Safety of intravitreal triamcinolone and its impact on optic nerve morphology in patients treated for diabetic macular edema

Risk of intraocular pressure elevation associated with triamcinolone acetonide administration via different routes in macular edema: a systematic review and network meta-analysis of randomized controlled trials

PURPOSE

The local application of triamcinolone acetonide (TA) in patients with macular edema (ME) is off-label and the data are limited. We designed a systematic review and network meta-analysis to compare risk of intraocular pressure (IOP) elevation among TA for different routes of administration used by patients diagnosed with macular edema.

METHODS

We obtained data from the PubMed, Medline, Embase, and Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs). The outcome was IOP at 4, 12 or 24 weeks. We performed random-effects model and consistency model in the Bayesian framework with the multinma package in R. The GRADE was accorded for assess the evidence.

RESULTS

A total of 1138 citations were identified by our search, of which 16 RCTs enrolled 834 eyes (575 patients). The network showed that TA administration via different local routes and placebo were no significant differences in either pairwise or network estimates at the 4th week. IVTA (intravitreal triamcinolone acetonide) was associated with a statistically significant higher IOP at the 12th week compared to STiTA (sub-Tenon's infusion of triamcinolone acetonide) (MD: 1.67, 95% CI: 0.25 to 3.15, P < 0.05). IVTA, SCTA (suprachoroidal triamcinolone acetonide) and STiTA were both exhibited a statistically significant variance in IOP compared to placebo at the 24th week [(MD: 1.35, 95% CI: 0.23 to 2.30, P < 0.05), (MD: 2.42, 95% CI: 0.19 to 4.53, P < 0.05), (MD: 1.31, 95% CI: 0.02 to 2.49, P < 0.05)]. The probabilities of rankings and SUCRA showed that, at 4 and 12 weeks of follow-up, IVTA posed the highest risk of IOP elevation, while at the 24-week mark, SCTA exhibited the highest risk. In addition, RITA (retrobulbar injections triamcinolone acetonide) was shown to be safer.

CONCLUSION

For the increased risk of IOP, we recommend that treatment within 4 weeks is safe. Nevertheless, it is advisable to exercise caution when administering IVTA, STiTA, SCTA beyond a duration of 12 weeks, due to the potential risk of IOP elevation. RITA emerged as the safest injection route in the treatment of macular edema in terms of IOP risk. However, more high-quality randomized controlled trials will be necessary to further confirm this.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022366513. https://www.crd.york.ac.uk/prospero/#recordDetails .

CLINICAL TRIAL NUMBER

Not applicable.

Diabetic macular edema (DME): dissecting pathogenesis, prognostication, diagnostic modalities along with current and futuristic therapeutic insights

One of the most common health concerns disturbing people within working years globally is diabetes mellitus (DM). One well-known consequence of DM is vascular damage, which can manifest as macro- and microangiopathy affecting the ocular retina. Therefore, Diabetic macular edema (DME) is a major sight-threatening complication of diabetic retinopathy (DR) worldwide. It is the most prevalent cause of significant vision impairment in diabetic patients. Long-term vision loss can be avoided by following early DME treatment guidelines in everyday life. Hence, there are various therapeutic approaches for DME management. Currently, the first-line treatment for DME is anti-VEGF family drugs, such as ranibizumab, brolucizumab, bevacizumab, and aflibercept. Nevertheless, relapses of the disease, inadequate response, and resistance during anti-VEGF therapy are still seen because of the intricate pathophysiological foundation of the disease. Consequently, there is an excellent requirement for therapeutic approaches to advance and become better at controlling diseases more satisfactorily and require fewer treatments overall. We conducted a thorough literature search in the current review to present a comprehensive overview of the primary data about the current DME therapeutic agents. We also covered the novel advances in DME management and probable future treatments being investigated and developed. This review recommended that Large clinical trials should afford sufficient evidence to support these innovative treatment modalities.