- VEGF = vascular endothelial growth factor
- IVA = Intravitreal Avastin
- IVT = Intravitreal triamcinolone
Macular oedema shown in green by the arrow. Macular oedema affects the centre
of the retina which is responsible for sharp vision, see
The front of the eye is on the
left, and the retina
is shown in red
Triamcinolone is a steroid injection.
Intravitreal triamcinolone (here called IVT) is an injection
of the steroid drug into the vitreous cavity of your eye.
IVT will gradually be replaced by the use of intravitral steroid implants,
but these are not yet generally available.
is given as an injection usually in the operating theatre or clean room in
the UK as below.
Macular oedema (diabetes, retinal vein occlusion, etc)
Macular oedema occurs in diabetic maculopathy and retinal
vein occlusion. It causes poor sight, that is difficult reading,
watching TV....your central or 'sharp' vision.
Avastin is the preferred
treatment, and intravitreal steroid implants are likely to
be more helpful than Triamcinolone.
- Usually the oedema is treated with several courses of laser/Avastin treatment,
but if these are not successful and your sight remains poor
this treatment may be offered
- Benefits. Bardak Part
of the treatment includes controlling the diabetes as below.
it is generally being replaced by intravitreal
Avastin or intravitreal steroid implants.
- NICE is likely to recommend steroid implants for macular
oedema due to retinal vein occlusion.
- We use 2mg intravitreal triamcinolone (this is a common dose).
- Retinal vein occlusion,
1 mg dose is effective see. For branch retinal
vein occlusions this
SCORE report suggests steroids are not helpful. But
retinal vein occlusions this
SCORE report suggests steroid injections (1 mg intravitreal
triamcinolone) repeated at regular intervals, improves
vision by 25%. The 4mg probably not worth the side effects
in diabetic retinopathy Bressler
09. Triamcinolone is not effective, Avastin is, Forte,
Eye, 2010. Laser
is helpful DRCRN 2008; DRCRN
2009 laser is best;
- A case (retinal
vein occlusion macular oedema)
- type of CME Retina 2011
- post op macular oedema and dmo..triamcinolone more sustained CEO16
Macular oedema in uveitis
IVT is particularly helpful in uveitis patients. Laser is
not needed in uveitis, and the success rate is higher, but
otherwise most of this page applies in uveitis. In addtion
to reducing the leakage, the steroid reduced the inflammation
Intravitreal steroid implants are likely to replace Triamcinolone.
Such steroids implants are particularly helpful if the uveitis is unliateral.
Bilateral uveitis, and indeed many cases of unilateral severe posterior uveitis,
usually need systemic immunosuppression.
- The eye is cleaned.
- Anaesthetic drops are instilled.
- In the injection room the eye is cleaned again, and a drape is placed around the eye
- a couple of minutes later the nearly painless injection is given
- (steroid implant insertion can be a little more painful)
- if triamcinolone is used
- Triamcinolone 40ml, 0.1ml=4mg
- So need 2mg = 0.05mls, same volume as Lucentis and Eyela, same size syringe
- Shake first just before draw up as there would otherwise be an uneven distrribution of the drug
- an alternative is Chlorhexidine, but in this area several infections have developed following Chlorhexidine use
- we are therefore recommending the continued use of iodine, but irrigation the out after 2 minutes after iodine installation
After the injection
By one month the drugs should be working. Many people will notice
some improvement in vision. Generally this improvement is temporary,
and the injection may be offered again months later. The macular
oedema reduces, with a maximum reduction at 2 weeks, and
starts to wear off after 3 months (see).
It gives a chance for laser treatment and lower blood pressure
etc to have their effect. Further injections are usually
needed, but as this treatment is new there is no definite
treatment plan available.
The injection will put the eye pressure up for
a few hours. It is therefore riskier is you have glaucoma, but this is
generally not a major problem. There should not be much pain. You may
see the drug floating around your eye for the next few hours.
- The cleaning solution can burn the surface of the eye, making it very sore during the night. There should be a full recovery over the next 1-2 days.
- There may be a small haemorrhage on the surface of the eye, and this should disappear over 1-2 weeks (subconjunctival haemorrhage).
- A bubble may appear in your vision, floating around: a bubble of gas may enter when the drug is injected. These disappears overnight.
About 1/1000 people
will develop a serious eye infection. The day after the injection your eye should be comfortable, there should
be very little pain. If your eye starts to get red, with misty vision
may be no pain), perhaps 2-5 days after the injection, you should
suspect an infection and attend your eye department urgently. In Birmingham
this is the Birmingham
and Midland Eye Centre Casualty at the
Birmingham & Midland
Eye Centre, City Hospital, Dudley Road, Birmingham B18 7QH
Tel: 0121-554 3801. Avastin, infection..preventing.
A scratchy after injentiosn is normal; a painful achy eye may be infected.
Check pressure 4, 8, & 16 weeks after injection EJO15 .
Symptoms of infection
These are the common symptoms that patients notice Eye 12
- blurred vision........96%
- redness ...............50%
- lid swelling ...........10%
- discharge .............10%
The drugs will reduce the retinopathy,
both the leakage and new vessel growth. Laser...if it has
not been carried out already will be needed, on many occasion. Rarely
the drugs will cause some loss of sight...there is no detailed information
as to the exact risk. Unlike a steroid, there should be
no long term pressure effects.
IVL or IVA may hasten cataract development or to vitreomacular traction Eye 17.
Please tell your doctor is you are pregnant,
and try and avoid getting pregnant for the 6 weeks following
the injection. This is a new drug and is probably UNWISE
IN PREGNANCY. In any respect, pregnancy makes active
diabetic retinopathy MUCH worse.Retina 2012
There is a 1% risk of a retinal tear
after this injection. Please seek attention (within 24 hours....the
next day is usually OK) from an ophthalmologist if you develop
the symptoms of a tear, that is (all of a sudden) a sudden
shower of floaters and flashes of light. These may happen in
the months after the injection.
Anticoagulants ...extra precautions
You should remind your ophthalmic team you use anticoagulants and ask for
specific advice. Treatment is safe continuing the anticoagulents (Retina
Extra precautions for Triamcinolone (steroid) and steroid implants
- About 50% of people develop a rise in eye pressure that
needs anti-glaucoma eye drops for a few months, or perhaps
- 16% develop a significant pressure rise, needing drops
and diamox tablets (diamox is best avoided in renal failure
- in some studies 7% develop a serious pressure rise that
may require glaucoma surgery (this is about half of the 16%
above) Eye 14
- sometimes the eye pressure is permanently raised, although
on some occasions it is just temporary
- the pressure rise may develop in a week (and is so is
likely to be troublesome). But it may not present until 4
weeks. If you have a normal or near-normal pressure at 4
weeks you are unlikely to develop severe glaucoma later.
- The pressure rise is not always related to the patient..we
have had one patient who had both eyes injected (on separate
occasions), but only one eye developed a pressure rise.
- The benefits
wear off if injections need to be repeated.
- See some
results...benefits may last 2 years. Other
no long term gain.
- Expect a bigger pressure rise with the second eye
Renal Failure or Diamox
Diamox is a drug given to lower eye pressure, and
is generally not used in renal failure as it it can make some patients
very ill. If this drug cannot be avoided, you must take precautions..as
your your ophthalmic team may not realise you aware you have renal
failure. Occasionally the benefits will outweigh the risks, but discuss
this with your ophthalmic and renal team.
Naturally it should not be given if you are allergic to it....remind
your ophthalmic team.
As IVT may put up your eye pressure, IVT is a problem (and ideally
would be avoided) in glaucoma patients. However, on most occasions
the pressure rise can be treated.
Follow up Schedule
This is an idea of your follow up schedule if your eye pressure
(IOP, intraocular pressure) stays low: 4 weeks IOP, 12 week IOP & clinic, 6 months IOP , 12 months IOP, every 12 months IOP. The steroid effect wears off, and often the njections needs to be repeated.
IVT hastens cataract development.
Please tell your doctor if you are pregnant, and
try and avoid getting pregnant for the 6 weeks following the injection.
Glaucoma treatment is not ideal in pregnancy.
Remember the 'targets' for good control
By keeping to these levels as much as possible (or lower still) you will be
doing your best to stop your eyes getting worse. Occasionally by sticking to
these targets your retinopathy will improve, even without laser. Review BMJ17 Eye 17
minutes exercise a
- moderate alcohol consumption only,
obesity if possible,
- balanced diet including
- 9 portions of vegetables
or fruit a day (9 for men, 7 for women), Lowers BP
of animal or 'hard' vegetable fats,
salt, see the evidence
be limited to one drink or unit a day, six days a week
(Mukamal 2004). More than this leads to brain damage.
fish such as sardine, salmon,
tuna, trout, at least twice a week (small amounts are
fine...not a whole salmon!).
and healthy fats in the diet slows down retinopathy. No transfats
and minimal saturated fat.
- generally 130/80 (see
graph) or preferably less BMJ 16. Even less if well <120 BMJ17
- (120/75 ..home monitoring)
- 125/75 or less if protein in urine present (115/70..
- ACE inhibitors
or Angiotensin Receptor Antagonists unless young/pregnant/very
low blood pressure/poorly tolerated
- The lower the better in macular oedema, as long as you feel well.
- An ideal pressure is below 115 (systolic, first number) for healthy people. <120 is is only suitable for new/well diabetes patients 2012. Otherwise slightly higher as above.
monitoring blood pressures should be 10mmHg (systolic) and 5mmHg (diastolic)
lower see than
these 'clinic' pressures.
- Depression & anxiety increase BP.
- 48-58 mmol/mol (6.5%-7.5%) or
less (see graph) with very few or preferably no hypos. These (or slightly
lower) levels are the best to prevent complications
- <58 mmol/mol (7.5%) for insulin users; <48 mmol/mol (6.5%) if not using insulin and have good
health. Problems with intensive control. Target should be adjusted according to health and age. If you are a type 1 patient and cannot achieve good control, you need to checked for other conditions such as coeliac disease (anti-TTG antibodies), addisons, and thyroid.
- If hypos develop, seek expert
advice from your diabetes nurse/doctor.
- if your HbA1c is high (say 97mmol/mol / 11%), then the next step may be to achieve
75 (9%)....in other words, and any improvement is helpful, gradually reaching
lower levels above.
- A sudden improvement in
control (HbA1c drop of 33 mmol/mol/3% ) will lead to a temporary rapid increase
in progression of retinopathy: laser may be needed.
- Good control is important
in the longer term, that is after about 2 years. When people who control
their diabetes well will be better off after this period. See
- A temporary increase in retinopathy is
most common when starting insulin for the first time, especially if
the diabetes is very badly controlled when you start the insulin.
- Individual targets Nice 16
- <4.0mmol/l, and statins recommended
for most adult patients with diabetes whatever the cholesterol.
- statins are recommended whatever the cholesterol,
if well tolerated age>40y
fibrate such as fenofibrate is advisable in
nearly every person with retinopathy. They reduce retinopathy
progression 40% (Fenofibrate 200mg od) Field
Study. We now recommend these for all adult patients, and
they can be used in addition to a statin.
- LDL <2
- Avoid if pregnant, GFR <15, pancreatitis
- If GFR low but still >15, need a lower dose.
- smoking 20
a day triples/quadruples retinopathy
- passive smoking may double
retinopathy: room-mates inhale at least 25%
- electronic cigarettes are much much safer and probably have a negligible effect on retinopathy
- everyone with diabetes should attend
an education course, such as DAFNE (insulin)
, DESMOND (type
2 at diagnosis), or XPERT (type
2). Primary Care Trusts are obliged to send you on such a course, but
very few patients have ever attended one. If you have not been on one,
discuss this with your diabetic team. Get a diabetes buddy.
- this contributes to macular oedema and loss of sight
(Schwartz, 2006), and many serious problems.
- It is common in
diabetes, particularly if you are overweight. Do you have sleep apnoea?
- see 15
- 5.0-7.2 mmol/l before meals
- <10.0 mmol/l after meals
- no serious hypos
- for patients who test their glucose levels and adjust insulin doses, the new glucose sensor is highly recommended and has transformed the lives of many patients. The cost is about £30/week).
- Rosiglitazone and pioglitazone should not be used
if there is significant retinopathy, and certainly not if macular oedema
is present, as they
increase macular oedema and fluid retention. Case
and Exenatide are drugs that can be used instead low also lower weight
(they are injections.)
- insulin users need to avoid serious hypoglycaemia.
Expert help is usually needed if episodes are severe/frequent. See
- many patients receive totally inadequate care BMJ 11. Some call this 'institutionalised neglect'.
- 10% compliance if multiple treatment,
? 60% one tablets
type 2 at diagnosis