Korean J Ophthalmol.  2012 Oct;26(5):362-368. 10.3341/kjo.2012.26.5.362.

A Three-year Follow-up of Intravitreal Triamcinolone Acetonide Injection and Macular Laser Photocoagulation for Diffuse Diabetic Macular Edema

• Cho HY
• Kang SW
• Kim YT
• Chung SE
• Lee SW

• KMID: 1397487
• DOI: http://doi.org/10.3341/kjo.2012.26.5.362

Abstract

PURPOSE
To report the three-year outcomes of macular laser photocoagulation following intravitreal injection of triamcinolone acetonide (IVTA) for diffuse diabetic macular edema (DME).
METHODS
A prospective, randomized controlled study was completed. Eighty-six eyes of 74 patients with diffuse DME were randomized into two groups. Eyes assigned to the combination group (n = 48) were subjected to macular laser photocoagulation three weeks after IVTA. Eyes in the IVTA group (n = 38) underwent IVTA alone. Central macular thickness was measured by optical coherence tomography, and the number of additional treatments and mean time to recurrence were assessed.
RESULTS
Thirty-seven eyes in the combination group and 26 eyes in the IVTA group completed the three-year follow-up. Recurrence of DME after initial treatment was not observed for nine of the 37 (24.3%) eyes in the combination group or for one of the 26 (3.9$) eyes in the IVTA group (p = 0.028). DME was absent for 19.9 months after treatment in the combination group compared to 10.3 months in the IVTA group (p = 0.027). The mean number of additional treatments was 0.92 in the combination group and 1.88 in the IVTA group (p = 0.001).
CONCLUSIONS
Results in the subset of subjects who completed the three-year follow-up demonstrated that laser photocoagulation following IVTA is more effective than IVTA monotherapy for diffuse DME. Combination therapy required fewer additional treatments and resulted in a lower recurrence rate than IVTA monotherapy.

Keyword

Diabetic retinopathy; Intravitreal injections; Laser therapy; Macular edema; Triamcinolone

MeSH Terms

Combined Modality Therapy
Diabetic Retinopathy/*therapy
Female
Fluorescein Angiography
Follow-Up Studies
Glucocorticoids/administration & dosage/*therapeutic use
Humans
Intravitreal Injections
Laser Coagulation/*methods
Macular Edema/*therapy
Male
Middle Aged
Prospective Studies
Tomography, Optical Coherence
Treatment Outcome
Triamcinolone Acetonide/administration & dosage/*therapeutic use
Visual Acuity

Figure

• 

  Fig. 1 Kaplan-Meier survival plot of diabetic macular edema recurrence. Seventeen eyes in the combination group and nine eyes in the intravitreal injection of triamcinolone acetonide (IVTA) group initially responded. Nine eyes in the combination group and one eye in the IVTA group completed the three-year follow-up without recurrence. Mean time to recurrence was 10.33 months (limited to 30 months) in the IVTA group and 19.88 months in the combination group (p = 0.027).

Reference

1. Early Treatment Diabetic Retinopathy Study research group. Photocoagulation for diabetic macular edema. Early Treatment Diabetic Retinopathy Study report number 1. Arch Ophthalmol. 1985. 103:1796–1806.

2. Bresnick GH. Diabetic maculopathy: a critical review highlighting diffuse macular edema. Ophthalmology. 1983. 90:1301–1317.

3. Lee CM, Olk RJ. Modified grid laser photocoagulation for diffuse diabetic macular edema: long-term visual results. Ophthalmology. 1991. 98:1594–1602.

4. Diabetic Retinopathy Clinical Research Network (DRCR.net). Beck RW, Edwards AR, et al. Three-year follow-up of a randomized trial comparing focal/grid photocoagulation and intravitreal triamcinolone for diabetic macular edema. Arch Ophthalmol. 2009. 127:245–251.

5. Jonas JB, Degenring RF, Kamppeter BA, et al. Duration of the effect of intravitreal triamcinolone acetonide as treatment for diffuse diabetic macular edema. Am J Ophthalmol. 2004. 138:158–160.

6. Jonas JB, Sofker A. Intraocular injection of crystalline cortisone as adjunctive treatment of diabetic macular edema. Am J Ophthalmol. 2001. 132:425–427.

7. Ciardella AP, Klancnik J, Schiff W, et al. Intravitreal triamcinolone for the treatment of refractory diabetic macular oedema with hard exudates: an optical coherence tomography study. Br J Ophthalmol. 2004. 88:1131–1136.

8. Kang SW, Sa HS, Cho HY, Kim JI. Macular grid photocoagulation after intravitreal triamcinolone acetonide for diffuse diabetic macular edema. Arch Ophthalmol. 2006. 124:653–658.

9. Lam DS, Chan CK, Mohamed S, et al. Intravitreal triamcinolone plus sequential grid laser versus triamcinolone or laser alone for treating diabetic macular edema: six-month outcomes. Ophthalmology. 2007. 114:2162–2167.

10. Diabetic Retinopathy Clinical Research Network. Elman MJ, Aiello LP, et al. Randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. Ophthalmology. 2010. 117:1064–1077.e35.

11. Gillies MC, McAllister IL, Zhu M, et al. Intravitreal triamcinolone prior to laser treatment of diabetic macular edema: 24-month results of a randomized controlled trial. Ophthalmology. 2011. 118:866–872.

12. Kang SW, Park SC, Cho HY, Kang JH. Triple therapy of vitrectomy, intravitreal triamcinolone, and macular laser photocoagulation for intractable diabetic macular edema. Am J Ophthalmol. 2007. 144:878–885.

13. Estabrook EJ, Madhusudhana KC, Hannan SR, Newsom RS. Can optical coherence tomography predict the outcome of laser photocoagulation for diabetic macular edema? Ophthalmic Surg Lasers Imaging. 2007. 38:478–483.

14. Gillies MC, Islam FM, Larsson J, et al. Triamcinolone-induced cataract in eyes with diabetic macular oedema: 3-year prospective data from a randomized clinical trial. Clin Experiment Ophthalmol. 2010. 38:605–612.

15. Arevalo JF, Sanchez JG, Wu L, et al. Primary intravitreal bevacizumab for diffuse diabetic macular edema: the Pan-American Collaborative Retina Study Group at 24 months. Ophthalmology. 2009. 116:1488–1497. 1497.e1

16. Nagasawa T, Naito T, Matsushita S, et al. Efficacy of intravitreal bevacizumab (Avastin) for short-term treatment of diabetic macular edema. J Med Invest. 2009. 56:111–115.

17. Querques G, Bux AV, Martinelli D, et al. Short-term fluctuation of diabetic macular edema after intravitreal ranibizumab injection. Retina. 2009. 29:1274–1281.

18. Papadopoulou DN, Mendrinos E, Mangioris G, et al. Intravitreal ranibizumab may induce retinal arteriolar vasoconstriction in patients with neovascular age-related macular degeneration. Ophthalmology. 2009. 116:1755–1761.

19. Von Hanno T, Kinge B, Fossen K. Retinal artery occlusion following intravitreal anti-VEGF therapy. Acta Ophthalmol. 2010. 88:263–266.