Korean J Ophthalmol.  2016 Feb;30(1):25-31. 10.3341/kjo.2016.30.1.25.

Effect of Posterior Subtenon Triamcinolone Acetonide Injection on Diabetic Macular Edema Refractory to Intravitreal Bevacizumab Injection

Affiliations
  • 1Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
  • 2Department of Ophthalmology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea. jsg1105@gmail.com

Abstract

PURPOSE
To evaluate the effects of posterior subtenon triamcinolone acetonide injection on refractory diabetic macular edema (DME) after intravitreal bevacizumab (IVB) injection failure.
METHODS
Patients with DME and central subfield thickness (CST) >300 microm who did not respond to IVB injections were retrospectively included. Specifically, we enrolled patients who were diagnosed with refractory DME and who experienced an increase in CST after 1 to 2 IVB injections or no decrease after > or =3 consecutive IVB injections. One clinician injected 20 mg of triamcinolone acetonide into the posterior subtenon space. All patients received ophthalmic examinations at baseline and at 2, 4, and 6 months post-baseline. Examinations included Snellen visual acuity, intraocular pressure, and spectral-domain optical coherence tomography.
RESULTS
Forty eyes of 34 patients were included. The average baseline CST was 476 microm. The average CST decreased to 368 microm at 2 months, 374 microm at 4 months, and 427 microm at 6 months (p < 0.001 for all results, Wilcoxon signed-rank test). The average intraocular pressure increased from 15.50 to 16.92 mmHg at 2 months but decreased to 16.30 mmHg at 4 months and 15.65 mmHg at 6 months. Logarithm of the minimum angle of resolution visual acuity improved from 0.56 to 0.50 at 2 months (p = 0.023), 0.50 at 4 months (p = 0.083), and 0.48 at 6 months (p = 0.133, Wilcoxon signed-rank test). No complications were detected.
CONCLUSIONS
Posterior subtenon triamcinolone acetonide is an effective and safe treatment for reducing CST in DME refractory to IVB.

Keyword

Bevacizumab; Macular edema; Posterior subtenon injection

MeSH Terms

Aged
Angiogenesis Inhibitors/*therapeutic use
Bevacizumab/*therapeutic use
Diabetic Retinopathy/diagnostic imaging/*drug therapy/physiopathology
Female
Glucocorticoids/*administration & dosage
Humans
Injections, Intraocular
Intraocular Pressure/physiology
Intravitreal Injections
Macular Edema/diagnostic imaging/*drug therapy/physiopathology
Male
Middle Aged
Retrospective Studies
Tenon Capsule/*drug effects
Tomography, Optical Coherence
Treatment Failure
Triamcinolone Acetonide/*administration & dosage
Vascular Endothelial Growth Factor A/antagonists & inhibitors
Visual Acuity/physiology
Angiogenesis Inhibitors
Bevacizumab
Glucocorticoids
Triamcinolone Acetonide
Vascular Endothelial Growth Factor A

Figure

  • Fig. 1 Changes in average central subfield thickness (CST) following posterior subtenon triamcinolone injection: mean CST had decreased by the 2-month visit and was maintained through the 4-month visit. However, mean CST had increased by the 6-month visit. The p-values are indicated by bars and were estimated using the Wilcoxon signed-rank test and represent comparisons to the baseline CST values.

  • Fig. 2 Two cases are illustrated. (A-D) The first case demonstrated a typical response to posterior subtenon triamcinolone acetonide (stTA) injection. The patient received 7 consecutive intravitreal bevacizumab (IVB) injections before receiving stTA. (A) Central subfield thickness (CST) was 467 µm after receiving 7 IVB injections, and visual acuity (VA) was 0.32 according to the Snellen visual acuity chart. (B) Two months later, CST decreased to 346 µm and VA improved to 0.4. (C) Four months later, CST increased slightly to 363 µm and VA decreased slightly to 0.32. (D) Six months later, CST increased to 424 µm and VA increased to 0.5. (E-H) Cystoid macular edema (CME) completely disappeared in the second case after only one stTA injection with no other treatments. This patient received 3 serial IVB injections. (E) CME did not respond, and VA was 0.63 after 3 IVB injections. (F,G) At 2 and 6 months later, CME decreased but VA improved to 0.8. (H) CME completely disappeared by the 9-month visit, and CME did not recur until the most recent 12-month visit. By then, VA had improved to 1.0.


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