; and revised recommendations based on customization capability (applicability, acceptability, external validity) were recorded in 4 tables, respectively. Customized recommendations were sent to the faculty members of all universities across the country to score the recommendations from 1 to 9.

RESULTS

Agreed recommendations were accepted as the final recommendations while the non-agreed ones were approved after revision. Eventually, 29 customized recommendations under three major categories consisting of screening, diagnosis and treatment of DR were developed along with their sources and levels of evidence.

CONCLUSION

This customized CPGs for management of DR can be used to standardize the referral pathway, diagnosis and treatment of patients with diabetic retinopathy.

Acute retinal necrosis after intraocular triamcinolone acetonide injection

PURPOSE

The purpose of this study was to report a case of acute retinal necrosis after combined cataract surgery and intracameral triamcinolone acetonide injection in a healthy elderly patient.

METHODS

Testing used was a clinical examination including fundus photographs, fluo-rescein angiography, and serologic testing.

RESULTS

A 75-year-old healthy white woman undergoing cataract extraction received an injection of intracameral triamcinolone acetonide as a substitute for postoperative topical steroids. Two weeks later, the patient developed acute retinal necrosis, which responded well to systemic antiviral therapy.

CONCLUSION

Acute retinal necrosis is a rare, but potentially devastating, complication that may be associated with intraocular triamcinolone acetonide injection.

Long-term outcomes of triamcinolone acetonide-assisted anterior vitrectomy during complicated cataract surgery with vitreous loss

PURPOSE

To report the long-term outcomes of triamcinolone acetonide-assisted anterior vitrectomy during complicated cataract surgery with vitreous loss.

SETTING

Tel Aviv Medical Center, Tel Aviv, Israel.

DESIGN

Case series.

METHODS

Consecutive patients who had triamcinolone acetonide-assisted anterior vitrectomy for complicated cataract surgery with vitreous loss between January 2010 and January 2012 were studied. The main outcome measures were the results of the ocular examination and spectral-domain optical coherence tomography of the macula at the last follow-up visit 12 months or more postoperatively. The ocular examination included corrected distance visual acuity (CDVA), intraocular pressure (IOP), and anterior segment and fundus biomicroscopy.

RESULTS

The study included 15 patients (15 eyes) with a mean age of 71 years (range 50 to 92 years). The mean follow-up was 21 months (range 12 to 29 months). At the last follow-up, the mean CDVA was statistically significantly better than preoperatively (0.24 logMAR ± 0.31 [SD] versus 0.89 ± 0.81 logMAR) (P=.0033); all patients had improved CDVA over the preoperative values. Except for 1 patient with a macular scar, all the patients had a CDVA between 20/40 and 20/20. At last follow-up, 1 patient required 2 IOP-lowering medications that had been used preoperatively as well. The mean IOP was 15.3 ± 2.4 mm Hg. There were no cases of residual vitreous strands in the anterior chamber, inflammatory reactions, triamcinolone acetonide crystals, retinal breaks, retinal detachment, or pseudophakic cystoid macular edema.

CONCLUSION

Triamcinolone acetonide-assisted anterior vitrectomy during complicated cataract surgery with vitreous loss was safe and effective.

Diabetic macular edema: new trends in management

The treatment of diabetic macular edema may be evolving from a laser ablative approach into a pharmacotherapeutic approach. The exponential growth that has occurred over the past decade in the retinal pharmacotherapy field has led to the development of several pharmacotherapies for retinal vascular diseases such as diabetic macular edema. Many of these agents, in the form of intravitreal injections or sustained delivery devices, have already undergone clinical trial testing for safety and efficacy and many others are currently being similarly evaluated. Some of these agents have proven to be more efficacious than traditional laser therapy, and it is possible that traditional laser therapy for diabetic macular edema may be abandoned altogether in the near future, especially with the introduction of the micropulse laser. However, more research and experience is still needed in order to determine the best treatment agent or combination of therapeutic modalities, as well as the best treatment regimen for a given patient. In this article, we briefly review the major new developments in the field of diabetic macular edema treatment. In addition, we touch on some of the promising forthcoming therapies.

[Efficacy of early injection of intravitreal triamcinolone acetonide (IVTA) versus delayed injection for macular edema resulting from retinal vein occlusion]

PURPOSE

To assess the efficacy of early injection of intravitreal triamcinolone acetonide (IVTA) versus delayed injection for macular edema from retinal vein occlusion.

METHODS

This was a retrospective monocentric study. Forty-four patients received an IVTA (4 mg) for macular edema resulting from central retinal vein or branch retinal vein occlusion. The patients were assigned to two groups: group 1 consisted of patients who received an IVTA less than 6 weeks after the diagnosis of macular edema, while group 2 consisted of patients who received the injection more than 6 weeks after. All patients underwent a comprehensive ophthalmological examination before the injection and 1, 3, and 6 months after. Each visit included best-corrected visual acuity measurement (BCVA), slit lamp examination, intraocular pressure measurement, fundus examination and central macular thickness (CMT) measurement by OCT.

RESULTS

The two groups were comparable in terms of age, sex-ratio, and the percentage of branch retinal vein occlusion (54 and 61% in groups 1 and 2, respectively). In group 1, the BCVA (logMAR) was 0.87 before the IVTA and significantly improved at 1 and 3 months (0.46 and 0.48, respectively; P<0.05) before worsening at the 6-month visit (0.62; P>0.05). The mean CMT was also significantly improved (from 567 μm before the injection to 276, 307, and 386 μm at the 1-, 3-, and 6-month visits, respectively) (P<0.05 at 1 and 3 months). In group 2, there were no significant differences in visual acuity at any time point (0.86 before the IVTA, 0.76, 0.76, and 0.78 at the 1-, 3-, and 6-month visits; P>0.05). The CMT was reduced after the injection from 552 μm to 294, 446, and 456 μm at the 1-, 3-, and 6-month visits, respectively (P<0.05 at 1 month).

CONCLUSION

Patients with macular edema due to retinal vein occlusions, who received a single intravitreal injection of triamcinolone acetate less than 6 months after the diagnosis, displayed both anatomical and functional improvement, whereas patients injected more than 6 weeks after the diagnosis of macular edema showed a CMT reduction but with less improvement in visual acuity. The difference observed at 1 month disappeared after 6 months.

Intraretinal deposition of triamcinolone acetonide after treatment of diabetic macular edema

PURPOSE

To report a case of intraretinal triamcinolone acetonide crystal deposition visualized both clinically and on optical coherence tomography after intravitreal injection for diabetic macular edema refractory to focal/grid laser treatment.

METHODS

Observational case report. A 46-year-old man with severe bilateral diabetic macular edema underwent focal/grid laser therapy, Avastin (Genetech, Inc., South San Francisco, CA) injections, and multiple intravitreal triamcinolone acetonide treatments but remained refractory to treatment.

RESULTS

Visual acuity continued to worsen, and clinical and optical coherence tomography examination revealed scattered hyperreflective deposits throughout the retina.

CONCLUSION

Intravitreal triamcinolone acetonide can deposit within the retina after treatment of refractory diabetic macular edema.

Pharmacotherapeutic efficacy of preservative-free intravitreal triamcinolone acetonide

Preservative-free formulations of triamcinolone acetonide have recently been introduced to the market over concerns of local toxicity of the vehicle and preservatives, including benzyl alcohol in the original formulation, which was not designed for intraocular use. The pharmacokinetics and pharmacodynamics of intravitreal triamcinolone (IVTA) are discussed. The therapeutic effects of IVTA include improvement of visual acuity and reduction of macular edema. However, ongoing treatment is usually required to maintain its effects. The efficacy of IVTA for both FDA-approved and 'off-labeled' indications is reviewed. Elevation of intraocular pressure and cataract formation are the two major side effects of IVTA; these are manageable but require close long-term follow-up. More studies are required to determine the optimal dosage and treatment frequency in different posterior segment disease.

Visual acuity after intravitreal triamcinolone for diabetic macular edema refractory to laser treatment: a meta-analysis

OBJECTIVE

To quantify the effect on visual acuity of intravitreal triamcinolone for the treatment of laser-refractory diabetic macular edema (DME).

STUDY DESIGN

Meta-analysis of eligible studies identified by searching MEDLINE, EMBASE, the Cochrane Library, and Google.

PARTICIPANTS

7 randomized controlled trials and 3 cohort studies.

METHODS

A search of the literature between 1950 and September 2008 identified 540 articles. Studies that evaluated the efficacy of triamcinolone for the treatment of DME refractory to laser photocoagulation, reported visual acuity data, and compared the intervention with an appropriate control group were included. Exclusion criteria were studies of non-DME, triamcinolone used as an adjunct to another treatment, and triamcinolone delivery other than intravitreally.

RESULTS

Using a random-effects model, there was a statistically significant summary mean difference in visual acuity of -0.313 logarithm of the minimum angle of resolution (logMAR) units (95% CI -0.551, -0.074) after 1 month of follow-up. This difference declined to -0.125 logMAR units (95% CI -0.181, -0.070) by 3 months and to -0.043 logMAR units (95% CI -0.090, 0.003) by 6 months. No evidence of publication bias was present. There was a high level of heterogeneity in this group of studies (meta-analysis of 1-month follow-up data: Q-statistic = 21.987, p< 0.001), attributable primarily to study design.

CONCLUSIONS

These meta-analyses demonstrate that intravitreal triamcinolone results in a temporary improvement of visual acuity in patients with laser-refractory DME, with a peak benefit of approximately 3 lines of visual acuity 1 month postinjection.

Visualizing vitreous in vitrectomy by triamcinolone

BACKGROUND

Visualizing vitreous and retinal surface during vitrectomy, choromovitrectomy, is a novel approach in vitrectomy.

METHODS

Triamcinolone acetonide (TA) is now most commonly used as an adjunct to vitrectomy for this purpose. Intraoperative use of TA can visualize posterior hyaloid, preretinal membrane, internal limiting membrane (ILM) during pars plana vitrectomy, and prolapsed vitreous during cataract surgery, which can make the procedure very safe and effective. TA-assisted vitrectomy is favorably applied to surgery for macular hole, proliferative vitreoretinopathy, diabetic retinopathy, uveitis, and others. In addition, this technique can disclose the residual hyaloid cortex pattern after surgical posterior vitreous detachment. Diffuse posterior hyaloids cortex is frequently seen in diabetic retinopathy and high myopia, and an island-like cortex is often left on the macula, which can be a scaffold of future macular pucker.

RESULTS

The prospective controlled clinical trial showed that TA-assisted vitrectomy reduced the incidence of intraoperative retinal break and retinal detachment more significantly than conventional vitrectomy, although post-operative visual acuity after 1 year was almost the same with each method. Adverse events related to TA-assisted vitrectomy included transient intraocular pressure elevation (approximately 5.0%); most of these events are manageable with topical treatment. The incidence of acute endophthalmitis was 0.03-0.05% , which was at a level comparable to conventional vitrectomy.

CONCLUSIONS

In this article, current status and the possible problems of TA-assisted vitrectomy are reviewed.

Anatomic and visual outcomes of noninfectious endophthalmitis after intravitreal triamcinolone

PURPOSE

To describe the anatomic and visual outcomes of patients in whom noninfectious endophthalmitis developed after injection of intravitreal triamcinolone acetonide.

DESIGN

Retrospective case series.

METHODS

Ophthalmologic evaluations of patients in whom noninfectious endophthalmitis developed after intravitreal triamcinolone took place on the day of injection, at the time of presentation of noninfectious endophthalmitis, at the time of clearance of inflammation, and on follow-up examination. Seventeen eyes of 17 patients were identified from 2 institutions. Noninfectious endophthalmitis was identified based on history of visual loss immediately or soon after injection, lack of ocular pain, hypopyon, anterior or vitreous inflammation, and triamcinolone crystals present in the anterior or posterior chambers. Main outcome measures were Snellen visual acuity (VA) and mean foveal thickness by optical coherence tomography.

RESULTS

Mean VA and mean foveal thickness on the day of injection of intravitreal triamcinolone were 20/132 (logarithm of the minimum angle of resolution [logMAR], 0.82 +/- 0.45) and 432 +/- 118 microm, respectively. Mean VA at time of noninfectious endophthalmitis (mean, 1.9 days after injection) was 20/4444 (logMAR, 2.35 +/- 0.98). At last follow-up (mean, 57.6 days), VA and mean foveal thickness were 20/56 (logMAR, 0.44 +/- 0.30) and 301 +/- 71 microm, respectively.

CONCLUSIONS

VA and mean foveal thickness in all patients with noninfectious endophthalmitis after intravitreal triamcinolone improved to better than preinjection levels in this series. At last follow-up, no patient had sustained visual loss from noninfectious endophthalmitis. Noninfectious endophthalmitis after intravitreal triamcinolone may not exclude good visual and anatomic prognoses.

Intravitreal triamcinolone acetonide injection for treatment of refractory diabetic macular edema: a systematic review

OBJECTIVE

To compare intravitreal triamcinolone acetonide (IVTA) injection versus no treatment or sub-Tenon triamcinolone acetonide (STTA) injection in improving visual acuity (VA) of patients with refractory diabetic macular edema (DME; unresponsive to focal laser therapy).

CLINICAL RELEVANCE

Diabetic macular edema is the leading cause of visual loss in diabetic retinopathy. Laser therapy has been the standard of care for patients with persistent or progressive disease. More recently, it has been suggested that IVTA injection may improve VA. METHODS AND LITERATURE REVIEWED: The following databases were searched: Medline (1950-September Week 2 2008), The Cochrane Library (Issue 3, 2008), and the TRIP Database (up to September 1, 2008), using no language or other limits. Randomized controlled trials were included that consisted of patients with refractory DME, those comparing IVTA injection with no treatment or STTA injection, those reporting VA outcomes, and those having a minimum follow-up of 3 months.

RESULTS

In the 4 randomized clinical trials comparing IVTA injection with placebo or no treatment, IVTA injection demonstrated greater improvement in VA at 3 months, but the benefit was no longer significant at 6 months. Those who received IVTA injection had significantly higher IOP at 3 months and at 6 months. In the 2 randomized clinical trials comparing IVTA injection with STTA injection, IVTA injection demonstrated greater improvement in VA at 3 months, but not at 6 months. Intravitreal triamcinolone acetonide injection demonstrated no difference in IOP at 3 months or at 6 months.

CONCLUSIONS

Intravitreal triamcinolone acetonide injection is effective in improving VA in patients with refractory DME in the short-term, but the benefits do not seem to persist in the long-term.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Testing retinal toxicity of drugs in animal models using electrophysiological and morphological techniques

Drugs are frequently tested for retinal toxicity in animal models in order to address applied and basic research questions. When a retinal toxicity study is designed, the researcher needs to consider several factors depending on his/her research questions. Among the factors that need to be addressed before a toxicity study is conducted are: the animal species to be used, choice of experimental (functional and/or morphological) techniques, procedure of testing, period of follow-up, and modes of data analysis. This review is a summary of 20 years' experience of studying retinal toxicity of different drugs in rabbits and rats. The use of the electroretinogram and the visual evoked potential for assessment of outer and inner retinal function, respectively, is described as well as the use of morphological techniques (histology, histochemistry, and immunocytochemistry). The advantages and limitations of functional and morphological techniques are discussed with specific examples from my experience. Recommendations for future drug toxicity studies are summarized.

Intravitreal triamcinolone reduces the morphologic changes of ciliary body after pars plana vitrectomy for retinal vascular diseases

PURPOSE

To investigate the early postoperative changes in ciliary body after pars plana vitrectomy (PPV) for retinal vascular disease and to determine whether intravitreal triamcinolone acetonide (IVTA) affects postvitrectomy changes of the ciliary body.

DESIGN

Prospective interventional case-control study.

METHODS

We recruited 46 patients who underwent uncomplicated PPV for retinal vascular disease (35 with proliferative diabetic retinopathy (PDR) and 11 with branch retinal vein occlusion) and divided the patients into two groups according to the use of IVTA at the end of the PPV. The morphologic changes of the anterior segments were measured by ultrasound biomicroscopy (UBM) one day before and one day, two days, three days, five days, two weeks, one month, and two months after the PPV. The main outcome measures were the thickness and area of the ciliary body, the frequency of supraciliary effusions (SEs), angle-opening, and anterior chamber depth (ACD). We compared the UBM parameters between the two groups.

RESULTS

The thickness and area of the ciliary body significantly increased from day 1 to day 5 postoperatively. Nineteen of 46 eyes had SEs that were frequently associated with divergent alterations of postoperative intraocular pressure (IOP). The angle-opening and ACD were significantly decreased and dependent upon the findings of ciliary body thickness and SEs. The degree of the morphologic changes of the ciliary body and the frequency of SEs were significantly lower and of shorter duration in the IVTA group compared to the non-IVTA group.

CONCLUSIONS

The PPV for retinal vascular disease induces the morphologic changes of the ciliary body associated with postoperative abnormalities in IOP during the early postoperative period. Administration of IVTA at the end of the PPV effectively reduces or shortens the duration of the postvitrectomy changes of the ciliary body.

Safety and pharmokinetics of triamcinolone hexacetonide in rabbit eyes

PURPOSE

The aim of this study was to evaluate whether intravitreal triamcinolone hexacetonide (TH) is a safe, longer lasting alternative to intravitreal triamcinolone acetonide (TA) in the rabbit eye.

METHODS

Three groups, each comprising of 15 Dutch-belted rabbits, received a unilateral injection of 0.1 mL of drug and 0.1 mL of physiologic salt solution in the fellow eye. Group I received TA, group II received commercially available TH, and group III received reformulated iso-osmolar triamcinolone hexacetonide (rTH). Simultaneous bilateral dark-adapted electroretinography was performed following the injection. Retinal morphology was assessed by using histopathology in each group enucleated 12 weeks after injection. High-performance liquid chromatography of vitreous isolated from the enucleated eyes was used to determine drug concentrations.

RESULTS

A significant reduction in saturated a-wave and maximal scotopic b-wave was observed in the group II eyes relative to the fellow control eyes at both 2 and 12 weeks postinjection (P < 0.001 for each comparison) but not in the other groups. Histopathology showed no differences between drug-injected eyes and fellow control eyes in groups I and III, but in group II there was severe degeneration of all retina layers. In group I, the drug half-life was 17.7 +/- 1.7 days, group II 44 +/- 13 days, and group III 12.8 +/- 2.3 days.

CONCLUSIONS

The half-life of commercially available TH in the vitreous is double that of TA, but the former is toxic to the retina in this rabbit model. Reformulated iso-osmolar TH showed no evidence of deleterious effects to retina function or structure but had a similar half-life to TA.

Inflammatory cystoid macular edema

PURPOSE OF REVIEW

The aim of this article is to update our current understanding and management of inflammatory cystoid macular edema.

RECENT FINDINGS

Cystoid macular edema is a common cause of visual loss in uveitis, which occurs predominantly in older patients with chronic uveitis forms and might be heralded by subclinical changes on optic coherence tomography. Cystoid macular edema is emerging as a major cause of visual loss in HIV-infected patients with immune recovery uveitis. Elevated levels of proinflammatory cytokines and vascular endothelial growth factor were found in all types of cystoid macular edema. Treatment with anti-inflammatory and anti-vascular endothelial growth factor drugs is widely applied for all forms of cystoid macular edema and usually has a beneficial, but temporary effect. So far, there are no clear guidelines for the treatment of subclinical cystoid macular edema in uveitis. The effect of vitrectomy in inflammatory cystoid macular edema is not yet clear and might become more important in the future. Recent advances in management include intravitreal drug delivery systems of cystoid macular edema-modifying drugs.

SUMMARY

This review summarizes current thoughts on inflammatory cystoid macular edema focusing on the new, clinically relevant findings. Upcoming data on aqueous constituents in cystoid macular edema and imaging with the new generation of optic coherence tomography offer the hope that a better treatment strategy will soon be established.

Effects of triamcinolone acetonide injections with and without preservative

Using triamcinolone acetonide without preservative may improve safety

Effects of intravitreal triamcinolone acetonide injection with and without preservative

AIMS

To evaluate the effects of intravitreal injection of preservative-free triamcinolone acetonide (PFTA) and TA containing preservative (KE).

METHODS

A retrospective review was conducted of 646 intravitreal 4 mg/0.1 ml steroid injections in 471 eyes. A total of 577 intravitreal injections of PFTA and 69 injections of KE were administered in non-randomised eyes. No supernatant removal from KE was performed. Non-infectious endophthalmitis was defined as pseudohypopyon/hypopyon with or without an inflammatory reaction that regressed after steroid eye drop instillation. Ocular hypertension was defined as more than 23 mm Hg with Goldman applanation tonometry. Patients were followed and examined 1, 7 and 28 days, and 3, 4, 6 and 12 months after injection and annually thereafter. Statistical analysis was performed using Fisher's exact test and Chi(2) test. p Values <0.05 were considered significant.

RESULTS

Both groups did not differ in demographics (p>0.05). Follow-up ranged from 6 to 57 months (mean 13, SD 7.5). Ocular hypertension was present in 127 eyes (20%), but both groups did not differ significantly (p = 0.167). Four eyes (3.15%) required trabeculectomy. Non-infectious endophthalmitis developed in 12 eyes (1.9%) and varied significantly in both groups (p = 0.005). One eye developed bacterial endophthalmitis (0.15%).

CONCLUSIONS

Non-infectious endophthalmitis was observed significantly more often after KE injections (7.3%) than after PFTA injections (1.2%) (p<0.05). An inflammatory reaction was more clinically relevant in the KE group than in the PFTA group.