Efficacy and safety of Suprachoroidal Triamcinolone Acetonide in cases of resistant diabetic Macular Edema

Effect of Suprachoroidal Triamcinolone Acetonide on Intraocular Pressure in Macular Edema: A Retrospective Study

Introduction Macular edema causes decreased vision in diseases like diabetic retinopathy, uveitis, retinal vein occlusions and post-cataract surgery cystoid macular edema. Steroids in the depot form of triamcinolone acetonide (TA) increase the duration of action, but due to a number of complications, especially raising intraocular pressure (IOP), anti-vascular endothelial growth factor (anti-VEGF) injections are now considered the mainstay of treatment. The suprachoroidal space provides an alternate route for steroid delivery, limiting the drug to the posterior segment, hence preventing the adverse effects on the anterior segment. This study aimed to determine the safety of suprachoroidal steroids with respect to their effect on IOP. Methods This retrospective study involved patients who received suprachoroidal TA injections for macular edema: diabetic retinopathy, retinal vein occlusions, uveitis and cystoid macular edema post-cataract surgery at Layton Rahmatulla Benevolent Trust (LRBT) Free Eye Hospital, Lahore, Pakistan. Manual medical records from two years were accessed and all patients were included in the study. Patients with a history of ocular hypertension, glaucoma and steroid responsiveness had not received the injection. Crystalline steroid particles of 4 mg/0.1 mL, using an intravenous TA (K-Kort; GlaxoSmithKline, Brentford, UK), were injected into the suprachoroidal space through a 30-gauge syringe with a custom plastic sleeve from a 24-gauge branula exposing 0.1 mm of the bevel. IOP was recorded at baseline before the injection and at weeks 2, 4 and 8. Repeated measures multivariate analysis of variance (ANOVA) was used to compare IOP measurements at the different time intervals. Results A total of 61 patients were included, with 70 eyes being assessed, at a mean age of 54.2 ± 10.4 years. Baseline mean IOP was 16.41 ± 2.62 mmHg, 17.04 ± 3.09 mmHg at week 2, 16.30 ± 2.95 mmHg at week 4 and 15.73 ± 1.83 mmHg at week 8. Between baseline IOP and week 2, the mean difference was 1.11 ± 0.66 mmHg (p = 0.59), 0.26 ± 0.43 mmHg from week 2 to week 4 (p = 1.00), and 1.36 ± 0.51 mmHg from week 4 to week 8 (p = 0.51). The mean IOP decreased by 0.50 ± 0.53 mmHg (p = 1.00) from baseline by eight weeks. The differences between IOP, different causes of macular edema and age or gender were not statistically significant. Two patients (1.4%) had a temporary rise in IOP above 24 mmHg requiring ocular medication, with one having a rise above 30 mmHg. Conclusion A single injection of suprachoroidal TA temporarily raises the mean IOP, but the increase is insignificant and settles to baseline by two months. Further studies would be required to establish suprachoroidal triamcinolone as a cost-effective and safe treatment for macular edema.

Effect of ranibizumab combined with laser photocoagulation in the treatment of diabetic macular edema

Objective

To explore the clinical effect of ranibizumab combined with laser photocoagulation (LP) in treating diabetic macular edema (DME).

Methods

We retrospectively reviewed the clinical data of 118 patients with DME admitted to The Affiliated Eye Hospital of Nanchang University from May 2021 to March 2023. Among them, 38 patients received LP alone (Laser-group), 39 patients received ranibizumab alone (Ranibizumab-group), and 41 patients received LP combined with ranibizumab (Combined-group). The improvement of macular edema (ME), visual acuity, and complications between the groups were compared.

Results

The time of ME regression, exudation absorption and fundus hemorrhage absorption in the Combined-group was shorter than in the Laser-group and the Ranibizumab-group (P<0.05). After treatment, the CMT and RNV of the three groups decreased compared to pretreatment levels and were lower in the Combined-group compared to the Laser-group and the Ranibizumab-group (P<0.05). BCVA increased after the treatment in all groups, and was markedly higher in the Combined-group than in the Laser and the Ranibizumab-groups (P<0.05). NO were higher in the Combined-group compared to the Laser-group and the Ranibizumab-group. The post-treatment VEGF levels decreased in all groups, and were significantly lower in the Combined-group compared to the Laser-group and the Ranibizumab-group (P<0.05). The incidence of complications in the Combined-group was lower than in the Laser-group and the Ranibizumab-group (P<0.05).

Conclusions

Compared to ranibizumab or LP alone, ranibizumab combined with LP is more effective in reducing ME in patients with DEM, and is associated with fewer complications.

Aflibercept combined with triamcinolone acetonide in the treatment of diabetic macular edema: optical coherence tomography and optical coherence tomography angiography

AIM

To analyze the relationship between optical coherence tomography (OCT) and OCT angiography (OCTA) imaging in patients with diabetic macular edema (DME) who are treated with a combination of aflibercept and triamcinolone acetonide (TA).

METHODS

A total of 76 eyes newly diagnosed DME were included in this study. They were randomly assigned to receive either aflibercept or a combination of aflibercept and TA. Injections once a month for a total of three injections. Central macular thickness (CMT), number of hyperreflective foci (HRF), height of subretinal fluid (SRF), and area of foveal avascular zone (FAZ) were evaluated using OCT and OCTA at baseline and after each monthly treatment.

RESULTS

Both groups showed improvement in best corrected visual acuity (BCVA) and reduction in macular edema after treatment, and the difference in BCVA between the two groups was statistically significant after each treatment (P<0.05). The difference in CMT between the two groups was statistically significant after the first two injections (P<0.01), but not after the third injection (P=0.875). The number of HRF (1mo: 7.41±8.25 vs 10.86±7.22, P=0.027; 2mo: 5.33±6.13 vs 9.12±8.61, P=0.034; 3mo: 3.58±3.00 vs 6.37±5.97, P=0.007) and height of SRF (1mo: 82.39±39.12 vs 105.77±42.26 µm, P=0.011; 2mo: 36.84±10.02 vs 83.59±37.78 µm, P<0.01; 3mo: 11.57±3.29 vs 45.43±12.60 µm, P<0.01) in combined group were statistically significant less than aflibercept group after each injection, while the area of FAZ showed no significant change before and after treatment in both groups.

CONCLUSION

The combination therapy of aflibercept and TA shows more significant effects on DME eyes with decreased HRF and SRF. However, both aflibercept and combination therapy show no significant change in the area of FAZ.

Suprachoroidal triamcinolone versus posterior subtenon triamcinolone either alone or formulated in the management of diabetic macular edema

PURPOSE

This study aims to compare posterior subtenon triamcinolone acetonide injection either formulated or alone versus suprachoroidal triamcinolone in the management of diabetic macular edema.

METHODS

This study is a prospective interventional study that included 75 patients, divided into three groups, each group with 25 patients. Group I received a combination of triamcinolone acetonide (TA) (40 mg) and VISCOAT, which is a combination of sodium chondroitin sulfate (20 mg) and sodium hyaluronate (15 mg). The injection was done in the posterior subtenon space using the NAGATA cannula. Group II received TA (40 mg) in the posterior subtenon space. Group III underwent an injection of 4 mg/100µl of TA in the supra choroidal space.

RESULTS

We found a statistically significant difference between the three studied groups regarding BCVA (P = 0.001) and CMT at six months postoperative (P = 0.001) with the highest median BCVA and lowest median CMT observed in the formulated TA group.

CONCLUSION

We concluded that early treatment of DME by formulated TA is better than TA alone, and suprachoroidal TA in the form of increasing the BCVA and decreasing the CMT without any elevation of IOP. Trial registration number NCT05464953. Date of registration 17/7/2022 (retrospectively registered).

Ocular barriers as a double-edged sword: preventing and facilitating drug delivery to the retina

In recent decades, the growing of the aging population in the world brings increasingly heavy burden of vision-threatening retinal diseases. One of the biggest challenges in the treatment of retinal diseases is the effective drug delivery to the diseased area. Due to the existence of multiple anatomical and physiological barriers of the eye, commonly used oral drugs or topical eye drops cannot effectively reach the retinal lesions. Innovations in new drug formulations and delivery routes have been continuously applied to improve current drug delivery to the back of the eye. Unique ocular anatomical structures or physiological activities on these ocular barriers, in turn, can facilitate drug delivery to the retina if compatible formulations or delivery routes are properly designed or selected. This paper focuses on key barrier structures of the eye and summarizes advances of corresponding drug delivery means to the retina, including various local drug delivery routes by invasive approaches, as well as systemic eye drug delivery by non-invasive approaches.

Effectiveness of Suprachoroidal Injection of Triamcinolone Acetonide in Resistant Diabetic Macular Edema Using a Modified Microneedle

Purpose

The present study evaluated the effectiveness of suprachoroidal injection of triamcinolone acetonide (TA) in resistant diabetic macular edema (DME) using a modified microneedle.

Patients and Methods

This is a prospective nonrandomized interventional study that was conducted on 55 eyes of 39 patients with centrally involving DME resistant to previous antivascular endotheli qal growth factor (VEGF) agents. All patients received suprachoroidal injection of triamcinolone acetonide 4 mg/0.1 mL by a modified specialized microneedle.

Results

The mean central macular thickness (CMT) decreased sign ificantly from 478.7±170.2 µm before injection to 230.2±47.4 µm after 12 months with p-value <0.001. Significant improvement of the mean best corrected visual acuity (BCVA) from 1.193±0.2 by logMAR at the baseline to 0.76±0.3 by logMAR was achieved after 12 months with p-value <0.001. The IOP increased significantly at one month after injection and returned to the baseline value at the third month. Eyes with more baseline CMT and worse baseline BCVA achieved worse final BCVA 12 months after injection. Eyes with inner segment/outer segment (IS/OS) disruption and neurosensory detachment (NSD) showed worse final visual outcomes. IS/OS segment disruption, NSD and baseline BCVA were the main independent predictors of the final BCVA.

Conclusion

Suprachoroidal injection of TA using this new modified microneedle resulted in marked anatomical and functional results in cases of DME resistant to previous anti-VEGF drugs with no serious ocular or systemic side effects. The study was prospectively registered with clinical trial.gov ID (NCT04690608) in 27–12-2020.

Suprachoroidal versus Intravitreal Triamcinolone Acetonide for the Treatment of Diabetic Macular Edema

Purpose

This article aims to compare between intravitreal (IV) and suprachoroidal (SC) triamcinolone acetonide (TA) injection for the treatment of diabetic macular edema (DME) in terms of improvement in both best-corrected visual acuity (BCVA) and central macular thickness (CMT), and development of complications (intraocular pressure (IOP) rise and cataract progression), and to identify the efficient dose of TA using the SC route.

Patients and Methods

This prospective interventional randomized comparative study included 45 eyes of 32 patients, randomly divided into three groups, group I received 4 mg/0.1 mL intravitreal TA (IVTA), group II received 4 mg/0.1 mL suprachoroidal TA (SCTA), and group III received 2mg/0.1 mL SCTA. Patients were followed up for 6 months.

Results

At 1 month, a maximum reduction in CMT (147.33 ± 110.97 µm, 160.80 ± 98.25 µm and 65.64 ± 46.19 µm in groups I, II, and III, respectively) was observed, which was associated with the greatest improvement of BCVA (0.09 ± 0.09, 0.19 ± 0.10 and 0.10 ± 0.09 logMAR lines) in groups I, II, and III, respectively. At 3 months, CMT started to increase, and reduction was not statistically significant compared to baseline, except in group II (4 mg SCTA group) (149.80 ± 106.57 µm with P-value = 0.013). At 6 months, CMT and BCVA returned close to baseline except for group II which had a sustained reduction of 60.16 µm from baseline. Regarding steroid-related complications, IOP elevation of 10 mmHg or more was noted in 1 eye (6.7%), 2 eyes (13.3%), and 1 eye in groups I, II, and III, respectively. Three phakic eyes per group showed cataract progression.

Conclusion

SCTA is a safe and effective route for the treatment of DME, which has comparable effects to IVTA, and may even last longer.

Recent Advancements in the Medical Treatment of Diabetic Retinal Disease

Diabetic retinal disease remains one of the most common complications of diabetes mellitus (DM) and a leading cause of preventable blindness. The mainstay of management involves glycemic control, intravitreal, and laser therapy. However, intravitreal therapy commonly requires frequent hospital visits and some patients fail to achieve a significant improvement in vision. Novel and long-acting therapies targeting a range of pathways are warranted, while evidence to support optimal combinations of treatments is currently insufficient. Improved understanding of the molecular pathways involved in pathogenesis is driving the development of therapeutic agents not only targeting visible microvascular disease and metabolic derangements, but also inflammation and accelerated retinal neurodegeneration. This review summarizes the current and emerging treatments of diabetic retinal diseases and provides an insight into the future of managing this important condition.