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      Triamcinolone-Induced Intraocular Pressure Elevation: Intravitreal Injection for Macular Edema and Posterior Subtenon Injection for Uveitis

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          Abstract

          Purpose

          To assess the effect of intravitreal and posterior subtenon injections of triamcinolone acetonide (TA) on intraocular pressure (IOP).

          Methods

          we reviewed 42 consecutive eyes after intravitreal TA injection (IVTA) and 43 eyes following posterior subtenon TA injection (PSTA). All cases had a minimum follow-up time of three months. After injection, the value and time of the maximal IOP, the amount of IOP elevation and the needs of the medication were assessed.

          Results

          The IOP increased significantly (p<0.001) from 16.3±2.5 mmHg preoperatively to a mean maximum of 21.7±5.3 mmHg in the IVTA group, and from 15.3±4.5 mmHg to 20.6±3.0 mmHg in the PSTA group. An elevation in the IOP of more than 5 mmHg from the baseline IOP was seen in 52.4% of the IVTA group at a mean time of 3.1 weeks postoperatively, and 44.2% of the PSTA group displayed an IOP elevation at 5.9 weeks.

          Conclusions

          Both developed significant elevations of IOP, but this appeared at a later date in the PSTA group. Careful follow-up after local injection of steroids is necessary.

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          Most cited references25

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          Intraocular concentration and pharmacokinetics of triamcinolone acetonide after a single intravitreal injection.

          To describe the pharmacokinetics occurring after the direct injection of triamcinolone acetonide into the vitreous humor of humans. Interventional case series. Five patients who received a single 4-mg intravitreal injection of triamcinolone acetonide. An aqueous humor sample was obtained from 5 eyes via an anterior chamber paracentesis at days 1, 3, 10, 17, and 31 after injection. At each visit, visual acuity and intraocular pressure were measured and indirect ophthalmoscopy was performed. A fluorescein angiogram was carried out at day 10. Concentrations were determined using high performance liquid chromatography; pharmacokinetic analysis was carried out using PK Analyst, an iterative, nonlinear, weighted, least-squares regression program. Intraocular concentrations of triamcinolone were measured and population pharmacokinetic parameters were calculated. Pharmacokinetic data followed a two-compartment model. Peak aqueous humor concentrations ranged from 2151 to 7202 ng/ml, half-lives from 76 to 635 hours, and the integral of the area under the concentration-time curve (AUC(0-t)) from 231 to 1911 ng/h per milliliter. After a single intravitreal injection of triamcinolone, the mean elimination half-life was 18.6 days in nonvitrectomized patients. The half-life in a patient who had undergone a vitrectomy was shorter at 3.2 days. There was considerable intrasubject variation among peak concentration, AUC(0-t) values, and elimination half-lives. After intravitreal injection, measurable concentrations of triamcinolone would be expected to last for approximately 3 months (93 +/- 28 days) in the absence of a vitrectomy. Because triamcinolone pharmacokinetics were characterized only in elderly patients with macular edema, the results cannot be extrapolated to other patient populations.
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            Intravitreal triamcinolone for uveitic cystoid macular edema: an optical coherence tomography study.

            To investigate the use of intravitreal injection of triamcinolone acetonide (TA) for the treatment of refractory uveitic cystoid macular edema (CME). Prospective, nonrandomized, self-controlled comparative trial. Six patients with chronic CME resistant to treatment with systemic steroids, orbital floor steroids, and cyclosporine A. Three patients were followed for more than 1 year, and the other three for between 3 and 9 months. Injection of 2 mg of TA into the vitreous cavity. Optical coherence tomography scanning of the fovea before and after injection and logarithmic minimal angle of resolution visual acuity. Visual acuity, retinal thickness, cystoid space height, and intraocular pressure. There was complete anatomic resolution of CME in five of the six cases within 1 week after injection. Cystoid spaces began to return between 6 weeks and 3 months after injection. Two patients with longer term follow-up responded to further orbital floor steroid injection and had no CME 1 year later. One patient had raised intraocular pressure develop, requiring a trabeculectomy. Mean improvement in visual acuity after 12 months was 0.27 (range, 0.14-0.42). Complete anatomic and, to some extent, functional recovery can be induced by intravitreal TA despite long-term refractory inflammatory CME. Optical coherence tomography aids in the management of these cases.
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              Safety of an intravitreal injection of triamcinolone: results from a randomized clinical trial.

              To determine the safety of a single intravitreal injection of triamcinolone acetonide (4 mg) in patients with subfoveal choroidal neovascularization caused by age-related macular degeneration. A double-masked, placebo-controlled, randomized clinical trial was conducted at a public tertiary referral eye hospital. Patients participating had age-related macular degeneration with evidence of choroidal neovascularization, any part of which was classic; age older than 59 years; and best-corrected visual acuity of 20/200 or better. Eyes were assigned to active study treatment or to placebo. Intraocular pressure and cataract grading were performed every 6 months for 3 years. Adverse events, from mild to vision-threatening or life-threatening, were recorded as procedure-related or corticosteroid-related. Seventy-five eyes were assigned to study treatment and 76 eyes to placebo. There were no moderate or severe adverse events related to the surgical procedure in either group. Triamcinolone-treated eyes had a significantly increased risk of developing mild or moderate elevation of the intraocular pressure. Topical glaucoma medication reduced intraocular pressure to acceptable levels in all patients. There was significant progression of cataract in the triamcinolone-treated eyes. Despite a significant adverse event profile, intravitreal triamcinolone is generally well tolerated by the human eye as long as patients are carefully followed up by their surgeon and treated appropriately, when necessary.
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                Author and article information

                Journal
                Korean J Ophthalmol
                KJO
                Korean Journal of Ophthalmology : KJO
                The Korean Ophthalmological Society
                1011-8942
                June 2006
                30 June 2006
                : 20
                : 2
                : 99-103
                Affiliations
                Department of Ophthalmology, College of Medicine, Pusan National University, Busan, Korea.
                Author notes
                Reprint requests to Seung-Youn Jea, MD. Department of Ophthalmology, Pusan National University Hospital, #1-10 Ami-dong, Seo-gu, Busan 602-739, Korea. Tel: 82-51-240-7318, Fax: 82-51-242-7341, jea-sy@ 123456hanmail.net
                Article
                10.3341/kjo.2006.20.2.99
                2908835
                16892645
                5b493789-fc38-4ee0-b41c-613a1bd6f9f0
                Copyright © 2006 by the Korean Ophthalmological Society

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 18 March 2005
                : 09 February 2006
                Categories
                Original Article

                Ophthalmology & Optometry
                subtenon injection,intravitreal injection,triamcinolon acetonide,intraocular pressure

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