The use of subretinal triamcinolone acetonide in the management of neovascular age-related macular degeneration: a pilot study.
BACKGROUND
We conducted this study to investigate the toxicity and efficacy of pars plana vitrectomy combined with a single dose of sub-retinally administered triamcinolone acetonide (4 mg) in patients with subfoveal choroidal neovascular membranes secondary to age-related macular degeneration (AMD).


METHODS
The important eligibility criteria included eyes with recent and progressive onset of decreased vision (<or= 20/400) secondary to active subfoveal choroidal neovascularization secondary to AMD demonstrable on fluorescein angiography, in which subretinal hemorrhage accounted for < 25% of the area of the choroidal neovascular complex. Eligible patients were offered vitrectomy surgery combined with subretinal injection of 0.1 mL of triamcinolone acetonide (40 mg/mL) followed by air-fluid exchange. Two eyes of 2 patients were enrolled and followed for 28 and 35 months with regular and serial complete ophthalmologic examinations, fluorescein and indocyanine green videoangiography, and multifocal electro-retinography. The primary outcome measures were best-corrected visual acuity, changes in the fluorescein angiographic area and in the greatest linear dimension of leakage of the choroidal neovascular complex, and changes in amplitude and latency of the multifocal electroretinogram (ERG).


RESULTS
Patient 1 sustained a limited subretinal hemorrhage intraoperatively that cleared spontaneously over approximately 3 months, as well as a rise in intraocular pressure that required the use of 2 topical medications to control. Patient 2 demonstrated progression of his nuclear sclerosis and posterior subcapsular lens changes over the 35 months of follow-up. Best-corrected visual acuity improved from 20/400 to 20/200 in patient 1 and improved from counting fingers to 20/320 in patient 2. For patient 1, the area of the neovascular complex increased from 4.5 mm2 at baseline to 7.2 mm2 at the 6-month follow-up; for patient 2, this increase was from 6.2 mm2 to 8.4 mm2. Over the same interval, the greatest linear dimension increased from 3.8 mm to 4.8 mm for patient 1 and from 4.1 mm to 4.8 mm for patient 2. With respect to the multifocal ERG, the response density increased in the first 4 months for patient 1 and declined marginally thereafter. For patient 2, the electro-retinal response density function was stabilized for a 5-month period but declined and stabilized thereafter.


CONCLUSIONS
Our results from this pilot study suggest that vitrectomy combined with subretinal injections of 0.1 mL of triamcinolone acetonide (40 mg/mL) and air-fluid exchange is easily accomplished. Although some complications were encountered, these did not appear to be prohibitive. A salutary effect was clearly demonstrated, not unlike the course seen with photodynamic therapy. Further study, perhaps in combination with other antiangiogenic agents, is warranted.
Kertes
Peter J
PJ
University of Ottawa Eye Institute, Ottawa, Ont. peter.kertes@sw.ca
Coupland
Stuart G
SG
D020256:Choroidal Neovascularization / Q000188:drug therapy* / Q000209:etiology; D003131:Combined Modality Therapy; D004596:Electroretinography; D005451:Fluorescein Angiography; D005938:Glucocorticoids / Q000009:adverse effects / Q000627:therapeutic use*; D006801:Humans; D007208:Indocyanine Green; D007267:Injections; D008268:Macular Degeneration / Q000150:complications / Q000188:drug therapy*; D010865:Pilot Projects; D016896:Treatment Outcome; D014222:Triamcinolone Acetonide / Q000009:adverse effects / Q000627:therapeutic use*; D014792:Visual Acuity; D014821:Vitrectomy
D005938:Glucocorticoids; D014222:Triamcinolone Acetonide; D007208:Indocyanine Green