Posterior Sub-Tenon Triamcinolone Acetonide Injection for Recurrent Diabetic Macular Edema after Repeated Intravitreal Bevacizumab Injections

Jong Ho Kim; Dong Ho Park; Jae Pil Shin; Si Yeol Kim

doi:10.3341/jkos.2011.52.9.1063

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

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

Original Article

J Korean Ophthalmol Soc 2011;52(9):1063-1070.

Published online: 7 September 2011

DOI: https://doi.org/10.3341/jkos.2011.52.9.1063

Posterior Sub-Tenon Triamcinolone Acetonide Injection for Recurrent Diabetic Macular Edema after Repeated Intravitreal Bevacizumab Injections

Jong Ho Kim, MD¹, Dong Ho Park, MD¹, Jae Pil Shin, MD¹, Si Yeol Kim, MD²

¹Department of Ophthalmology, Kyungpook National University School of Medicine, Daegu, Korea

²Nune Eye Hospital, Daegu, Korea

Address reprint requests to Si Yeol Kim, MD Nune Eye Hospital 18∼21F LIG Bldg, #41-3 Beomeo-dong, Suseong-gu, Daegu 706-010, Korea Tel: 82-1661-1175, Fax: 82-53-426-6552, E-mail: kimsy@knu.ac.kr

Received 3 March 2011 Revised 22 March 2011 Accepted 7 July 2011

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 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

Keywords: Bevacizumab, Diabetic macular edema, Posterior sub-Tenon injection, Triamcinolone acetonide

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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.

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.

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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