Posterior Subtenon Injection Research Articles

The effect of posterior subtenon methylprednisolone acetate in the refractory diabetic macular edema: a prospective nonrandomized interventional case series

BackgroundTo investigate the efficacy of posterior subtenon methylprednisolone acetate injection in treatment of refractory diffuse clinically significant diabetic macular edema (CSME).MethodsIn a prospective, nonrandomized, interventional case series, 52 eyes were diagnosed with CSME and treated with at least two sessions of laser photocoagulation according to Early Treatment Diabetic Retinopathy Study guidelines. At least 3 months after laser therapy, eyes with a residual central macular thickness were offered posterior subtenon injection of 40 mg methylprednisolone acetate. Main outcome measures were visual acuity, macular thickness and intraocular pressure. Potential complications were monitored, including intraocular pressure response, cataract progression and scleral perforation.ResultsMean baseline visual acuity (in logMAR) improved significantly (p = 0.003) from 0.8 ± 0.36 to 0.6 ± 0.41 at 3 months. Mean foveal thickness decreased from 388 ± 78 μm at baseline to 231 ± 40 μm after 3 months (p < 0.0001). Visual acuity improvement in eyes with CSME with extrafoveal hard exudates was significant (p = 0.0001), but not significant in eyes with CSME with subfoveal hard exudates (p = 0.32). Intraocular pressure increased from 14.7 ± 2.0 mmHg (range, 12–18 mmHg) to a maximum value of 15.9 ± 2.1 mmHg (range, 12–20 mmHg) during the follow-up period. Complications in two eyes developed focal conjunctival necrosis at the site of injection.ConclusionPosterior subtenon methylprednisolone acetate may improve early visual outcome in diffuse diabetic macular edema that fails to respond to conventional laser photocoagulation. Visual acuity improvement in eyes with CSME with extrafoveal hard exudates was significant; and this improvement is depends on location of hard exudates. Further study is needed to assess the long-term efficacy, safety, and retreatment.

Intravitreal versus Posterior Subtenon Injection of Triamcinolone Acetonide for Diabetic Macular Edema

PurposeTo compare the short-term effects of intravitreal versus posterior subtenon injection of triamcinolone acetonide for diabetic macular edema.MethodsThis is a prospective and interventional study. Sixty eyes of 60 patients who had diffuse diabetic macular edema were assigned to receive a single intravitreal injection (4 mg) or a single posterior subtenon injection (40 mg) of triamcinolone acetonide. The central retinal thickness was measured using optical coherent tomography before injection and at 1 and 3 months after injection. Visual acuity and intraocular pressure (IOP) were also measured.ResultsBoth intravitreal and posterior subtenon injections of triamcinolone acetonide resulted in significant improvements in visual acuity at 1 month and 3 months after injection. Both groups resulted in a significant decrease in central macular thickness (CMT) at 1 month and 3 months post-injection. IOP in the intravitreal injection group was significantly higher than in the posterior subtenon injection group at 3 months after injection.ConclusionsThe posterior subtenon injection of triamcinolone acetonide had a comparable effect to the intravitreal triamcinolone injection and showed a lower risk of elevated IOP. Posterior subtenon injection of triamcinolone acetonide may be a good alternative for the treatment of diffuse diabetic macular edema.

Triamcinolone-Induced Intraocular Pressure Elevation: Intravitreal Injection for Macular Edema and Posterior Subtenon Injection for Uveitis

PurposeTo assess the effect of intravitreal and posterior subtenon injections of triamcinolone acetonide (TA) on intraocular pressure (IOP).Methodswe reviewed 42 consecutive eyes after intravitreal TA injection (IVTA) and 43 eyes following posterior subtenon TA injection (PSTA). All cases had a minimum follow-up time of three months. After injection, the value and time of the maximal IOP, the amount of IOP elevation and the needs of the medication were assessed.ResultsThe IOP increased significantly (p<0.001) from 16.3±2.5 mmHg preoperatively to a mean maximum of 21.7±5.3 mmHg in the IVTA group, and from 15.3±4.5 mmHg to 20.6±3.0 mmHg in the PSTA group. An elevation in the IOP of more than 5 mmHg from the baseline IOP was seen in 52.4% of the IVTA group at a mean time of 3.1 weeks postoperatively, and 44.2% of the PSTA group displayed an IOP elevation at 5.9 weeks.ConclusionsBoth developed significant elevations of IOP, but this appeared at a later date in the PSTA group. Careful follow-up after local injection of steroids is necessary.

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.

Posterior Sub-Tenon Triamcinolone for Refractory Diabetic Macular Edema: A Randomized Clinical Trial

To evaluate the effect of posterior sub-tenon triamcinolone acetonide (TA) injection on clinical, angiographic, and optical coherence tomographic (OCT) parameters in refractory diabetic macular edema (DME). In a double-masked placebo-controlled clinical trial, 64 eyes were randomly assigned to two groups. The treatment group (32 eyes) received 40 mg posterior sub-tenon injection of TA and the placebo group (32 eyes) received subconjunctival injection of a placebo. The injections were repeated after 2 months in both groups. Complete ophthalmologic examination, fluorescein angiography, and OCT were performed before intervention and after 4 months. Quantitative measurement of angiographic variables such as the amount of hard exudates (HE), size of foveal avascular zone (FAZ), and leakage severity was performed by computer, using Photoshop software. Initial best-corrected visual acuity (VA) was 0.93+/-0.39 logMAR in the placebo group and 0.75+/-0.38 logMAR in the treatment group. At 4 months, corrected VA was 0.88+/-0.48 logMAR in the controls versus 0.71+/-0.42 logMAR in the cases. Mean central macular thickness measured by OCT before and 4 months after injection was 392 and 377 microns in the treatment group and 388 and 357 microns in the placebo group, respectively. No statistically significant difference was detected between the two groups. The difference was also not significant in HE, FAZ, and leakage in the angiograms. Two injections of posterior sub-tenon TA had no therapeutic effect on refractory DME.

Posterior subtenon triamcinolone acetonide for refractory diabetic macular edema

To evaluate posterior subtenon injection of triamcinolone acetonide for refractory diabetic macular edema (DME). Retrospective, interventional, case series. Clinical practice. Patients with persistent clinically significant DME involving the center of the fovea 3 or more months after one or more treatments of focal macular photocoagulation were included. Exclusion criteria were a history of corticosteroid-responsive intraocular pressure (IOP) rise, intraocular surgery within 3 months, and any laser treatment within 1 month. All patients received an ophthalmic history and examination including best-corrected Snellen visual acuity, IOP measurement, anterior segment examination including evaluation of lens status with LOCS II criteria, dilated fundus examination, and a posterior subtenon injection of 40 mg triamcinolone acetonide at baseline. Patients were reevaluated at 1, 3, 6, and 12 months after injection. Seventy-three injections were performed in 63 eyes of 50 patients. The mean baseline visual acuity was 20/80. Mean visual acuity significantly improved to 20/50 at 1 month, then stabilized to 20/65 at 3 months, 20/68 at 6 months, and 20/63 at 12 months. Complications were rare, with a transient significant rise in intraocular pressure at the 3-month evaluation and ptosis in two patients. Visual acuities remained stable or improved over a 12-month period after posterior subtenon triamcinolone injections for refractory DME. There was a statistically significant improvement in visual acuity at 1 month.

Clinical trial to compare efficacy and side‐effects of injection of posterior sub‐Tenon triamcinolone versus orbital floor methylprednisolone in the management of posterior uveitis

To compare the efficacy and side-effects of posterior sub-Tenon injection of triamcinolone acetonide (Kenalog) with orbital floor injection of methylpredisolone acetate (Depomedrone) in the management of posterior uveitis. Non-randomized comparative prospective clinical study. Sixty-four eyes from 60 consecutive patients with non-infectious posterior uveitis requiring treatment were allocated on an alternate 1:1 basis to receive either orbital floor methylprednisolone or sub-Tenon triamcinolone using standard procedures and assessed at 6 and 12 weeks. After five eyes of five patients who had received the same treatment bilaterally were excluded from the statistical analysis, 14 out of 29 eyes treated with orbital floor methylprednisolone and 10 out of the 30 eyes given sub-Tenon triamcinolone improved at 6 weeks. There was no statistically significant difference in the improvement rate between the two groups. However, two patients given triamcinolone had prolonged upper lid ptosis, which required surgery, and another two developed markedly raised intraocular pressure, neither of which occurred in the methylprednisolone-treated group. Although the two drugs and routes compared were of similar efficacy, lid ptosis occurred in the triamcinolone-treated but not the methylprednisolone group. This should be borne in mind when choosing the preferred route of delivery of periocular corticosteroid in the treatment of posterior uveitis.

Cutaneous hypopigmentation following a posterior sub-tenon triamcinolone injection

Purpose To report a case of cutaneous skin hypopigmentation following a posterior sub-Tenon triamcinolone acetonide injection for uveitis. Design Observational case report. Methods A 28-year-old African American female with Adamantiades-Behcet disease and panuveitis was administered a posterior sub-Tenon injection of triamcinolone acetonide and developed cutaneous hypopigmentation. Results The patient developed skin hypopigmentation of the upper eyelid adjacent to the site of the sub-Tenon injection. Conclusion Injection of corticosteroids into the sub-Tenon space can cause hypopigmentation of the adjacent tissues, especially in heavily pigmented individuals.

Retinal and choroidal vascular occlusion after posterior sub-tenon triamcinolone injection

PURPOSE: To report a case of retinal and choroidal vascular occlusion occurring as a complication after posterior sub-Tenon triamcinolone injection for treatment of uveitic cystoid macular edema.DESIGN: Interventional case report.METHODS: Retrospective study. A 32-year-old woman with uveitis and cystoid macular edema underwent a right posterior sub-Tenon injection of triamcinolone (40 mg/ml, 1 ml total) through a superotemporal approach after topical anesthesia. After the procedure, the patient experienced severe eye pain, orbital ecchymosis, and globe proptosis consistent with retrobulbar hemorrhage.RESULTS: Dilated fundus examination of the right eye (OD) demonstrated multiple intraretinal hemorrhages with particulate white emboli occluding the retinal and choroidal vessels. Visual acuity was no light perception. Ocular massage and hypotensive therapy was initiated for an intraocular pressure of 50 mm Hg. Canthotomy and cantholysis were performed. A total of 39 months post-incident, her visual acuity improved to 20/100.CONCLUSION: Posterior sub-Tenon triamcinolone injection can rarely result in retinal and choroidal occlusion. Immediate intervention may preserve limited visual acuity.

Posterior subtenon injection of corticosteroids using polytetrafluoroethylene (PTFE) intravenous cannula.

Injection of corticosteroids into the posterior subtenon space is a well established and highly effective modality in the treatment of intermediate uveitis. The conventional technique of posterior subtenon injection involves the use of a sharp tipped 26-gauge, 5/8 inch needle that must be inserted up to its hub to obtain adequate placement of the drug into the posterior subtenon space. With this technique the risk of perforation of the globe, although minimal, remains a potential complication. Herein is described a new technique for injection of corticosteroids into the posterior subtenon space using an intravenous cannula made of polytetrafluoroethylene (PFTE) that allows safer delivery of the drug into the posterior subtenon space.

Systemic toxicity of topical and periocular corticosteroid therapy in an 11-year-old male with posterior uveitis

PURPOSE: To report a case of systemic corticosteroid toxicity resulting from topical and periocular therapy. METHODS: Treatment and follow-up of an 11-year-old male with uveitis are illustrated. Initial presentation of the patient was bilateral iridocyclitis, for which he was treated with prednisolone acetate 1% every 2 hours for 6 months. Subsequently, posterior uveitis developed, necessitating posterior subtenon injections. RESULTS: After initial topical corticosteroid therapy, the patient developed a cushingoid habitus accompanied by increased lanugo hair, acanthosis nigricans, posterior subcapsular lens opacities, and increased intraocular pressure. Cushingoid stigmata worsened after administration of posterior subtenon injection of corticosteroids. The patient’s truncal obesity worsened, and his linear growth stopped. CONCLUSIONS: Systemic toxic effects may develop as a result of topical and local use of ophthalmic corticosteroid preparations in susceptible patients.

Examination of the posterior eye segment during HIV infection: what is new?

A patient was till now considered at high risk of developing a cytomegalovirus retinitis when the CD4+ cells were under 100/mm3. The risk was major when the CD4+ were under 50/mm3. With the onset of a Highly Active Antiretroviral Therapy (HAART) the follow-up of AIDS patients has changed. The introduction of a HAART is associated with an increase in CD4+ cells. The aim of the study was to highlight clinical modifications of classical AIDS associated ocular diseases. Clinical observations will be correlated to recent data published in literature. An immune response can be present against opportunitic infections. Cytomegalovirus retinitis can present an atypical pattern: The host immune response can be responsible for an increase of ocular inflammation, a hypopyon can even be seen. An intense vitritis can be present and frosted angiitis syndrome can be observed. A severe macular edema can be present and has to be treated with posterior sub-Tenon's steroid injections. With the restoration of an immune response under HAART therapy, clinical manifestation of AIDS associated ocular diseases has changed and the differential diagnosis of ocular lesions must include endogenous uveitis.

The pathogenesis and clinical presentation of macular edema in inflammatory diseases.

Cystoid macular edema (CME) is a classical complication of ocular inflammation. This syndrome was already described by Irvine in 1953 but the pathogenesis of this condition remains unclear. Cystoid macular edema can result either from a rupture of the inner or from the outer blood ocular barrier. Clinical CME that is responsible for a low visual acuity must be differentiated from angiographic CME that can be present even without any decrease in visual acuity. Fluid progressively accumulates into the outer plexiform layer of the retina and pools into cystic spaces. Fluid accumulation can now be better seen with optical coherence tomography (OCT). In chronic CME fluid accumulation is associated with thinning of the retina and fibrosis. At this stage irreversible lesions are present and CME does not respond to medical therapies. Inflammatory CME must be differentiated from CME resulting from irreversible vascular damage such as in diabetic CME or due to vein occlusions. Experimental research on cystoid macular edema has been hampered by the lack of animal model: most of laboratory animals have no macula, monkeys appear to be highly resistant to macular edema. Five major causes have been suspected to be at the origin of CME: (1) photic retinopathy, (2) trauma of ocular tissue, (3) secondary irritation of the ciliary body, (4) vitreous traction and (5) pharmaceutically induced CME. Clinical experience has shown that pseudophakic CME usually responds well to local therapy of steroids and non-steroidal antiinflammatory drugs (NSAIDs) and/or in association with systemic acetazolamide. Acetazolamide is increasing fluid resorption through the retinal pigment epithelium. Postoperative CME rarely needs additional posterior subtenon's injections to resolve. But in CME occurring secondary to uveitis additional posterior sub-Tenon's steroid injections or systemic steroids may be necessary to decrease the constant release of inflammatory mediators.

The effect of deep posterior subtenon injection of corticosteroids on intraocular pressure

To investigate the effect of posterior subtenon injections of corticosteroids on intraocular pressure in a variety of ocular diseases. We retrospectively analyzed 202 consecutive posterior subtenon corticosteroid injections (148 of methylprednisolone acetate, 80 mg, and 54 of triamcinolone acetonide, 40 mg) in 63 eyes of 55 patients (26 male, 29 female; mean age +/- SD, 60.17 +/- 26.55 years). All patients had received topical or systemic corticosteroids before the injection, and no rise in intraocular pressure had been noted. Preinjection and postinjection intraocular pressure measurements were compared by two-tailed paired t test. Statistical analysis was performed separately by patient (first injection of first injected eye), by eye (first injection of each eye), and by all injections. To detect increase in intraocular pressure during follow-up, statistical analysis was performed separately 14 to 90 days, 91 to 150 days, and 151 to 270 days after injection. No statistically significant difference was found between preinjection and postinjection intraocular pressure measurements. A power calculation in the most stringent subanalysis (by patient) proved that there is only a 3.87% chance to statistically miss a clinically significant rise in intraocular pressure from 15 to 21 mm Hg. Posterior subtenon injection of corticosteroids does not cause an increase in intraocular pressure. All patients in our study had been treated previously with topical or systemic corticosteroids and did not react with an excessive increase in intraocular pressure. This safety of repository corticosteroids may therefore not apply to patients whose status in responding to corticosteroids is not known.

A Comparison of Retrobulbar versus Sub-Tenon's Corticosteroid Therapy for Cystoid Macular Edema Refractory to Topical Medications

The objective is to compare the effectiveness of retrobulbar and posterior sub-Tenon's injection of corticosteroids for treatment of post-cataract cystoid macular edema that was refractory to topical medications. A retrospective study was performed. A total of 48 patients (49 eyes) with post-cataract cystoid macular edema refractory to topical medications was studied. Patients received either a single retrobulbar injection (18 eyes) or 3 biweekly posterior sub-Tenon's injections (31 eyes) of corticosteroids. Patients were observed for clinical resolution of the cystoid macular edema, visual acuity, and intraocular pressure. Both treatment methods resulted in significant improvement in visual acuity. The posterior sub-Tenon's group had a visual improvement from 20/92 pretreatment to 20/50 post-treatment (P = 0.0001) with a median follow-up of 12 months. The retrobulbar group had a visual improvement from 20/97 pretreatment to 20/58 post-treatment (P = 0.035) with a median follow-up of 10 months. The visual improvement was not significantly different between the two groups. The average intraocular pressure increased from a pretreatment level of 14.1 mmHg to a high of 17.7 mmHg (P < 0.00005) in the sub-Tenon's group. The average intraocular pressure increased from 15.1 mmHg to a high of 17.6 mmHg (P = 0.04) in the retrobulbar group. Cystoid macular edema that persists after treatment with topical medications may improve after retrobulbar or posterior sub-Tenon's corticosteroid injections. There was no significant difference in outcome between the two treatment groups.

The Effects of Posterior Subtenon Injection of Triamcinolone Acetonide in Patients With Intermediate Uveitis

Periocular injection of corticosteroids is a common treatment for vision loss in patients with intermediate uveitis. However, this treatment has the potential for serious side effects. We sought to determine the effects of such injections in a series of patients. We reviewed charts of 20 consecutive patients (20 eyes, 43 injections) who had received posterior subtenon injections of triamcinolone acetonide for treatment of intermediate uveitis. We collected data on visual outcome and side effects. Median follow-up was 23.5 months (range, one to 50 months). Snellen visual acuity improved by at least two lines in 12 (67%) of 18 patients who were examined after initial injection. Median time to improvement was three weeks. Patients with visual improvement had a median age of 29.0 years, compared with 41.5 years for nonresponders (P = .024). There was a weak association between response to treatment and a history of not smoking (P = .073) after correction for patient age. Increase of intraocular pressure (> 21 mm Hg) occurred in six patients (30%), with onset at a median of three weeks after initial injection; the median interval to peak increase (median, 32 mm Hg; range, 25 to 40 mm Hg) was 14 weeks after the injection. A subtenon injection of triamcinolone acetonide appears to be an effective treatment for decreased vision associated with intermediate uveitis but may contribute to increase of intraocular pressure in some patients with this disorder.

A Randomized, Controlled Comparison of Anterior and Posterior Periocular Injection of Antibiotic in the Prevention of Postoperative Endophthalmitis

A randomized, controlled, prospective comparison of the effectiveness of anterior and posterior injections of antibiotics in the prevention of endophthalmitis following cataract extraction was carried out in a village hospital in Pakistan. The study involved 77,015 cataract operations performed mainly by two surgeons. Anterior subTenon injections ("subconjunctival") and posterior subTenon injections ("retrobulbar") were equally effective in preventing postoperative infection.

Regional Differences in Ocular Concentration of Gentamicin After Subconjunctival and Retrobulbar Injection in the Rabbit

We compared the penetration of radioactive carbon (14C) labeled-gentamicin into ocular tissues and fluids of albino rabbit eyes after subconjunctival (anterior subtenon's) and retrobulbar (posterior subtenon's) injections. In both normal and infected (Staphylococcus aureus endophthalmitis) eyes, higher levels of drug were produced with subconjunctival rather than with retrobullar admininistration in cornea, sclera, choroid and retina (as a unit), and iris; levels in the aqueous and vitreous humors of infected eyes were similar with the two routes of injection. Marked regional variations in the concentrations of gentamicin were noted in cornea, sclera, and choroid-retina after subconjunctival therapy. The pattern of these variations suggests that subconjunctival antibiotic penetrates the eye by direct diffusion. The low levels of drug after retrobulblar injection may be due to systemic absorption through the highly vascular orbital plexus of the rabbit.