Triamcinolone acetonide edema

Cardillo JA, Melo LA, Costa RA, et al. Comparison of intravitreal versus posterior sub-Tenon s capsule injection of triamcinolone acetonide for diffuse diabetic macular edema. Ophthalmology 2005 112 1557-1563. 

Androudi S, Letko E, Meniconi M, et al. Safety and efficacy of intravitreal triamcinolone acetonide for uveitic macular edema. AAO Annual Meeting 2003. November 15-18, Anaheim, CA. 

The FDA approved intraocular injections include miotics, triamcinolone acetonide, pegaptanib sodium, ranibizumab, formivirsen sodium, viscoelastics and viscoadherents, and an antiviral agent for intravitreal injection. There are many small and large molecules currently in clinical trials that are delivered via intravitreal injection for the treatment of a variety of retinal diseases with a large area of focus on the treatment of AMD and macular edema. 

Periocular injections, subconjunctival, subtenons, and retrobulbar injection of drugs have been frequently investigated as a means to increase ocular availability. Subtenon injections of steroids, such as triamcinolone acetonide, are frequently used to control inflammatory conditions of the posterior segment such as cystoid macular edema, although this delivery route carries a risk of inadvertent intraocular injection (45). 

The use of intravitreal corticosteroids was first popularized by Machemer in 1979 (33) in an effort to halt cellular proliferation after retinal detachment surgery, and Graham (34), McCuen (35), Tano (36), and others have studied its use in both animal models and humans. In contrast to other corticosteroids with short half-lives following intravitreal injection, triamcinolone acetonide is an effective and well-tolerated (35,37) agent for intravitreal injection in conditions such as uveitis (38,39), macular edema secondary to ocular trauma or retinal vascular disease (40), proliferative diabetic retinopathy (41), intraocular proliferation such as proliferative vitreoretinopathy (42), and choroidal neovascularization from AMD (43,44). 

Intravitreal triamcinolone acetonide use has increased recently following case series of successful treatment of edema due to various etiologies as well as choroidal neovascularization. It has been advocated for the treatment of macular edema associated with diabetes (54), uveitis (38,39), and central retinal vein occlusion (55). In addition, it has been proposed as adjunctive treatment for proliferative diabetic retinopathy (41) and exudative AMD (43,44). 

Recently, macular edema associated with uveitis (29), diabetic retinopathy (30), and central retinal vein occlusion (31,32) has been treated with intravitreal injection of triamcinolone acetonide. Macular edema decreased after treatment but recurred three to six months after injection. A sustained-release steroid delivery system may be more attractive than a simple injection of triamcinolone as it could reduce or eliminate the need for multiple intravitreal injections. 

Ip MS, Kumar KS. Intravitreous triamcinolone acetonide as treatment for macular edema from central retinal vein occlusion. Arch Ophthalmol 2002 120 1217-1219. 

Micelli-Ferrari T, Sborgia L, Furino C, et al. Intravitreal triamcinolone acetonide evaluation of retinal thickness changes measured by optical coherence tomography in diffuse diabetic macular edema. Eur J Ophthalmol 2004 14(4) 321—334. 

Massin P, Audren F, Haouchine B, et al. Intravitreal triamcinolone acetonide for diabetic diffuse macular edema preliminary results of a prospective controlled trial. Ophthalmology 2004 111(2) 218-227. 

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(1) 158—160. 

As discussed previously, corticosteroids downregulate VEGF production in experimental models and possibly reduce breakdown of the blood retinal barrier (15,16). Similarly, corticosteroids have antiangiogenic properties possibly due to attenuation of the effects of VEGF (20,21). These properties of steroids are commonly used. Clinically, triamcinolone acetonide is used locally as a periocular injection to treat cystoid macular edema secondary to uveitis or as a result of intraocular surgery (22,23). In animal studies, intravitreal triamcinolone acetonide has been used to prevent proliferative vitreoretinopathy and retinal neovascularization (24—27). Intravitreal triamcinolone acetonide has been used clinically to treat proliferative vitreoretinopathy and choroidal neovascularization (28-31). 

Recently, intravitreal triamcinolone acetonide has been used clinically to treat retinal vascular disease (Fig. 4). A case report by Jonas and Sofker (32) described a patient with nonproliferative diabetic retinopathy and a six-month history of persistent, diffuse macular edema despite grid photocoagulation. Following one intravitreal injection of triamcinolone acetonide, the visual acuity of this patient improved from 20/200 to 20/50 over a five-month follow-up period. It was also noted that there was marked regression of macular edema on clinical examination. Martidis et al. (33,34) reported on the use of intravitreal triamcinolone for refractory diabetic macular edema. Sixteen eyes with a macular thickness of at least 300 pm despite prior photocoagulation were treated with 4 mg injections of triamcinolone. At three-month follow-up the mean decrease in central retinal thickness was 57.5%, with a visual acuity increase of 2.4 Snellen lines. Those with six-month follow-up demonstrated some recurrence of edema and visual acuity improvement was reduced to 1.3 lines. 

Jonas JB, Kreissig I, Degenring RF. Intravitreal triamcinolone acetonide as treatment of macular edema in central retinal vein occlusion. Graefes Arch Clin Exp Ophthalmol 2002 240 782-783. 

Park CH, Jaffe GJ, Fekrat S. Intravitreal triamcinolone acetonide in eyes with cystoid macular edema associated with central retinal vein occlusion. Am J Ophthalmol 2003 136 419-425. 

Intravitreal triamcinolone has been used to treat diffuse diabetic macular edema. Also, an intravitreal implant delivering fluocinolone acetonide (Retisert) is effective in the treatment of patients with noninfectious posterior uveitis who have failed to respond to conventional treatment. 

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