Frequency and risk factors for intraocular pressure elevation after posterior sub-Tenon capsule triamcinolone acetonide injection

Outcomes of Eyes Lost to Follow-up After Treatment With Intraocular or Periocular Steroid Injections

Purpose: To evaluate the visual, intraocular pressure (IOP), and anatomic outcomes of eyes with loss to follow-up (LTFU) after intravitreal or periocular steroid injections. Methods: Patients receiving intraocular or periocular steroid injections and with LTFU for at least 180 days were included in this retrospective cohort study. Charts were reviewed for the visual acuity (VA), IOP, and central foveal thickness at the visit before LTFU, the first return visit, and 3, 6, and 12 months after return. Results: Fifty-three eyes of 47 patients were identified. The mean (±SD) age was 62.3 ± 14.9 years, the mean LTFU time was 295 ± 181.2 days (range, 182-1101), and the mean follow-up after return was 354 ± 339.3 days (range, 32-1141). The overall mean number of steroid injections was 5.2 ± 3.9 (range, 1-18). Compared with the mean logMAR VA at the visit before LTFU (0.59 [Snellen 20/77]), the mean VA remained stable at all timepoints after return as follows: return visit (0.62 [20/83]; P = .6), month 3 (0.55 [20/70]; P = .6), month 6 (0.55 [20/70]; P = .5), month 12 (0.64 [20/87]; P = .6), and final visit (0.69 [20/97]; P = .2). At the first return visit, 8 (15%) of 53 patients had an IOP of 21 mm Hg or higher (range, 21-31); 2 required treatment with a new antihypertensive medication (latanoprost and timolol, respectively). Conclusions: Patients with LTFU after receiving steroid injections maintained their VA. No patient required incisional glaucoma surgery. Compared with other etiologies, eyes with diabetic macular edema had a greater increase in IOP.

Characteristics of Eyes Requiring Trabeculotomy for Glaucoma With Steroid Treatment: Atopic Dermatitis and Factors Affecting Surgical Outcomes

PURPOSE

The aim is to analyze the surgical outcomes of glaucomatous patients with steroid treatment and investigate the factors, including atopic dermatitis, associated with the surgical success rate.

MATERIALS AND METHODS

We retrospectively enrolled participants who required first trabeculotomy for glaucoma with steroid treatment between May 2005 and February 2018 and then compared the postoperative outcomes according to the history of atopic dermatitis or surgical procedures. Surgical success was defined as postoperative IOP ≤ 21 mmHg, ≥20% reduction from baseline, and absence of reoperation. The factors influencing the surgical success rates were investigated using mixed-effects Cox regression.

RESULTS

The study included 70 eyes of 46 patients (18 eyes of 12 patients with atopic dermatitis). Postoperative intraocular pressure was not significantly different between eyes with and without atopic dermatitis (12 months after the surgery: patients without atopic dermatitis, 15.4 ± 3.6 mmHg; patients with atopic dermatitis, 16.1 ± 3.9 mmHg; P = 0.65). Twelve months after the surgery, the number of postoperative medications was higher in patients with atopic dermatitis than in those without (2.8 ± 1.3 vs. 2.0 ± 1.7; P = 0.060). However, no significant differences were noted in surgical success rates between patients with atopic dermatitis and those without (P = 0.54). Mixed-effects Cox regression of surgical success rate indicated that only the number of preoperative medications significantly influenced surgical success (P = 0.03).

CONCLUSIONS

Regardless of the presence of atopic dermatitis, patients taking many preoperative glaucomatous medications might require reoperation.

Anti-Vascular Endothelial Growth Factor Therapy with or Without Initial Steroid Therapy for Macular Edema in Branch Retinal Vein Occlusion

Purpose

In branch retinal vein occlusion (BRVO), administering steroid injections to inhibit expression of inflammatory factors in the first phase of macular edema may reduce recurrence of the edema. The purpose of our study was to investigate the functional and morphological prognosis and frequency of recurrence after injection of an anti-vascular endothelial growth factor (VEGF) with and without initial steroid therapy to treat macular edema with BRVO.

Patients and Methods

Patients with BRVO and macular edema (41 eyes) received intravitreal ranibizumab injection (IRI) alone (IRI group, 21 eyes) or subtenon triamcinolone (STTA) injection and IRI (combination group, 20 eyes). Patients in both groups with recurrent macular edema received further IRI as appropriate. A laser flare meter was used to assess aqueous flare values, and an optical coherence tomography device was used to measure central macular thickness (CMT). Before the first treatment, we obtained samples of aqueous humor and analyzed them by the suspension array method to evaluate VEGF, placental growth factor (PlGF), platelet-derived growth factor (PDGF)-AA, soluble intercellular adhesion molecule (sICAM)-1, monocyte chemoattractant protein 1 (MCP-1), interleukin (IL)-6, IL-8, and interferon-inducible 10-kDa protein (IP-10).

Results

The two groups were not significantly different with regard to levels of VEGF, PlGF, PDGF-AA, sICAM-1, MCP-1, IL-6, IL-8, or IP-10. Best-corrected visual acuity, CMT, and aqueous flare value (IRI group, baseline 8.69 ± 4.55 photon counts/ms; combination group, baseline 9.21 ± 3.72 photon counts/ms) improved significantly in both groups without significant intergroup differences. Analyses showed no significant intergroup differences in the mean number of IRIs during the 12-month follow-up, but the proportion of patients without recurrence (ie, who received only one IRI) was significantly higher in the combination group than in the IRI group (P = 0.032). Furthermore, the time to initial recurrence was significantly longer in the combination group than in the IRI group (P = 0.003).

Conclusion

These findings suggest that initial STTA injection and IRI may have a synergistic effect in patients with BRVO and macular edema in that they increase the time between anti-VEGF treatments.

Recent advances and future prospects: current status and challenges of the intraocular injection of drugs for vitreoretinal diseases

Effective drug therapy for vitreoretinal disease is a major challenge in the field of ophthalmology; various protective systems, including anatomical and physiological barriers, complicate drug delivery to precise targets. However, as the eye is a closed cavity, it is an ideal target for local administration. Various types of drug delivery systems have been investigated that take advantage of this aspect of the eye, enhancing ocular permeability and optimizing local drug concentrations. Many drugs, mainly anti-VEGF drugs, have been evaluated in clinical trials and have provided clinical benefit to many patients. In the near future, innovative drug delivery systems will be developed to avoid frequent intravitreal administration of drugs and maintain effective drug concentrations for a long period of time. Here, we review the published literature on various drugs and administration routes and current clinical applications. Recent advances in drug delivery systems are discussed along with future prospects.

Nanomedicine and drug delivery to the retina: current status and implications for gene therapy

Blindness affects more than 60 million people worldwide. Retinal disorders, including age-related macular degeneration (AMD), diabetic retinopathy (DR), and glaucoma, are the leading causes of blindness. Finding means to optimize local and sustained delivery of drugs or genes to the eye and retina is one goal to advance the development of new therapeutics. Despite the ease of accessibility of delivering drugs via the ocular surface, the delivery of drugs to the retina is still challenging due to anatomic and physiologic barriers. Designing a suitable delivery platform to overcome these barriers should enhance drug bioavailability and provide a safe, controlled, and sustained release. Current inventions for posterior segment treatments include intravitreal implants and subretinal viral gene delivery that satisfy these criteria. Several other novel drug delivery technologies, including nanoparticles, micelles, dendrimers, microneedles, liposomes, and nanowires, are now being widely studied for posterior segment drug delivery, and extensive research on gene delivery using siRNA, mRNA, or aptamers is also on the rise. This review discusses the current state of retinal drug/gene delivery and highlights future therapeutic opportunities.

Intermediate Uveitis: A Review

PURPOSE

This review aims to provide an update on the clinical presentation, etiologies, complications, and treatment options in intermediate uveitis (IU).

METHODS

Narrative literature review.

RESULTS

IU affects all age groups with no clear gender predominance and has varied etiologies including systemic illnesses and infectious diseases, or pars planitis. In some instances, IU may be the sole presentation of an underlying associated condition or disease. Management of IU and its complications include administration of corticosteroids, antimetabolites, T-cell inhibitors, and/or biologics, along with surgical interventions, with varying degrees of effectiveness across literature. In particular, increasing evidence of the safety and efficacy of immunomodulatory agents and biologics has seen greater adoption of these therapies in clinical practice.

CONCLUSIONS

IU is an anatomical description of uveitis, involving intraocular inflammation of the vitreous, peripheral retinal vasculature, and pars plana. Various treatment options for intermediate uveitis are currently used in practice.

Anterior Migration of Triamcinolone Acetonide after Posterior Subtenon Injection for Macular Edema Predisposes to Intraocular Pressure Elevation

PURPOSE

To evaluate the effect of anterior migration of triamcinolone acetonide on intraocular pressure (IOP) elevation after posterior subtenon injection of triamcinolone acetonide (PSTA) for macular edema.

METHODS

One hundred and ten eyes from 89 patients who received PSTA for macular edema were prospectively enrolled. The extent of anterior migration of triamcinolone acetonide was recorded immediately after the injection. If TA particles were visible in the subtenon space (or subconjunctival space), it was recorded as "anterior subtenon migration" (or "anterior subconjunctival migration"). The correlation between anterior migration of triamcinolone acetonide and severe IOP elevation, which was defined as an increase of 8 mm Hg or more in IOP, was evaluated.

RESULTS

A total of 159 PSTAs were given to 110 eyes. After PSTA, anterior subtenon migration occurred in 70.4% and anterior subconjunctival migration occurred in 12.0% of injection. Severe IOP elevation occurred in 7.1% of those without anterior migration, in 25.9% of those with anterior subtenon migration, and in 31.6% of those with anterior subconjunctival migration after PSTA (P = .052). Compared to those without anterior migration of triamcinolone acetonide, the hazard ratio for severe IOP elevation was 3.307 in those with anterior subtenon migration (P = .12) and 5.289 in those with anterior subconjunctival migration (P = .042).

CONCLUSIONS

Anterior migration of triamcinolone acetonide after PSTA predisposes eyes to severe IOP elevation. Careful injection to restrict the triamcinolone particle within the subtenon space and behind the equator may lower the rate of IOP elevation after PSTA.

Ocular hypertension following 40 mg sub-Tenon triamcinolone versus 0.7 mg dexamethasone implant versus 2 mg intravitreal triamcinolone

OBJECTIVE

To compare rates of ocular hypertension (OHT) in eyes receiving 40 mg sub-Tenon triamcinolone (STT), 0.7 mg dexamethasone implant (DEX), and 2 mg intravitreal triamcinolone (IVT).

METHODS

This study is a single-centre, retrospective case series. All patients receiving STT and DEX between 4/1/2014 and 3/1/2017 and IVT between 3/1/2012 and 3/1/2017 with a minimum of 3 months' follow-up were included. OHT was defined as an intraocular pressure (IOP) >24 mm Hg. Patients receiving any other form of topical, oral, or intravitreal steroid were excluded.

RESULTS

113 eyes from 104 patients in the STT group, 122 eyes from 109 patients in the DEX group, and 109 eyes from 103 patients in the IVT group were included. The mean number of injections for each eye was 1.7 in the STT group, 2.6 for the DEX group, and 2.8 for the IVT group (p < 0.001). Twenty eyes (17.7%) developed OHT in the STT group, 19 eyes (15.6%) developed OHT in the DEX group, and 14 eyes (12.8%) developed OHT in the IVT group (p = 0.60). IOP was controlled in all eyes with observation, topical IOP-lowering medication, or surgical intervention. The rate of incisional glaucoma surgery was 1.7% in the STT group, 1.6% in the DEX group, and 0% in the IVT group (p = 0.55).

CONCLUSIONS

The rate of OHT was similar across treatment groups. The proportion of OHT in patients with a history of glaucoma was no different from that in patients without a history of glaucoma. All cases were successfully managed with observation, medical treatment, or incisional surgery.

Ocular hypertension and severe intraocular pressure elevation after posterior subtenon injection of triamcinolone acetonide for various diseases

AIM

To evaluate and compare the incidences of ocular hypertension and severe intraocular pressure (IOP) elevation after posterior subtenon injection of triamcinolone acetonide (PSTA) for various diseases.

METHODS

Totally 179 eyes that had received PSTA for diabetic macular edema (n=108), pseudophakic cystoid macular edema (n=20), branch retinal vein occlusion (n=16), central retinal vein occlusion (CRVO, n=14), choroidal neovascularization (n=14) or noninfectious uveitis (n=7) were retrospectively enrolled. The primary outcomes included ocular hypertension defined as an IOP>21 mm Hg, and severe IOP elevation defined as a rise of 10 mm Hg or more in IOP compared with baseline. Cox regression models were used to analyze the hazard ratios (HRs) among different diseases.

RESULTS

After PSTA, the mean IOPs from month 1 to month 6 all significantly increased (P<0.05). Ocular hypertension occurred in 30.7% of eyes (median time: 8wk), and severe IOP elevation occurred in 16.2% of eyes (median time: 9wk). Patients receiving PSTA for CRVO or uveitis had a significantly higher risk for ocular hypertension (HR=3.049, P=0.004 for CRVO; HR=5.464, P=0.019 for uveitis) and severe IOP elevation (HR=2.913, P=0.034 for CRVO; HR=7.650, P=0.009 for uveitis).

CONCLUSION

IOP significantly increases within 6mo after PSTA, with the onset of ocular hypertension happening mostly at 2 to 3mo. Patients of CRVO or noninfectious uveitis have a higher risk of ocular hypertension or severe IOP elevation after PSTA and should be monitored for IOP more carefully.

Steroid-induced glaucoma: Epidemiology, pathophysiology, and clinical management

Glucocorticoids are a class of anti-inflammatory drugs commonly used to treat various ocular and systemic conditions. Although the role of glucocorticoids in the treatment of numerous serious inflammatory diseases is pivotal, their prolonged use may increase intraocular pressure resulting in steroid-induced glaucoma. We provide a detailed update on steroid-induced glaucoma as a preventable cause of blindness in the adult and pediatric population and describe its epidemiology, social impact, and risk factors. Furthermore, we explore the propensity of different steroids to increase the intraocular pressure, the role of different routes of steroid administration, dosage and duration of treatment, as well as the clinical features, genetics, and management of steroid-induced glaucoma.

Comparison of Modified Posterior Sub-Tenon's vs. Trans-Septal Triamcinolone Injection for Non-infectious Uveitis

Purpose: To compare the safety and efficacy of trans-septal vs. modified posterior sub-Tenon's (PST) corticosteroid injections for noninfectious uveitis.Methods: Retrospective comparison of periocular triamcinolone injection by modified PST (n = 36) vs. traditional trans-septal (n = 79) techniques. Safety and efficacy outcomes were analyzed with regression models.Results: There was no significant difference in visual acuity improvement between the groups at 6 months. There were higher rates of vitritis resolution in the modified PST group but this was not statistically significant (85.7% vs 62.9%, p = .07). Intraocular pressure (IOP) elevation rate trended higher with the modified PST injection (21.9% vs 9.0%, p = .06), with no instances of glaucoma surgery in either group. Two modified PST injection patients with refractory IOP rises had IOP normalization after corticosteroid depot removal. One year cataract surgery rates were similar.Conclusion: Modified PST injection offers clinical efficacy but with possibly higher IOP response rate which could be managed with corticosteroid removal.

Intraocular pressure elevation after subtenon triamcinolone acetonide injection; Multicentre retrospective cohort study in Japan

Purpose

To evaluate real-world evidence for intraocular pressure (IOP) elevation after subtenon triamcinolone acetonide injection (STTA) in 1252 Japanese patients (1406 eyes) in the Japan Clinical REtina STudy group (J-CREST).

Methods

This was a multicentre retrospective study of the medical records of 1252 patients (676 men (758 eyes); mean age: 63.8 ± 12.9 years) who received STTA in participating centres between April 2013 and July 2017.

Results

IOP elevation was observed in 206 eyes (14.7%) and IOP increase ≥ 6 mmHg was found in 328 eyes (23.3%). In total, 106 eyes (7.5%) needed medication and two eyes (0.14%) needed surgical procedures. Younger age, higher baseline IOP, and steroid dose were risk factors associated with IOP elevation. Risk factors associated with IOP increase ≥ 6 mmHg were younger age, lower baseline IOP, steroid dose, and higher incidences of diabetic macular oedema (DME) and uveitis. In contrast, with steroid dose fixed at 20 mg, a lower incidence of DME was a risk factor for increased IOP, suggesting that STTA had dose-dependent effects on IOP increase, especially in patients with DME.

Conclusion

Our real-world evidence from a large sample of Japanese patients who received STTA showed that the incidence of IOP elevation after STTA was 14.7%, and was associated with younger age, higher baseline IOP, and steroid dose. Thus, IOP should be monitored, especially in patients with younger age, higher baseline IOP, and higher incidences of DME and uveitis.

Update in treatment of uveitic macular edema

Macular edema (ME) represents the most common cause for visual loss among uveitis patients. The management of uveitic macular edema (UME) may be challenging, due to its often recalcitrant nature. Corticosteroids remain the mainstay of treatment, through their capability of effectively controlling inflammation and the associated ME. Topical steroids may be effective in milder cases of UME, particularly in edema associated with anterior uveitis. Posterior sub-Tenon and orbital floor steroids, as well as intravitreal steroids often induce rapid regression of UME, although this may be followed by recurrence of the pathology. Intra-vitreal corticosteroid implants provide sustained release of steroids facilitating regression of ME with less frequent injections. Topical nonsteroidal anti-inflammatory drugs may provide a safe alternative or adjuvant therapy to topical steroids in mild UME, predominantly in cases with underlying anterior uveitis. Immunomodulators including methotrexate, mycophenolate mofetil, tacrolimus, azathioprine, and cyclosporine, as well as biologic agents, notably the anti-tumor necrosis factor-α monoclonal antibodies adalimumab and infliximab, may accomplish the control of inflammation and associated ME in refractory cases, or enable the tapering of steroids. Newer biotherapies have demonstrated promising outcomes and may be considered in persisting cases of UME.

Outcomes of Ahmed glaucoma valve implantation for steroid-induced elevated intraocular pressure in patients with retinitis pigmentosa

PURPOSE

To evaluate the outcomes of Ahmed glaucoma valve (AGV) in the management of elevated intraocular pressure (IOP) secondary to steroid use for macular edema in patients with retinitis pigmentosa (RP).

METHODS

A total of nine eyes of five patients were evaluated retrospectively. Complete success was defined as IOP ≤ 21 mmHg without glaucoma medications, while qualified success was defined as IOP ≤ 21 mmHg with glaucoma medications.

RESULTS

Mean age at surgery was 25.0 ± 8.3 years, and mean follow-up time was 38.4 ± 13.2 months. Mean IOP was 41.0 ± 8.3 mmHg preoperatively, 9.4 ± 3.5 mmHg at first week (p = 0.008), 13.1 ± 3.6 mmHg at first month (p = 0.008), 14.8 ± 4.1 mmHg at 6th month (p = 0.008), 11.7 ± 2.6 mmHg at 12th month (p = 0.008), 12.4 ± 2.9 mmHg at 24th month (p = 0.008), 12.6 ± 3.6 mmHg at 36th month (p = 0.043) and 12.8 ± 4.2 mmHg at 48th month (p = 0.068) postoperatively. The mean number of topical anti-glaucomatous medications decreased from 2.8 ± 0.4 preoperatively to 0.4 ± 0.9 postoperatively (p = 0.007). Complete success was obtained in 7 (77%) eyes, and qualified success in 2 (23%) eyes. No failure was detected.

CONCLUSIONS

AGV implantation can be considered as an alternative and safe option in the management of resistant, elevated IOP secondary to steroid treatment for macular edema in patients with RP.

Episcleral drug film for better-targeted ocular drug delivery and controlled release using multilayered poly-ε-caprolactone (PCL)

Triamcinolone acetonide (TA) and poly-ε-caprolactone (PCL) were engineered into a micro drug film for episcleral application to better manage chronic vitreoretinal diseases such as proliferative vitreoretinopathy (PVR). Compared to an intravitreal drug injection, this drug film is much safer without breaking into ocular barriers. Compared to a traditional subtenon injection, this drug film demonstrated superior therapeutic duration, better drug bioavailability in the choroid and retina, and better-targeted drug delivery ability. The rabbit eye study demonstrated that using the PCL-TA film led to 5.6 and 3.4 times higher drug AUC in the choroid and the retina respectively than in eyes following a subtenon drug injection. The mean drug residence time in the rabbit choroid was also doubled by using the episcleral TA film (86days versus 43days). Remaining TA in the drug film was consistently higher than that in the subtenon space, indicating controlled release of TA by the PCL-TA film. The pharmacokinetics of triamcinolone in the choroid and retina were optimized from typical first-order kinetics to a more sustained release by use of this film. This episcleral film system worked better on rabbit eyes than on guinea pig eyes, indicating that scleral thickness and eye size may be crucial aspects to consider when choosing an animal model or when designing a transscleral delivery device for human use. This engineered drug film may be very useful in preventing and managing PVR associated with open globe trauma or surgical repair for retinal detachment.

STATEMENT OF SIGNIFICANCE

This study demonstrated a novel micro episcleral drug film that is made from the engineering of triamcinolone acetonide (TA) into poly-ε-caprolactone (PCL). The film can be conveniently placed at the injury or disease site during primary surgery and provide controlled release of TA for four months that covers the high-risk time window for developing proliferative vitreoretinopathy (PVR). This engineered drug film may be very useful in preventing and managing PVR associated with open globe trauma or intraocular surgery.

Combination therapy of intravitreal bevacizumab with single simultaneous posterior subtenon triamcinolone acetonide for macular edema due to branch retinal vein occlusion

PurposeTo evaluate efficacy and safety of combination therapy of intravitreal bevacizumab (IVB) with single simultaneous posterior subtenon triamcinolone acetonide (STA) for treatment of macular edema (ME) secondary to branch retinal vein occlusion (BRVO).MethodsThis was a prospective, randomized, interventional comparative study conducted in 45 eyes with ME secondary to BRVO who were treated primarily with IVB 1.25 mg (23 eyes, IVB group) or combination therapy of IVB 1.25 mg with a single simultaneous STA 40 mg (18 eyes, IVB/STA group). Reinjections were performed with IVB if optical coherence tomography (OCT) showed recurrent ME associated with decreased visual acuity. The main outcome measurement was the number of additional IVB injections, and changes of best-corrected visual acuity (BCVA) and central macular thickness (CMT) during a 6-month follow-up period were compared.ResultsBCVA showed significant improvement in two groups at 6 months. In addition, CMT showed significant decrease in two groups at 6 months. No significant differences in the change of BCVA and CMT at 6 months after injection (P=0.973, P=0.639) were observed between the two groups. A statistically significant difference was found regarding the number of additional IVB injections (IVB group 0.96±0.83; IVB/STA group 0.44±0.70, P=0.034).ConclusionAlthough combination therapy of IVB with a single simultaneous STA for treatment of ME secondary to BRVO did not affect the visual outcomes compared with IVB monotherapy, it had a benefit of reducing the number of additional IVB injections.

Combined Intravitreal Ranibizumab and Sub-Tenon Injection of Triamcinolone for the Treatment of Diabetic Macular Edema with Retinal Detachment

PURPOSE

To evaluate the efficacy of intravitreal ranibizumab (IVR) combined with posterior sub-Tenon injection of triamcinolone acetonide (STTA) for treatment of diabetic macular edema (DME) with serous retinal detachment (SRD).

METHODS

Eighty-five eyes of 65 patients with DME and SRD were enrolled in this retrospective study. Fifty-eight eyes were treated with IVR and STTA (combined group), whereas 27 eyes were treated with pro re nata (PRN) IVR (control group). The combined group patients received a single and the control group patients received mean 1.29 ± 0.46 injections and followed for 3 months. The primary outcome measures were change in central macular thickness (CMT) and best corrected visual acuity (BCVA). The secondary outcome measure was the complication rate.

RESULTS

In the combined group, mean initial CMT was 543.9 ± 133.5 μm. Macular thickness was significantly reduced both after 1 month (334 ± 88 μm; P < 0.001) and after 3 months (387.6 ± 131.9 μm; P < 0.001) of treatment. At the 3-month follow-up, BCVA improved in 37.2% of the eyes. Complications were drug reflux at the time of STTA injection, elevation of intraocular pressure, and migration of hard exudates to the fovea. The decrease in CMT was statistically significant in the combined group in the first month, but not in the third month compared with the control group. The improvement in BCVA was not statistically significant between the 2 groups both after the first and third months. SRD disappeared with a higher rate with the combined therapy in the first month.

CONCLUSION

IVR and STTA seem to be effective in improving BCVA in DME with SRD.

Periocular corticosteroid injections in uveitis: effects and complications

PURPOSE

To evaluate the benefits and complications of periocular depot corticosteroid injections in patients with ocular inflammatory disorders.

DESIGN

Multicenter, retrospective cohort study.

PARTICIPANTS

A total of 914 patients (1192 eyes) who had received ≥ 1 periocular corticosteroid injection at 5 tertiary uveitis clinics in the United States.

METHODS

Patients were identified from the Systemic Immunosuppressive Therapy for Eye Diseases Cohort Study. Demographic and clinical characteristics were obtained at every visit via medical record review by trained reviewers.

MAIN OUTCOME MEASURES

Control of inflammation, improvement of visual acuity (VA) to ≥ 20/40, improvement of VA loss attributed to macular edema (ME), incident cataract affecting VA, cataract surgery, ocular hypertension, and glaucoma surgery.

RESULTS

Among 914 patients (1192 eyes) who received ≥ 1 periocular injection during follow-up, 286 (31.3%) were classified as having anterior uveitis, 303 (33.3%) as intermediate uveitis, and 324 (35.4%) as posterior or panuveitis. Cumulatively by ≤ 6 months, 72.7% (95% CI, 69.1-76.3) of the eyes achieved complete control of inflammation and 49.7% (95% CI, 45.5-54.1) showed an improvement in VA from <20/40 to ≥ 20/40. Among the subset with VA <20/40 attributed to ME, 33.1% (95% CI, 25.2-42.7) improved to ≥ 20/40. By 12 months, the cumulative incidence of ≥ 1 visits with an intraocular pressure of ≥ 24 mmHg and ≥ 30 mmHg was 34.0% (95% CI, 24.8-45.4) and 15.0% (95% CI, 11.8-19.1) respectively; glaucoma surgery was performed in 2.4% of eyes (95% CI, 1.4-3.9). Within 12 months, among phakic eyes initially ≥ 20/40, the incidence of a reduction in VA to <20/40 attributed to cataract was 20.2% (95% CI, 15.9-25.6); cataract surgery was performed within 12 months in 13.8% of the initially phakic eyes (95% CI, 11.1-17.2).

CONCLUSIONS

Periocular injections were effective in treating active intraocular inflammation and in improving reduced VA attributed to ME in a majority of patients. The response pattern was similar across anatomic locations of uveitis. Overall, VA improved in one half of the patients at some point within 6 months. However, cataract and ocular hypertension occurred in a substantial minority.

Sustained release of triamcinolone acetonide from an episcleral plaque of multilayered poly-ε-caprolactone matrix

A subtenon injection of triamcinolone acetonide (TA) is a widely used treatment modality for various chorio-retinal diseases. Although it is less invasive than intravitreal injection, it can produce dose-associated ocular complications and has the disadvantages associated with systemic TA exposure. In this study we have developed and evaluated an episcleral film consisting of TA and poly-ε-caprolactone (PCL). The films were prepared by spraying a mixture of PCL in dichloromethane and TA in acetone. The films were produced as 6mm wide and 12 mm long episcleral plaques. X-ray diffraction demonstrated an even distribution of TA crystals in PCL, although the TA was less crystalized than a native TA control. Fourier transform infrared spectroscopy revealed effective integration of TA within the PCL matrix. An in vitro study of the release of TA from the episcleral plaques showed that TA release rate was only 40-50% that of the equivalent native TA control. An in vivo study demonstrated that the plaques were well tolerated in rabbit eyes with significantly less systemic TA exposure. The episcleral plaques provided therapeutic vitreous TA levels for 3 months, while TA levels in the vitreous were detectable for only 1 month following an equivalent dose by subtenon TA injection. The PCL-TA 30-60 episcleral plaque may be further developed as a better alternative treatment for many chronic vitreo-retinal diseases, providing longer and controlled release and fewer drug-associated complications than those associated with a conventional subtenon injection of TA.

Congenital cataract surgery with intracameral triamcinolone: pre- and postoperative central corneal thickness and intraocular pressure

PURPOSE

To evaluate the change in intraocular pressure (IOP) and central corneal thickness (CCT) of children who underwent congenital cataract surgery with injection of triamcinolone acetonide into the anterior chamber at the end of the procedure.

METHODS

Fifty-three eyes of 34 children <2 years of age who underwent congenital cataract surgery with injection of 1.2 mg/0.03 mL of preservative-free triamcinolone acetonide into the anterior chamber at the end of the procedure were included in this study. IOP and CCT were measured preoperatively and at a mean of 2 and 12 months' follow-up.

RESULTS

The mean IOP was 8.7 ± 0.4 mm Hg preoperatively, 8.4 ± 0.6 mm Hg at the 2-month follow-up, and 8.1 ± 0.3 mm Hg at the 12-month follow-up. The mean CCT was 562 ± 11 μm preoperatively, 563 ± 10 μm at the 2-month follow-up, and 570 ± 10 μm at the 12-month follow-up. There was no significant change in either pre- or postoperative IOP (P = 0.700) or CCT (P = 0.419) over the study period.

CONCLUSIONS

Injection of 1.2 mg triamcinolone acetonide at the end of congenital cataract surgery in children <2 years of age did not significantly affect IOP or CCT in the first year after surgery.

Steroid-induced iatrogenic glaucoma

Steroids in susceptible individuals can cause a clinical condition similar to primary open-angle glaucoma. Five percent of the population are high steroid responders and develop an intraocular pressure (IOP) elevation of more than 15 mm Hg above baseline. IOP elevation may occur as early as 1 day to as late as 12 weeks after intravitreal triamcinolone in 20-65% of patients. On average, 75% of eyes with steroid implants require IOP-lowering therapy at some point within 3 years of follow-up. The exact mechanism of steroid-induced glaucoma is not totally understood, but decreased trabecular meshwork outflow is regarded as the main cause of IOP elevation. High-risk patients who receive steroids should be monitored closely and if they develop elevated IOP, steroids with lower potency or steroid-sparing agents should be used. The IOP usually returns to normal within 2-4 weeks after stopping the steroid. About 1-5% of patients do not respond to medical therapy and need surgery. Trabeculectomy, trabeculotomy, shunt surgery, and cyclodestructive procedures are among the methods employed. Removal of residual sub-Tenon or intravitreal steroids may help hasten the resolution of the steroid response. Early results with anecortave acetate, an analog of cortisol acetate with antiangiogenic activity, in controlling IOP have been promising.

Success rates of trabeculotomy for steroid-induced glaucoma: a comparative, multicenter, retrospective cohort study

PURPOSE

To evaluate the surgical outcomes of trabeculotomy for steroid-induced glaucoma.

DESIGN

Multicenter, retrospective cohort study.

METHODS

At 17 Japanese clinical centers, 121 steroid-induced glaucoma patients who underwent trabeculotomy between 1997 and 2006 were reviewed. Surgical failure was defined by the need for additional glaucoma surgery, deterioration of visual acuity to no light perception, or intraocular pressure ≥21 mm Hg (criterion A) and ≥18 mm Hg (criterion B). Surgical outcomes were compared with those of 108 primary open-angle glaucoma (POAG) patients who underwent trabeculotomy and 42 steroid-induced glaucoma patients who underwent trabeculectomy. Prognostic factors for failure were evaluated using the Cox proportional hazards model.

RESULTS

The probabilities of success at 3 years for trabeculotomy for steroid-induced glaucoma vs trabeculotomy for POAG was 78.1% vs 55.8% for criterion A (P = .0008) and 56.4% vs 30.6% for criterion B (P < .0001), respectively. At 3 years, the success of trabeculotomy for steroid-induced glaucoma was comparable to trabeculectomy for steroid-induced glaucoma for criterion A (83.8%; P = .3636), but lower for criterion B (71.6%; P = .0352). Prognostic factors for failure of trabeculotomy for steroid-induced glaucoma were previous vitrectomy (relative risk [RR] = 5.340; P = .0452 on criterion A, RR = 3.898; P = .0360 for criterion B) and corticosteroid administration other than ocular instillation (RR = 2.752; P = .0352 for criterion B).

CONCLUSIONS

Trabeculotomy is effective for controlling intraocular pressure <21 mm Hg in steroid-induced glaucoma eyes.

Intravitreal versus sub-tenon posterior triamcinolone injection in bilateral diffuse diabetic macular edema

PURPOSE

To compare the efficacy of intravitreal and sub-Tenon (ST) posterior triamcinolone injection in the treatment of bilateral diabetic diffuse macular edema (DDME).

METHODS

28 eyes of 14 diabetic patients with bilateral DDME were included in this prospective randomized study. One eye of each individual received a sub-Tenon (ST) posterior triamcinolone injection (ST group), whereas the fellow eye received an intravitreal triamcinolone injection (IV group). All eyes were treated with supplementary focal laser after the injections. Cases were evaluated 1, 2, 3 and 6 months after the initial treatment.

RESULTS

Both groups had visual improvement and macular edema reduction following the injections. This temporary effect was prominent for 24 weeks in the IV group and for 8 weeks in the ST group. Edema resorption and visual improvement were more pronounced in the IV group, although this difference was not statistically significant. No major complications were observed except for moderate and reversible intraocular pressure elevation in some cases.

CONCLUSION

Both intravitreal and ST injections of triamcinolone appear to yield a significant visual recovery and prompt resolution of DDME. The beneficial outcome appears to be more longstanding with intravitreal injection.

Combined fluocinolone acetonide intravitreal insertion and glaucoma drainage device placement for chronic uveitis and glaucoma

PURPOSE

To determine whether a fluocinolone acetonide sustained-release intravitreal drug delivery system can be implanted safely at the same time that a glaucoma drainage device is placed for eyes with uveitis and elevated intraocular pressure (IOP) receiving maximum tolerated IOP-lowering therapy.

DESIGN

Retrospective, observational case series.

METHODS

Subjects had chronic noninfectious intermediate or posterior uveitis and elevated IOP while receiving maximum tolerated medical therapy. Fluocinolone acetonide implantation and glaucoma tube shunt placement were performed in a single surgical session. The main outcome measures were inflammatory recurrences, visual acuity (VA), use of adjunctive anti-inflammatory therapy, IOP, and adverse events.

RESULTS

Seven eyes of 5 patients were studied. The average number of recurrences 12 months before implantation was 3 episodes per eye; of the 3 eyes followed up for more than 30 months, none had an inflammatory recurrence within 30 months after implantation. The mean Snellen visual acuity 12 months after the combined surgery was 20/114, compared with 20/400 at baseline. Adjunctive steroid use decreased. Average IOP decreased from 27.3 mm Hg at baseline to 14.6 mm Hg 12 months after the combined surgery (P = .019).

CONCLUSIONS

The favorable results observed in all eyes suggest that fluocinolone acetonide implantation can be safely combined with glaucoma tube shunt placement in a single surgical session in eyes with uveitis and elevated IOP receiving maximum tolerated IOP-lowering therapy. Uveitis recurrences decreased, visual acuity improved, and IOP decreased. There were no adverse events during insertion of the fluocinolone acetonide implant and placement of the glaucoma tube shunt.

Intravitreal bevacizumab vs sub-tenon triamcinolone acetonide for choroidal neovascularization attributable to pathologic myopia

PURPOSE

To compare the visual outcomes of intravitreal bevacizumab (Avastin; Genentech Inc, South San Franciso, California, USA) and sub-Tenon triamcinolone acetonide (TA) for choroidal neovascularization attributable to pathologic myopia (mCNV).

DESIGN

Retrospective, comparative, interventional case series.

METHODS

Fifty-four consecutive eyes of 53 patients with mCNV treated with either sub-Tenon TA or intravitreal bevacizumab in an institutional setting were included. Twenty eyes were treated with sub-Tenon TA and 34 eyes were treated with intravitreal bevacizumab. The main outcome measures included best-corrected visual acuity (BCVA) 12 months after the initial injection and logarithm of the minimum angle of resolution gain from baseline compared with analysis of covariance (ANCOVA).

RESULTS

At 12 months, the BCVA improved by 1.9 lines in the intravitreal bevacizumab group and worsened by 0.3 lines in the sub-Tenon TA group. Thus, the intravitreal bevacizumab group had significantly greater visual improvement than the sub-Tenon TA group (P < .01). Statistical analysis (ANCOVA) revealed that age (P = .01), pretreatment BCVA (P < .01), and the treatment choice (intravitreal bevacizumab or sub-Tenon TA; P < .01) correlated significantly with the BCVA and the BCVA gain at 12 months. The refractive error was of borderline significance (P = .06).

CONCLUSIONS

Although this study is limited because of its retrospective nature, intravitreal bevacizumab seems to result in a more favorable visual outcome than sub-Tenon TA in the treatment of mCNV. Patient age, the BCVA before treatment, and the refractive error must be considered to initiate the treatment.

Intracameral dexamethasone reduces inflammation on the first postoperative day after cataract surgery in eyes with and without glaucoma

Purpose:

To evaluate whether dexamethasone injected intracamerally at the conclusion of surgery can safely and effectively reduce postoperative inflammation and improve surgical outcomes in eyes with and without glaucoma.

Methods:

Retrospective chart review of 176 consecutive eyes from 146 patients receiving uncomplicated phacoemulsification (PE) (n = 118 total, 82 with glaucoma), glaucoma drainage device (GDD) (n = 35), combined PE/GDD (n = 11) and combined PE/endoscopic cyclophotocoagulation (n = 12). Ninety-one eyes from 76 patients were injected with 0.4 mg dexamethasone intracamerally at the conclusion of surgery. All eyes received standard postoperative prednisolone and ketorolac eyedrops. Outcomes were measured for four to eight weeks by subjective complaints, visual acuity (VA), slit-lamp biomicroscopy, intraocular pressure (IOP) and postoperative complications.

Results:

Dexamethasone significantly reduced the odds of having an increased anterior chamber (AC) cell score after PE (p = 0.0013). Mean AC cell score ± SD in nonglaucomatous eyes was 1.3 ± 0.8 in control and 0.8 ± 0.7 with dexamethasone; scores in glaucomatous eyes were 1.3 ± 0.7 in control and 0.9 ± 0.8 with dexamethasone. Treated nonglaucomatous eyes had significantly fewer subjective complaints after PE (22.2% vs 64.7% in control; p = 0.0083). Dexamethasone had no significant effects on VA, corneal changes, IOP one day and one month after surgery, or long-term complications.

Conclusions:

Intracameral dexamethasone given at the end of cataract surgery significantly reduces postoperative AC cells in eyes with and without glaucoma, and improves subjective reports of recovery in nonglaucomatous eyes. There were no statistically significant risks of IOP elevation or other complications in glaucomatous eyes.

Periocular triamcinolone for prevention of macular edema after plaque radiotherapy of uveal melanoma: a randomized controlled trial

OBJECTIVE

To determine the efficacy and safety of periocular triamcinolone acetonide (40 mg) for the prevention of macular edema in patients undergoing plaque radiotherapy for uveal melanoma.

DESIGN

Prospective, randomized, controlled clinical trial.

PARTICIPANTS AND CONTROLS

One-hundred sixty-three patients with newly diagnosed uveal melanoma undergoing iodine 125 plaque radiotherapy were entered into the study. Fifty-five patients were randomized to the control group and 108 to the triamcinolone group. Eighteen-month data were available for 143 (88%) of the 163 patients.

INTERVENTION

Periocular injection of triamcinolone acetonide (40 mg in 1 ml) at the time of plaque radiotherapy and 4 months and 8 months later. Optical coherence tomography was performed at each patient evaluation.

MAIN OUTCOME MEASURES

Optical coherence tomography-evident macular edema, moderate vision loss, and poor final visual acuity.

RESULTS

Optical coherence tomography-evident macular edema occurred significantly less often in the triamcinolone group compared with the control group up to 18 months after plaque radiotherapy (hazard estimate, 0.45; 95% confidence interval, 0.19-0.70; P = 0.001). At the 18-month follow-up, moderate vision loss (loss of 3 lines or more of best-corrected visual acuity [BCVA]) and severe vision loss (BCVA <5/200 Snellen) occurred significantly less frequently in the triamcinolone group than in the control group (31% vs. 48% [P = 0.039] and 5% vs. 15% [P = 0.048], respectively). Rates of elevated intraocular pressure and cataract progression were similar in both groups.

CONCLUSIONS

Periocular triamcinolone is beneficial in reducing the risk of macular edema up to 18 months after plaque radiotherapy for uveal melanoma and significantly reduces the risk of moderate vision loss and poor visual acuity in these patients.

Drug reflux during posterior subtenon infusion of triamcinolone acetonide in diffuse diabetic macular edema not only brings insufficient reduction but also causes elevation of intraocular pressure

BACKGROUND

At the time of posterior subtenon infusion of triamcinolone acetonide (STI-TA) in patients with diabetic macular edema (DME), drug reflux of TA has sometimes been observed from the conjunctival incision site. We investigated the influence of this reflux on regression of DME and postoperative intraocular pressure (IOP).

METHODS

STI-TA was performed on one hundred and twenty-four eyes of 88 consecutive patients with DME. Eligible eyes were divided into two groups: those with observed drug reflux of TA and those without observed drug reflux of TA. Visual acuity (VA), foveal thickness (FT) and IOP were monitored in each eye for up to 12 weeks after STI-TA.

RESULTS

STI-TA with drug reflux was observed in ten individual eyes of seven patients. These patients were significantly younger than those patients without observed drug reflux. After STI-TA, both improvement of VA and regression of FT in reflux(+) eyes were less than in reflux(-) eyes. Postoperative IOP elevation in reflux(+) eyes was much higher, and four of the ten eyes needed anti-glaucoma therapy. This was in contrast to three of the 118 eyes without drug reflux that required anti-glaucoma therapy.

CONCLUSIONS

At the time of STI-TA in DME, drug reflux of TA is a risk factor not only for insufficient reduction of edema, but also for postoperative IOP elevation.

Intraocular pressure elevation after injection of triamcinolone acetonide: a multicenter retrospective case-control study

PURPOSE

To determine the risk factors for intraocular pressure (IOP) elevation after the injection of triamcinolone acetonide (TA).

DESIGN

Retrospective interventional case-control study.

METHODS

SETTING

Multicenter.

PATIENT POPULATION

Four hundred and twenty-seven patients.

OBSERVATION PROCEDURES

Intraocular pressure levels after TA treatment by the sub-Tenon capsule injection (STI; 12 mg, 20 mg, or 40 mg), intravitreal injection (IVI; 4 mg or 8 mg), or the combination of STI (20 mg) and IVI (4 mg), and IOP levels after two TA treatments.

MAIN OUTCOME MEASURE

Risk factors for IOP levels of 24 mm Hg or higher.

RESULTS

Younger age (hazards ratio [HR], 0.96/year; P < .0001), IVI (HR, 1.89/year; P < .0001), and higher baseline IOP (HR, 1.15/mm Hg; P = .003) were identified as risk factors. Dose dependency was shown in STI-treated eyes (HR, 1.07/mg; P = .0006), as well as after IVI (HR, 1.64/mg; P = .013). The combination of STI and IVI was a significant risk factor (HR, 2.27; P = .003) compared with STI alone. In eyes receiving two TA treatments, IVI (HR, 2.60; P = .010), higher IOP elevation after the first injection (HR, 1.18/mm Hg; P = .011), and increased dosage of STI (HR, 1.07/mm Hg; P = .033) were risk factors.

CONCLUSIONS

Younger age, higher baseline IOP, IVI, and increased TA dosage were associated with TA-induced IOP elevation. IOP elevation after repeated TA injection was frequently associated with eyes treated with IVI, high IOP elevation after the first injection, and high doses of STI.