Intravitreal Triamcinolone Injection Research Articles

Intravitreal triamcinolone and retrobulbar chlorpromazine as alternative to blind painful eye management

Objective: The objective of this study was to evaluate the efficacy of intravitreal triamcinolone and retrobulbar chlorpromazine as alternatives in the management of ocular pain in blind eyes. Methods: This was a non-randomized interventional prospective study of patients with painful blind eye unresponsive to topical treatment and without indication of evisceration treated at the Hospital Governador Celso Ramos Ophthalmology Service in 2010. After ocular examination and ocular B mode ultrasound, patients were divided into two groups. Group 1 patients had intractable glaucoma and received retrobulbar injection of chlorpromazine 2.5ml, and Group 2 patients had phthisics eyes with inflammatory component and received intravitreal triamcinolone injection 0.3ml. Evaluations were performed at 1, 3 and 6 months after the procedure and quantified pain subjectively on a scale from 0 to 10 (no pain and maximum pain, respectively). Results: 38 eyes were included, 15 in Group 1 and 21 in Group 2. There was a predominance of males with a mean age of 54 years. The most prevalent cause of painful blind eye was the neovascular glaucoma. Any retrobulbar injection of chlorpromazine as the intravitreal triamcinolone shown to be effective in the control of ocular pain in the eye blind study period (p <0.001). There was a 77.1% reduction in eye drops (p <0.01) after application of medication. Conclusion: Both the retrobulbar injection chlorpromazine as the intravitreal triamcinolone showed significant results in the control of ocular pain in blind eyes, and a reduction in the use of eye drops. Chlorpromazine is a low cost product, with a better adverse effect profile and showed slightly better results compared to triamcinolone. Potential bias identified in the study are the time and selection.

The combination of phacoemulsification surgery and intravitreal triamcinolone injection in patients with cataract and diabetic macular edema

PurposeTo assess the safety and efficiency of combined phacoemulsification (PHACO) surgery and intravitreal triamcinolone (IVTA) injection with or without macular grid laser photocoagulation in patients with cataract and diabetic macular edema. Material and methodsThis prospective study included 41 eyes of 36 diabetic patients with cataract and coexisting clinically significant macular edema (CSME). After PHACO and IVTA injection eyes were divided into two groups: the laser and IVTA group (Group 1) and only IVTA group (Group 2). Preoperative and postoperative best corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP) were recorded. Paired sample t-test was used to compare data in the groups and C square test for qualitative variables. ResultsPostoperative BCVA was significantly higher than the initial BCVA during the follow-up period in both groups (p<0.01). The BCVA 6months after surgery was significantly higher in group 1 than in group 2 (p<0.01). There was no statistically significant difference in IOP between two groups preoperatively and postoperatively during the follow-up period (p>0.05). There was no statistically significant difference between both groups in mean CMT preoperatively and 2nd week, 2nd month and 3rd month after surgery (p>0.05). The mean CMT 6months after surgery was statistically significantly lower in group 1 than in group 2 (p<0.01). ConclusionsPHACO surgery combined with IVTA injection improves BCVA and provides a decrease in CMT in diabetic patients with CSME. Additional macular grid laser photocoagulation after surgery helps to preserve this improvement in BCVA and decrease in CMT.

Macular Infarction Following Intravitreal Triamcinolone Injection for Treatment of Central Retinal Vein Occlusion

PurposeTo report a case of macular infarction following intravitreal triamcinolone injection for treatment of central retinal vein occlusionMethodsA 75‐year‐old man visited our clinic for visual disturbance in his left eye, who had diagnosed with macular infarction in his right eye. The patient's best‐corrected visual acuity was 0.6 in his left eye. His medical history included type 2 diabetes, alcoholic liver cirrhosis, hepatocellular carcinoma. After fundus examination, the patient was diagnosed with central vein occlusion with macular edema, intravitreal triamcinolone was administered in an attempt to reduce edema.ResultsWithin 1 week of treatment with intravitreal injection, the patient noted a significant decrease in visual acuity. Flurorescein angiogram demonstrated an enlargement of the foveal avascular zone following intravitreal triamcinolone, although optical coherence tomography (OCT) showed a decresed maculr edema. Despite normalization of macular thickness on OCT and cessation of leakage on angiography, visual acuity remained at the same level until 2 month of follow‐up.ConclusionsNot only intravitreal anti‐VEGF injection, but also intravitreal triamcinolone injection can cause macular ischemia. This must be taken into consideration when the treatment regime is adopted for use in patients with ischemic risk factors.

Intravitreal Triamcinolone Injection for Uveitic Macular Edema: A Randomized Clinical Study

Purpose: To evaluate the additive effect of intravitrial triamcinolone (TA) injection in uveitic macular edema compared to systemic anti-inflammatory treatment only.Methods: Patients were randomized into the intravitreal TA injection group and the sham group. All patients received systemic anti-inflammatory treatment with follow-up monthly to 6 months, with additional treatment as needed.Results: Fifty eyes of 50 patients were enrolled. Central foveal thickness decreased significantly from month 1 in the TA group, and from month 3 in the sham group. Parafoveal area thickness significantly decreased in both groups from month 1, with greater decrease in the TA group at months 2 and 3. Leakage area on fluorescein angiography was significantly smaller in the TA group at months 1 to 3. Intraocular pressure increased in the TA group at months 1 and 2.Conclusions: Intravitreal TA injection showed earlier reduction of leakage and retinal edema compared to systemic anti-inflammatory treatment alone.

Treatment of stage 3 Coats' disease by endolaser photocoagulation via a two-port pars plana nonvitrectomy approach.

BackgroundTo evaluate the effectiveness of endolaser photocoagulation by a two-port pars plana nonvitrectomy approach for treating Coats’ disease with shallow exudative retinal detachment.MethodsThis study included 24 patients (23 boys with an age range of 2–17 years, and one girl, age 6 years) with stage 3 Coats’ disease (25 eyes) from December 2012 and May 2014 at a single center. All of the 25 eyes were complicated with serous or total retinal detachment and received none-vitrectomized endolaser: two (23- or 25-gauge) incisions were routinely made 3 mm posterior to the corneal limbus and a laser was applied directly on the abnormal blood vessels. Additional treatments included subretinal fluid drainage (five eyes), intravitreal triamcinolone injection (seven eyes), and intravitreal anti-vascular endothelial growth factor (VEGF) injection (17 eyes). Best-corrected visual acuity, intraocular pressure, and fundus and abnormal vascular changes were recorded to determine therapeutic effects.ResultsTwenty-four out of the 25 treated eyes (96 %) had retina reattached. The number of treatment sessions differed case by case (1–5 sessions, average 1.96) and the time to full treatment of retinal reattachment was 4 months in average. One patient (4 %) presented with retinal redetachment. Five (20 %) eyes received further laser treatment with indirect ophthalmoscope and four eyes (16 %) presented with total retinal detachment at their first visits received consecutive treatments. At the end of the follow-up period (mean, 10.08 months), telangiectasias of 24 (96 %) eyes were resolved and no severe complications occurred.ConclusionsEndolaser photocoagulation by a two-port pars plana nonvitrectomy approach is an effective treatment for advanced Coats’ disease with serous retinal detachment. The long-term safety of the approach needs further investigation.

Repeated Intravitreal Bevacizumab Injections versus Single Combined Intravitreal Bevacizumab and Posterior Subtenon Triamcinolone Injections for Treatment of Diabetic Macular Edema

Aim: To compare efficacy of combined intravitreal bevacizumab and subtenon triamcinolone versus three intravitreal injections of bevacizumab at one month interval for reducing foveal thickness. Methods: Sixty eyes of 30 diabetic patients with bilateral diabetic macular edema were randomly enrolled in two groups, group A eyes treated with three intravitreal injections of Bevacizumab of 1 month apart, and group B eyes treated with a single intravitreal injection of Bevacizumab comb ined with a subtenon triamcinolone in the same operative session. Pre and postoperative clinical data were measured and followed up over 6 months. Results: Difference between pre - treatment and post - treatment clinical data for each parameter in the same gro up was highly statistically significant. However, on comparing results of post treatment BCVA, IOP and CMT in both groups, there was no statistically significant difference. Conclusion: Combination of subtenon triamcinolone and intravitreal bevacizumab i s a safe and effective choice to treat DME. Original Research Article

Short-Term Results of Dexamethasone Intravitreal Implant in Patients with Refractory Diabetic Macular Edema

Purpose: To evaluate the effectiveness of a dexamethasone intravitreal implant (Ozurdex) in the treatment of diabetic macular edema refractory to combined treatment of bevacizumab and triamcinolone. Methods: We reviewed 9 eyes of 9 patients with diabetic macular edema treated with dexamethasone intravitreal implant. The patients were included in the study if presenting with refractory diabetic macular edema of more than 3 months despite combined treatment of intravitreal bevacizumab injection with posterior subtenon triamcinolone injection or intravitreal triamcinolone injection. We assessed the best-corrected visual acuity (BCVA) and central macular thickness (CMT) using optical coherence tomography at initial visit and 1, 3 and 4 months. Results: The mean follow-up was 6.7 ± 2.2 months. The baseline mean BCVA was 0.81 ± 0.47 logarithm of the minimum angle of resolution (log MAR), which improved to 0.61 ± 0.37 log MAR (p = 0.017), 0.57 ± 0.38 log MAR (p = 0.011) and 0.62 ± 0.36 log MAR (p = 0.027) at 1 month, 3 months and 4 months, respectively. The baseline mean CMT was 558.0 ± 110.32 μm and decreased to 325 ± 64.21 μm (p = 0.008) and 300.22 ± 59.46 μm (p = 0.008) at 1 month and 3 months, respectively, then increased to 468.44 ± 150.85 μm (p = 0.058) at 4 months after injection. Conclusions: Dexamethasone intravitreal implant showed short-term efficacy in the treatment of diabetic macular edema refractory to combined treatment of bevacizumab and triamcinolone and produced significant improvements in BCVA and CMT until 3 months after injection. The CMT then increased, but BCVA was sustained until the fourth month. J Korean Ophthalmol Soc 2015;56(8):1201-1207

Macular Infarction Following Intravitreal Triamcinolone Injection for Treatment of Central Retinal Vein Occlusion

Purpose: To report a case of macular infarction following intravitreal triamcinolone injection for treatment of central retinal vein occlusion. Case summary: A 75-year-old male visited our clinic for visual disturbance in his left eye and was diagnosed with macular infarction in his right eye. His medical history included type 2 diabetes, alcoholic liver cirrhosis, and hepatocellular carcinoma. After fundus examination, the patient was diagnosed with central vein occlusion with macular edema and intravitreal triamcinolone was administered to reduce edema. Within 1 week of treatment with the intravitreal injection, the patient experienced a significant decrease in visual acuity. Fluorescein angiogram showed an enlargement of the foveal avasacular zone, although optical coherence tomography (OCT) showed a decreased macular edema. Despite normalization of macular thickness on OCT and cessation of leakage on angiography, visual acuity remained at the same level during 2 months of follow-up. Conclusions: Intravitreal anti-vascular endothelial growth factor injection as well as intravitreal triamcinolone injection can cause macular ischemia which should be considered with the adopted treatment regimen for patients with ischemic risk factors. J Korean Ophthalmol Soc 2015;56(11):1804-1809

The effect of combined treatment of bevacizumab and triamcinolone for diabetic macular edema refractory to previous intravitreal mono-injections.

The purpose of this study is to evaluate the efficiency of combined treatment of bevacizumab and triamcinolone in refractory diffuse DME (DDME). Twenty-five pseudophakic eyes with DDME refractory to previous successive intravitreal bevacizumab (IVB, 1.25 and 2.5 mg/0.1 ml) and triamcinolone (IVT, 4 mg and 10 mg/0.1 ml) injections were included. The average number of injections was two (1-4). The mean best corrected visual acuity (BCVA) was 0.8 (0.3-1.5) logMAR before enrollment, 0.6 (0.0-1.5) logMAR at 6 months and 0.6 (0-1.8) logMAR at 12 months (p = 0.0001, p = 0.003). The median central macular thickness (CMT) of all the eyes was 575 (502-1049) µm at baseline, 370 (179-983) µm at 6 months, and 410 (198-929) µm at 12 months (p = 0.0001; p = 0.0001). At 6 months, the VA of 13 (52 %) patients was stabilized (± 0.2 logMAR of initial BCVA) and 12 (48 %) patients showed visual improvement (>0.2 logMAR). At 12 months, 10 (40 %) patients had stabilized vision, 13 (52 %) showed visual improvement and 2 (8 %) showed visual loss. At 6 months, 18 (72 %) patients showed anatomic stabilization (a decrease of 10 % to 50 % in initial CMT) and 7 (28 %) anatomical success (a decrease in CMT more than 50 % or ≤250 µm at final visit). At 12 months, 13 (52 %) patients showed anatomic stabilization, 10 (40 %) anatomic success, and 2 (8 %) anatomical failure (decrease in CMT less than 10 %). The combined application of IVB and triamcinolone may improve vision and decrease CMT in severe DDME cases refractory to previous monotherapies.

Influence of lornoxicam and triamcinolone on the dynamics of eye remodeling in concanavalin model of inflammation

AbstractPurpose To compare the effects of NSAID lornoxicam and corticosteroid triamcinolone on the dynamics of eye remodeling in concanavalin model of inflammation.Methods Eye of Wistar rat was injected with 0,5 mcg (2,5 mcl) concanavalin A (ConA) in vitreous cavity. After 20 min rats received a saline, 16 mcg lornoxicam or 80 mcg triamcinolone intravitreal injection (2 mcl). On 1 and 2 day after that the medication was administered systemically. Histological evaluation of retinas was made on 7, 14, 28 and 56 days after inravitreal injection of ConA.Results The total frequency of cararactogenesis after the injection of ConA was 72%. Lornoxicam and triamcinolone suppressed the development of cataracts. Lornoxicam 6 times decreased the total frequency of eye hemorrhage. After 7 days following ConA injection lornoxicam decreased thickness of more retina layers than triamcinolone. After 14 days triamcinolone increased the thickness of the outer plexiform, inner nuclear, inner plexiform layers as compared with the control group. At day 14 lornoxicam but not triamcinolone reduced the thickness of ganglion cell layer (GCL). At day 28 both drugs reduced the thickness of GCL. Phospholipase A2 and cyclooxygenase (COX) blocking reduced structural abnormalities of the retina, but its thickness increased on 56 day after triamcinolone administration.Conclusion Lornoxicam prevented the development of proliferative vitreoretinopathy (PVR), reduced the severity of symptoms typical for proliferative diseases of the eye. It also inhibited the proliferation of retinal cells. Triamcinolone impaired the overall health of animals, less prevented the development of PVR compared to lornoxicam. Its effect on the proliferation of retinal cells was ambiguous.

EFFECT OF INTRAVITREAL TRIAMCINOLONE IN DIABETIC MACULAR EDEMA UNRESPONSIVE TO INTRAVITREAL BEVACIZUMAB

To evaluate the efficacy of intravitreal triamcinolone injection in diabetic macular edema unresponsive to intravitreal bevacizumab. Patients with diabetic macular edema unresponsive to at least three monthly intravitreal bevacizumabs were included. At least 2 months after the last intravitreal bevacizumab, intravitreal triamcinolone was performed after obtaining an aqueous humor sample. Multiplex cytokine array was used to assay vascular endothelial growth factor, interleukin (IL)-2, IL-6, IL-8, tumor necrosis factor-α, and transforming growth factor-β2. Best-corrected visual acuity and central subfield thickness were evaluated from Month 0 to 3. Twenty eyes were enrolled. The mean best-corrected visual acuity was 47.1 ± 18.9 letters at baseline, and significantly increased to 53.3 ± 19.7 letters at 1 month (P = 0.002) and 52.4 ± 19.1 letters at 2 months (P = 0.041). These visual gains were not sustained at 3 months (50.9 ± 18.6; P = 0.204). A decrease in central subfield thickness more than 11% of baseline occurred in 12 eyes at 1 month. Multivariate analysis showed that intraocular levels of IL-8 (β = 0.538 P = 0.006) was an independent factor for anatomic response at 1 month. Intravitreal triamcinolone has a role in patients who are unresponsive to intravitreal bevacizumab over the short-term. Elevated intraocular IL-8 levels were related to the efficacy.

Subtenon Vs Intravitreal Triamcinolone injection in Diabetic Macular Edema, A prospective study in Chinese population.

Purpose of this study was to validate that Subtenon (SB) Triamcinolone (TA) injection is an alternative to Intravitreal (IV) Triamcinolone (TA) injection for the treatment of diabetic macular edema (DME). Forty eyes were selected having DME due to type 1 or type 2 diabetes. All the patients were treated with photocoagulation. IVTA was administered in one eye and SBTA in following eye of same patient. Improvement in visual acuity, macular edema and intraocular pressure was assessed before treatment and on 2(nd), 4(th), 8(th) and 12(th) week after treatment. After administration of IVTA, MVA was reduced from baseline value (0.805 ± 0.069Log/MAR) to (0.577 ± 0.091 Log/MAR, p<.001) at the end of treatment. Similar results were observed after SBTA administration. MVA was reduced from (0.814 ± 0.082Log/MAR) to (0.49 ± 0.080 Log/MAR, p<.001) at 12(th) week. After IVTA injection Central macular thickness was significantly reduced to (246.8 ± 25 µm, p<0.001) from (390.5 ± 17 µm). There were no significant (p=0.51) difference in both eyes receiving different routes of same treatment. After SBTA injection CMT was significantly reduced to lower values (241.5 ± 27 µm, p<0.001) from (394.4 ± 21 µm). Intraocular pressure after IVTA administration was high (2.32 ± 0.72 mm/Hg, p=0.04) as compared to baseline (1.82 ± 0.94 mm/Hg). Similar pattern was also seen after SBTA administration but to significant extent. Elevation of IoP was observed in both eyes. Subtenon Triamcinolone injection is an alternative to Intravitreal Triamcinolone Injection for Diabetic Macular Edema.

Clinical and Pathologic Features ofBipolarisEndophthalmitis After Intravitreal Triamcinolone

This is a notice to ophthalmologists performing intravitreal injections of triamcinolone or other medications of the risk for endophthalmitis caused by Bipolaris hawaiiensis-contaminated medications. Histopathologic review of 5 eyes from a series of 17 treated with intravitreal triamcinolone for retinal vascular disease and diabetes mellitus over 1 year from 1 lot prepared by a compounding pharmacy. Endophthalmitis occurred in 14 of 17 eyes, the first presenting a mild vitritis 5 days following injection. The onset of signs and symptoms of endophthalmitis (eg, decreased vision, anterior chamber, or vitreous cells) in the 5 cases presented here varied from 5 to 174 days. Vitreous biopsy with cytospin and periodic acid–Schiff stain for hyphae was the most sensitive method for proving that fungus was present (positive in 3 of 5 of our cases). Five of 5 sample results from the whole series of 14 clinical cases were confirmed as positive for Bipolaris hawaiiensis by genotyping at the Centers for Disease Control and Prevention. Three of the removed eyes received fresh were culture negative; however, all 5 demonstrated organisms with fungal stains. Symptoms of fungal endophthalmitis can be minimal and delayed long beyond the 5 to 7 days expected for acute bacterial endophthalmitis. Also, apparently viable organisms persist in ocular tissues despite prolonged exposure to antifungal agents. This series reminds us that cytological or histological examination of tissue specimens may be necessary to exclude fungal infections that fail to grow in culture.

Comparative study of grid laser alone and grid laser with Intravitreal Triamcinolone Acetonide in Diabetic Macular Edema.

Background: Diabetic retinopathy (DR) is a leading cause of new cases of blindness, macular edema being most frequent cause of visual impairment in patients with non-proliferative diabetic retinopathy (NPDR). Photocoagulation was established treatment for macular edema but more recently intravitreal steroids have been used primarily and also in refractory macular edema with promising results. Methods: A hospital based non randomised prospective case series of 60 patients with diabetic macular edema assigned into group A treating with Grid laser alone and group B with grid laser and intravitreal triamcinolone acetonide. Results: Group- A:15patients (50%) have stable visual acuity (6/18 - 6/9) with persistent macular edema in comparison with 33%in group B. 50% improved one line with regression of macular edema in comparing 67% in group B, clearly indicating superiority of combination therapy. Conclusion: Study shows better visual outcome and improvement in ophthalmoscopic appearance after intravitreal triamcinolone injection followed by grid laser as compared to grid laser alone. Key words: Diabetic macular edema, Grid laser, Intravitreal triamcinolone

Subthreshold diode-laser micropulse photocoagulation as a primary and secondary line of treatment in management of diabetic macular edema.

BackgroundThe purpose of this study was to evaluate subthreshold diode-laser micropulse (SDM) photocoagulation as a primary and secondary line of treatment for clinically significant diabetic macular edema (CSDME).MethodsIn this prospective nonrandomized case series, 220 cases of nonischemic CSDME were managed primarily and secondarily by SDM photocoagulation on a 15% duty cycle with a mean power of 828 mW and a spot size of 75–125 μm. SDM treatment was repeated at 3–4-month intervals if residual leakage was observed. Additional intravitreal pharmacologic therapy was used according to the response. Follow-up varied from 12 to 19 (mean 14±2.8) months. Novel software designed by the authors was used to record the subvisible threshold laser applications and their parameters on the fundus image of the eye. Evaluation of the results of treatment was done using fluorescein angiography and optical coherence tomography (OCT). Primary outcome measures included changes in visual acuity and foveal thickness at OCT. Secondary outcome measures included visual loss of one or more Snellen lines and laser scars detectable on fundus biomicroscopy or fluorescein angiography.ResultsIn the primary treatment group, there was significant improvement or stabilization of visual acuity after the first 3–4 months, which was stable thereafter. Visual acuity was stable in the secondary treatment group. A corresponding reduction of macular thickness on OCT was noted during the follow-up period in both groups. Additional therapy included repeat SDM photocoagulation, intravitreal injection of triamcinolone, and pars plana vitrectomy. Laser marks seen as changes in retinal pigment epithelium on fundus biomicroscopy and fluorescein angiography were noted in 3.3% and 5.7% of cases. Our novel software could accurately record the location of all SDM-invisible applications.ConclusionMicropulse laser is an effective minimal intensity therapy that offers the clear advantage of minimizing or avoiding laser-induced visible retinal burn/scarring while reducing the foveal thickness in the management of selected cases of CSDME. Future prospective studies should include the use of SDM photocoagulation as a combined minimally invasive therapy to consolidate the prompt but temporary effects of anti-vascular endothelial growth factor or anti-inflammatory agents. Virtual localization of SDM-invisible applications using our proprietary software could be used to guide further retreatments.

Results of intravitreal triamcinolone acetonide in patients with macular edema secondary to branch retinal vein occlusion

Macular edema is one of the most common causes of visual loss in patients with retinal vein oclusions. Intravitreal corticosteroids and intravitreal anti-vascular endothelial growth factors are modalities of treatment for macular edema secondary to branch retinal vein occlusion (BRVO). To present the results of intravitreal triamcinolone acetonide therapy in patients with macular edema secondary to BRVO. A retrospective clinical interventional study included 32 patients with macular edema secondary to BRVO. The records of 32 eyes of 32 patients who received 4 mg/0.1 mL injection of intravitreal triamcinlone for macular edema secondary to BRVO were evaluated. Patients with visual acuity <0.40 logMAR (logarithm of the minimum angle of resolution), central macular thickness (CMT) >260 μm and no neovascularization at baseline were included. Patients with diabetes mellitus, a history of intravitreal anti vascular endothelial growth factor injection, grid laser photocoagulation and ischemic BRVO were excluded. The re-injections were performed in cases with increased CMT >100 μm or vision loss of five or more letters. The mean follow-up was 12 ± 1.9 months. The visual acuity increased from 0.58 ± 0.16 at baseline to 0.25 ± 0.11 logMAR (P < 0.001). The CMT decreased from 490 ± 107 μm at baseline to 266 ± 90 μm at 12 months (P < 0.001). Both cataract and glaucoma developed in 18.75 % patients. Intravitreal triamcinolone, due to absence of systemic side effects, can be used with confidence for treatment macular edema secondary to BRVO. However the main disadvantages of intravitreal triamcinolone injection are elevation of intraocular pressure and formation of cataract.

Onset of an Outbreak of Bipolaris hawaiiensis Fungal Endophthalmitis after Intravitreal Injections of Triamcinolone

To report a series of cases with fungal endophthalmitis occurring after intravitreal injection of triamcinolone derived from a single lot prepared by a compounding pharmacy. Retrospective, observational case series. Seventeen eyes treated with triamcinolone obtained from a single lot subsequently found to be contaminated with Bipolaris hawaiiensis. A retrospective chart review in a single retina practice was performed for 15 patients (n= 17 eyes) who received intravitreal injections of triamcinolone obtained from a single compounding pharmacy. Medical records and cytologic and microbiologic results were reviewed from December 2011 through January2013. Visual acuity; presence of vitreous cell, anterior chamber cell, or both; and fungal detection in samples obtained by vitreous needle aspiration or vitreous biopsy. Fungal endophthalmitis developed in 82% (14/17) of eyes after intravitreal triamcinolone obtained from the same lot. Median onset was 83 days (range, 6-322 days). Preinjection visual acuity ranged from 20/20 to counting fingers (median, 20/50). Median visual acuity at last follow-up was 20/400 (range, 20/30-no light perception). The most common signs and symptoms included decreased vision (57% [8/14]), vitreous cell (64% [9/14]), and anterior chamber cell (50% [7/14]). Fungus was detected by cytologic or culture examination in 7% (1/14) from initial vitreous tap. By comparison, vitreous samples obtained by pars plana vitrectomy (PPV) resulted in fungus-positive cytologic results in 43% (6/14) of eyes and positive culture results in 36% (5/14) of eyes. All culture-positive specimens (100% [5/5]) were identified as B.hawaiiensis. Overall, fungal infection was confirmed in 57% (8/14) of eyes by either cytologic or microbiologic analysis. Fungal endophthalmitis resulting from B.hawaiiensis developed in a series of eyes after intravitreal injections of triamcinolone obtained from a single compounding pharmacy. Clinical presentation of infection can be delayed up to 10 months. Vitreous tap may be inadequate, and direct vitreous biopsy by PPV may be preferred to identify fungal endophthalmitis and facilitate prompt diagnosis and treatment.

A study comparing ranibizumab monotherapy versus ranibizumab plus dexamethasone combination therapy for treatment of diffuse diabetic macular edema

Purpose The aim of the study was to evaluate the hypothesis that combination therapy of intravitreal ranibizumab and dexamethasone would be more effective than ranibizumab monotherapy in patients with diffuse diabetic macular edema (DME). Patients and methods The study included 24 eyes of 24 patients with center-involved DME. The study included eyes with central foveal thickness greater than 300 μm on cross-hair protocol, diffuse macular thickening of greater than two disc-areas on slit-lamp biomicroscopy. Eligible study participants in this prospective, nonrandomized, comparative, interventional case series were divided into two groups. The first group was chosen to receive 0.5 mg/0.05 ml ranibizumab, whereas the other group was chosen to receive 0.4 mg/0.1 ml intravitreal dexamethasone (IVD) and 0.5 mg/0.05 ml ranibizumab. Exclusion criteria included: (a) eyes with previous treatments (such as focal laser therapy, vitrectomy, and intravitreal injection of triamcinolone or antivascular endothelial growth factor injections) beyond a 6-month period; (b) evidence of proliferative diabetic retinopathy on fundus fluorescein angiography or clinical examination; (c) any evidence of macular ischemia on fundus fluorescein angiography; (d) presence of a taut posterior hyaloid, vitreomacular traction or epiretinal membrane on optical coherence tomography (OCT); and (e) presence of subfoveal hard exudates. All patients were followed up for 6 weeks postinjection; changes of retinal thickness, visual acuity, and intraocular pressure were evaluated. Results Twelve eyes of 12 patients were treated with ranibizumab (group 1), and 12 eyes of another 12 patients were treated with IVD + ranibizumab (group 2). In group 1, the postinjection central macular thickness showed a statistically significant improvement from a baseline of 500.1 ± 40.1 to 456.7 ± 28.4 μm (reduction of 43.4 μm, P P Conclusion A single injection of intravitreal ranibizumab (IVR) demonstrated similar efficacy compared with IVD + ranibizumab in terms of OCT macular thickness reduction in selected cases of diffuse DME after 6-week follow-up.

Short-term effect of a single intravitreal injection of bevacizumab (Avastin) alone, triamcinolone alone, or in combination, followed by macular grid laser photocoagulation on diffuse diabetic macular edema

Purpose This study aimed to perform a short-term evaluation of best-corrected visual acuity (BCVA) and assess improvement central foveal thickness (CFT) in patients with diffuse diabetic macular edema (DME) after an intravitreal injection of triamcinolone alone, bevacizumab (Avastin) alone, or a combination of both, followed by modified grid macular laser photocoagulation. Study design This was a randomized prospective interventional study. Materials and methods This was a randomized prospective interventional study that included 90 eyes of 78 patients with diffuse DME, divided into three groups of interventions: group A received a single intravitreal triamcinolone injection, group B received a single bevacizumab (Avastin) injection, and group C received a single injection of both, followed by a modified grid macular laser photocoagulation 2 weeks after the injection. Patients were observed for a 6-month period and their BCVA, intraocular pressure (IOP), and CFT were recorded. Results In group A, the mean preoperative BCVA was 0.17 ± 0.15 and 0.345 ± 0.211 decimal at 6 months, in group B, the mean preoperative BCVA was 0.245 ± 0.162 and 0.462 ± 0.171 decimal at 6 months, and in group C, the mean preoperative BCVA was 0.238 ± 0.152 and 0.617 ± 0.200 decimal at 6 months, with a statistically significant improvement in all groups throughout the follow-up period ( P In group A, the mean preoperative CFT was 458.17 ± 79.4 μm and at 6 months the mean CFT was 358.53 ± 74.92 μm. In group B, the mean preoperative CFT was 398.40 ± 41.17 μm and at 6 months, the mean CFT was 335.10 ± 46.99 μm. In group C, the mean preoperative CFT was 388.00 ± 43.61 μm, and at 6 months, the mean CFT was 304.37 ± 54.44 μm. Statistical analysis of the difference in CFT between 3 and 6 months showed that there was no statistical difference between groups A and B ( P = 0.6), but there was a statistically significant difference when comparing groups A and C ( P = 0.006) and also when comparing groups B and C ( P = 0.003). Conclusion Combined Avastin and triamcinolone intravitreal injection, followed by modified grid macular photocoagulation led to more stable improvement in the treatment of eyes with diffuse DME.

Comparison of Injection of Intravitreal Drugs with Standard Care in Macular Edema Secondary to Branch Retinal Vein Occlusion

PurposeTo compare the long-term efficacy and safety of intravitreal triamcinolon with or without rescue laser therapy (intravitreal triamcinolone injection [IVTA] group), bevacizumab with or without rescue laser treatment (intravitreal bevacizumab injection [IVB] group), or a combination of both with or without rescue laser therapy (IVTA + IVB group), with standard care for patients with macular edema secondary to branch retinal vein occlusion (BRVO).MethodsWe reviewed the medical records of 151 patients treated with intravitreal injection with or without rescue laser for treatment of macular edema caused by BRVO, and who were followed up at 1, 3, 6, 12, and 24 months. During the observation period, rescue grid laser or repeated intravitreal injection with initial drug was performed if recurrence of macular edema was confirmed. Visual acuity, change in visual acuity, and intraocular pressure were compared in each phase.ResultsTotals of 16%, 5.6%, and 0% of participants in the three groups showed significant visual loss of more than three lines of the Snellen chart at last follow-up. The IVTA group was the least effective treatment modality, with statistical significance. The development rates of elevated intraocular pressure were similar among the groups.ConclusionsAlthough IVTA yielded effects similar to those of standard grid photocoagulation based on the Standard Care vs Corticosteroid for Retinal Vein Occlusion study, IVB or IVTA + IVB with or without rescue laser treatment resulted in improvement in visual acuity at 24 months after the start of treatment and was associated with few serious adverse side effects. Thus, these approaches could be useful for treating macular edema arising secondary to BRVO.