Intraocular Pressure Changes after Triamcinolone Acetonide Intravitreal Injection

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Intraocular Pressure Changes after Triamcinolone Acetonide Intravitreal Injection
Med. J. Cairo Univ., Vol. 79, No. 2, December: 147-151, 2011
www.medicaljournalofcairouniversity.com

Intraocular Pressure Changes after Triamcinolone Acetonide
Intravitreal Injection
HOSSAM EL-DIN KHALIL, M.D.*; WALEEDMAHRAN, M.D.*; HAZEM HAROUN, M.D.*;
HOSSAM BEKEIR, M.D.* and AHMED EL-SHAFIE, M.Sc.**
The Departments of Ophthalmology, Beni-Swif University* and Ophthalmplogist, Rod El-Farag Hospital**

                         Abstract                                       (range 13-24mmHg) postoperatively. 5 (12.5%) of patients
                                                                        in group B showed significant elevation of IOP (>25mmHg)
    Aim: To investigate the intraocular pressure (IOP) respon-          after topical administration of prednisolone acetate and were
seafter intravitreal triamcinolone acetonide (IVTA) injections          excluded from injection. 4 of them were managed by topical
astreatment of intraocular neovascular or oedematous diseases           B-blockers, and 1 eye required trabeculoplasty. Preoperative
and the ability to predict secondary steroid-induced glaucoma.          predictive factor for the rise in IOP was younger age
                                                                        (p=0.0002). It was statistically independent of refractive error,
     Methods: The prospective consecutive comparative inter-            presence of diabetes mellitus, and indication for the injection.
ventional case series study included 80 eyes of 76 patients,            In all but two eye, IOP could be lowered to the normal range
group (A), 40 eyes; group (B), 40 eyes, who received an                 with topical medication during the follow-up period, without
intravitreal injectionof 4mg triamcinolone acetonide and had            development of glaucoma tousoptic nerve head changes.
a follow-up time of 1 weeks interval for 6 weeks. In group
(B), topical prednisolone acetate (0.1%) was administrated 3                 Conclusions: After intravitreal injections of 4mg oftriam-
times daily for 2 weeks before injection, and the follow-up             cinolone acetonide, an IOP elevation can develop in about
started 1 day before injection.                                         25% of eyes starting 1 week after injection, but the onset is
                                                                        inconstant in all cases. In the vast majority, IOP can be
    Results: In group (A) IOP increased significantly (p=0.001)         normalized by topical medication. Topical steroid administra-
from 13.8 (1.9) mmHg preoperatively to a mean maximum                   tion pre-injection helped knowing the steroid responders and
of 15.6 (2.7) mmHg postoperatively. An IOP rise to values               non-responders, so avoiding the occurrence of 2 ry refractory
higher than 20mmHg was observed in 6 (15%) eyes. Elevation              glaucoma steroid-injection.
of IOP occurred 1 week after the injection. In group (B) IOP
increased non significantly (p>0.001) from 14.8 (2.1) mmHg              Key Words: Glaucoma – Diabetic macular – Intraocular
preoperatively to a mean maximum of 16.35 (2.7) mmHg                               injection – Triamcinolone acetonide.

          410

          519
  496 626 557 418 316

          488
          365
  A
           316

           376
  297 337 325 389 329

           399
           364
  B

     Fluorescein angiography and optical coherence tomography (OCT) before (A), and OCT 6 weeks after intravitreal injection
of triamcinolone acetonide (B). Note: Central corneal thickness before (557 µ ) and after (325 µ ).

Correspondence to: Dr. Hossam El-Din Khalil,
The Department of Ophthalmology, Beni-Swif University

                                                                  147
Intraocular Pressure Changes after Triamcinolone Acetonide Intravitreal Injection
148                             Intraocular Pressure Changes after Triamcinolone Acetonide Intravitreal Injection

                     Introduction                               lower intraocular concentrations of steroids than
                                                                if the steroids were injected intravitreally, we aimed
INJECTION Intravitreal triamcinolone acetonide                  to evaluate the response of IOP after the intravitreal
has increasingly been used in previous studies as               injection of corticosteroids. As well as the IOP
treatment for intraocular proliferative, edematous,             changes when the intravitreal triamcinolone ace-
and neovascular diseases, such as central retinal               tonide injection is preceded by administration of
vein occlusion, neovascular glaucoma without or                 topical steroid as a provocative test.
with cataract surgery, chronic pre-phthisical ocular
hypotony, chronic uveitis, persistent pseudophakic                             Patients and Methods
cystoid macular edema, exudative age-related
macular degeneration, proliferative diabetic retin-                Patients were selected outpatient Cairo and
opathy, ischemic ophthalmopathy, sympathetic                    Beni-Swif Universities from 2010-2011.
ophthalmia, and in other clinical situations [1] .
Direct intraocular injection of steroids delivers the               The prospective interventional case series study
desired drug to its target tissue in the most direct            included 76 patients (80 eyes) divided into 2 groups.
fashion without extraocular side effects as that                Group A included 36 patients (40 eyes) (22 women,
happened after oral steroids administration. After              18 men; 16 right eyes, 24 left eyes) who consecu-
a single intravitreal injection of triamcinolone                tively received an intravitreal injection of 4mg
acetonide, one can deliver a concentration of thou-             triamcinolone acetonide with topical anaesthesia,
sands of nanograms of triamcinolone to the vitreous             and who had a follow-up time of 6 weeks. Group
cavity. Drug concentrations rapidly decrease and                B included 40 patients (40 eyes) (24 women, 16
are followed by a subsequent prolonged rate of                  men; 22 right eyes, 18 left eyes) who consecutively
elimination. A measurable concentration is main-                received topical prednisolone acetate (0.1%) 3
tained in the vitreous humor for approximately 90               times daily for 2 weeks as a provocative testprior
days [2] .                                                      to triamcinolone acetonide intravitreal injection.
                                                                The reasonfor the intravitreal injection of triamci-
    Side effects reported so far include cataract;              nolone acetonide were progressive decrease of
secondary ocular hypertension leading in some                   visual acuity due to exudative agerelated macular
patients to secondary chronic open-angle glaucoma;              degeneration with subfoveal neovascularization
and post injection, infectious, or sterile endoph-              (n=11 eyes), or diffuse diabetic macular oedema
thalmitis [1] . Previous studies have shown that one            (n=68 eyes) or Retinal vein occlusion (1 eye).
of the most common side effects of intravitreal                 Mean age was 50.4 (9.5) years (range 20.1-65.1
triamcinolone acetonide was a steroid-induced                   years). All patients were fully informed about the
elevation of IOP [3] . Since previous studies exam-             experimental character of thetherapy. All patients
ined the rate and amount of elevation of IOP after              signed an informed consent. The ethicscommittee
topical application of cortisone leading to much                of the university had approved the study.

     Fluorescein angiography and optical coherence tomography before (A-C), and 6 weeks after (B-D) intravitreal injection
of triamcinolone acetonide. Note: Decrease in fluorescein leakage and decrease in retinal thickening.
Hossam E. Khali, et al.                                                                                         149

    Patients received an intravitreal injection of         of the retina, such as diffuse diabetic macular
4mg of crystalline triamcinolone acetonide under           oedema and persistent cystoid macular oedema
sterile conditions in the operating theatre. The           due to various other diseases, and chronic intraoc-
solution was prepared by the hospital’s pharmacy           ular inflammation are some of the leading causes
removing the solvent agent. Using the operation            of impaired vision. The intraocular proliferation
microscope, the injection was transconjunctivally          of cells is often accompanied and stimulated by
carried out under topical anaesthesia after a para-        intraocular inflammation, and macular oedema can
centesis had been performed to decrease the volume         be caused by a damaged blood-retinal barrier due
of the globe. Using applanation tonometry, IOP             to capillary leakage. Corticosteroids have long
was determined before, and in intervals of 1 week          been known to tighten up blood vessels resulting
after the injectionfor 1 month.                            in a decrease of vessel leakage and, depending on
                                                           the concentration, to suppress proliferation of cells.
    For inter individual comparisons, only one             Consequently, steroids have been used for the
randomly selected eye per patient was taken for            treatment of various ocular diseases, applied either
statistical analysis. For intra individual bilateral       topically or systemically. Often, however, the
comparison, the four patients with both eyes treated       intraocular concentrations of corticosteroids were
were included in the analysis.                             not sufficiently high, or the systemic side effects
                       Results                             were too serious, to effectively treat the ocular
                                                           disorder.
      In group A, IOP increased significantly
(p
150                                Intraocular Pressure Changes after Triamcinolone Acetonide Intravitreal Injection

about 25% of the eyes treated. A predictive factor                     edema: Preliminary results of a prospective controlled
for the rise of IOP may have been the presence of                      trial. Ophthalmology, 111: 218-225, 2004.
glaucoma before the injection. This relation, how-                4- GRAHAM R.O. and PEYMAN G.A.: Intravitreal injection
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                                                                     endophthalmitis. Arch. Ophthalmol., 92: 149-54, 1974.
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for the younger age with a post-injection rise in                    of intraocular proliferation with intravitreal corticosteroid.
IOP. Other parameters, such as sex and refractive                    Am. J. Ophthalmol., 89: 131-6, 1980.
error of the patient did not show a marked influence              6-   TANO Y., CHANDLER D. and MACHEMER R.: Treat-
on frequency and amount of the elevation of IOP.                       ment of intraocular proliferation with intravitreal injection
Interestingly, the presence of diabetes mellitus did                   of tramcinolone acetonide. Am. J. Ophthalmol., 90: 810-
                                                                       16, 1980.
not demonstrate a marked influence on the rate of
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