Suprachoroidal injection of triamcinolone acetonide using a custom-made needle to treat diabetic macular edema post pars plana vitrectomy: a case series
Abstract:Objective Diabetic macular edema (DME), the most common cause of diabetes-related visual impairment, may occur following pars plana vitrectomy (PPV) to manage proliferative diabetic retinopathy complications. This retrospective single-centre case series evaluated the efficacy and safety of injecting 4 mg/0.1 ml triamcinolone into the suprachoroidal space using a custom-made needle to treat DME post PPV. Methods Data regarding central macular thickness (CMT) using spectral domain-optical coherence tomography an… Show more
“…The findings revealed an increase in visual acuity and a marked reduction of CFT with no cataract progression in the phakic eye. During the 8-week follow-up period, no increase in intraocular pressure or adverse effects were observed [80].…”
Ophthalmic drug delivery to the posterior segment of the eye has been challenging due to the complex ocular anatomy. Intravitreal injection of drugs was introduced to deliver therapeutic doses in the posterior segment. Different posterior segment diseases including age-related macular degeneration, diabetic macular edema, retinal vein occlusions, uveitis, and cystoid macular edema, among others, have been historically treated with intravitreal corticosteroids injections, and more recently with intravitreal corticosteroids drug implants. Triamcinolone acetonide (TA) is the most frequently used intraocular synthetic corticosteroid. Using nanoparticle-based TA delivery systems has been proposed as an alternative to intravitreal injections in the treatment of posterior segment diseases. From these novel delivery systems, topical liposomes have been the most promising strategy. This review is oriented to exhibit triamcinolone acetonide drug evolution and its results in treating posterior segment diseases using diverse delivery platforms.
“…The findings revealed an increase in visual acuity and a marked reduction of CFT with no cataract progression in the phakic eye. During the 8-week follow-up period, no increase in intraocular pressure or adverse effects were observed [80].…”
Ophthalmic drug delivery to the posterior segment of the eye has been challenging due to the complex ocular anatomy. Intravitreal injection of drugs was introduced to deliver therapeutic doses in the posterior segment. Different posterior segment diseases including age-related macular degeneration, diabetic macular edema, retinal vein occlusions, uveitis, and cystoid macular edema, among others, have been historically treated with intravitreal corticosteroids injections, and more recently with intravitreal corticosteroids drug implants. Triamcinolone acetonide (TA) is the most frequently used intraocular synthetic corticosteroid. Using nanoparticle-based TA delivery systems has been proposed as an alternative to intravitreal injections in the treatment of posterior segment diseases. From these novel delivery systems, topical liposomes have been the most promising strategy. This review is oriented to exhibit triamcinolone acetonide drug evolution and its results in treating posterior segment diseases using diverse delivery platforms.
“…The technique of manufacturing the stopper, mounting it on the needle, and injection techniques are already well described in previous publications and a video published by the author [ 14 – 17 ] Fig 1 . Fig.…”
Background
Previous studies have shown promising effects of combining intravitreal bevacizumab and suprachoroidal injection of triamcinolone acetonide in treating DME. However, further research is needed.
Objective
To assess the efficacy and safety of combining both intravitreal Ziv-aflibercept and suprachoroidal injection of triamcinolone acetonide using a custom-made needle in naïve and de novo central diabetic macular edema (DME) patients every eight weeks for 24 weeks.
Methods
Central macular thickness was measured via spectral domain-optical coherence tomography, and best-corrected visual acuity was measured via a Snellen chart at baseline and at 4, 8, 12, 16, and 24 weeks postinjection. Additionally, cataract progression, intraocular pressure (IOP), and ocular safety were analyzed.
Results
A total of 10 eyes of 6 patients were treated with suprachoroidal injections of triamcinolone acteonid combined with an intravitreal injection of Ziv-aflibercept. Vision improved from 0.69 log minimum angle of resolution (MAR) at baseline to 0.39 log MAR after treatment. Central macular thickness significantly decreased from 462.3 ± 166 μm at baseline to 362.7 ± 77.6 μm at 24 weeks postinjection.
Conclusion
Suprachoroidal injection of triamcinolone using a custom-made needle with the intravitreal agent Ziv-aflibercept to treat de novo/naïve central DME has favorable outcomes and adequate safety results. Moreover, this study demonstrated the benefit of adapting the previous treatment combination for extending the interval between anti-VEGF treatments from 4 to 8 weeks, which could prevent further expenses, especially in low-income countries.However, large multicenter randomized clinical trials with longer follow-up periods are needed to assess this treatment route, especially in low-income and resourced countries.
“…213 Furthermore, the exposure of the lens, iris, and vitreous humor to triamcinolone acetonide was significantly decreased with minimal exposure in the aqueous humor in the suprachoroidal injection group. 213 Recently, several other studies evaluated the efficacy of suprachoroidal injection of GCs in several retinal diseases including diabetic macular edema, 168 , 169 uveitic macular edema, 170 , 214 , 215 and retinal detachment secondary to Vogt-Koyanagi Harada disease. 216 The results showed good efficacy with no significant increase in IOP.…”
Section: Clinical Science Review Of Gig/giohtmentioning
Glucocorticoid (GC) therapy is indicated in many diseases, including ocular diseases. An important side-effect of GC therapy is GC-induced ocular hypertension (GIOHT), which may cause irreversible blindness known as GC-induced glaucoma (GIG). Here, we reviewed the pathological changes that contribute to GIOHT including in the trabecular meshwork and Schlemm’s canal at cellular and molecular levels. We also discussed the clinical aspects of GIOHT/GIG including disease prevalence, risk factors, the type of GCs, the route of GC administration, and management strategies.
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