Bilateral Macular Edema Research Articles

Retrospective Analysis of Rosiglitazone and Macular Oedema in Patients with Type 2 Diabetes Mellitus

Macular oedema tends to be a more rapid complication of diabetic retinopathy and represents the major cause of blindness. Among subjects with type 2 diabetes mellitus, it can be found in 15% of those who use insulin and 4% of those who do not. Use of thiazolidinediones (glitazones) has recently been associated with some cases of macular oedema. We recalled 102 diabetic subjects treated with rosiglitazone to our diabetes centre in order to evaluate a possible association of this drug with macular oedema. Of these 102 subjects, we evaluated all 76 who provided written informed consent to participate in the analysis. All of these underwent a battery of four diagnostic tests: (1) visual acuity, (2) Amsler visual field test, (3) Ishihara colour recognition test, and (4) retinal fundus photography. All retinal photographs were examined by two experienced ophthalmologists. The most noticeable result was that most subjects (80%) had satisfactory visual acuity. The Ishihara test chart showed that three subjects were colour blind, but this abnormality was already known. On the Amsler test, one subject had a positive result consisting of visual distortion of a series of straight lines. In the retinal photos, two expert ophthalmologists independently identified one case of 'paramacular oedema' in a subject with diabetes of long duration with a proliferative retinopathy. The patient developed bilateral macular oedema during treatment with rosiglitazone 8 mg/day. The patient had been diagnosed with diabetes at the age of 45 years and after a period of 6 years taking oral antihyperglycaemic agents had been switched to insulin, up to four injections per day (total 60-70 IU/day), for the next 15 years. In 2000 a routine examination demonstrated the presence of sustained hypertension and the patient was started on an ACE inhibitor. A computerized test for autonomic neuropathy demonstrated abnormal deep breathing and lying-to-standing responses. Treatment with rosiglitazone was interrupted and the subject underwent a series of retinal photocoagulations for proliferative retinopathy. Two months after rosiglitazone therapy had been discontinued, the visual acuity of the patient reversed to baseline values. The study shows that rosiglitazone was not linked to formation of macular oedema, with the exception of one case of bilateral and clinically reversible paramacular oedema, where rosiglitazone was given in co-administration with a long-term insulin treatment regimen in a subject with pre-existing diabetic retinopathy. This patient had a long duration of diabetes and had also been hypertensive since 2000.

Intravitreal and posterior subtenon triamcinolone acetonide in idiopathic bilateral uveitic macular oedema

To study the efficacy of intravitreal triamcinolone acetonide (IVTA) versus posterior subtenon triamcinolone acetonide (PSTA) in bilateral macular oedema secondary to idiopathic intermediate uveitis. In a prospective, interventional case series, 10 patients (20 eyes) with bilateral uveitic macular oedema were included. Patients underwent fundus fluorescein angiography, record of visual acuity and intraocular pressure (IOP). Patients received IVTA 4 mg/0.1 mL in one eye and PSTA 20 mg/0.5 mL in the fellow eye at an interval of > or =4 weeks. The outcome measures were record of IOP, best corrected visual acuity and angiographic resolution of cystoid macular oedema at 3 and 6 months. The mean pre-intervention IOP at baseline between the IVTA and the PSTA group was comparable. At 1 week, the mean IOP recorded was greater in the eyes that received IVTA than those that received PSTA (P < 0.001). However, at 1- and 3-month follow up, the mean IOP between the two groups was similar. Best corrected visual acuity of > or =6/12 achieved at 3 and 6 months in the IVTA and PSTA group was comparable (77.8% vs. 44.4% [P = 0.14] and 88.9% vs. 77.8% [P = 0.53]). There was also no significant difference in angiographic resolution of cystoid macular oedema at 3 (P = 0.32) and 6 months (P = 0.53) between the two groups. Recurrence of macular oedema was seen in one and two eyes that received IVTA and PSTA, respectively, at 6 months. Triamcinolone acetonide injection, whether administered intravitreally or via posterior subtenon route, is an effective treatment option in achieving complete anatomic and functional improvement in cases treated for macular oedema secondary to idiopathic intermediate uveitis.

Evaluation of Intravitreal Kenalog Toxicity in Humans

To evaluate possible functional toxicity of intravitreal Kenalog (commercial triamcinolone acetonide) in patients' retinas. Observational case series. Thirty-two phakic eyes of 16 patients who had nonproliferative diabetic retinopathy and bilateral macular edema refractory to laser therapy, which had no other eye disorder and no previous ophthalmic operation. Kenalog (4 mg/0.1 ml) was injected intravitreally to one eye, whereas the second eye served as the control. The experimental eye was chosen as the eye with worse visual acuity (VA). Deterioration of electroretinogram parameters of the study eye measured at 3 months of follow-up when compared with the electroretinogram responses of the fellow, control eye and when compared with electroretinogram responses obtained before injection. Visual acuity, intraocular pressure (IOP), and eventual complications were assessed. No improvement or deterioration of VA or any increase in IOP was regarded as a secondary outcome. Average maximal response amplitude ratios of the dark-adapted b-wave (treated/control eyes) of the electroretinogram were 0.93 before (P = 0.221) and 0.94 (P = 0.387) 3 months after Kenalog injection. Average ratios of the light-adapted b-wave amplitude (treated/control eyes) of the electroretinogram were 1.04 (P = 0.702) before and 0.86 (P = 0.138) 3 months after Kenalog injection. No significant differences (P>0.05) were found between the electroretinogram parameters obtained from all eyes before and 3 months after Kenalog injection. Average VAs in the treated eyes were 1.08, 0.8, and 1.0 logarithm of the minimum angle of resolution units before and 2 and 4 months after injection, respectively. Temporary elevation of IOP was found in 4 treated eyes of 4 patients (25%). No electroretinographic evidence of a retinotoxic effect of intravitreal Kenalog was found in our patients.

Optical Coherence Tomography and Focal Electroretinogram Evaluation of Cystoid Macular Edema Secondary to Retinitis Pigmentosa Treated with Intravitreal Triamcinolone: Case Report

To assess macular structure and function by optical coherence tomography (OCT) and focal electroretinogram (FERG) before and after intravitreal triamcinolone acetonide (IVTA) administration for cystoid macular edema (CME) in a patient with retinitis pigmentosa (RP). A 33-year-old man with RP and refractory bilateral macular edema was treated with IVTA in his left eye and evaluated with visual acuity, OCT, and FERG for 6 months. RESULTS. Compared to the fellow eye, after IVTA mean retinal thickness significantly decreased, while FERG amplitude and phase did not show significant changes at the end of follow-up. Visual acuity showed a significant tendency to improve. In this case report, IVTA improved macular anatomy and visual acuity; this result, however, was not associated with a similar electrophysiologic response.

Comparison of Topical and Subconjunctival Anesthesia in Intravitreal Injection Administrations

To compare the effectiveness of topical and subconjunctival anesthesia in intravitreal injection administrations. Twenty-eight patients from a university clinic with bilateral diabetic macular edema were prospectively randomized to receive intravitreal injection of 4 mg triamcinolone under topical anesthesia for one eye and subconjunctival anesthesia for the other eye by using lidocaine 4%. Patients were asked to grade the pain they experienced during administration of both anesthesia and intravitreal injection by using a 4-point pain scale: from 0=no pain to 3=severe pain. Complications that developed during both procedures were recorded. The mean pain score experienced during subconjunctival injections was 0.78+/-0.62, whereas no anesthesia-related pain was reported in the topical group. The mean pain score experienced during intravitreal injection was 1.64+/-0.67 in the topical and 0.85+/-0.52 in the subconjunctival group (p<0.001). The mean total pain scores of both procedures were 0.82+/-0.34 in the topical and 0.82+/-0.51 in the subconjunctival group (p>0.05). Nine eyes (32%) developed subconjunctival haemorrhage after subconjunctival injection, whereas no anesthesia-related complication developed in the topical group. Subconjunctival haemorrhage was also observed in 5 eyes (18%) in the topical group and in 11 eyes (40%) in the subconjunctival group (p>0.05) after intravitreal injection. Although subconjunctival anesthesia provides better pain control during intravitreal injections, its application is more painful and leads to subconjunctival haemorrhage. Moreover, the mean total pain scores are similar in both methods. Therefore, topical anesthesia may be more suitable for daily practice.

Intravitreal triamcinolone acetonide for diffuse diabetic macular oedema: 6‐month results of a prospective controlled trial

To evaluate prospectively the efficacy and safety of one intravitreal injection of 4 mg triamcinolone acetonide for refractory diffuse diabetic macular edema. Seventeen patients with bilateral diabetic macular edema unresponsive to laser photocoagulation. In all patients, one eye was injected, and the other served as a control. The intervention consisted in intravitreal injection of 4 mg triamcinolone acetonide. The main outcome measure was central macular thickness (CMT) at 4, 12 and 24 weeks, measured by Optical Coherence Tomography. Secondary outcomes were Early Treatment Diabetic Rentinopathy Study (ETDRS) scores, intraocular pressure and cataract PROGRESSION. Before injection, mean +/- SD CMT was 566.4 +/- 182.4 mum in injected eyes. Four, 12, and 24 weeks after injection, it was 228.4 +/- 47.5 mum, 210.9 +/- 87.2 mum and 358.5 +/- 160.5 mum respectively. CMT was significantly lower in injected eyes vs. control eyes except 24 weeks after injection because of a recurrence of macular edema in 9/17 injected eyes. Mean +/- SD gain in ETDRS score was significantly better in injected eyes vs. control eyes 4, 12 and 24 weeks after TA injection. In 9 of the 17 injected eyes, intraocular pressure exceeded 24 mmHg and was controlled by topical medication. In the short-term, intravitreal injection of triamcinolone effectively reduces macular thickening due to diffuse diabetic macular edema and improves visual acuity in most cases. The long-term effect of this treatment and predictive factors of visual recovery remain to be elucidated.

Intravitreal triamcinolone acetonide for treatment of intraocular oedematous and neovascular diseases

Intravitreal triamcinolone acetonide (IVTA) has increasingly been applied as treatment for various intraocular neovascular and oedematous diseases. Comparing the various diseases with respect to effect and side-effects of the treatment, the best response in terms of gain in visual acuity (VA) has been achieved for intraretinal oedematous diseases such as diffuse diabetic macular oedema, branch retinal vein occlusion, central retinal vein occlusion and pseudophakic cystoid macular oedema. In eyes with various types of non-infectious uveitis, including acute or chronic sympathetic ophthalmia and Adamantiadis-Behcet's disease, VA increased and the degree of intraocular inflammation decreased. Some studies have suggested that intravitreal triamcinolone may be useful as angiostatic therapy in eyes with iris neovascularization and proliferative ischaemic retinopathies. Intravitreal triamcinolone may possibly be helpful as adjunct therapy for exudative age-related macular degeneration (AMD), particularly in combination with photodynamic therapy. In eyes with chronic, therapy-resistant ocular hypotony, intravitreal triamcinolone can induce an increase in intraocular pressure (IOP) and may stabilize the eye. The complications of intravitreal triamcinolone therapy include: secondary ocular hypertension in about 40% of the eyes injected; medically uncontrollable high IOP leading to antiglaucomatous surgery in about 1-2% of the eyes; posterior subcapsular cataract and nuclear cataract leading to cataract surgery in about 15-20% of elderly patients within 1 year of injection; postoperative infectious endophthalmitis occurring at a rate of about one per 1000; non-infectious endophthalmitis, perhaps due to a reaction to the solvent agent, and pseudo-endophthalmitis with triamcinolone acetonide crystals appearing in the anterior chamber. Intravitreal triamcinolone injection can be combined with other intraocular surgeries, including cataract surgery, particularly in eyes with iris neovascularization. Cataract surgery performed some months after the injection does not show a markedly elevated complication rate. The injection may be repeated if the resultant benefits decrease after the initial IVTA injection. In non-vitrectomized eyes, the duration of the effect and side-effects of a single intravitreal injection of triamcinolone is about 6-9 months for a dosage of about 20 mg, and about 2-4 months for a dosage of 4 mg. So far, it has remained unclear whether the solvent agent should be removed, and if so, how.

Radiation Retinopathy Caused by Low Dose Irradiation and Antithyroid Drug-Induced Systemic Vasculitis

We report on a patient with Graves' disease with radiation retinopathy caused by low-dose irradiation and antithyroid drug-induced antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis. A 38-year-old woman with Graves' disease presented with bilateral blurred vision, microaneurysms, telangiectasia, and macular edema. The patient was examined by ophthalmoscopy and fluorescein angiography, and radiation retinopathy was diagnosed. The patient had been treated with low-dose irradiation for her Graves' ophthalmopathy a few years earlier. She also had ANCA-positive vasculitis induced by the antithyroid drug (propylthiouracil, PTU) that had been prescribed for her at that time. Because of multiple avascular areas on both retinas, she was treated by intensive retinal photocoagulation to control progressive retinopathy. The radiation doses used to treat Graves' disease ophthalmopathy are low. Nevertheless, there is still a risk of radiation retinopathy developing in patients with PTU-induced ANCA-positive vasculitis.

Modified Grid Laser Photocoagulation Versus Pars Plana Vitrectomy With Internal Limiting Membrane Removal in Diabetic Macular Edema

To compare the effectiveness of pars plana vitrectomy (PPV) and removal of the internal limiting membrane (ILM) with modified grid laser photocoagulation in diabetic macular edema. Randomized, comparative, interventional study. In this prospective study, 24 eyes of 12 patients with bilateral diabetic macular edema were evaluated. PPV with removal of the ILM was performed at random in one eye of 12 patients (ILM group), and a single session of modified grid laser photocoagulation was performed in the fellow eyes (grid group). Main outcome measures were the foveal thickness measured with optical coherence tomography, preoperative, and postoperative visual acuities. Mann-Whitney U and Wilcoxon tests were used in statistical analysis. All patients were followed up for 6 months. In the ILM group, mean foveal thickness was 439.2 +/- 106.5 microm preoperatively and 219.8 +/- 63.2 mum postoperatively (P = .002). In the grid group, mean foveal thickness was 407 +/- 100.2 microm preoperatively and 378.5 +/- 141.6 microm postoperatively (P = .433). A mean decrease in foveal thickness was found to be 219.4 +/- 127.6 microm in the ILM group and 28.5 +/- 90.5 microm in the grid group (P = .001). In the ILM group, best-corrected logMAR visual acuity was 0.75 +/- 0.41 preoperatively and 0.53 +/- 0.41 postoperatively (P = .006). In the grid group, best-corrected logMAR visual acuity was 0.59 +/- 0.27 preoperatively and 0.49 +/- 0.27 postoperatively (P = .058). Visual acuity improved by 2 or more lines in six eyes (50%) in the ILM group and in three eyes (25%) in the grid group. Visual acuity remained stable in six eyes (50%) in the ILM group and in nine eyes (75%) in the grid group. PPV with ILM removal appears to be more effective than a single session of modified grid laser photocoagulation in the treatment of diabetic macular edema. Further studies with a large number of patients are required for a more reliable conclusion.

Inter-eye difference in diabetic macular edema after unilateral intravitreal injection of triamcinolone acetonide

To report on visual outcome of patients receiving intravitreal triamcinolone acetonide for treatment of diffuse diabetic macular edema. Prospective, comparative clinical interventional study. Institutional. patient population: The study included 25 consecutive patients (50 eyes) with bilateral diabetic macular edema. Intervention procedure: Unilateral intravitreal injection of about 20 mg triamcinolone acetonide into the eye (study group) more severely affected by diabetic maculopathy. The contralateral eyes served as control group. Mean follow-up was 7.1 +/- 4.1 months. Visual acuity, intraocular pressure. In the study group, visual acuity increased significantly (P < or = .001) by 3.0 +/- 2.6 Snellen lines to a peak at two to six months after the injection, and decreased significantly (P = .001) towards the end of follow up. At the end of follow-up, visual acuity was higher, not significantly (P = .18) higher, than at baseline. An increase in visual acuity was found in 23 eyes (92%). In the control group, differences between visual acuity at baseline and at any of the re-examinations during follow-up were not significant (P > .10). In an intra-individual inter-eye comparison, gain in visual acuity was significantly (P < .05) higher in the injected eyes, for the measurements obtained up to four months after injection. Intravitreal triamcinolone acetonide may temporarily increase visual acuity in eyes with diabetic macular edema.

Intravitreal triamcinolone acetonide for diabetic diffuse macular edema : Preliminary results of a prospective controlled trial

Objective To evaluate prospectively the efficacy and safety of 1 intravitreal injection of 4 mg of triamcinolone acetonide for refractory diffuse diabetic macular edema. Design Interventional case series. Participants Fifteen patients with bilateral diabetic macular edema unresponsive to laser photocoagulation. In all patients, one eye received the injection, and the other served as a control. Intervention Intravitreal injection of 4 mg of triamcinolone acetonide under subconjunctival anesthesia. Main outcome measures The main outcome measure was central macular thickness (CMT) at 1, 3, and 6 months, measured by optical coherence tomography. Secondary outcomes were Early Treatment Diabetic Retinopathy Study (ETDRS) scores, intraocular pressure, and cataract progression. Results In this preliminary report, we give the results for 12 patients who had a follow-up of at least 3 months. Seven of them were followed up for 6 months. Before injection, CMT was 509.6±143.5 μm (mean ± standard deviation [SD]) in injected eyes, versus 474.4±82.6 μm in control eyes. Four weeks after injection, it was 207.3±44.2 μm in injected eyes and 506.7±122.4 μm in control eyes ( P<0.001, bilateral Wilcoxon test for paired samples), and after 12 weeks, 207±96.7 μm and 469.3±117.6 μm, respectively ( P = 0.005). The difference between the CMTs of injected and control eyes was no longer significant at 24 weeks because of the recurrence of macular edema in 5 of 12 injected eyes. Before triamcinolone injection, the ETDRS score was 47.8±13 (mean ± SD; range, 28–66) in injected eyes, versus 51.9±14.6 (range, 31–71) in control eyes. Twelve weeks thereafter, the corresponding values were 52.7±10.8 (range, 34–70) and 50.8±14.3 (range, 29–69), respectively, and at 24 weeks, 54.7±7.6 (range, 47–68) and 50.6±18.4 (range, 28–71). At no time was the difference between the ETDRS scores for injected and control eyes significant. In 6 of the 12 injected eyes, intraocular pressure exceeded 25 mmHg, and was controlled by topical medication. Conclusion Intravitreal injection of triamcinolone effectively reduces macular thickening due to diffuse diabetic macular edema, at least in the short term. Further studies are required to demonstrate that it provides visual benefit.

Clear evidence that long-term, low-dose tamoxifen treatment can induce ocular toxicity. A prospective study of 63 patients.

The current study has prospectively investigated the incidence and course of ocular toxicity after low-dose tamoxifen treatment. Sixty-three patients with cancer who could be examined were analyzed. Tamoxifen was administered on a 20-mg daily dose. Median duration of treatment was 25 months. Median total tamoxifen dose was 14.4 gr. Four patients had retinopathy and/or keratopathy 10, 27, 31, and 35 months, respectively, after tamoxifen initiation (an incidence of 6.3%). Ophthalmologic findings consisted of decreased visual acuity, bilateral macular edema, yellow-white dots in the paramacular and fovea areas in all patients as well as corneal opacities in one patient. After tamoxifen withdrawal almost all ocular abnormalities were found to be reversible, except for the retinal opacities. This is the first prospective study in the literature indicating that even conventional low-dose tamoxifen treatment can induce ocular toxicity. In addition, the authors review and discuss the literature of the last decades.