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Letters to the Editor

Intravitreal triamcinolone to treat refractory macular edema in a postvitrectomized eye

Rishi, Pukhraj MS; Sharma, Tarun MD, FRCSEd; Arora, Anshu MS

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Indian Journal of Ophthalmology: Oct–Dec 2006 - Volume 54 - Issue 4 - p 284-286
doi: 10.4103/0301-4738.27963
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Dear Editor,

Macular edema can occur in a large variety of ocular diseases.1 Several treatment options such as oral and topical therapy, lasers and vitreous surgery by various mechanisms help in the resolution of macular edema.1 Recently, intravitreal Triamcinolone Acetonide has been used to treat refractory macular edema with encouraging results.23

This communication elucidates the efficacy of intravitreal Triamcinolone Acetonide to treat refractory macular edema in an eye that had undergone vitreous surgery to manage infectious endophthalmitis. A 53-year-old man presented with infectious endophthalmitis following phacoemulsification and intraocular lens implantation. He had already received two intravitreal injections by the treating physician elsewhere but no details were available. His visual acuity was bare light perception. After comprehensive examination, he underwent parsplana vitrectomy with removal of intraocular lens. At the time of vitrectomy vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml and dexamethasone 400 micrograms were given. Pseudomonas aeruginosa was isolated in the culture. Sensitivity pattern showed susceptibility to ceftazidime. Systemic ceftazidime was started and intravitreal dosage repeated. Oral and topical steroids were also started. In addition, topical medications of ceftazidime, ciprofloxacin and tobramycin were used.

Three months after surgery, vision was 20/30 with no evidence of intraocular inflammation. A month and a half later, he noticed decreased vision. Fundus examination showed mild vitreous turbidity and few superficial hemorrhages in peripapillary area; visual acuity was 20/120 [Figure 1]. Since there were clinically no signs of infection in the form of anterior chamber reaction/ hypopyon/ vitritis, it wasn′t considered to be due to an infective etiology and hence no additional investigations were done. Fundus fluorescein angiography showed leakage from perifoveal network and disc capillaries [Figure 2]. Optical coherence tomography (OCT) showed increased retinal thickness and cystoid changes in macula [Figure 3].

Figure 1
Figure 1:
Left fundus shows mild vitreous haze, few superficial hemorrhages temporal to optic disc, which is hyperemic
Figure 2
Figure 2:
Fundus fluorescein angiogram revealed leakage of dye from disc and perifoveal capillaries
Figure 3
Figure 3:
OCT showed gross retinal thickening, cystoid changes in the neurosensory retina with foveolar detachment

As conservative treatment, ketorolac tromethamine 0.5% eye drops and prednisolone acetate 1% eye drops were prescribed four times per day for one month, without improvement. A month later, intravitreal Triamcinolone Acetonide was injected. A month later, visual acuity remained 20/120; however OCT showed good resolution of macular thickness [Figure 4]. Nine months later, visual acuity improved to 20/60 with no evidence of recurrence of macular edema [Figure 5] or inflammation.

Figure 4
Figure 4:
OCT shows resolution of macular edema and recovery of foveal contour
Figure 5
Figure 5:
Montage photograph shows clear vitreous cavity with healthy appearance of the central and peripheral retina

While indications of use of Triamcinolone are expanding, its role in resolving macular edema in eyes that underwent vitreous surgery for infectious endophthalmitis has not been reported. In the present report, despite the highly virulent organism responsible for acute endophthalmitis, the eye responded well. This is supported by the complete anatomic and to some extent functional recovery, substantiated and quantified by OCT, as in other causes of macular edema by other case series.4 In the present report, the eye responded quite well to vitreous surgery with improvement of vision to 20/30. However, the recurrence of inflammation along with refractory macular edema caused decreased vision. Intravitreal Triamcinolone Acetonide not only helped in resolving the macular edema, but also in improving vision. Hence, it is worth evaluating the role of peroperative Triamcinolone injection in eyes with infectious or inflammatory etiology.5

1. Tranos PG, Wickremasinghe SS, Stangos NT, Toupozis F, Tsinopoulos I, Pavesio CE. Macular edema Surv Ophthalmol. 2004;49:470–90
2. Benhamou N, Massin P, Haouchine B, Audren F, Tadayoni R, Gaudric A. Intravitreal triamcinolone for refractory pseudophakic macular edema Am J Ophthalmol. 2003;135:246–9
3. Martidis A, Duker JS, Greenberg PB, Rogers AH, Puliafito CA, Reichel E, et al Intravitreal triamcinolone for refractory diabetic macular edema Ophthalmology. 2002;109:920–7
4. Ciardella AP, Klancnik J, Schiff W, Barile G, Langton K, Chang S. Intravitreal triamcinolone for the treatment of refractory diabetic macular oedema with hard exudates: An optical coherence tomography study Br J Ophthalmol. 2004;88:1131–6
5. Das T, Jalali S, Gothwal VK, Sharma S, Naduvilath TJ. Intravitreal dexamethasone in exogenous bacterial endophthalmitis: Results of a prospective randomized study Br J Ophthalmol. 1999;83:1050–5
© 2006 Indian Journal of Ophthalmology | Published by Wolters Kluwer – Medknow