| Intravitreal injection of triamcinolone acetonide has been used to controlthe retinitis, uveitis and optic neuritis and to suppress proliferativevitreoretinopathy and the neovascular formation of retina, choroid and iris andto treat macular edema induced by age-related macular degeneration, retinalvein occlusion and diabetic retinopathy and so on. Besides that, triamcinoloneacetonide can help to recognize the vitreous during vitreoretinal surgery.However, the treatment is not without risk: reported complications includeintraocular pressure (IOP) elevation, cataract formation, retinal detachment,vitreous hemorrhage and endophthalmitis. And those reported complications'occurrence were not the same at all. Complications may be due to the injectionprocedure or the corticosteroid suspension. The purpose of this investigationwas to report the complications of intravitreal triamcinolone acetonideinjection ,especially, IOP elevation and to provide clinic staffs with accordanceon clinical diagnosis,treatment and preservation.Subjects and Methods : This investigation retrospectively reviewed themedical records of 95 patients (107 eyes) who were diagnosed as diffusedor(and) cystoid macular edema by examinations of ophthalmoscope, opticalcoherence tomography (OCT) and fundus fluorescein angiography(FFA) andthen received one or more intravitreal injections of triamcinolone acetonideforvarious indications at the Department of Ophthalmology, No.2 hospital of JilinUniversity,between July 2005 and March 2006. And there are 69 eyes of 69patients with retinal vein occlusion , 32 eyes of 20 patients with diabeticretinopathy, 2 eyes of 2 patients with uveitis, 2 eyes of 2 patients with centralexudative chorio-retinitis, 1 eye of 1 patient with intraocular lens implantationand 1 eye of 1 patient with age-related macular degeneration. Three eyesreceived a second intravitreal injection. The length of follow-up ranged from 1to 9 months, (mean 4.6 months).A total of 110 injections were performed by the same skillful surgeon inoperating room under rigorous sterile operation. The standard commerciallyavailable preparation of triamcinolone acetonide at a concentration of 40 mg/mLwas used. The triamcinolone acetonide must be prepared in detail. The patientreceived a drop of topical proparacaine 0.5% into the affected eye. The eyelidsand surrounding areas were scrubbed with Povidone-iodine 10%, and an eyelidspeculum was placed. Then 4 mg/0.1 mL of triamcinolone acetonide wasinjected transconjunctivally through the inferior pars plana with a 26gauge×1/2 needle attached to a 1.0-ml tuberculin syringe the anterior chamber wasentered temporally just anterior to the limbus, with the bevel of the needlepointing up and away from the iris. The needle was withdrawn after the syringehad filled with 0.1 ml of fluid. A cotton-tipped applicator was applied at theinjection site immediately after the needle was removed to prevent drugegressing from the needle track. The patient was given a vial of antibiotic eyedrops and was instructed to instill one drop in the affected eye 4 times daily for3 days. Confirm proper intravitreal location of the suspension through thepatients' puppil . Topical ciprofloxacin drops were applied, and the patient wasinstructed to sit upright to ensure that the drug settled inferiorly. The eyes wereexamined each time everyday during the first week and examined one time 1～2week during the second month and after that the eyes were examined each timeevery 1 month(IOP should be taken every week in the patients' hometown ). Ineach examination the visial activity, intraocular pressure, lens and posteriorsegment must be instructured.Pressure elevation was defined as an IOP greater than21mmHg. The mean increase in intraocular pressure, defined as differencebetween maximal postoperative intraocular pressure and baseline intraocularpressure.Complications related to the injection procedure and to the corticosteroidwere recorded. Statistical analyses were performed by use of a commerciallyavailable statistical software package SPSS11.0. The results were expressed asmean and standard deviation (SD). The data obtained were analyzed withfrequency and descriptive statistics. We used the χ2 test , Pearson's correlationcoefficient and two-way analysis of variance in statistical analysis, as indicated.A difference was considered statistically significant when the p value was lessthan 0.05.Results (1) Of the 95 patients, 52 were women and 43 were men;the ageranged from 19 to 72 years old(the mean age 49.18〔SD=11.29〕years). Themean baseline IOP was 16.25mmHg (SD=3.09) with a mean change of 8.0mmHg.(2) Elevation of the IOP above 21 mmHg was observed in 41 eyes(38.32%). Thirty-three (47.8%) of the 69 eyes with retinal vein occlusion(RVO),had such IOP elevation, compared with 7 (21.9%) of the 32 eyes with diabeticretinopathy. The occurrence rate of elevation of intraocular pressure in RVOwas significantly higher than in diabetic retinopathy significantly(p < 0.05).(3)Dividing the entire study group into five subgroups according to theage, there were 6 eyes (lower than 30 years), 12 eyes (from 30 to 40 years), 29eyes (from 40 to 50 years), 50 eyes (from 50 to 60 years) and 10 eyes (higherthan 60 years). The eyes and the occurrence rate of elevation of intraocularpressure of each subgroup are different: 5 eyes(83.3%),6 eyes (50.0%),12 eyes(41.4%),16 eyes(32.0%),2 eyes(20.0%). So rise in intraocularpressure was negatively correlated with patients' age (P<0.05).(4) According to the frequency of different intraocular pressure beforeinjection and at 1 week, 1, 3 and 6 months, the mean IOP values at 1 and 3months were statistically significantly higher than the mean preinjection value(p < 0.05).And there was not significant correlation between the mean IOP valueat 1 week and the mean preinjection value. ( P>0.05).(5) The most common complication encountered during follow-up waselevation of the IOP above 21mmHg (41 eyes [38.32%]).Pseudoendophthalmitis occurred in two eyes (1.87%), and refractory ocularhypertension , as the same as conjunctival ulceration and macular hole , wasobserved in one eye (0.93%). There are twenty eyes(18.69%) with aqueous flareand nine eyes(8.41%) with excipient remain.Conclusions (1) The occurrence rate of elevation of intraocular pressure inRVO was significantly higher than in diabetic retinopathy significantly. (2)Elevation of intraocular pressure mostly occurred at 1 and 3 months afterinjection. (3) Elevation of intraocular pressure was negatively correlated withpatients' age. (4) Intravitreal triamcinolone injection was effective in a varietyof ocular disorders. Since complications related to the injection procedure or tothe corticosteroid suspension shouldn't be taken for granted , rigorous sterileoperation and follow-up closely should be payed attention to. |
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