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Lashay et al - Intravitreal TA on CME
Iranian Journal of Ophthalmology - Volume 19, Number 2, 2006
Assessment of Intravitreal Triamcinolone
Acetonide on Cystoid Macular Edema in
Branch Retinal Vein Occlusion
Alireza Lashay, MD1, Haj-Mohammad Jalili, MD2, Ahmad Mirshahi, MD3 Houshang Faghihi, MD3, Reza Karkhaneh, MD1, Mehdi Nili-Ahmadabadi, MD3 Mohammad-Sadegh Farahvash, MD3, Seyed-Ali Tabatabaei, MD4 Mohammad Riazi-Esfahani, MD3, Ahmad Javadian, MD1, Hormoz Chams, MD1 Morteza Movasat, MD3, Zahra Aalami-Harandi, MD3 Abstract
Purpose: To assess the effectiveness of intravitreal injection of triamcinolone acetonide on macular
edema associated with branch retinal vein occlusion (BRVO).
Design: A prospective noncomparative interventional case series.
Patients & Methods: Fourteen eyes of 14 patients with macular edema associated with BRVO were
enrolled. In all patients after thorough ophthalmic examination, 4 mg triamcinolone acetonide was
injected intravitreally, then all eyes followed at 1 day, 1 week, 1, 3 and 6 months. Ten eyes were
followed until 9 months. Central macular thickness was measured with Optical Coherence
Tomography (OCT) at baseline and 3 months after injection. Best Corrected Visual Acuity (BCVA)
and 1-mm central macular thickness were main outcome measurements.
Results: Mean baseline BCVA: 1.33±0.52: logarithm of Minimum Angle of Resolution (logMAR)
improved to 0.81±0.56 (P=0.002) at 1 month, 0.65±0.48 (P=0.001) at 3 months, but decreased to
0.85±0.44 (P=0.005) at 6 months. In 10 eyes of 14 eyes that were followed for 9 months, mean
BCVA decreased to 1.20±0.48 (P=0.171).
A 32% reduction of pre injection value of 1 mm central foveal thickness observed at 3 months
(565±199.58µm versus 383.78±145.70µm, P=0.001). Ocular hypertension was developed in six
patients that was controlled by topical antiglaucoma medication. Cataract developed or progressed
in two eyes.
Conclusion: Intravitreal triamcinolone acetonide can decrease macular edema and improve visual
acuity in BRVO in short term but further study is required with control group and longer follow up to
clarify the benefits and risks of this treatment.
Key words: Intravitreal Triamcinolone Acetonide, Branch Retinal Vein Occlusion, Central Macular
Thickness.
Iranian Journal of Ophthalmology 2006; 19(2):1-5
1. Professor of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical
Correspondence
Sciences
Mehdi Nili-Ahmadabadi, MD
Tehran, Farabi Eye Hospital
2. Resident in Ophthalmology, Farabi Eye Hospital, Tehran University of Medical
Tel: 55414941-6
Sciences
Email: [email protected]
3. Associate Prof. of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical
Sciences
4. Assistant Prof. of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical
Sciences
Received: February 23, 2006
Accepted: April 27, 2006
(With Cooperation of Eye Research Center, Farabi Eye Hospital, Tehran University of
Medical Sciences)
Lashay et al - Intravitreal TA on CME
Iranian Journal of Ophthalmology - Volume 19, Number 2, 2006
Introduction
Branch retinal vein occlusion (BRVO) is a
diagnosis of glaucoma or intraocular pressure visual loss by macular edema, retinal capillary non perfusion or intraretinal hemorrhage.1 Occlusion in BRVO occurs at arteriovenous photography, retinal map thickness analysis with optical coherence tomography ([OCT] associated with a disruption of the blood- Germany) and fluorescein angiography (FA) retinal barrier and persistent decrease in were performed at presentation. All patients consents were obtained. All injections were reported that laser photocoagulation resulted performed under sterile condition in operating in a reduction in visual loss 6 months or more room. After topical anesthesia with tetracaine 0.5%, and instillation of povidone-iodine 5% in A sterile speculum was placed. An anterior anastomosis4 , surgical cannulation of branch chamber paracentesis (0.1)ml was performed. retinal veins5 , vitrectomy with adjunctive The drug (4mg triamcinolone acetonide in sheathotomy of the retinal vein adventitia.6 0.1ml) was injected into the vitreous cavity inferotemporally through pars plana with a toxicity when injected intravitreally7 and has 27-gauge needle on a 1ml tuberculin syringe. been shown to reduce breakdown of the inner blood-retinal barrier and stabilize it.8 A few ointment. Then the patients were instructed to instill ciprofloxacine 0.3% ophthalmic drop for one week. Patients were thoroughly examined 1 day, 1 week, 1, 3, 6, and 9 months after BRVO do not respond to laser injection. At 3 months follow up, fundus photocoagulation and with this belief, that, triamcinolone acetonide can reduce macular edema we proposed this study to investigate the effectiveness of intravitreal triamcinolone determined by the Early Treatment Diabetic acetonide as treatment of macular edema with Retinopathy Study chart and calculated as corresponding improvement of visual acuity logMAR, and 1-mm central macular thickness that measured with OCT. Paired-sample t-test and Pearson correlation analysis were used Patients and Methods
This study was a prospective interventional case series performed following the tenets of Declaration of Helsinki, and after approval by Fourteen eyes of 14 patients with macular 2005, 14 eyes of 14 patients with macular minimum angle of resolution (logMAR) and at 55.43±10.83 years (range: 37-75) at injection time. There were 6 females and 8 males. All Exclusion criteria were macular BRVO with BCVA>0.4 log MAR, one eye patients, eyes with hazy media, other ocular diseases that may prominently affect VA (cataract, age symptoms to treatment was 89.64±56.16 days Lashay et al - Intravitreal TA on CME
Iranian Journal of Ophthalmology - Volume 19, Number 2, 2006
35-240). One patient had diabetes mellitus. Four patients had hypertension and 2 of them had history of old BRVO in the other eye. Two photocoagulation in the region of the edema has been recommended1,11,12, but this is known that to be ineffective in many cases.13 Another option for the treatment of macular improved to 0.81±0.56 logMAR (P=0.002), (0.65±0.48 logMAR (P=0.001), 0.85±0.44 sheathotomy at the site of occlusion in patient respectively, but was decreased to 1.20±0.48 technique of vitrectomy with sheathotomy is logMAR, (P=0.171) in 10 of 16 eyes, that difficult and the complication rate is not low. Reroute the blood flow by a laser-induced A 32.22% reduction in mean pre injection 1 chorioretinal venous anastomosis is the other mm central macular thickness: 565±199µm to approach for the treatment of macular edema some complications such as fibrovascular Six eyes (42.08%) developed IOP value of proliferation hemorrhage and tractional retinal 22 mmHg or above. Elevation of IOP occurred detachment.16 Intravitreal tissue plasminogen between 1 week and 1 month after injection activator administration has also been tested, which was assumed to be a side effect of triamcinolone acetonide. Elevation of IOP in all patients was controlled with one to tree implicated pathogenesis of macular edema.18 with 6 month visual acuity gain, (P=0.169). Corticosteroids may also downregulate the There was no correlation between baseline production of vascular endothelial growth 1mm central macular thickness and visual factor (VEGF), a known permeability factor.19 acuity gain at 6 months, (P=0.335). There was Triamcinolone acetonide is a corticosteroid a correlation between the change in baseline that has been shown to reduce breakdown of the inner blood-retinal barrier and stabilize it corresponding visual acuity gain (P=0.008) at significant correlation between the baseline reduction in baseline macular thickness at 3 VA with VA gain at 6 months of follow up maximal improvement of visual acuity was observed at 3 months of follow up. Reduction of the mean visual acuity was observed after 3 months and declined to a level at 9 months, that not significantly different with the mean baseline visual acuity (P=0.171). This finding Discussion
is in agreement with other studies20-22 that, Macular edema is a common cause of visual intravitreal triamcinolone acetonide can, loss in patients with BRVO. Elevation of distal reduces macular edema and correspondingly intravascular pressure causes disruption of improves of VA in short term. After then, the inner blood-retinal barrier and is often associated with significant leakage and a deterioration of VA occurs, that may be due to relatively poor prognosis.3 In the acute phase intraretinal hemorrhage, it may be impossible In our study 42.08% of patients developed to evaluate potential vision and difficult to IOP value of 22mmHg or higher, which was provide a prognosis. One third to one half of assumed to be a side effect of triamcinolone patients with BRVO have a return of vision to acetonide. Elevation of IOP in all patients was controlled with topical medications. At final visit IOP was controlled despite Lashay et al - Intravitreal TA on CME
Iranian Journal of Ophthalmology - Volume 19, Number 2, 2006
discontinuation of drugs. Jonas et al24 reported intraocular pressure rise in 70% of injection. This dose is higher than our study Conclusion
that may be related to the injection of higher In conclusion, a single intravitreal injection of triamcinolone acetonide can cause reduction In our study, all patients were phakic and cataract progression was observed in 2 eyes improvement of visual acuity at least in short but not required cataract extraction. çekiç et term, but further study is required particularly al22 reported cataract progression in 7 of 12 with a control group and longer follow up to phakic patients during mean follow up of 13 clarify the effects and complication rates of months. Cataract extraction was performed in triamcinolone acetonide injection for macular five eyes of them. The cause of higher rate of cataract progression in this study compared to our study may be the higher mean age of their Acknowledgment
patients, multiple injections of triamcinolone 132/10593 from Tehran University of Medical We did not observe any other injection or triamcinolone related complications such as


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