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Intravitreal triamcinolone Intravitreal triamcinolone acetonide acetonide for treatment of for treatment of intraocular intraocular oedematous and neovascular oedematous and neovascular diseases diseases Presenter: clerk Presenter: clerk 陳陳陳 陳陳陳 Advisor: Advisor: 陳陳陳 陳陳 陳陳陳 陳陳

Presenter: clerk 陳豪宏 Advisor: 柳景豑 醫師

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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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Page 1: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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

Page 2: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

AuthorAuthor

Jost B. Jonas Department of Ophthalmology,

Faculty of Clinical Medicine Mannheim, Ruprecht-Karls-University of Heidelberg, Germany

Page 3: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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.

Page 4: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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.

Page 5: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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.

Page 6: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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).

Page 7: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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.

Page 8: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

The steroids can…The steroids can…

1. reduce intraocular inflammation 2. tighten the capillary walls3. suppress proliferation of cells

Page 9: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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.

Page 10: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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

Page 11: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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

Page 12: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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.

Page 13: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

vitrectomy for proliferate DM vitreoretinopathy combined with

IVTA IVTA -> no higher postoperative

complications rate. It had not shown a marked

therapeutic benefit.

Page 14: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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.

Page 15: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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

Page 16: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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.

Page 17: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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.

Page 18: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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.

Page 19: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

Other conditions:Other conditions:

ocular ischemic syndromes CME due to retinitis pigmentosa foveal telangiectasia Progressive ocular hypotony

Page 20: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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

Page 21: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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.

Page 22: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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.

Page 23: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

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.)

Page 24: Presenter: clerk  陳豪宏 Advisor:  柳景豑 醫師

EndEnd

Thank you.Thank you.