www.diabeticretinopathy.org.uk

Intravitreal triamcinolone

 

David Kinshuck

Introduction

macular oedema

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.

IVT 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.

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 itself.

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 procedure

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.

 

Risks etc

Hours

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.

 

Night

Days

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 (there 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.

 

Symptoms of infection

These are the common symptoms that patients notice   Eye 12  

  1. blurred vision........96%
  2. pain/photophobia...73%
  3. redness ...............50%
  4. floaters................25%
  5. lid swelling ...........10%
  6. discharge .............10%

Months..sight

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.

Years

IVL or IVA may hasten cataract development.

 

Pregnancy

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

 

Retinal tears

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 2010).  Epidemiology 2010

 

Extra precautions for Triamcinolone (steroid) and steroid implants

Months...Eye pressure

Renal Failure or Diamox allergies

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.

Pre-existing glaucoma

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.

Years

IVT hastens cataract development.

Pregnancy

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.

 

lifestyle

blood pressure

HbA1c

sudden decrease in HbA1c

cholesterol

smoking

insulin

education

sleep apnoea

glucose level

Glitazones

hypoglycaemia

neuropathy

issues

compliance

type 2 at diagnosis