alexa Subtenon Triamcinolone Acetonide versus Intravitreal Triamcinolone Acetonide for the Treatment of Diabetic Cystoid Macular Edema | Open Access Journals
ISSN: 2155-9570
Journal of Clinical & Experimental Ophthalmology
Like us on:
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Subtenon Triamcinolone Acetonide versus Intravitreal Triamcinolone Acetonide for the Treatment of Diabetic Cystoid Macular Edema

Ayman Lotfy*

Faculty of Medicine, Zagazig University, Egypt

*Corresponding Author:
Ayman Lotfy
Faculty of Medicine, Zagazig University, Egypt
Tel: 00201224276447
E-mail: [email protected]

Received date: July 02, 2016; Accepted date: August 16, 2016; Published date: August 20, 2016

Citation: Lotfy A (2016) Subtenon Triamcinolone Acetonide versus Intravitreal Triamcinolone Acetonide for the Treatment of Diabetic Cystoid Macular Edema. J Clin Exp Ophthalmol 7:590. doi:10.4172/2155-9570.1000590

Copyright: © 2016 Lotfy A. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Journal of Clinical & Experimental Ophthalmology

Abstract

Purpose: To investigate the efficacy of the posterior subtenon (SBT) capsule injection of TA as compared to intravitreal (IVT) injection of Triamcinolone Acetonide (TA) for the management of cystoid diabetic macular edema in pseudophakic patients. Methods: This prospective randomized comparative study included 100 pseudophakic eyes with cystoid macular edema. They were divided into two equal groups; IVT group, treated with 2 mg IVT injection of TA and SBT group, treated with 40 mg SBT injection of TA. Central Subfield thickness SFT, best corrected visual acuity BCVA and intraocular pressure IOP were measured before and after one and three months of treatment Results: There was statistically significant improvement in visual acuity in IVT and SBT groups. The SFT was significantly reduced both after one month and after three months when compared to the baseline values in both IVT and SBT groups. The SFT was comparable between the two groups especially after three months of treatment. The IOP of the eyes treated with IVT and SBT injection was significantly increased when compared to baseline value, but well controlled with glaucoma medication. There was insignificant difference between the IVT and SBT groups as regard to the mean IOP. Conclusion: The subtenon approach of triamcinolone injection can be considered a valid safe and effective alternative to the intravitreal injection; however larger and longer multicenter studies are needed.

Keywords

Diabetes; Macular edema; Triamcinolone; Acetenoide; Intravitreal subtenone

Background

Macular edema is the commonest cause of visual loss in diabetic patients. Damaged tight junction between endothelial cells and pigmented epithelial cells lead to water and electrolytes leakage. According to the Early Treatment Diabetic Retinopathy Study (ETDRS), macular laser blocked further visual loss in half of patients. However, it was unable to restore the vision and not effective in the treatment of cystoid macular edema. Complications of intravitreal triamcinolone injections include hemorrhage, endophthalmitis and retinal detachment. Subtenon injection of steroids appears to offer a better choice, less invasive and deliver same therapeutic dose for the management of diabetic macular edema and intermediate uveitis [1-3]. the purpose of this study was to assess the efficacy of posterior subtenon (SBT) capsule injection for the treatment of cystoid diabetic macular edema in pseudophakic patients.

Methods

This comparative prospective controlled study treated 100 eyes. Fifty two patients were males and forty eight were females, aged between 41 and 74 years (mean 67.3). Inclusion criteria included pseudophakic diabetic patients complaining from cystoid diabetic macular edema without retinal-vitreous traction. Patients were informed about the procedures and the study aim. They signed informed consent form to participate according to the declaration of Helsinki (1983). In all the patients the best corrected visual acuity in logarithm of the minimum angle of resolution (log MAR) was reported using Snellen chart, as well as intraocular pressure (IOP) applanation tonometry, anterior and posterior segment biomicroscopy. Central subfield thickness (SFT) was evaluated by optical coherence tomography (OCT 2000, Topcon, Japan). Exclusion criteria included previous ocular surgery other than cataract, glaucoma, ocular hypertension and uveitis. The patients were divided equally and randomly using computer software into two groups; IVT group and SBT group.

Procedures

Procedures for the IVT injection, the surface anesthesia with topical 0.4% benoxinate hydrochloride was performed, followed by skin sterilization with 5% povidone iodine. A paracentecis was done. A volume of 0.05 ml containing 2 mg TA (Kenacort, Bristol-Myers Squibb, Sermoneta, Italy) was injected via the inferotemporal parsplana (3 mm posterior to the limbus) using a 27-gauge needle. For the posterior SBT injection, 1 ml of a 40 mg/ml of triamcinolone acetonide (Kenacort, Bristol-Myers Squibb, Sermoneta, Italy) was given in the inferotemporal quadrant. The patients were direct to look in the extreme superonasal field of gaze. The conjunctiva and the Tenon's capsule were incised and penetrated with 23 G cannula. A paracentecis was done. Topical gatefloxacin and dexamethasone eye drops were used postoperatively for one week. The BCVA log MAR, IOP and SFT were reported one week, one month and three months postoperatively.

Statistical analysis

The data were statistically evaluated using SPSS 16.0 software. The ANOVA test and paired t test were used for comparison between the two groups. A “p<0.05” was considered significant.

Results

The eyes treated with an IVT of TA displayed significant improvement in visual acuity, both after one month (0.35 ± 0.1 ) (Log MAR 0.45 ± 0.05; p<0.001) and after three months ( 0.3 ± 0.1 ) (Log MAR 0.5 ± 0.08; p<0.001) of treatment when compared to the baseline values (0.14 ± 0.1) (Log MAR 0.85 ± 0.1). Significant improvement was displayed also in eyes treated with an SBT injection, again after one month (0.35 ± 0.09) (Log MAR 0.45 ± 0.07; p<0.001) and after three months (0.3 ± 0.09) (Log MAR 0.49 ± 0.06; p<0.001) when compared to the baseline values (0.13 ± 0.09) (Log MAR 0.86 ± 0.1). There was no statistically significant difference in visual acuity between both groups during follow-up visits (Table 1). The SFT of the eyes treated with IVT injection were significantly reduced both after one month (225 ± 14 μm; p<0.001) and after three months (230 ± 10 μm; p<0.001) when compared to the baseline values 385 ± 12 μm. The eyes treated with SBT injections displayed significant improvement after one month (220 ± 15 μm; p<0.001) and after three months (235 ± 12 μm; p<0.001) of treatment when compared to the baseline values of 383 ± 18 μm. The improvement in SFT was statistically insignificant between the two groups (Table 2). The IOP of the eyes treated with IVT injection was significantly increased after one month (18.8 ± 1.8 mmHg; p=0.03), three months (17.2 ± 1.2 mmHg; p=0.02) when compared to baseline value (16.6 ± 1.6 mmHg). Glaucoma medication was used to control the IOP. The eyes treated with SBT injection displayed significant increase of the IOP only after one month (17.4 ± 1.4 mmHg; p=0.01). IOP after three ms was (16.6 ± 1.6 mmHg) comparable to baseline value (16.4 ± 1.4 mmHg) (p=0.1). The mean IOP was significantly higher in IVT group than in SBT group after one month. However, it was statistically insignificant after three months of treatment (Table 3).

  Pretreatment visual acuity First month after injection three month after injection
visual acuity p value* visual acuity p value*
Group I † (n=50) 0.85 ± 0.1 0.45 ± 0.05 <0.001 0.5 ± 0.05 <0.001
Group II ‡ (n=50) 0.86 ± 0.1 0.45 ± 0.06 <0.001 0.49 ± 0.06 <0.001
p value** 0.2 0.3 -- 0.3 --
* Student t test against preoperative values
** Student t test between the two groups
† Intravitreal Triamcinolone Acetonide treated eyes
‡ Sub-Tenon Triamcinolone Acetonide treated eyes

Table 1: Visual acuity (log MAR) (mean ± standard deviation) of studied groups.

  Pretreatment SFT First month after injection three month after injection
SFT p value* SFT p value*
Group I † (n=50) 385 ± 12 225 ± 14 <0.001 230 ± 10 <0.001
Group II ‡ (n=50) 383 ± 18 230 ± 15 <0.001 235 ± 12 <0.001
p value** 0.493 0.364 -- 0.134 --
* Student t test against preoperative values
** Student t test between the two groups
† Intravitreal Triamcinolone Acetonide treated eyes
‡ Sub-Tenon Triamcinolone Acetonide treated eyes

Table 2: Central subfield thickness (SFT) (mean ± standard deviation) (μm) of studied groups.

  Pretreatment IOP First month after injection three month after injection
IOP p value* IOP p value*
Group I † (n=50) 16.6 ± 1.6 18.8 ± 1.8 0.03 17.2 ± 1.2 0.02
Group II ‡ (n=50) 16.4 ± 1.4 17.4 ± 1.4 0.01 16.6 ± 1.6 0.1
p value** o.712 <0.001 -- 0.056 --
* Student t test against preoperative values
** Student t test between the two groups
† Intravitreal Triamcinolone Acetonide treated eyes
‡ Sub-Tenon Triamcinolone Acetonide treated eyes

Table 3: Intraocular pressure (IOP) (mean ± standard deviation) (mmHg) of studied groups.

Discussion

Macular edema is the main cause of loss of visual acuity in diabetic patients. Damaged tight junction in-between endothelial cells and pigmented epithelial cells, lead to water and electrolytes leakage. According to the Early Treatment Diabetic Retinopathy Study (ETDRS), macular laser blocked further visual loss in half of patients. However, it was unable to restore the vision and not effective in the treatment of cystoid macular edema. The diabetic retinopathy presents with features of chronic inflammation such as; vasodilatation, increased blood flow, tissue edema and an increase in the vascular permeability. All experimental data such as; leukostasis in diabetes with adhesion of activated molecules to the endothelium, increased production of prostacyclin, vascular endothelial growth factor (VEGF) and macrophage cellular component confirm the involvement of pro-inflammatory molecules in the early stages of diabetic retinopathy. Corticosteroids inhibit the initial arachidonic acid cascade, down-regulate the cytokines and support the blood-retinal barrier [1,2]. The complications of intravitreal TA were endophthalmitis, intraocular hemorrhages, retinal detachment and IOP elevation in 20% to 80% of patients [1].

The subtenon TA was used in the management of cystoid macular edema and intermediate uveitis. Correct injection makes it possible to deliver the drug in the macular area [1]. This work proved that intravitreal injection of TA and the subtenon injection of TA improved the visual acuity and an equally reduced the retinal thickness. A statistically significant rise of the IOP in the eyes treated with IVT injection was proved after one and three months. In a pilot study performed by Chew et al, they proved less central subfield thickness after SBT but after longer follow up [2]. Song et al. found a better improvement in visual acuity 8 weeks after IVT with less macular thickness which was superior to intravitreal bevacizumab injection [3]. On the other hand Marey et al. stated that intravitreal bevacizumab alone was better and safer than both intravitreal TA and combined intravitreal bevacizumab-TA because of higher IOP [4]. Also Chung et al. proved the visual and foveal thickness improvement after SBT combined with laser macular therapy. It was comparable to IVT with lower IOP elevation [5]. Wang et al. proved that, intravitreal injection of bevacizumab combined with or without triamcinolone acetonide was effective in treatment of DME [6]. Choi et al. Cellini et al. and Qi et al. reported that IVTA and SBT had same effects on DME, but that IVTA elevated IOP. Ozdek et al. proved that 8.2% of the SBT cases showed a significant elevation in IOP (>21 mmHg), and 24.3% of cases in the IVT group had a significant elevation in IOP. Bakri and Kaiser reported minimal elevation in IOP at 3 months that was normalized at 6 months [7-9]. Ozdek et al. compared the IVT and SBT effects. They stated that both SBT and IVT significantly reduced the retinal edema, although the effects were more pronounced in the IVT group, SBT also seemed to be a safe and effective technique for treating DME. Bakri and Kaiser reported that SBT was safe and effective on DME are refractory to laser photocoagulation [7]. Jonas et al. found that 50% of IVT patients had increased IOP. The SBT is considered to be less invasive than the intravitreal one. IOP is not increased by the use of this approach with the exception of steroid responder patients. Cataract progression, central retinal vein occlusion, globe perforation and central retinal artery occlusion were found to be complication of SBT. Other complications described are blepharoptosis, orbital fat atrophy, strabismus and conjunctiva necrosis [9,10].

Conclusion

The subtenon route, although involving a limited number of cases, can be considered an easy, safe and valid alternative to the intravitreal route.

Competing Interest “The author declares that they have no competing interests.”

Acknowledgments

Authors do not have someone to acknowledge to. "This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors”.

The author does not have any financial competing interests. The author does not have any financial competing interests (political, personal, religious, ideological, academic, intellectual or commercial).

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Article Usage

  • Total views: 8332
  • [From(publication date):
    August-2015 - Nov 20, 2017]
  • Breakdown by view type
  • HTML page views : 8225
  • PDF downloads : 107
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri & Aquaculture Journals

Dr. Krish

[email protected]

1-702-714-7001Extn: 9040

Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

[email protected]

1-702-714-7001Extn: 9042

Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001Extn: 9040

Clinical Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

Food & Nutrition Journals

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

General Science

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics & Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Materials Science Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Nursing & Health Care Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

Ann Jose

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001Extn: 9042

 
© 2008- 2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version
adwords