Journal List > J Korean Ophthalmol Soc > v.52(9) > 1008879

Kim, Park, Shin, and Kim: Posterior Sub-Tenon Triamcinolone Acetonide Injection for Recurrent Diabetic Macular Edema after Repeated Intravitreal Bevacizumab Injections

Abstract

Purpose

To evaluate posterior sub-Tenon injection of triamcinolone acetonide (TA) for recurrent diabetic macular edema (DME) after repeated intravitreal bevacizumab (IVB).

Methods

This is a retrospective interventional case series comprised of 35 eyes (32 patients) with recurrent clinically significant DME after two or more IVB treatments. All patients were administered TA 40 mg injections. Best-corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP) were reevaluated at months 1, 3, and 6.

Results

The baseline OCT showed five eyes with diffuse retinal thickening, 18 eyes with cystoid macular edema, and 12 eyes with serous retinal detachment. Mean BCVA improved at months 1 and 3, and mean CMT decreased at months 1 and 3. However, mean BCVA and CMT at six months was not different from baseline. Each DME pattern showed significant improvements in BCVA and CMT at three months. Mean IOP at months 1, 3, and 6 did not show any significant difference from baseline. No eyes showed complications including cataract progression or endophthalmitis.

Conclusions

Posterior sub-Tenon injection of TA should be considered for patients with recurrent DME after repeated IVB. The studied eyes showed improvements in BCVA and CMT during three months in all of the three patterns of DME. J Korean Ophthalmol Soc 2011;52(9):1063–1070

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Figure 1.
Changes in central macular thickness (CMT) and best-corrected visual acuity (BCVA) of eyes with diabetic macular edema (DME) after posterior sub-Tenon triamcinolone acetonide (TA) 40 mg (1 ml) injection. (A, B, C) Horizontal optical coherence tomography (OCT) scan of a 67-year-old patient with recurrent DME despite 3 repeated intravitreal bevacizumab (IVB) injections. (A) At baseline, OCT showed cystoid macular edema with intraretinal cystoid spaces with 735 μ m of CMT and BCVA was 20/200. (B) Three months after TA injection, OCT showed complete resolution of intraretinal cystoid spaces with 244 μ m of CMT and BCVA improved to 20/50. (C) Six months after TA injection, CMT increased to 560 μ m and BCVA decreased to 20/100.
jkos-52-1063f1.tif
Figure 2.
Changes in central macular thickness (CMT) and best-corrected visual acuity (BCVA) of eyes with diabetic macular edema (DME) after posterior sub-Tenon triamcinolone acetonide (TA) 40 mg (1 ml) injection. (A, B C) Horizontal optical coherence tomography (OCT) scan of a 64-year-old patient with recurrent DME despite 3 repeated intravitreal bevacizumab (IVB) injections. (A) At baseline, OCT showed serous retinal detachment with low subretinal reflectivity with 545 μ m of CMT and BCVA was 20/125. (B) Three months after TA injection, OCT showed nearly complete resolution of subretinal fluid with 242 μ m of CMT and BCVA improved to 20/80. (C) Six months after TA injection, CMT increased to 431 μ m and BCVA decreased to 20/125.
jkos-52-1063f2.tif
Table 1.
Demographics and clinical data
Group
Eyes, n (patient) 35 (32)
Sex (M/F) 17/15
Age (mean ± SD, yr) 60.6 ± 8.2
Duration of diabetes (mean ± SD, yr) 11.7 ± 4.5
Type of diabetes
  Type 1/Type 2 0/32
Hypertension, n (%) 14 (43.8)
Bilaterality, n (%) 3 (9.4)
Lens status
  Phakic/pseudophakic 35/0
Grade of DR, n (%)
  Moderate NPDR 0 (0)
  Severe NPDR 11 (31.4)
  PDR 24 (68.6)
Previous PRP treatment, n (%) 24 (68.6)
No. of IVB injections, n (%)
  Mean ± SD 2.6 ± 0.8
  Twice 20 (57.1)
  Three times 11 (31.4)
  Four times 3 (8.6)
  Five times 1 (2.9)
Pattern of DME by OCT before posterior sub-Tenon TA injection, n (%)
  Diffuse retinal thickening 5 (14.3)
  Cystoid macular edema 18 (51.4)
  Serous retinal detachment 12 (34.3)
Follow-up after posterior sub-Tenon TA injection (mean ± SD, mon) 6.9 ± 0.7

DME = diabetic macular edema; DR = diabetic retinopathy; IVB = intravitreal bevacizumab; NPDR = nonproliferative diabetic retinopathy; OCT = optical coherence tomography; PDR = proliferative diabetic retinopathy; PRP = panretinal photocoagulation; SD = standard deviation; TA = triamcinolone acetonide.

Table 2.
Changes in best-corrected visual acuity and central macular thickness
n = 35 p-value
BCVA (log MAR)
 Baseline 0.77 ± 0.36
 After posterior sub-Tenon TA injection
  1 month 0.68 ± 0.33 0.017*
  3 months 0.66 ± 0.30 0.001*
  6 months 0.75 ± 0.38 1.0*
Improvement of BCVA ≥ 0.3 log MAR 3 (8.6)
Unchanged BCVA 32 (91.4)
Deterioration of BCVA ≥ 0.3 log MAR 0 (0)
CMT (μ m)
 Baseline 512 ± 134
 After posterior sub-Tenon TA injection
  1 month 356 ± 100 <0.001*
  3 months 323 ± 109 <0.001*
  6 months 456 ± 101 0.171*

Values are presented as mean ± standard deviation.

BCVA = best-corrected visual acuity; CMT = central macular thickness; log MAR = logarithm of the minimum angle of resolution; TA = triamcinolone acetonide.

* Comparison with baseline BCVA or CMT by repeated measures analysis of variance (ANOVA) corrected by Bonferroni's method.

Table 3.
Changes in best-corrected visual acuity and central macular thickness according to the patterns of diabetic macular edema by optical coherence tomography
Baseline 3 months p-value
BCVA (log MAR)
  Diffuse retinal thickening (n = 5) 0.78 ± 0.29 0.64 ± 0.26 0.031*
  Cystoid macular edema (n = 18) 0.76 ± 0.31 0.64 ± 0.25 0.008*
  Serous retinal detachment (n = 12) 0.77 ± 0.43 0.68 ± 0.40 0.036*
p-value 0.532 0.982
CMT (μ m)
  Diffuse retinal thickening (n = 5) 454 ± 144 319 ± 50 0.033*
  Cystoid macular edema (n = 18) 540 ± 127 322 ± 81 <0.001*
  Serous retinal detachment (n = 12) 493 ± 140 327 ± 111 0.002*
p-value 0.186 0.851

Values are presented as mean ± standard deviation.

BCVA = best-corrected visual acuity; CMT = central macular thickness; log MAR = logarithm of the minimum angle of resolution.

* Comparison between baseline and 3 months by Wilcoxon signed-rank test

Comparison among three patterns of diabetic macular edema by Kruskal-Wallis test.

Table 4.
Changes in intraocular pressure
IOP (mm Hg) p-value
Baseline 15.5 ± 3.2
After posterior sub-Tenon TA injection
  1 month 15.7 ± 3.1 1.0*
  3 months 16.3 ± 4.1 1.0*
  6 months 16.4 ± 3.1 0.125*

Values are presented as mean ± standard deviation.

IOP = intraocular pressure; TA = triamcinolone acetonide.

* Comparison with baseline IOP by repeated measures analysis of variance (ANOVA) corrected by Bonferroni's method.

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