The Combined Effect of Subtenon Triamcinolone Injection and Panretinal Photocoagulation on Diabetic Retinopathy

Seungbum Kang; Young-Hoon Park

doi:10.3341/jkos.2008.49.1.71

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Kang and Park: The Combined Effect of Subtenon Triamcinolone Injection and Panretinal Photocoagulation on Diabetic Retinopathy

Original Article

J Korean Ophthalmol Soc 2008;49(1):71-80.

Published online: 3 August 2008

DOI: https://doi.org/10.3341/jkos.2008.49.1.71

The Combined Effect of Subtenon Triamcinolone Injection and Panretinal Photocoagulation on Diabetic Retinopathy

Seungbum Kang, M.D., Young-Hoon Park, M.D.

Department of Ophthalmology and Visual Science, College of Medicine, The Catholic University of Korea, Seoul, Korea

Address reprint requests to Young-Hoon Park, M.D. Department of Ophthalmology, Uijeongbu St. Mary’s Hospital The Catholic University of Korea #65-1 Kumoh-dong, Uijeongbu, Gyeonggi-do 480-130, Korea Tel: 82-31-820-3110, Fax: 82-31-847-3418, E-mail: parkyh@catholic.ac.kr

Received 3 April 2007 Accepted 17 September 2007

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To investigate the result of posterior sub-tenon triamcinolone acetonide injection combined with panretinal photocoagulation (PRP) in patients with diabetic retinopathy.

Methods

A prospective study was performed on patients with diabetic retinopathy who required PRP. The study group consisted of 12 patients (12 eyes) of diabetic retinopathy without clinically significant macular edema (CSME) and 13 patients (13 eyes) with CSME. All patients were injected posteriorly with sub-tenon triamcinolone acetonide (40 mg) one week before PRP. During a six-month follow-up, best-corrected visual acuity, the development of macular edema, changes in fluorescein angiography, and related complications were monitored.

Results

During a six-month follow-up, visual acuity was well preserved in patients with diabetic retinopathy without CSME (12 eyes). Only one patient in this group experienced temporary macular edema at 3 months after combined therapy. In the CSME group (13 eyes), the visual acuities of seven patients (53.8%) increased, those of five patients (38.5%) remained same, and one patient’s visual acuity (7.7%) decreased in a study period of six months. Fluorescein angiography showed that macular edema was resolved in most patients except in one patient in whom macular edema remained for up to 6 months. Complications from combined therapy occurred in two patients who showed slight and temporary increase of intraocular pressure.

Conclusions

Combined treatment with posterior sub-tenon triamcinolone acetonide injection and PRP may provide benefits for patients with diabetic retinopathy who require urgent PRP by preventing exacerbation of macular edema.

Keywords: Panretinal photocoagulation, Posterior sub-tenon injection, Triamcinolone acetonide

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Figure 1.

Graph illustrating the change of mean best- corrected visual acuity (logMAR) in four groups. Group I: patients received combined therapy of triamcinolone sub-tenon injection and panretinal photocoagulation. Group II: patients received only panretinal photocoagulation. Group III: patients who had CSME received combined therapy of triamcinolone sub-tenon injection and panretinal photocoagulation. Group IV: patients who had CSME received focal or grid retinal photocoagulation before panretinal photocoagulation. In Group I and II, there was no difference of visual acuity between baseline and at 6 month. In Group III, compared with its baseline, values of visual acuity (logMAR) were significantly lower at 4, 5 and 6 months (p=0.019, p=0.044, p=0.042, respectively). In Group IV, compared with its baseline, values of visual acuity (logMAR) were significantly lower only at 6 months (p=0.028).

Figure 2.

Color fundus photographs and late-phase fluorescein angiograms of a male patient aged 58 without clinically significan macular edema. Fundus photograph (A) and fluorescein angiogram (B) before posterior sub-tenon injection of triamcinolon acetonide. (C, D) Same patients 6 months after combined sub-tenon injection of triamcinolone acetonide and panretina photocoagulation. Note that there was no macular edema before and after combined therapy.

Figure 3.

Color fundus photographs and late-phase fluorescein angiograms of a male patient aged 54 with clinically significant macular edema. Fundus photograph (A) and fluorescein angiogram (B) before posterior sub-tenon injection of triamcinolone acetonide showing macular edema and fluorescein leakage at macula (C, D) Same patient 6 months after combined sub-tenon injection of triamcinolone acetonide and panretinal photocoagulation. Note the decreased amount of late leakage in the macula as seen on the fluorescein angiogram. The macular edema improved.

Table 1.

Demographic data and diabetic retinopathy status of each treatment group without CSME

Variables	Group I (n=12)	Group II (n=12)	P-value^*
Age (years)
Range	47-69	39-68
Mean±S.D.	57.5±7.89	56.8±8.48	0.932
Sex
Male	3	3
Female	9	9
Duration of DM (years)
Range	4-21	5-20
Mean±S.D.	8.56±5.58	9.23±6.12	0.486
DM status (No. of eyes)
PDR	2	3
Severe NPDR	10	9

Group I: patients received combined therapy of triamcinolone sub-tenon injection and panretinal photocoagulation. Group II: patients received only panretinal photocoagulation. CSME=clinically significant macular edema; PDR=proliferative diabetic retinopathy; NPDR=non-proliferative diabetic retinopathy; S.D.=standard deviation;

P-value^*=the significance of the difference was assessed by the Mann-Whitney U test.

Table 2.

Demographic data and diabetic retinopathy status of each treatment group with CSME

Variables	Group III (n=13)	Group IV (n=13)	P-value^*
Age (years)
Range	36-73	43-63
Mean±S.D.	55.1±9.71	56.5±6.80	0.794
Sex
Male	8	8
Female	5	5
Duration of DM (years)
Range	3-28	4-25
Mean±S.D.	9.89±6.24	9.01±7.36	0.756
DM status (No. of eyes)
PDR	6	7
Severe NPDR	7	6

Group III: patients who have CSME received combined therapy of triamcinolone sub-tenon injection and panretinal photocoagulation. Group IV: patients who have CSME received focal retinal photocoagulation before panretinal photocoagulation. CSME=clinically significant macular edema; PDR=proliferative diabetic retinopathy; NPDR=non-proliferative diabetic retinopathy; S.D.=standard deviation;

P-value^*=the significance of the difference was assessed by the Mann-Whitney U test.

Table 3.

Mean visual acuity and IOP during in both groups without CSME

Study Peroid	Group I (n=12)		Group II (n=12)
Study Peroid	VA (logMAR±S.D.)	IOP (mmHg±S.D.)	VA (logMAR±S.D.)	IOP (mmHg±S.D.)
Baseline	0.135±0.10	16.67±3.73	0.127±0.09	15.85±4.21
1 month	0.155±0.14	15.50±4.35	0.268±0.18^*	16.02±4.02
2 months	0.161±0.14	14.91±3.02	0.256±0.13^*	15.41±3.62
3 months	0.111±0.12	15.27±3.07	0.213±0.11	15.73±3.97
4 months	0.103±0.12	16.17±3.16	0.199±0.11	15.89±3.41
5 months	0.103±0.12	15.92±3.48	0.214±0.10	15.76±3.01
6 months	0.104±0.11	15.83±4.24	0.199±0.12	16.01±3.84

Group I: patients received combined therapy of triamcinolone sub-tenon injection and panretinal photocoagulation. Group I patients received only panretinal photocoagulation. CSME=clinically significant macular edema; VA=visual acuity IOP=intraocular pressure; S.D.=standard deviation;

^* =the statistical difference between baseline VA and VA at each follow-up was assessed by Wilcoxon signed rank test (p<0.05).

Table 4.

Mean visual acuity and IOP during study peroid in both groups with CSME

Study Peroid	Group III (n=13)		Group IV (n=13)
Study Peroid	VA (logMAR±S.D.)	IOP (mmHg±S.D.)	VA (logMAR±S.D.)	IOP (mmHg±S.D.)
Baseline	0.708±0.46	16.23±4.00	0.717±0.43	15.33±3.53
1 month	0.643±0.48	14.58±3.38	0.709±0.45	15.58±4.01
2 months	0.549±0.32	15.15±3.28	0.603±0.53	16.15±3.87
3 months	0.539±0.33	15.53±2.90	0.590±0.40	15.94±3.31
4 months	0.509±0.34^*	14.53±3.04	0.571±0.36	15.37±4.03
5 months	0.506±0.37^*	14.92±3.45	0.580±0.39	15.27±3.59
6 months	0.492±0.38^*	14.61±3.42	0.545±0.38^*	15.21±3.58

Group III: patients who have CSME received combined therapy of triamcinolone sub-tenon injection and panretinal photocoagulation. Group IV: patients who have CSME received focal retinal photocoagulation before panretinal photocoagulation. CSME=clinically significant macular edema; VA=visual acuity; IOP=intraocular pressure; S.D.=standard deviation;

^* =the statistical difference between baseline VA and VA at each follow-up was assessed by Wilcoxon signed rank test (p<0.05).

Table 5.

Summary of patients who received re-treatment after combined therapy

Group	No. of eyes	Re-treatment	Interval from baseline	Comments
without CSME (n=12)	1	Subtenon injection	4 months	ME was developed at 3 months and resolved at 5 months after subtenon re-injection.
with CSME (n=13)	4	Subtenon injection	1 month	Because initial CSME was just slightly resolved after combined therapy, subtenon re-injection was done again at 1 month. However, CSME has not decreased until 6 months. Thin ERM was developed.
		Grid laser	7 weeks	Initial CSME was nearly subsided after combined therapy. CSME re-appeared at 6 weeks and was subsided at 4 months with grid laser treatment. After re-treatment, retina was flat up to 6 months.
		Subtenon injection	2 months	CSME was decreased much but small amout of CSME was still remained up to 2 months. Subtenon re-injection was performed at 2 months, which resulted in disappearing remained CSME.
		Subtenon injection	3 months	CSME was remained slightly up to 3 months. It was completely subsided 2 weeks after subtenon re-injection.

CSME=clinically significant macular edema; ME=macular edema; ERM=epiretinal membrane.

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