Triamcinolone acetonide for refractory pseudophakic cystoid macular edema after intravitreal bevacizumab

Abstract

Dear Editor, An important cause of unfavourable visual outcome after cataract surgery is pseudophakic cystoid macular edema (PCME). The pathophysiology of PCME has not been clearly elucidated; however, a breakdown of the bloodretinal barrier secondary to postoperative inflammation is thought to be one of the main factors involved. In the absence of vitreomacular traction, a wide range of therapeutic options including topical non-steroidal anti-inflammatories, acetazolamide, topical steroids, periocular steroids and intravitreal steroids, have been proposed [3]. More recently, the use of intravitreal bevacizumab injections (IVB; Avastin, Genentech Inc., San Francisco, CA, USA) in eyes with PCME has been studied [1,2,5,8]. In this report, a case of PCME refractory to IVB treated with sub-Tenon's triamcinolone acetonide is described.An 82-year-old woman underwent a right-eye phacoemulsification with intraoperative zonular dialysis of less than 90°without vitreous loss. A capsular tensional ring and intraocular lens were inserted in the bag. Thirty days postoperative, her visual acuity (VA) was 20/30. Four months later, VA decreased to 20/80, while the ocular coherence tomography revealed the presence of PCME with a foveal thickness of 723 μm without signs of vitreomacular traction. Different therapeutic options were explained to the patient, and the decision to administer 0.125 mg/0.05 ml of IVB was taken. One month later, VA was 20/80 and foveal thickness 451 μm. Because of a partial resolution of PCME, a second IVB was given, but VA 1 month later was 20/100 and foveal thickness 802 μm. A third IVB was administered, and after 1 month VA was 20/63, but retinal thickness was 880 μm. As the PCME was persistent, a 40 mg/1.0 ml sub-Tenon's injection of triamcinolone acetonide was given, and 1 month later VA was 20/63 and foveal thickness decreased to 359 μm. Four and 8 months after triamcinolone, VA was 20/40 and 20/30, while central foveal thickness decreased to 287 μm and 221 μm respectively, with no signs of PCME. No complications related to IVB or triamcinolone acetonide administration were observed.Bevacizumab is a full-length humanized monoclonal antibody that blocks the effect of vascular endothelial growth factor (VEGF) and has been approved for the treatment of metastatic colorectal cancer. The off-label use of IVB has shown a decrease in macular edema in patients with exudative age-related macular degeneration [7]. In our case, IVB was considered to be a first therapeutic option for PCME, so that secondary effects associated with the use of periocular corticosteroids, especially intraocular hypertension, could be avoided [4]. Little is known about the role of IVB in PCME, and there is no agreement between authors. Arevalo et al.[1] observed a short-term improvement in patients treated with bevacizumab as primary therapy, while Spitzer et al. [8] did not observe a significant increase of VA in patients with PCME refractory to other therapies. In a single case report, a partial increase of VA and reabsorption of...

Pseudophakic Cystoid Macular Edema

“…66 A different published case study, however, showed failure of edema to resolve after 3 injections of bevacizumab followed by improvement with a sub-Tenon injection of triamcinolone. 67 In another retrospective series, 10 eyes of 10 patients with refractory CME after cataract surgery were injected with intravitreal bevacizumab (1 or more times). 68 The bestcorrected visual acuity improved from a mean of 20/80 to 20/32, associated with a significant decrease in mean central macular thickness, with 6 months of follow-up.…”

Intravitreal fluocinolone acetonide implant for chronic postoperative cystoid macular edema – two years results

“…Most postoperative CME cases can be successfully treated either with topical and systemic nonsteroidal antiinflammatory drugs or periocular, systemic, and intravitreal corticosteroid such as a dexamethasone intravitreal implant (OZURDEX®) or intravitreal anti-VEGF therapy. 3,[15][16][17][18][19][20][21][22][23] However, a particular subset of patients develops recalcitrant CME which could benefit from longer lasting intravitreal corticosteroids in order to achieve prolonged anatomical and functional improvement.…”