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Intravitreal triamcinolone acetonide for treatment of intraocular oedematous 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. - PowerPoint PPT Presentation
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Intravitreal triamcinolone Intravitreal triamcinolone acetonideacetonide
for treatment of intraocularfor treatment of intraocularoedematous and neovascular oedematous and neovascular
diseasesdiseases
Presenter: clerk Presenter: clerk 陳豪宏陳豪宏Advisor: Advisor: 柳景豑 醫師 柳景豑 醫師
AuthorAuthor
Jost B. Jonas Department of Ophthalmology,
Faculty of Clinical Medicine Mannheim, Ruprecht-Karls-University of Heidelberg, Germany
Abstract-Usage 1Abstract-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 2Abstract-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-ComplicationsAbstract-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 Abstract-Combo and durationduration
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).
IntroductionIntroduction
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…The steroids can…
1. reduce intraocular inflammation 2. tighten the capillary walls3. suppress proliferation of cells
The steroids have been used The steroids have been used toto……
1. topically as drops2. given systemically3. 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 to overcome these limitationslimitations……
IV application 1. to locally suppress IO inflammation2. 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 verteporfin photodynamic treatments for exudative MD are combined with IVTA.
Diffuse diabetic macular edema and
Proliferative diabetic retinopathy: Recent studies: temporarily
increase VA for diffuse diabetic macular edema
For 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 vitreous
body 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.
1. VA increased2. 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: 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 UveitisFor 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: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
PharmacokineticsPharmacokinetics
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 IIPharmacokinetics 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.
ConclusionConclusion
IVTA -> new avenues for the IVTA -> new avenues for the treatment of intraocular edematous treatment of intraocular edematous and neovascular diseases.and neovascular diseases.
Great caution needed.Great caution needed. Long term experience not yet Long term experience not yet
available.available. many open questions still
unanswered. (ex: dosage, best mode of application, other possible complications, among others.)
EndEnd
Thank you.Thank you.