Subtenon Injection Of Triamcinolone Acetonide Research Articles

Involvements of choroidal vascular structures with local treatments in patients with diabetic macular edema.

To examine changes of the choroidal morphology in patients with diabetic macular edema (DME) before and after local treatments. This study was on 20 eyes with DME, observed for more than 24 months. All patients underwent laser photocoagulation (Laser), sub-tenon triamcinolone acetonide injection (TA), or intravitreal aflibercept injection (IVA). Central macular and choroidal thicknesses (CMT/CCT), and choroidal vascular structures consisting of the total choroidal area (TCA), luminal area (LA), and stromal area (SA) were measured by a binarization method. The ratios of LA in TCA were eventually determined as the L/C ratio in each case. The L/C ratio significantly decreased for 24 months in patients with DME (p = 0.01), whereas no significant differences were noted in other parameters including TCA, LA, SA, or CCT. Among patients treated with Laser ± TA ± IVA, a significant correlation was found between a high L/C ratio at pretreatment and a lower cumulative number of injections (1-2 times/24 months) (p = 0.04). The L/C ratio in pretreatment showed a significantly inverse correlation with CMT (-0.60, p = 0.02) and subsequent BCVA (logMAR) (-0.59, p = 0.03). This study highlighted that the L/C ratio in pretreatment might predict a change of the visual acuity in DME.

Three cases of brolucizumab-associated retinal vasculitis treated with systemic and local steroid therapy.

To describe three Japanese cases of retinal vasculitis that occurred following intravitreal brolucizumab injections and the systemic and local steroid treatment administered. Three patients developed intraocular inflammation (IOI) and retinal vasculitis following the first injection of brolucizumab for age-related macular degeneration. For two eyes, monthly aflibercept injections did not control exudation, and therapy was changed to brolucizumab; one eye was treatment-naïve. All three patients noticed blurry vision and floaters 11-18 days after brolucizumab injections, and the treated eyes exhibited anterior chamber cells, fine keratic precipitates, vitreous cells, and vitreous haze. Ultra-widefield color images of the fundus showed retinal hemorrhage in the peripheral retina and, in two cases vascular sheathing. Ultra-widefield fluorescein angiography (FA) showed segmental vascular leakage in all eyes and leakage from the optic disc in two eyes. Vascular filling defects were noted in the peripheral retinae of two eyes. Brolucizumab-associated retinal vasculitis was diagnosed, and treated with 30 mg/day of oral prednisolone, subtenon triamcinolone acetonide injection (20 mg/0.5 ml), and 0.1% betamethasone sodium phosphate solution. After 1 week, color fundus images and FA showed improvements in vascular sheathing, leakage from retinal vessels, and optic disc leakage, but the vascular filling defects remained. Visual acuity was restored in all three eyes 6 weeks after the onset. Brolucizumab-associated IOI, including retinal vasculitis and retinal occlusion, is a rare but important adverse event that can cause severe vision loss. Prompt diagnosis with FA and treatment with systemic or local steroids should be considered.

Combined intravitreal ranibizumab and posterior subtenon triamcinolone acetonide injections for patients with diabetic macular edema refractory to intravitreal ranibizumab monotherapy.

PURPOSE:The purpose of this study is to compare the efficacy of intravitreal ranibizumab (IVR) alone and concurrent IVR with posterior subtenon triamcinolone acetonide (PSTA) injection for patients with diabetic macular edema (DME) refractory to IVR monotherapy.MATERIALS AND METHODS:We enrolled 43 eyes of 43 patients with DME who received at least three times of IVR, which resulted in poor anatomical responses, with central foveal thickness (CFT) reduction <10% and postinjection CFT >300 μm. All the eyes received initial 3 monthly then pro re nata (PRN) IVR 0.5-mg injections. Twenty eyes continued PRN injections and 23 eyes received combined IVR 0.5 mg and PSTA 40 mg with at least 1-year follow-up. Best-corrected visual acuity (BCVA) and CFT were recorded from 1-month to 1-year follow-up.RESULTS:Following switch to combined therapy, the mean BCVA significantly improved from 0.61 ± 0.32 logarithm of the minimum angle of resolution (logMAR) to 0.45±0.39 logMAR at 6 month (P = 0.003), 0.43±0.35 logMAR at 9 months (P < 0.001), and 0.48±0.45 logMAR at 1 year (P = 0.03). In eyes with IVR alone, no significant VA improvement was noted throughout the year. Significantly better BCVA was noted in the combined group at 6-month, 9-month, and 1-year follow-up compared to IVR-alone group. The timing of combined therapy showed a significant association with 1-year BCVA (t = 3.25, P = 0.018).CONCLUSION:Concurrent IVR and PSTA resulted in significantly better visual outcomes in 1-year follow-up for those refractory to preceding ranibizumab monotherapy for DME. Early addition of PSTA predicted a better visual outcome.

Comparative study on pharmacokinetics and toxicity of intravitreal and sub-Tenon injection of triamcinolone acetonide in ocular tissues.

To compare the differences in kinetics, distribution, and toxicity of triamcinolone acetonide (TA) between the injection methods, sub-Tenon and intravitreal injections in rabbit ocular tissues. TA was injected into the vitreous or the sub-Tenon in rabbits. For pharmacokinetic study, rabbits were sacrificed periodically and then TA in blood and ocular tissues (retina/choroids, vitreous, and aqueous humor) were measured over 91d. For toxicological study, clinical signs, slit-lamp microscopic examination, ophthalmological test were performed. The eyeballs and surrounding tissues were collected and fixed with glutaraldehyde-formalin solution, and then paraffin embedded for histological investigation. Higher levels of TA were distributed in the intraocular tissues when injected into the vitreous compared to the sub-Tenon. Conversely, TA level was remarkably lower in the rabbits which received intravitreal TA injections than those treated with sub-Tenon injection throughout the study period in plasma. Optical discharge probably caused by systemic circulation of TA was observed by receiving sub-Tenon TA injection. Meanwhile, technic-associated toxicological ocular symptoms and findings were more frequently observed in intravitreal injection than in sub-Tenon injection. There are significant differences in kinetics and distribution of TA in vitreous body, aqueous humor and plasma, between the two injection methods. Although further study is needed to explain the species difference between human and rabbit, it is assumed that the difference in the frequency of intraocular pressure elevation and cataract formation by TA between the two injection methods are directly related to the TA concentrations in aqueous humor and vitreous body in each injection methods. Systemic toxicity and technic-associated toxicity are also closely related to kinetics of TA in plasma and each injection method itself, respectively.

Anterior Migration of Triamcinolone Acetonide after Posterior Subtenon Injection for Macular Edema Predisposes to Intraocular Pressure Elevation

ABSTRACT Purpose To evaluate the effect of anterior migration of triamcinolone acetonide on intraocular pressure (IOP) elevation after posterior subtenon injection of triamcinolone acetonide (PSTA) for macular edema. Methods One hundred and ten eyes from 89 patients who received PSTA for macular edema were prospectively enrolled. The extent of anterior migration of triamcinolone acetonide was recorded immediately after the injection. If TA particles were visible in the subtenon space (or subconjunctival space), it was recorded as “anterior subtenon migration” (or “anterior subconjunctival migration”). The correlation between anterior migration of triamcinolone acetonide and severe IOP elevation, which was defined as an increase of 8 mm Hg or more in IOP, was evaluated. Results A total of 159 PSTAs were given to 110 eyes. After PSTA, anterior subtenon migration occurred in 70.4% and anterior subconjunctival migration occurred in 12.0% of injection. Severe IOP elevation occurred in 7.1% of those without anterior migration, in 25.9% of those with anterior subtenon migration, and in 31.6% of those with anterior subconjunctival migration after PSTA (P = .052). Compared to those without anterior migration of triamcinolone acetonide, the hazard ratio for severe IOP elevation was 3.307 in those with anterior subtenon migration (P = .12) and 5.289 in those with anterior subconjunctival migration (P = .042). Conclusions Anterior migration of triamcinolone acetonide after PSTA predisposes eyes to severe IOP elevation. Careful injection to restrict the triamcinolone particle within the subtenon space and behind the equator may lower the rate of IOP elevation after PSTA.

Effect of posterior sub-tenon injection of triamcinolone acetonide as ‎an adjunct therapy to intravitreal anti-vascular endothelial growth ‎factor in the management of diabetic macular oedema

ABSTRACT Background: to monitor and compare the effect of posterior sub-tenon triamcinolone acetonide injection as an adjunct therapy to intravitreal ranibizumab injection on patients with diabetic macular oedema. Aim of the Work: To assess the effect of combined intravitreal ranibizumab injection, and sub-tenon triamcinolone acetonide injection in the management of diabetic macular oedema. Patients and Methods: Patients with diabetic retinopathy associated with DME (Central macular thickness over 300 um) which are randomly allocated into two groups. In group 1, three monthly doses (0.5 mg) of intravitreal ranibizumab are received. In group 2, the anti-VEGF injection was performed 3times monthly with the sub-tenon steroid injection [triamcinolone acetonide] during the 1st injection. All patients’ best-corrected visual acuity (BCVA), IOP and CMT were followed up for six months. Results: The combined treatment showed improved best-corrected visual acuity from baseline 0.15 ± 0.15 log MAR to 0.46 ± 0.19 log MAR (p 0.001). When comparing the combination treatment with the anti-VEGF treatment alone, recovery of BCVA and CMT was statistically significant (p <0.001‎). Conclusion: sub-tenon triamcinolone addition to the routine anti-VEGF therapy is an effective method for the treatment of diabetic macular oedema not only in rapid and great improvement but also in decreased frequent injections.

Orbital abscess caused by Exophiala dermatitidis following posterior subtenon injection of triamcinolone acetonide: a case report and a review of literature related to Exophiala eye infections

BackgroundSubtenon injection of triamcinolone acetonide (STTA) has been widely adopted in the clinical setting of ophthalmology and its infectious complications are rare. However, orbital abscess following STTA has been reported in seven cases. Furthermore, although eye infections due to Exophiala species are uncommon, there have been 19 cases to date. E. jeanselmei, E. phaeomuriformis, E. werneckii, and E. dermatitidis have been reported to cause human eye infections; however, to the best of our knowledge, orbital abscess caused by E. dermatitidis has not yet been reported. We describe the first documented case of fungal orbital abscess caused by E. dermatitidis following STTA. We also review the related literature of orbital abscess following STTA, as well as eye infections caused by the four Exophiala species.Case presentationThe patient was a 69-year-old Japanese woman with diabetic mellitus. She had a macular oedema in her right eye, which occurred secondary to branch retinal vein occlusion. An orbital abscess caused by E. dermatitidis occurred 4 months after the second STTA for the macular oedema, which was successfully treated by a surgical debridement and systemic administration of voriconazole.ConclusionsOur findings in the patient and from our literature survey caution ophthalmologists to the fact that STTA can cause fungal orbital infections, especially in diabetic patients. Furthermore, surgical treatment is one of the most important risk factors.

Vogt\u2013Koyanagi\u2013Harada disease-like uveitis following nivolumab administration treated with steroid pulse therapy: a case report

BackgroundImmune checkpoint inhibitors can cause various adverse effects. Recently it has been shown that Vogt–Koyanagi–Harada (VKH) disease-like uveitis can occur in patients treated with nivolumab.Case presentationA 69-year-old man developed bilateral panuveitis after nivolumab treatment for recurrent hypopharyngeal cancer. Slit lamp examination revealed bilateral granulomatous keratic precipitates, anterior chamber cells and partial synechiae. Fundus examination revealed bilateral optic disc edema and diffuse serous retinal detachment. His human leukocyte antigen (HLA) typing showed HLA-DRB1*04:05 allele. A lumbar puncture did not demonstrate pleocytosis. Bilateral sub-tenon injections of triamcinolone acetonide were initiated. As his panuveitis did not regress completely, steroid pulse therapy was administered. That therapy led to the resolution of his serous retinal detachment and to rapid improvement in his vision. Following this, we treated him with 50 mg/day of prednisolone for 1 week and then reduced it by 5 mg every week. No bilateral uveitis relapse had occurred by his 3-month follow-up; however, he subsequently died because of his cancer.ConclusionTo our knowledge, this is the first report of a patient with NVKH who underwent a lumbar puncture. Unlike VKH, our case did not show meningismus or pleocytosis. NVKH may, therefore, have a different etiology from VKH.In cases of NVKH with posterior uveitis, steroid pulse therapy may be considered as a treatment option, as it is in VKH.

Ocular hypertension and severe intraocular pressure elevation after posterior subtenon injection of triamcinolone acetonide for various diseases.

To evaluate and compare the incidences of ocular hypertension and severe intraocular pressure (IOP) elevation after posterior subtenon injection of triamcinolone acetonide (PSTA) for various diseases. Totally 179 eyes that had received PSTA for diabetic macular edema (n=108), pseudophakic cystoid macular edema (n=20), branch retinal vein occlusion (n=16), central retinal vein occlusion (CRVO, n=14), choroidal neovascularization (n=14) or noninfectious uveitis (n=7) were retrospectively enrolled. The primary outcomes included ocular hypertension defined as an IOP>21 mm Hg, and severe IOP elevation defined as a rise of 10 mm Hg or more in IOP compared with baseline. Cox regression models were used to analyze the hazard ratios (HRs) among different diseases. After PSTA, the mean IOPs from month 1 to month 6 all significantly increased (P<0.05). Ocular hypertension occurred in 30.7% of eyes (median time: 8wk), and severe IOP elevation occurred in 16.2% of eyes (median time: 9wk). Patients receiving PSTA for CRVO or uveitis had a significantly higher risk for ocular hypertension (HR=3.049, P=0.004 for CRVO; HR=5.464, P=0.019 for uveitis) and severe IOP elevation (HR=2.913, P=0.034 for CRVO; HR=7.650, P=0.009 for uveitis). IOP significantly increases within 6mo after PSTA, with the onset of ocular hypertension happening mostly at 2 to 3mo. Patients of CRVO or noninfectious uveitis have a higher risk of ocular hypertension or severe IOP elevation after PSTA and should be monitored for IOP more carefully.

Outcomes of 25-Gauge Vitrectomy for Tractional and Nontractional Diabetic Macular Edema with Proliferative Diabetic Retinopathy.

The benefit of pars plana vitrectomy with internal limiting membrane peeling for tractional macular edema and diffuse nontractional macular edema in diabetic retinopathy has been reported. Although these studies had included various stages, use of conventional 20-gauge vitrectomy system, small number of cases, single-center study, and lack of retinal structure measurements were limitations. We compared one-year outcomes of 25-gauge vitrectomy for refractory diabetic macular edema with or without the tractional proliferative membrane in proliferative diabetic retinopathy (PDR) eyes and examined the prognostic factors for postoperative visual acuity. A total of consecutive 116 PDR eyes of 116 patients that underwent 25-gauge vitrectomy for tractional macular edema (TME group: 56 eyes) or nontractional macular edema (nTME group: 60 eyes) at six centers were retrospectively reviewed. Visual acuity (VA), central macular thickness (CMT), complications, and postoperative treatments before and 12 months after vitrectomy were compared. Mean VA improved significantly in each group (both P < 0.01), and mean CMT decreased significantly in each group (both P < 0.01). Thirteen eyes underwent additional vitrectomy, six eyes developed neovascular glaucoma, six eyes received intravitreal anti-VEGF injection, and thirteen eyes received subtenon triamcinolone acetonide injection. Multiple linear regression analysis showed that baseline VA and CMT in the TME group and kidney function in the nTME group were the predictable factors of the 12-month postoperative VA. Twenty-five-gauge vitrectomy effectively improved VA and macular structure both in TME and nTME groups. Baseline VA, CMT, and kidney function are important factors affecting postoperative VA.

Intraocular pressure elevation after subtenon triamcinolone acetonide injection; Multicentre retrospective cohort study in Japan.

To evaluate real-world evidence for intraocular pressure (IOP) elevation after subtenon triamcinolone acetonide injection (STTA) in 1252 Japanese patients (1406 eyes) in the Japan Clinical REtina STudy group (J-CREST). This was a multicentre retrospective study of the medical records of 1252 patients (676 men (758 eyes); mean age: 63.8 ± 12.9 years) who received STTA in participating centres between April 2013 and July 2017. IOP elevation was observed in 206 eyes (14.7%) and IOP increase ≥ 6 mmHg was found in 328 eyes (23.3%). In total, 106 eyes (7.5%) needed medication and two eyes (0.14%) needed surgical procedures. Younger age, higher baseline IOP, and steroid dose were risk factors associated with IOP elevation. Risk factors associated with IOP increase ≥ 6 mmHg were younger age, lower baseline IOP, steroid dose, and higher incidences of diabetic macular oedema (DME) and uveitis. In contrast, with steroid dose fixed at 20 mg, a lower incidence of DME was a risk factor for increased IOP, suggesting that STTA had dose-dependent effects on IOP increase, especially in patients with DME. Our real-world evidence from a large sample of Japanese patients who received STTA showed that the incidence of IOP elevation after STTA was 14.7%, and was associated with younger age, higher baseline IOP, and steroid dose. Thus, IOP should be monitored, especially in patients with younger age, higher baseline IOP, and higher incidences of DME and uveitis.

Short-term outcomes of subtenon triamcinolone acetonide injections in patients with retinitis pigmentosa-associated cystoid macular edema unresponsive to carbonic anhydrase inhibitors.

To investigate the functional and anatomical results of subtenon triamcinolone acetonide injection (TA) in eyes with retinitis pigmentosa (RP) that had cystoid macular edema (CME) unresponsive to carbonic anhydrase inhibitors (CAIs). This is a prospective, interventional study. Forty-eight consecutive eyes that underwent subtenon TA for CME due to RP were recorded. Central macular thickness (CMT), best-corrected visual acuities (BCVAs) and intraocular pressures (IOPs) were evaluated before and after injection at 2nd week, 1st month, 2nd month and 3rd month, respectively. Spectral-domain optical coherence tomography (SD-OCT) was used to show anatomic findings. Complications such as cataract and glaucoma were recorded. A total of 48 eyes of 42 patients with a mean age of 36.25 ± 15.59years (range 13 to 63years) and a mean follow-up of 4.45 ± 0.74months (range 4 to 6months) were recorded in the study. The mean initial BCVA increased from 1.09 ± 0.52 to 0.54 ± 0.29 logarithmic minimum angle of resolution (log MAR) (p < 0.001) at 3months after injection and the mean central macular thickness decreased from 591.45 ± 209.55µm to 270.83 ± 95.48µm (p < 0.001). The mean iOP increased from 13.58 ± 2.87mmHg to 15.91 ± 2.47mmHg (p < 0.001). Multiple injections (3 injections) in 1 eye, 2 injections in 4 eyes and 1 injection in rest of the eyes were performed at 3-month intervals. Complications such as glaucoma and cataract were not observed in any patient during and after the treatment. In the present study, a significant improvement in visual acuity and CMT were observed in eyes with subtenon TA for CME due to RP unresponsive to CAIS. Further studies with a long follow-up period of the population are required to investigate the role of subtenon TA of CME due to RP.

Evaluation of The Effect of Combined Intra-Vitreal Ranibizumab Injection and Sub-Tenon Tri-Amcinolone Acetonide Injection in The Management of Diabetic Macular Edema

Background: to monitor and compare the effect of intravitreal ranibizumab injection alone or with sub-tenon triamcinolone acetonide injection on patients with diabetic macular edema. Aim of the Work: To assess the effect of combined intravitreal ranibizumab injection, and sub-tenon triamcinolone acetonide injection in the management of diabetic macular edema. Patients and Methods: Patients with non-proliferative diabetic retinopathy associated with DME (Central macular thickness over 300 um) which are aimlessly divided into two groups. In group 1, three monthly doses (0.5 mg) of intravitreal ranibizumab are received. In group 2, the anti-VEGF injection was performed 10 days after the sub-tenon steroid injection [triamcinolone acetonide]. All patients’ visual acuity, IOP and CMT were followed up for 3 months. Results: The combined treatment showed improved best corrected visual acuity from baseline 0.24 ± 0.32 log MAR to 0.56 ± 0.18 log MAR (p = 0.023) which was statistically significant. In addition, there was decreased CMT from baseline 420.1 ± 112.84 to 275.73 ± 90.81 which was highly statistically significant (p > 0.001). When comparing the combination treatment with the anti-VEGF treatment alone, recovery of BCVA and CMT was statistically significant (p = 0.041 and p = 0.001, respectively). Conclusion: Steroid addition to the routine anti-VEGF therapy is an effective method of treatment of diabetic macular edema

Evaluation of The Effect of Combined Intra-Vitreal Ranibizumab Injection and Sub-Tenon Tri-Amcinolone Acetonide Injection in The Management of Diabetic Macular Edema

Background: to monitor and compare the effect of intravitreal ranibizumab injection alone or with sub-tenon triamcinolone acetonide injection on patients with diabetic macular edema. Aim of the Work: To assess the effect of combined intravitreal ranibizumab injection, and sub-tenon triamcinolone acetonide injection in the management of diabetic macular edema. Patients and Methods: Patients with non-proliferative diabetic retinopathy associated with DME (Central macular thickness over 300 um) which are aimlessly divided into two groups. In group 1, three monthly doses (0.5 mg) of intravitreal ranibizumab are received. In group 2, the anti-VEGF injection was performed 10 days after the sub-tenon steroid injection [triamcinolone acetonide]. All patients’ visual acuity, IOP and CMT were followed up for 3 months. Results: The combined treatment showed improved best corrected visual acuity from baseline 0.24 ± 0.32 log MAR to 0.56 ± 0.18 log MAR (p = 0.023) which was statistically significant. In addition, there was decreased CMT from baseline 420.1 ± 112.84 to 275.73 ± 90.81 which was highly statistically significant (p > 0.001). When comparing the combination treatment with the anti-VEGF treatment alone, recovery of BCVA and CMT was statistically significant (p = 0.041 and p = 0.001, respectively). Conclusion: Steroid addition to the routine anti-VEGF therapy is an effective method of treatment of diabetic macular edema

The Efficacy of Posterior Subtenon Triamcinolone Acetonide Injection in Treatment of Irvine-Gass Syndrome

ABSTRACTPurpose: To evaluate the efficacy and safety of posterior 40 mg subtenon triamcinolone acetonide (PST) injection in treating Irvine-Gass syndrome.Methods: The retrospective study included 21 patients (mean age: 76 ± 8.2) with a treatment-naïve eye subjected to topical anesthesia and injection of 40 mg/ml triamcinolone via a blunt tip SubTenon cannula through a single inferonasal peritomy. Best corrected visual acuity (BCVA; logMAR), intraocular pressure (IOP), biomicroscopic and funduscopic findings, and optical coherence tomography (OCT) measurements were recorded.Results: Baseline central macular thickness decreased from 431 ± 136 µm to 300 ± 67 µm (1st month; p = .002), to 292 ± 56 µm (3rd month; p = .002), and to 299 ± 66 µm (6th month; p = .005). Mean BCVA increased from 0.71 ± 0.23 to 0.27 ± 0.11, 0.19 ± 0.06, and 0.24 ± 0.17, respectively (all visits; p < 0.001). Mean IOP values did not change significantly (p = .12).Conclusion: PST injection is an effective and safe treatment for Irvine-Gass syndrome.

Clinical efficacy of subtenon injection of triamcinolone acetonide for anterior ischemic optic neuropathy

Objective To evaluate the efficacy of subtenon injection of triamcinolone acetonide(TA) for non-arteritic anterior ischemic optic neuropathy (NAION). Methods The data of 60 eyes of 60 patients with NAION from Jun. 2015 to May 2017 were analyzed retrospectively. All cases were randomly divided into two groups, 30 eyes of 30 patients in each group. The treatment group underwent injection of compound anisodine around superficial temporal artery combined with subtenon injection of TA(20 mg). The control group underwent injection of compound anisodine around superficial temporal artery. Results The best corrected visual acuity (BCVA), visual field and optic papilla swelling were improved 60 days after treatment. BCVA of treatment group after treatment was better than that of the control group(χ2=17.800, P=0.003). In the treatment group, the visual field was improved in 14 eyes (93.33%) after treatment in 15 eyes with visual field examination.In the control group, the visual field was improved in 3 eyes (16.67%) after treatment in 15 eyes with visual field examination. The difference was significant between the two groups(χ2=18.680, P=0.0025). Conclusion Compound anisodine combined with TA is more effective than compound anisodine separately on the treatment of NAION. Key words: Optic neuropathy, anterior ischemic, non-arteritic; Triamcinolone acetonide; Subtenon injection

Real-world evidence of treatment for relapse of noninfectious uveitis in tertiary centers in Japan: A multicenter study.

Noninfectious uveitis (NIU), which pathogenesis is often autoimmune nature, occurs as a symptom of systemic syndromes or only in the eye. The standard treatment of NIU is local, topical, and oral administration of corticosteroids (CS) in combination with immunomodulatory therapy (IMT). However, additional therapeutic strategies involving topical and systemic administration of CS or others to treat relapse or exacerbation of ocular inflammation in NIU which present as various ocular manifestations have not been established. The aim of this study was to investigate therapeutic strategies used for various ocular inflammations in relapse or exacerbation of NIU and to evaluate factors associated with the treatment pattern in Japan. The subjects were 198 eyes of 156 NIU patients with relapse or exacerbation of ocular inflammation at 6 university hospitals in Japan. The most frequent disease was sarcoidosis in 23.7% of the cases, followed by Behçet disease (BD) in 21.2%, Vogt-Koyanagi-Harada (VKH) disease in 13.6%, acute anterior uveitis (AAU) in 5.6%, tubulointerstitial nephritis and uveitis syndrome (TINU) in 4.0%, and juvenile idiopathic arthritis (JIA)-associated uveitis in 3.0%. Common ocular findings were worsened anterior inflammation (AI) in 67.2% of the cases, vitreous opacity (VO) in 46.5%, macular edema (ME) in 26.8%, retinal vasculitis (RV) in 23.7%, serous retinal detachment (SRD) in 9.1%, and optic perineuritis (OPN) in 4.0%. Reinforcement of betamethasone eye drop (ED) monotherapy for only AI in both unilateral and bilateral AI, sub-tenon injection of triamcinolone acetonide (STTA) for unilateral posterior inflammation including VO and ME, and systemic therapy using CS and/or IMT for bilateral anterior and posterior inflammation were significantly more frequent. Frequencies of exacerbated individual ocular findings in sarcoidosis and BD were similar, and severe ocular inflammation associated with panuveitis required both topical and systemic therapies. These results demonstrate that reinforcement of betamethasone EDs, topical administration of triamcinolone acetonide, and long-term administration of systemic corticosteroids are the major therapeutic strategies, and reinforcement of betamethasone EDs was used for exacerbated AI independently from its use for posterior inflammation. In addition, STTA was preferentially used for VO and ME associated with posterior inflammation.

Ophthalmic Immune-Related Adverse Events of Immunotherapy: A Single-Site Case Series

To report a case of panuveitis and retinal vasculitis associated with pembrolizumab therapy for metastatic lung cancer.A 71-year-old man, who was diagnosed with metastatic lung cancer (squamous cell carcinoma), presented with blurry vision 2 weeks after the initiation of pembrolizumab monotherapy. His best-corrected visual acuity (BCVA) was 20/20 OU, and slitlamp examination revealed fine keratic precipitates, anterior chamber cells (1+) and flare (1+) in both eyes. Dilated fundus examination showed no remarkable finding in the right eye and vitreous haze (2+), perivascular exudates, and vessel sheathing in the left eye. Fluorescence angiography demonstrated dye leakage from the optic disc and both retinal arteries and veins extending from the posterior to the peripheral retina in both eyes. The patient was diagnosed with panuveitis and retinal vasculitis as Grade 3 immune-related adverse event (irAE). Pembrolizumab was discontinued and oral prednisone 70mg/day was given for 1 week. The dose was reduced to 30mg/day for the next 3 weeks and was then stopped. One month after the treatment, intraocular inflammation became quiescent. With a good response to the treatment of irAE, pembrolizumab was restarted. Recurrence of ocular inflammation occurred over the next 1.5 years, but all of which were successfully treated with sub-Tenon's injection of triamcinolone acetonide (STTA). The patient maintained BCVA of 30/20 OU at the latest visit.We showed a case of retinal vasculitis occurred as an irAE of pembrolizumab for metastatic lung cancer. Retinal vasculitis was well managed with transient pembrolizumab discontinuation and oral corticosteroid therapy, and pembrolizumab was restarted with the aid of STTA. As ocular irAEs might be controlled by local corticosteroid therapy, the decision to continue immune checkpoint inhibitor therapy should be made on a case-by-case basis.

Effect of intravitreal or sub-tenon triamcinolone acetonide injection at completion of vitrectomy on peripheral retinochoroidal thickness in eyes with proliferative diabetic retinopathy

The effect of triamcinolone acetonide (TA) on the peripheral retinochoroidal thickness was determined after pars plana vitrectomy (PPV) with scatter photocoagulation in eyes with proliferative diabetic retinopathy. The peripheral retinochoroidal thickness was measured at 5 mm from the limbus in the four quadrants using anterior segment optical coherence tomography before, and 3 days, and 1 and 2 weeks after the surgery. The total peripheral thickness was significantly thicker than the baseline thickness after PPV alone (P < 0.001; 18 eyes), PPV combined with intravitreal TA injection (IVTA; P = 0.011; 19 eyes), and PPV combined with sub-tenon TA injection (STTA; P = 0001; 23 eyes). The total peripheral thickness in the PPV group at 3 days after surgery was significantly thicker than that of the PPV + IVTA (P = 0.015) and of the PPV + STTA groups (P = 0.016). Multiple linear regression analyses showed that the injection of TA by the two routes and the number of photocoagulation burns were significantly correlated with the total peripheral thicknesses at 3 days after the surgery. The results indicate that the PPV with large number of intraoperative scatter photocoagulation burns caused an increase in the total peripheral thickness and an administration of either IVTA and STTA can reduced the degree of thickening.

Phacoemulsification with Posterior Sub-Tenon Triamcinolone Acetonide Injection for Prevention of Progression of Diabetic Macular Edema after Cataract Surgery

Background: diabetic macular edema (DME) is the most common cause of visual loss in diabetic patients. The pathogenesis of DME is multifactorial. It results from multiple biochemical and cellular changes that eventually cause leakage and exudation. A number of patient characteristics such as increasing age, females, duration of DM, poor glycemic control and moderate to severe retinopathy have been found associated with poor prognosis after cataract surgery in diabetic patients. Objective: the aim of this study was to evaluate the efficacy of phacoemulsification with posterior sub-Tenon’s triamcinolone acetonide injection for prevention of progression of diabetic macular edema following uneventful cataract surgery by phacoemulsification. Patients and Methodology: this interventional study included 20 eyes of 20 diabetic patients with visually significant cataract and coexisting DME during the period from December 2017 to October 2018. Preoperative and postoperative best corrected visual acuity (BCVA) using LogMAR and intraocular pressure (IOP) were recorded. Results: statistically significant improvement in BCVA was detected when comparing postoperative values at one week, one month and three months to corresponding preoperative values. In addition, values at one month and three months were significantly improved when compared to values at one week post-operative. On other hand, values at three months revealed non-significant difference when compared to values at one month. Conclusion: this study suggests that posterior sub-Tenon’s triamcinolone acetonide injection can be given safely and easily at the time of phacoemulsification surgery in patients with visually significant cataract and DME.