Presenter: clerk 陳豪宏 Advisor: 柳景豑醫師

Intravitreal triamcinolone acetonidefor treatment of intraocularoedematous and neovascular diseases Presenter: clerk 陳豪宏 Advisor: 柳景豑醫師

Author • Jost B. Jonas • Department of Ophthalmology, Faculty of Clinical Medicine Mannheim, Ruprecht-Karls-University of Heidelberg, Germany

Abstract-Usage 1 • Intravitreal triamcinolone acetonide (IVTA) for • intraocular neovascular and oedematous diseases. • Best response in visual acuity (VA) for Intraretinal oedematous diseases: • diffuse diabetic macular oedema • branch retinal vein occlusion • central retinal vein occlusion • pseudophakic cystoid macular oedema. • Non-infectious uveitis • acute or chronic sympathetic ophthalmia • Adamantiadis–Behcet’s disease • VA increased • intraocular inflammation decreased.

Abstract-Usage 2 • angiostatic therapy • iris neovascularization • proliferative ischaemic retinopathies • adjunct therapy for • exudative age-related macular degeneration(AMD) • (in combination with photodynamic therapy) • For hypotony: • increase in IOP and may stabilize the eye.

Abstract-Complications • secondary ocular hypertension 40% • medically uncontrollable high IOP • ->antiglaucomatous surgery in 1–2% • posterior subcapsular cataract and nuclear cataract • -> cataract surgery in 15–20% for elderly within 1 year • postoperative infectious endophthalmitis(1/1000) • non-ID endophthalmitis • pseudo-endophthalmitis with TA in AC.

Abstract-Combo and duration • can be combined with other intraocular surgeries • cataract surgery particularly in eyes with iris neovascularization. • Cataract surgery performed some months after • -> no markedly elevated complication rate. • The injection maybe repeated. • In non-vitrectomized eyes, the duration of the effect and side-effects of a single IVTA: • 6–9 months (with 20 mg) • 2–4 months (with 4 mg).

Introduction • The abnormal proliferation of IO Cells is often accompanied and stimulated by intraocular inflammation. • defects in the blood–retina barrier due to capillary leakage • -> accumulation of fluid in the intraretinal and subretinal spaces of the macula -> impaired vision.

The steroids can… • reduce intraocular inflammation • tighten the capillary walls • suppress proliferation of cells

The steroids have been used to… • topically as drops • given systemically • injected into the subconjunctival or sub-Tenon space. • Not enough IO concentration to achieve a therapeutic level • the systemic side-effects too pronounced for a prolonged treatment.

to overcome these limitations… • IV application • to locally suppress IO inflammation • To reduce proliferation of cells • Soluble cortisone-> easy washout-> • Machemer(1996): triamcinolone acetonide (crystalline) • Many other clinical uses were studied and been reported using IVTA

For Exudative AMD: • Recent estimates: about 70~90% of all verteporfinphotodynamic treatments for exudative MD are combinedwith IVTA. • Diffuse diabetic macular edema and • Proliferative diabetic retinopathy: • Recent studies: temporarily increase VA for diffuse diabetic macular edema

For Diffuse DM macular edema and Proliferative DM retinopathy: • IVTA -> NO clinically significant serum concentration shortly after IVI of about 20 mg TA • Agrees with: clinical observations: no marked metabolic influence. • sub-Tenon method: less invasive. • A recent study: IVTA -> higher concentrations than sub-Tenon application.

vitrectomy for proliferate DM vitreoretinopathy combined with IVTA • IVTA -> no higher postoperative complications rate. • It had not shown a marked therapeutic benefit.

Vitrectomy combined with IVTA to visualize membranes and vitreousbody • Several studies: using TA during vitrectomy may facilitate both: • removal of the epiretinal membrane around the macular hole • separation of the residual vitreous cortex from the retina in highly myopic eyes with retinal detachment.

Cataract surgery in eyes with iris neovascularization combined with IVTA • A study: IVTA may be a useful adjunctive treatment tool in eyes with iris neovascularization undergoing cataract surgery. • VA increased • without additional retinal ablative treatments, iris neovascularization markedly regressed

For pseudophakic CME • In some studies: For persistent pseudophakic CME: increase in VA from 0.26±0.13 to a mean best VA of 0.60±0.19. • The increase in VA was statistically independent of the time interval of the surgery and IVTA.

For retinal vein occlusions • For BRVO: Some studies: IVTA may be helpful in patients not responding to laser photocoagulation. • For CRVO: Some studies: • benefit from IVTA in terms of VA and macular edema for non-ischemic CRVO. • direct or indirect anti-angiogenic effect.

For Uveitis • Based on the clinical experience gathered for the use of IVTA for other indications, TA has also been applied in eyes with chronic therapy-resistant uveitis.

Other conditions: • ocular ischemic syndromes • CME due to retinitis pigmentosa • foveal telangiectasia • Progressive ocular hypotony

Complications of IVTA • Secondary ocular hypertension • Secondary steroid-induced, open-angle glaucoma • Post-injection endophthalmitis • Post-injection pseudo-endophthalmitis • Rhegmatogenous retinal detachment • Post-injection, steroid-induced cataract • Central serous chorioretinopathy • Toxic effects

Pharmacokinetics • Considerably higher vitreous concentrations of TA were achieved after IVI than after sub-Tenon injection. • IV conc. of TA were detectable up to 2.75 months after a single 4 mg injection in non-vitrectomized eyes.

Pharmacokinetics II • found in aqueous humour and in silicone oil up to 1.5 years after IVI. • In vitrectomized eyes, the turnover rate of IVTA is considerably shorter than in nonvitrectomized eyes.

Conclusion • IVTA -> new avenues for the treatment of intraocular edematous and neovascular diseases. • Great caution needed. • Long term experience not yet available. • many open questions still unanswered. (ex: dosage, best mode of application, other possible complications, among others.)

End • Thank you.

Presenter: clerk 陳豪宏 Advisor: 柳景豑醫師