The Evolution of Triamcinolone Acetonide Therapeutic Use in Retinal Diseases: From Off-Label Intravitreal Injection to Advanced Nano-Drug Delivery Systems

Intravitreal low-dose triamcinolone acetonide for nonarteritic anterior ischemic optic neuropathy

AIM

To evaluate the efficacy and safety of intravitreal low-dose (1 mg) triamcinolone acetonide (TA) in Chinese acute nonarteritic anterior ischemic optic neuropathy (NAION) patients.

METHODS

Twenty-eight eyes of 28 patients with acute NAION (<30d of visual acuity loss) were enrolled and given intravitreal TA (IVTA) once. Visual field (VF), best corrected visual acuity (BCVA), retinal nerve fiber layer (RNFL) thickness, ganglion cell complex (GCC) thickness, radial peripapillary capillary (RPC) density, and intraocular pressure (IOP) were evaluated at baseline and 7d, 1, 3, and 6mo after IVTA.

RESULTS

VF and BCVA were significant improved during the follow-up according to the mean deviation (MD), visual field index (VFI), and Early Treatment Diabetic Retinopathy Study (ETDRS) scores (all P<0.001). There was no significant difference between the group that received an injection less than 14d after illness onset and the group that received an injection more than 14d after illness onset. The RNFL thickness, GCC thickness and RPC density were significantly decreased (all P<0.001). Temporary ocular hypertension was present in five eyes.

CONCLUSION

Low-dose IVTA may be an alternative safe treatment option for some NAION patients in the acute stage. However, optic nerve atrophy still existed.

ROS-Responsive Nanoparticles with Antioxidative Effect for the treatment of Diabetic Retinopathy

Diabetic retinopathy (DR) is a common microvascular complication of diabetes necessitating early intervention to impede progression, despite current clinical treatments focusing on advanced stages. Essential oils from Fructus Alpiniae zerumbet (EOFAZ) have demonstrated efficacy in protecting against high glucose (HG)-induced Müller cell activation and DR development. This study introduced a reactive oxidative species (ROS)-responsive drug delivery system (NPSPHE@EOFAZ) targeting early DR stages and oxidative stress. Our engineered nanoparticles effectively deliver EOFAZ into HG-exposed Müller cells by detecting and responding to elevated oxidative stress levels. The NPSPHE@EOFAZ significantly inhibited abnormal cell growth, reduced oxidative stress, and alleviated inflammation in vitro. In vivo experiments on diabetic mice with DR revealed that NPSPHE@EOFAZ mitigated early pathological changes by reducing oxidative stress and inflammation while also alleviating organ damage in the heart, liver, spleen, lung, and kidney. These findings underscore the potential of NPSPHE@EOFAZ as a promising antioxidant for early intervention in DR pathogenesis.

Recent advances and prospects of nanoparticle-based drug delivery for diabetic ocular complications

Diabetes mellitus (DM) is a chronic metabolic disorder that significantly affects various organ systems. The systemic effects of DM lead to numerous complications, with ocular manifestations being of particular concern due to their severity and impact on quality of life. Hyperglycemia-induced ocular damage often results in a range of lesions, including diabetic retinopathy (DR), keratopathy, cataracts, and glaucoma. These conditions impose considerable physical discomfort on patients and place a substantial economic burden on healthcare systems. The advent of nanotechnology has facilitated the development of innovative therapeutic strategies for managing diabetic ocular complications. This review highlights several common ocular complications associated with DM, focusing on their pathogenesis and treatment strategies. Emphasis is placed on the innovative applications and potential of nanotechnology in treating diabetic ocular complications.

Efficacy and safety of dexamethasone or triamcinolone in combination with anti-vascular endothelial growth factor therapy for diabetic macular edema: A systematic review and meta-analysis with trial sequential analysis

BACKGROUND

The clinical efficacy of anti-vascular endothelial growth factors (anti-VEGFs), corticosteroids, and their combined treatment for diabetic macular edema (DME) has been substantiated by numerous studies. However, it remains uncertain whether the therapeutic benefits of the combined treatment with corticosteroids and anti-VEGFs is superior to those of anti-VEGF monotherapy. Consequently, we conducted a meta-analysis to compare the efficacy and safety of combined treatment with dexamethasone or triamcinolone and anti-VEGF versus anti-VEGF monotherapy in DME treatment.

METHODS

An exhaustive search of the literature was performed on February 23, 2024, scanning through the databases including PubMed, Web of Science, Embase, and the Cochrane Library, with the aim of identifying all relevant studies. The combined results for efficacy and safety were analyzed using the standard mean difference (SMD) and relative risk (RR), both of which were presented with 95% confidence interval (CI). The assessment of heterogeneity was conducted via Cochran's Q test, I2 statistics, and the implementation of a 95% prediction interval (PI). All analyses were performed by R 4.3.1, Stata 12.0, and TSA v0.9.5.10 Beta software.

RESULTS

This meta-analysis incorporated 21 eligible studies. The overall analysis revealed that combined treatment of dexamethasone or triamcinolone with anti-VEGF agents did not demonstrate superiority over anti-VEGF monotherapy in improving best-corrected visual acuity (BCVA) (Dexamethasone: SMD -0.266, 95% CI -1.001 to 0.468, 95% PI -2.878 to 2.346; Triamcinolone: SMD -0.340, 95% CI -1.230 to 0.550, 95% PI -3.554 to 2.874) and reducing central macular thickness (CMT) (Dexamethasone: SMD -1.255, 95% CI -2.861 to 0.350; Triamcinolone: SMD -0.207, 95% CI -0.895 to 0.481, 95% PI -2.629 to 2.215). However, the combination therapy significantly increased the risk of elevated intraocular pressure (RR 5.783, 95% CI 3.007 to 11.121, 95% PI 0.520 to 56.931) and ocular hypertension (RR 8.885, 95% CI 2.756 to 28.649, 95% PI 1.262 to 39.208). Subgroup analysis suggests that dexamethasone plus anti-VEGF therapy showed a greater reduction in central subfield thickness (SMD -0.440, 95% CI -0.755 to -0.126) compared to anti-VEGF monotherapy among patients with persistent DME.

CONCLUSION

Our study confirmed that dexamethasone or triamcinolone plus anti-VEGF therapy did not show superior efficacy in improving BCVA and reducing CMT in DME patients compared with anti-VEGF monotherapy. Clinicians should weigh the pros and cons comprehensively when implementing combined therapy.

Nanotechnological approaches to improve corticosteroids ocular therapy

The administration of corticosteroids is the first-line treatment of the clinical conditions with ocular inflammation. Nonetheless, ocular physiological mechanisms, anatomical barriers and corticosteroid properties prevent it from reaching the target site. Thus, frequent topical administered doses or ocular injections are required, leading to a higher risk of adverse events and poor patient compliance. Designing novel drug delivery systems based on nanotechnological tools is a useful approach to overcome disadvantages associated with the ocular delivery of corticosteroids. Nanoparticle-based drug delivery systems represent an alternative to the current dosage forms for the ocular administration of corticosteroids, since due to their particle size and the properties of their materials, they can increase their solubility, improve ocular permeability, control their release and increase bioavailability after their ocular administration. In this way, lipid and polymer-based nanoparticles have been the main strategies developed, giving rise to novel patent applications to protect these innovative drug delivery systems as a product, its preparation or administration method. Additionally, it should be noted that at least 10 clinical trials are being carried out to evaluate the ocular application of different pharmaceutical formulations based on corticosteroid-loaded nanoparticles. Through a comprehensive and extensive analysis, this review highlights the impact of nanotechnology applications in ocular inflammation therapy with corticosteroids.

Efficacy of different routes of triamcinolone acetonide administration on macular edema: A systematic review and network meta-analysis

There is different administration routes of triamcinolone acetonide (TA) administration for macular edema, but the efficacy ranking remains unclear. The purpose of this study is to assess the efficacy of different administration routes of TA employed in macular edema. PubMed, Medline, Embase, and Cochrane Central Register of Controlled Trials were systematically searched for published articles comparing macular edema in patients with triamcinolone acetonide in different administration. The sparse network was evaluated using a random-effects model and consistency model within the Bayesian framework, utilizing the multinma package in R. The evidence was assessed based on the Grading of Recommendations. Assessment, Development, and Evaluation (GRADE) criteria. A total of 1138 citations were identified by our search, of which 20 RCTs enrolled 892 eyes. The network showed that intravitreal triamcinolone acetonide (IVTA) was associated with a statistically significant better best corrected visual acuity (BCVA) at the 12th week compared to placebo (MD: - 0.15, 95% CI: - 0.30 to - 0.01, P < 0.05), which was moderate-quality evidence. IVTA and suprachoroidal triamcinolone acetonide (SCTA) were both associated with a statistically significant reduction in central macular thickness (CMT) at the 12th week, which was moderate evidence. The probabilities of rankings and SUCRA demonstrated that sub-Tenon's infusion of triamcinolone acetonide (STiTA) might be the worst. SCTA and IVTA were proven to be the best administration routes for improving BCVA and reducing CMT. In addition, STiTA was less advisable than other administration routes of triamcinolone acetonide according to the rankings and SUCRA.

Evidence-based guidelines for drug dosing in intravitreal injections in silicone oil-filled eyes: Pharmacokinetics, safety, and optimal dosage

We evaluate the pharmacokinetics, safety, and optimal dosages of intravitreal agents in silicone oil (SO)-filled eyes, addressing challenges in administering such therapies. We assessed the pharmacological properties and safety profiles of intravitreal drugs in SO-filled eyes, deriving conclusions and guidance from available literature and expert consensus. Preclinical data suggest comparable half-lives of anti-vascular endothelial growth factoragents in SO-filled eyes, but clinical evidence is mainly from case reports and small series. Available research prioritizes standard dosages, particularly for bevacizumab (1.25 mg), supported by stronger evidence than aflibercept (2 mg) or ranibizumab (0.5 mg). Intravitreal steroids, especially dexamethasone at 0.7 mg, show efficacy and safety, while evidence for fluocinolone acetonide at 0.19 mg is limited. Intravitreal methotrexate has been reported at the dosage of 250-400 μg, with keratitis as the primary expected side effect. Case reports indicate tolerability of standard dosages of antivirals (foscarnet 1.2-2.4 mg/0.1 mL, ganciclovir 4 mg/0.1 mL) and the antibiotic combination piperacillin/tazobactam (250 μg/0.1 mL). We offer guidance based on current, but limited, literature. Standard dosage of intravitreal agents should be carefully considered, along with close monitoring for potential side effects, which should be discussed with patients.

Nanomedicine in Ophthalmology: From Bench to Bedside

Ocular diseases such as cataract, refractive error, age-related macular degeneration, glaucoma, and diabetic retinopathy significantly impact vision and quality of life worldwide. Despite advances in conventional treatments, challenges like limited bioavailability, poor patient compliance, and invasive administration methods hinder their effectiveness. Nanomedicine offers a promising solution by enhancing drug delivery to targeted ocular tissues, enabling sustained release, and improving therapeutic outcomes. This review explores the journey of nanomedicine from bench to bedside, focusing on key nanotechnology platforms, preclinical models, and case studies of successful clinical translation. It addresses critical challenges, including pharmacokinetics, regulatory hurdles, and manufacturing scalability, which must be overcome for successful market entry. Additionally, this review highlights safety considerations, current marketed and FDA-approved nanomedicine products, and emerging trends such as gene therapy and personalized approaches. By providing a comprehensive overview of the current landscape and future directions, this article aims to guide researchers, clinicians, and industry stakeholders in advancing the clinical application of nanomedicine in ophthalmology.

Geraniin Alleviates Mouse Laser-Induced Choroidal Neovascularisation by Inhibiting Choroidal Endothelial Cell ACE2/Ang-(1-7)/MasR/IL-10 Pathway

Anti-vascular endothelial growth factor (VEGF) drugs suppress choroidal neovascularisation (CNV), thus improving vision. However, some patients may have a poor response or develop resistance to anti-VEGF drugs. Geraniin (GE), a polyphenol isolated from an herb called Phyllanthus amarus, possesses anti-angiogenic properties. This study aimed to explore the mechanism of action of GE in CNV. GE was found to activate the angiotensin-converting enzyme 2 (ACE2)/angiotensin 1-7 (Ang-[1-7])/MAS1 proto-oncogene, G protein-coupled receptor (MasR)/interleukin-10 (IL-10) pathway in hypoxic human choroidal endothelial cells (HCECs) in vitro and mouse models of laser-induced CNV in vivo. Activation of the ACE2/Ang-(1-7)/MasR/IL-10 pathway by GE attenuated the proliferative, migratory, and tube-forming abilities of hypoxic HCECs and prevented the development of CNV in mice. Notably, GE did not cause ocular or systemic toxicity in mice with CNV. These findings suggest that GE alleviates CNV by activating the ACE2/Ang-(1-7)/MasR/IL-10 pathway in choroidal endothelial cells (CECs).

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.

Beyond the Local Effect: An Examination of Cardiovascular and Other Systemic Complications of Ophthalmologic Drugs

Ophthalmologic drugs may be delivered to the eye via a number of ways, including topical drops and gels, intraocular injections, and parenteral or oral administration. The inadvertent systemic absorption of these drugs may lead to a myriad of side effects, ranging from benign cosmetic changes to potentially fatal cardiovascular complications. Historically, glaucoma treatment, including β-blockers and α-agonists, have been particularly examined for such events. However, recent studies suggest that the systemic absorption of many drugs commonly used in ophthalmology may lead to acute and serious secondary reactions. The following review examines ocular drugs delivered through various pathways, the mechanisms by which they may be systemically absorbed, and the potential adverse events that may ensue.

The Role of Adjunctive Triamcinolone Acetonide in Post-traumatic Vitreoretinal Surgery: Current Insights and Future Perspectives

Post-traumatic vitreoretinal surgery is pivotal for repairing damage to the retina and vitreous body, commonly resulting from blunt or penetrating ocular trauma. Incorporating adjunctive pharmacological agents, particularly triamcinolone acetonide (TA), has gained considerable prominence in optimizing surgical outcomes. TA, a potent corticosteroid, is applied intraoperatively to improve the visualization of vitreous structures and epiretinal membranes, enabling surgeons to perform more precise maneuvers. Furthermore, its anti-inflammatory properties are instrumental in reducing postoperative complications such as macular edema and proliferative vitreoretinopathy (PVR), conditions that could hinder recovery and compromise visual acuity. TA use during vitrectomy enhances surgical precision and contributes to a smoother postoperative recovery. However, concerns surrounding potential side effects, such as steroid-induced ocular hypertension and cataract formation, necessitate careful patient selection and close monitoring throughout its use. Looking ahead, innovations in sustained-release formulations and combination therapies may further augment TA efficacy while reducing associated risks. This review provides current insights into TA application in post-traumatic vitreoretinal surgeries and highlights emerging trends poised to enhance its therapeutic role.

The Treatment of Diabetic Retinal Edema with Intravitreal Steroids: How and When

Diabetic macular edema (DME) is a common complication of diabetes mellitus and a leading cause of visual impairment worldwide. It is defined as the diabetes-related accumulation of fluid, proteins, and lipids, with retinal thickening, within the macular area. DME affects a significant proportion of individuals with diabetes, with the prevalence increasing with disease duration and severity. It is estimated that approximately 25-30% of diabetic patients will develop DME during their lifetime. Poor glycemic control, hypertension, hyperlipidemia, diabetes duration, and genetic predisposition are recognized as risk factors for the development and progression of DME. Although the exact pathophysiology is still not completely understood, it has been demonstrated that chronic hyperglycemia triggers a cascade of biochemical processes, including increased oxidative stress, inflammation, activation of vascular endothelial growth factor (VEGF), cellular dysfunction, and apoptosis, with breakdown of the blood-retinal barriers and fluid accumulation within the macular area. Early diagnosis and appropriate management of DME are crucial for improving visual outcomes. Although the control of systemic risk factors still remains the most important strategy in DME treatment, intravitreal pharmacotherapy with anti-VEGF molecules or steroids is currently considered the first-line approach in DME patients, whereas macular laser photocoagulation and pars plana vitrectomy may be useful in selected cases. Available intravitreal steroids, including triamcinolone acetonide injections and dexamethasone and fluocinolone acetonide implants, exert their therapeutic effect by reducing inflammation, inhibiting VEGF expression, stabilizing the blood-retinal barrier and thus reducing vascular permeability. They have been demonstrated to be effective in reducing macular edema and improving visual outcomes in DME patients but are associated with a high risk of intraocular pressure elevation and cataract development, so their use requires an accurate patient selection. This manuscript aims to provide a comprehensive overview of the pathology, epidemiology, risk factors, physiopathology, clinical features, treatment mechanisms of actions, treatment options, prognosis, and ongoing clinical studies related to the treatment of DME, with particular consideration of intravitreal steroids therapy.