Intravitreal Triamcinolone Acetonide
`for Idiopathic Cystoid Macular Edema
`Ingrid U. Scott, MD, MPH,
`Harry W. Flynn, Jr., MD, and
`Philip J. Rosenfeld, MD, PhD
`
`PURPOSE: To report intravitreal triamcinolone acetonide
`for idiopathic cystoid macular edema (ICME).
`DESIGN: Interventional case series.
`METHODS: Two patients with ICME were treated with
`intravitreal triamcinolone.
`RESULTS: In one patient, best-corrected acuity was 20/70
`before treatment and 20/30 6 months posttreatment in
`both eyes. Foveal thickness was 606 ␮m before and 197
`␮m posttreatment in the right eye and 542 ␮m before
`and 190 ␮m posttreatment in the left eye. In another
`patient, best-corrected acuity was 20/200 before treat-
`ment and 20/50 5 months posttreatment; foveal thick-
`ness was 580 ␮m before and 208 ␮m posttreatment.
`Recurrence of macular edema responded to repeat intra-
`vitreal triamcinolone acetonide in both patients.
`CONCLUSIONS: Intravitreal triamcinolone may be associ-
`ated with reduced edema and improved vision in patients
`with ICME; however, these changes may be transient.
`(Am J Ophthalmol 2003;136:737–739. © 2003 by
`Elsevier Inc. All rights reserved.)
`
`I NTRAVITREAL TRIAMCINOLONE ACETONIDE HAS BEEN
`
`reported to be associated with decreased macular edema
`and improved vision in patients with refractory macular
`edema associated with such conditions as diabetic retinop-
`athy,1 central retinal vein occlusion,2 uveitis,3,4 and bird-
`shot
`retinochoroidopathy.5 We
`report
`intravitreal
`triamcinolone acetonide in the treatment of idiopathic
`cystoid macular edema (ICME).
`
`● CASE 1: A 52-year-old woman presented in May 2001
`with a 1-year history of progressive visual loss in both eyes
`(OU). Five months earlier, she had been treated with laser
`photocoagulation in the left eye for “retinal swelling.” Two
`months earlier, she had been treated with a periocular
`injection of triamcinolone acetonide in both eyes. The
`patient reported no improvement in her vision after the
`previous treatments. Examination demonstrated a best-
`corrected visual acuity of 20/40 OU. Intraocular pressure
`was 12 mm Hg OU. The remainder of the examination was
`
`Accepted for publication Feb 27, 2003.
`InternetAdvance publication at ajo.com July 16, 2003.
`From the Bascom Palmer Eye Institute, University of Miami School
`of Medicine, Miami, Florida.
`This study was supported in part by Research to Prevent Blindness,
`New York, New York.
`Inquiries to Ingrid U. Scott, MD, MPH, Bascom Palmer Eye Institute,
`PO Box 016880, Miami, FL 33101;
`fax: (305) 326-6417; e-mail:
`iscott@bpei.med.miami.edu
`
`notable for ICME OU. These clinical findings were con-
`firmed by fluorescein angiography. Observational manage-
`ment was recommended. When the patient returned in
`January 2002, examination demonstrated a best-corrected
`acuity of 20/70 in the right eye (OD) and 20/40 in the left
`eye (OS); the remainder of the examination was notable
`for increased cystoid macular edema OD; optical coher-
`ence tomography (OCT) demonstrated a foveal thickness
`of 606 ␮m OD and 284 ␮m OS (Figure 1A). The patient
`underwent intravitreal triamcinolone injection (4 mg/
`0.1cc) OD. She returned in July 2002 noting decreased
`vision OS. Examination demonstrated a best-corrected
`visual acuity of 20/30 OD and 20/70 OS. Optical coher-
`ence tomography demonstrated a foveal thickness of 197
`␮m OD (Figure 1B) and 542 ␮m in the left eye (Figure
`1C). The patient underwent intravitreal triamcinolone
`injection (4 mg/0.1cc) OS. She returned for follow-up in
`September 2002, at which time her best-corrected acuity
`was 20/100 OD and 20/30 OS. Optical coherence tomog-
`raphy demonstrated a foveal thickness of 442 ␮m OD and
`190 ␮m OS (Figure 1 D). The patient underwent intra-
`vitreal triamcinolone injection (4 mg/0.1cc) OD; in De-
`cember 2002, the patient had a best-corrected acuity of
`20/30 OU and a foveal thickness (measured by OCT) of
`200 ␮m OD and 197 ␮m OS. Due to progressive cataract
`OU, phacoemulsification with posterior chamber intraoc-
`ular lens implantation was performed (OD in January
`2003; OS in February 2003). By April 2003, best-corrected
`visual acuity had dropped to 20/100 OU and macular
`edema had recurred. Reinjection of intravitreal triamcin-
`olone (4 mg/0.1cc) was performed OU. By May 2003,
`visual acuity had improved to 20/30 OU and OCT
`measurements were 216 ␮m OD and 169 ␮m OS.
`
`● CASE 2: A 47-year-old woman with a history of topical
`corticosteroid treatment and nonsteroidal therapy as well
`as focal laser photocoagulation OS for chronic cystoid
`macular edema presented in July 2000 with a 1-year history
`of decreased vision OS and no improvement following
`prior treatment. Examination demonstrated a best-cor-
`rected acuity of 20/20 OD and 20/70 OS. Intraocular
`pressure was 15 mm Hg in each eye. The remainder of the
`examination was notable for ICME of the left eye. Fluo-
`rescein angiography confirmed the clinical findings. Ob-
`servational management was recommended. In July 2001,
`the patient returned with a 6-month history of further
`decreased vision OS with no improvement with topical
`prednisolone acetate 1% eye drops. Examination of the left
`eye was notable for a best-corrected acuity of 20/200 and
`increased cystoid macular edema with a foveal thickness
`measured by OCT of 580 ␮m (Figure 2A). The patient
`underwent intravitreal triamcinolone injection (4 mg/
`0.1cc) OS; 8 days after injection, acuity had improved to
`20/100 and OCT demonstrated marked improvement in
`cystoid macular edema (Figure 2B). In December 2002,
`acuity OS was 20/50 and foveal thickness measured by
`
`VOL. 136, NO. 4
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`BRIEF REPORTS
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`FIGURE 1. Case 1. (A) Optical coherence tomography of the right eye demonstrates a marked increase in foveal thickness (606 ␮m)
`and retinal cystic changes consistent with cystoid macular edema. Best-corrected visual acuity is 20/70. (B) Optical coherence tomography
`6 months after treatment demonstrates restoration of a normal foveal contour (foveal thickness is 197 ␮m). Best-corrected visual acuity
`is 20/30. (C) Optical coherence tomography of the left eye demonstrates a marked increase in foveal thickness (542 ␮m) and retinal cystic
`changes consistent with cystoid macular edema. Best-corrected visual acuity is 20/70. (D) Optical coherence tomography of the left eye
`2 months after treatment demonstrates restoration of a normal foveal contour (foveal thickness is 190 ␮m). Best-corrected visual acuity
`is 20/30. Recurrent macular edema responded to repeat intravitreal triamcinolone acetonide in both eyes.
`
`FIGURE 2. Case 2. (A) Optical coherence tomography of the left eye demonstrates a marked increase in foveal thickness (580 ␮m) and
`retinal cystic changes consistent with cystoid macular edema. Best-corrected visual acuity is 20/200. (B) Eight days after treatment with
`intravitreal triamcinolone acetonide, optical coherence tomography demonstrates marked improvement in cystoid macular edema. (C)
`Optical coherence tomography 5 months after treatment demonstrates restoration of a normal foveal contour (foveal thickness is 208
`␮m). Best-corrected visual acuity is 20/50. Recurrent macular edema responded to repeat intravitreal triamcinolone in the left eye.
`
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`AMERICAN JOURNAL OF OPHTHALMOLOGY
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`OCTOBER 2003
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`

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`OCT was 208 ␮m (Figure 2C). Recurrent visual loss to
`20/200 OS occurred in February 2003; OCT foveal thick-
`ness was 550 ␮m. A second injection of
`intravitreal
`triamcinolone (4 mg/0.1 cc) was administered OS but
`visual acuity was limited by progressive posterior subcap-
`sular cataract. Phacoemulsification with posterior chamber
`intraocular lens implantation was performed OS in April
`2003. Best-corrected visual acuity in July 2003 was 20/50
`OS and the OCT was 207 ␮m.
`Intravitreal triamcinolone is a promising therapeutic
`modality for treating refractory macular edema associated
`with a variety of diseases, although the potential risks
`associated with administration of intraocular corticoste-
`roids (such as intraocular pressure elevation and cataract
`formation) must be considered. Reported treatments for
`ICME have demonstrated limited, if any, visual benefit;
`the two cases reported here suggest that intravitreal triam-
`cinolone may be of therapeutic value in patients with
`decreased vision due to ICME; however, the effects of
`intravitreal triamcinolone may be transient.
`
`REFERENCES
`
`1. Martidis A, Duker JS, Greenberg PB, et al. Intravitreal
`triamcinolone for refractory diabetic macular edema. Oph-
`thalmology 2002;109:920 –927.
`2. Greenberg PB, Martidis A, Rogers AH, et al. Intravitreal
`triamcinolone acetonide for macular oedema due to central
`retinal vein occlusion. Br J Ophthalmol 2002;86:247–248.
`3. Antcliff RJ, Spalton DJ, Stanford MR, et al. Intravitreal
`triamcinolone for uveitic cystoid macular edema: an optical
`coherence tomography study. Ophthalmology 2001;108:765–
`772.
`4. Young S, Larkin G, Branley M, Lightman S. Safety and
`efficacy of
`intravitreal triamcinolone for cystoid macular
`oedema in uveitis. Clin Exp Ophthalmol 2001;29:2–6.
`5. Martidis A, Duker JS, Puliafito CA. Intravitreal triamcinolone
`for refractory cystoid macular edema secondary to birdshot
`retinochoroidopathy. Arch Ophthalmol 2001;119:1380–1383.
`
`Intravitreal Triamcinolone for
`Choroidal Neovascularization in
`Ocular Histoplasmosis Syndrome
`Ehud Rechtman, MD, Valerie D. Allen, OD,
`Ronald P. Danis, MD, Linda M. Pratt, RN,
`Alon Harris, PhD, and Matthew A. Speicher, MD
`
`Accepted for publication March 24, 2003.
`InternetAdvance publication at ajo.com August 27, 2003.
`From the Department of Ophthalmology, Indiana University School of
`Medicine, Indianapolis, Indiana (E.R., V.D.A., R.P.D., L.M.P., A.H.,
`M.A.S.) and Department of Ophthalmology, Kaplan Medical Center,
`Rehovot, Israel (E.R.).
`Inquiries to Ronald P. Danis, MD, Department of Ophthalmology,
`Indiana University School of Medicine, Indianapolis, 702 Rotary Circle,
`IUMC, Indianapolis, IN, 46202; fax: (317) 274-1288; e-mail: rdanis@
`iupui.edu, erechtma@iupui.edu.
`
`PURPOSE: To report the effects of intravitreal triamcino-
`lone acetonide injections for subfoveal and juxtafoveal
`choroidal neovascularization (CNV) in ocular histoplas-
`mosis syndrome.
`METHODS: In a retrospective analysis, the proportion of
`eyes that gained >5 or lost >5 and >15 Early Treatment
`of Diabetic Retinopathy Study (ETDRS) letters, best-
`corrected visual acuity using ETDRS letter score (VA),
`greatest linear dimension (GLD), and treatment side
`effects were assessed.
`RESULTS: Ten patients (five subfoveal, five juxtafoveal
`CNV; median follow-up: 17 months; range, 6 – 41
`months) were evaluated. Thirty percent gained >5 let-
`ters, 20% lost 5 to 14 letters, and 50% maintained stable
`VA. Overall, mean VA and GLD remained stable. Side
`effects were transient intraocular pressure elevation and
`mild cataract development.
`CONCLUSIONS: Intravitreal triamcinolone acetonide for
`CNV resulting from OHS was found to be relatively safe
`and showed good visual outcome for both subfoveal and
`juxtafoveal CNV. Further studies are warranted to eval-
`uate this treatment.
`(Am J Ophthalmol 2003;136:
`739 –741. © 2003 by Elsevier Inc. All rights reserved.)
`
`L ASER PHOTOCOAGULATION WAS NOT FOUND TO BE
`
`for subfoveal choroidal neovascularization
`beneficial
`(CNV) resulting from ocular histoplasmosis syndrome
`(OHS).1 Laser photocoagulation, based on the Macular
`Photocoagulation Study,2 is currently a common treatment
`choice for juxtafoveal CNV resulting from OHS. Photo-
`dynamic therapy with verteporfin has recently shown
`favorable outcomes in subfoveal CNV cases in a prospec-
`tive uncontrolled study,3 whereas submacular surgery re-
`mains under evaluation. Previously, we found oral
`prednisone and subtenon triamcinolone to have a stabiliz-
`ing effect on visual acuity in the treatment of CNV for this
`condition.4 No published study has reported treatment of
`CNV resulting from OHS with intravitreal triamcinolone
`acetonide (iTAAC). Therefore, we retrospectively ana-
`lyzed the clinical records of all subjects who were treated at
`Indiana University with iTAAC injections (0.1 ml, Kena-
`log 40 mg/ml) for subfoveal and juxtafoveal CNV resulting
`from OHS and who had a follow-up of 6 months or longer.
`The proportion of eyes that gained ⱖ5 Early Treatment of
`Diabetic Retinopathy Study (ETDRS) letters, lost ⱖ5 and
`ⱖ15 letters, best-corrected visual acuity ETDRS letter
`score (VA), lesion greatest linear dimension (GLD), and
`treatment side effects were assessed. We found and evalu-
`ated the clinical records of 10 patients, ages 44.9 ⫾ 17.7
`(mean ⫾ standard deviation [SD]) years, with CNV
`resulting from OHS. Only one had received earlier treat-
`ment for CNV (laser photocoagulation for extrafoveal
`CNV). At baseline, five had subfoveal CNV (three pre-
`dominantly classic and two occult) and five had juxtafo-
`veal CNV (four predominantly classic and one minimally
`classic) (Figures 1 and 2). Median follow-up was 17
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`VOL. 136, NO. 4
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`BRIEF REPORTS
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