Original Paper Ophthalmic Res 2014;52:160–164 DOI: 10.1159/000362882
Received: February 6, 2014 Accepted: April 12, 2014 Published online: October 18, 2014
Influence of Intravitreal Triamcinolone Acetonide Injection in Scleral Buckling Surgery for Macula-Off Retinal Detachment Ahmad Mirshahi Reza Karkhaneh Javad Zamani Amir Morteza Movassat Pejvak Azadi Tehran University of Medical Sciences, Farabi Eye Hospital, Eye Research Center, Tehran, Iran
Abstract Purpose: To investigate the effect of intravitreal triamcinolone acetonide injection on the resolution of subretinal fluid (SRF), and its correlation with visual outcome after scleral buckle (SB) surgery. Methods: A prospective consecutive case series was conducted in patients who underwent SB surgery for macula-off rhegmatogenous retinal detachment (RRD) at Farabi Eye Hospital from February 1, 2012 to August 30, 2013. Exclusion criteria included previous ocular surgery (e.g. primary surgical failure) except cataract surgery, recurrent retinal detachment, macular hole, epiretinal membrane, proliferative vitreoretinopathy grade C, history of trauma, other retinal diseases, and diabetes mellitus. Patients were assigned to two groups. In group 1, patients received 2 mg of intravitreal triamcinolone acetonide injection at the end of surgery while patients in group 2 received intravitreal balanced saline solution for balancing the intraocular pressure (IOP). Patients were followed up at 1 day, 1 week, 1 month, 2 months and 3 months after the surgery by best-corrected visual acuity (BCVA), slitlamp examination, indirect ophthalmoscopy and optical coherence tomography (OCT). OCT (Heidelberg Engineering, Heidelberg,
© 2014 S. Karger AG, Basel 0030–3747/14/0523–0160$39.50/0 E-Mail [email protected] www.karger.com/ore
Germany) was used at all visits except day 1 after the surgery. Student’s t test and χ2 tests were used for comparisons; p value ≤0.05 was considered significant. Results: Sixty-two eyes of 62 patients were enrolled in the study. There were 33 male patients (53%) and 29 female patients (47%). The average age was 43.8 years (18–72 years). The mean duration of symptoms was 34.7 ± 46.8 days. There were 29 eyes in group 1 and 33 eyes in group 2. Twelve weeks after the operation, 25 patients (40%) had SRF beneath the macula, but there was no significant difference (p = 0.24, χ2 test) between the two groups. Improvement in BCVA in both groups was statistically significant (p ≤ 0.001) but did not differ between the two groups (p = 0.09) apart from week 12, in which the improvement in group 1 was significantly higher (p = 0.03). The incidence of cystoid macular edema did not differ in a statistically significant way between the groups (p = 0.19). IOP in 4 (15%) patients in group 1 rose above 21 mm Hg but responded quickly to 2 weeks of topical antiglaucoma medication. There was no cataract progression in either group. There was no correlation between the incidence of persistent SRF and the extent of detachment in both groups (p = 0.83). There was no surgical failure or redetachment in either group during the study period. Conclusion: Single-dose intravitreal triamcinolone may increase the final BCVA in macula-off RRD patients despite persistent SRF, suggesting the anti-inflammatory role of this drug. © 2014 S. Karger AG, Basel
Pejvak Azadi Fellowship of Vitreoretinal Surgery, Eye Research Center, Farabi Eye Hospital Tehran University of Medical Sciences South Kargar Street, Ghazvin Square, Tehran (Iran) E-Mail azadipe @ yahoo.com
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Key Words Intravitreal injection · Triamcinolone acetonide · Scleral buckling · Subretinal fluid · Visual acuity · Optical coherence tomography
Visual recovery after successful surgery for macula-off rhegmatogenous retinal detachment (RRD) is often not complete [1, 2]. Several preoperative and postoperative factors which could compromise visual outcome have been investigated. The most important predictive risk factors which have been shown to negatively influence visual outcome recovery are low preoperative visual acuity and long duration of macular detachment [3, 4]. When the duration of macular detachment is more than 6 days, the final postoperative best-corrected visual acuity (BCVA) could be worse. However, in a considerable number of patients, final postoperative visual acuity remains poor in spite of having a low-risk profile and a complete follow-up. Postoperatively the macula may seem attached in funduscopy, but assessment with optical coherence tomography (OCT) still shows persistent macular subretinal fluid (SRF) in a substantial number of patients in whom the macula was detached preoperatively [4, 5]. The incidence of persistent SRF at 4–6 weeks after scleral buckle (SB) surgery ranges from 27 to 100% [2–10]. While such fluid is associated with poor vision, by SRF resolution BCVA would improve. OCT studies have revealed that resolution of macular SRF usually takes several months [4, 9]. While delayed absorption of SRF has been shown by some authors to be associated with a worse visual outcome, others did not find such a correlation. Benson et al. [11] reported that the incidence of residual SRF is reduced by cyclooxygenase-2 (COX-2) inhibitor treatment and enhanced anti-inflammatory activity. Wu et al. [12] showed that postoperative systemic steroid treatment may decrease the incidence of SRF and facilitate the absorption of SRF. Patients treated with steroids had greater improvement of BCVA [12]. The purpose of this study was to investigate the effect of intravitreal triamcinolone acetonide injection on the incidence of persistent SRF and its correlation with visual outcome after SB surgery. Because both visual outcome and incidence of persistent SRF are different between macula-on and macula-off RRD, we chose to recruit only macula-off RRD patients in this prospective study.
had recurrent retinal detachment or primary surgical failure, macular hole, epiretinal membrane, proliferative vitreoretinopathy C, history of trauma, retinal diseases other than retinal detachment, previous ocular surgery except cataract surgery and patients with diabetes mellitus. All surgeries were performed by an experienced vitreoretinal specialist (A.M.). Informed consent was obtained from all participants and the study adhered to the tenets of the Declaration of Helsinki. All patients were examined preoperatively including BCVA, slitlamp examination, binocular indirect ophthalmoscopy and checking intraocular pressure (IOP). Cataract severity was recorded based on the Lens Opacities Classification System. Age, gender, duration of symptoms and quadrants of detachment of all patients were recorded. Patients were assigned to one of two groups with simple randomization as follows: patients in group 1 received 2 mg of intravitreal triamcinolone acetonide at the end of surgery while patients in group 2 served as controls and received intravitreal balanced salt solution for balancing the IOP. The surgical procedure including the extent of buckling (place and number of clock hours of buckle) and the site of SRF drainage were recorded in all cases. At each follow-up visit for all patients thorough ophthalmologic examination including BCVA, checking IOP, and status of the lens was performed. OCT of the foveal region was taken at weeks 1, 4, 8 and 12 for each patient and the presence of SRF was assessed. The accumulation of SRF was defined as a clear space between the photoreceptor layer and the retinal pigment epithelium on OCT. For statistical analysis, Snellen visual acuity was transformed into the logarithm of the minimum angle of resolution (logMAR). Comparisons of demographic or clinical variables between two groups were done using the Student’s t test and the χ2 test. Data are presented as mean ± SD, unless stated otherwise. SPSS version 18.0 software (SPSS Inc., Chicago, Ill., USA) was used for statistical analysis; p values of ≤0.05 were considered to be statistically significant.
Results
A prospective consecutive case series was conducted in patients who underwent SB surgery for macula-off RRD at Farabi Eye Hospital from April 1, 2011 to October 31, 2012. Sixty-two eyes of 62 patients were enrolled. Excluded from this study were patients who
Sixty-two eyes of 62 patients were included in this study. All patients underwent SB surgery for primary RRD. There were 33 male patients (53%) and 29 female patients (47%). The average age was 43.8 years, ranging from 18 to 72 years. The mean duration of symptoms was 34.7 ± 46.8 days (26 ± 16 days in group 1 and 42 ± 16 days in group 2; p = 0.17). Forty-two (68%) patients had 2 quadrants of retinal detachment. In 2 patients (3.2%) intravitreal injection of sulfur hexafluoride was done intraoperatively and 23 patients (37%) had external SRF drainage intraoperatively. There were 29 eyes in group 1 and 33 eyes in group 2. The demographic data of groups is presented in table 1. Statistically, there was no significant difference between these groups in the preoperative clinical features, including age, gender, duration of symptoms, preoperative BCVA, extent of retinal detachment, external drainage, and type or extent of buckling. Twelve
Intravitreal Triamcinolone in Scleral Buckling
Ophthalmic Res 2014;52:160–164 DOI: 10.1159/000362882
Material and Methods
161
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Introduction
Group 1
Group 2
Age, years 42.97±14.49 44.3±14.3 Gender Male 14 (48) 19 (57) Female 15 (52) 14 (43) Extent, quadrants One 4 (13) 3 (9) Two 21 (74) 21 (63) Three 4 (13) 6 (18) Four 0 (0) 3 (9) Duration of symptoms, days 26±16 42±16 Preoperative BCVA 1.67±0.65 1.66±0.63 Preoperative IOP 10.14±1.50 9.97±1.53 Type of buckle Segmental 27 (93) 30 (90) Encircling 2 (7) 3 (10) External drainage of SRF 12 (41) 11 (33)
p value 0.71 0.46 0.34
2.0 Case Control 1.5
1.0
0.5
0.17 0.93 0.71
0
0 BCVA
1 BCVA
4 BCVA
8 BCVA
12 BCVA
0.85 0.50
Mean ± SD or number of patients with percentages in parentheses.
Fig. 1. Changes in BCVA in logMAR at follow-up visits in both groups (statistically significant at week 12; p = 0.003). Higher numbers indicate worse visual acuity.
Table 2. Surgical outcome in the two groups at week 12
cept for week 12, which was better in group 1 (p = 0.03; fig. 1). The rate of BCVA ≤0.4 (logMAR) was significantly higher in group 1 (44 vs. 30%, p = 0.03). At week 12, the proportion of patients with persistent SRF who had BCVA better than 0.4 logMAR was 50% (5 of 10 patients) in group 1 and 35% (5 of 15 patients) in group 2 (p = 0.03). In patients who had persistent SRF, the photoreceptor layer was less violated in group 1 compared with group 2 (40 vs. 64%, p = 0.02). Postoperative inflammation such as conjunctival injection was seen in 4 (13%) patients in group 1 and in 10 (30%) patients in group 2 (p = 0.04). IOP in 4 (15%) patients in group 1 rose above 21 mm Hg, which responded to 2 weeks of topical antiglaucoma medication. There was no cataract progression in either group. There was no correlation between the incidence of persistent SRF and extent of the detachment in both groups (p = 0.83). No major systemic or local complications occurred intra- and postoperatively. There was no surgical failure or redetachment in either group during the study period.
PSRF Postoperative CME Patients with PSRF and BCVA better than 0.4 logMAR Patients with PSRF and an intact photoreceptor layer Conjunctival inflammation
Group 1
Group 2
10 (34) 6 (20.7)
15 (45) 11 (33.3)
5 (50)
5 (35)
6 (60) 4 (13)
5 (33) 10 (30)
Figures in parentheses are percentages. PSRF = Persistent subretinal fluid; CME = cystoid macular edema.
weeks after the operation, OCT revealed macular SRF in 25 patients (40%), but there was no significant difference in the incidence of macular SRF (p = 0.24, χ2 test; table 2) between group 1 (10 eyes, 34%) and group 2 (15 eyes, 45%). Improvement in BCVA in both groups was statistically significant (p ≤ 0.001; fig. 1), but the trend between the two groups was not statistically significant (p = 0.09). The incidence of cystoid macular edema was 27% (6 patients in cases and 11 in controls, which was not statistically significant; p = 0.19). The difference in BCVA between the two groups was not statistically significant ex162
Ophthalmic Res 2014;52:160–164 DOI: 10.1159/000362882
Discussion
The incidence of persistent SRF after successful SB surgery varies in the existing literature. It ranges from 47 to 100% for macula-off retinal detachment [2–5] and Mirshahi/Karkhaneh/Zamani Amir/ Movassat/Azadi
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Variable
Color version available online
Table 1. Demographic and clinical data of 62 RRD patients
from 27 to 50% for macula-on retinal detachment [2–6, 8–10]. Our study demonstrates that 41% patients with macula-off RRD have persistent SRF at 12 weeks postoperatively. Although several factors have been postulated to contribute to the chance of persistent SRF formation, such as the height and extent of retinal detachment, clock hours of buckle placement, gender, age, refractive status, and drainage of SRF, little evidence of any association has been shown between these factors and the presence of persistent SRF, except the extent of retinal detachment [5, 9]. SRF is believed to damage the photoreceptor outer segments by blocking the diffusion of oxygen and nutrients [5]. Although Woo et al. [1] reported that the presence and extent of persistent SRF do not affect the final visual acuity or anatomic attachment, Hagimura et al. [2, 7] and Benson et al. [5] suggested that there is an association of poor vision in patients with residual SRF and that resolution of the SRF is followed by vision improvement. According to previous reports, persistent macular SRF often lasts from 5 to 10 months before it is reabsorbed, and most SRF disappears within 1 year after surgery [13]. The long duration of persistent SRF after an SB procedure is probably multifactorial. First, SRF in RRD is composed of hyaluronic acid, various proteins (plasmin, globulin, apoprotein, fibronectin, etc.), lipids and glucides. After water is largely reabsorbed by successful SB procedures, the residual SRF is much more concentrated with respect to hyaluronic acid, protein, and other components, which makes its reabsorption through the outer blood-retinal barrier harder [13]. Besides, surgical trauma induced by SB procedures may further increase the protein concentration of SRF, preventing the SRF from being reabsorbed efficiently. Kaga et al. [10] suggest that a combination of cryopexy and buckling causes a breakdown of the blood-retinal barrier, thus allowing excessive amounts of protein to enter the SRF. In a study, Kang et al. [14] report that indocyanine green angiography reveals choroidal vascular congestion and hyperpermeability near the area with SRF. They presume that the origin of SRF may be associated with choroidal vascular changes resulting from cryotherapy [14]. Several procedures including vitrectomy [4] and scatter laser [15] have been performed to treat the persistent SRF after pneumatic retinopexy but without definite efficacy [16, 17]. Benson et al. [11] found that residual SRF is reduced by COX-2 inhibitor treatment. Because COX-2 inhibitors are anti-inflammatory agents, this indicates that inflammation may
play a part in the pathogenesis of persistent SRF. Steroid and traditional nonsteroidal anti-inflammatory drugs (nonselective COX-1 and COX-2 inhibitors), in addition to their anti-inflammatory role, have been found to reduce the blood-retinal barrier breakdown induced by cryotherapy. Wu et al. [12] reported that systemic steroids could decrease the incidence of persistent SRF and shorten its duration. Based on the possibility that inflammation and blood-retinal barrier breakdown might be one of the possible mechanisms of persistent SRF after retinal detachment surgery, steroids may also be efficacious in reducing the incidence of persistent SRF. In our study the incidence of persistent SRF was at the lower limit of other studies (41% compared with 47–100%), which may be due to the low case number in our study. Although the incidence of persistent SRF was not lower in group 1, the number of patients that had BCVA better than 0.4 logMAR was significantly higher in group 1 compared with group 2 (50 vs. 33%; p = 0.03). The final 12week postoperative BCVA in group 1 was statistically significantly better compared with group 2 (0.52 ± 0.30 vs. 1.06 ± 0.90; p = 0.003). This improvement in BCVA could be attributed to the effect of triamcinolone on the photoreceptor layer, which we found to be less violated in group 1 (fig. 2). We noticed that interruption of the inner section/outer section junction in spite of the small amount of SRF is a contributing factor in incomplete visual recovery in group 2, and preservation of this layer even in the presence of a large amount of SRF could explain the better BCVA in group 1 (fig. 3). In our study we noticed a lower incidence of IOP increase in group 1 comparing with other studies (15 vs.
Intravitreal Triamcinolone in Scleral Buckling
Ophthalmic Res 2014;52:160–164 DOI: 10.1159/000362882
200 μm
163
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Fig. 2. Week 12 OCT of a patient in group 2 (control group) which shows interruption in the photoreceptor layer. In spite of scant SRF, BCVA remained at 1.00 logMAR.
this condition has been noted elsewhere to occur after 10–12 months postoperatively. The anti-inflammatory effect of triamcinolone acetonide is thought to play a role in reducing postoperative conjunctival inflammation in group 1. Our study had some limitations: (1) the short duration of follow-up which makes it hard to evaluate the duration of persistent SRF and cataract progression, and (2) lack of preoperative OCT to evaluate the level of SRF and its influence on the incidence of persistent SRF.
Conclusion
Fig. 3. Week 12 OCT of a patient in group 1 (cases). The photore-
ceptor layer seems to be intact. BCVA is 0.22 logMAR.
20–53%). The explanation for this result may be the lower concentration of the drug we used (2 mg per 0.5 ml compared with 4 and 8 mg in other studies) and exclusion of diabetic or glaucomatous patients in our study. We did not have any cataract progression in both groups because
Single-dose intravitreal triamcinolone acetonide injection may increase the final BCVA in macula-off RRD patients despite persistent SRF, suggesting that anti-inflammatory drugs could play a role in the good results of SB surgery. Disclosure Statement The authors have no proprietary or commercial interest in the products of companies mentioned in the article and they did not receive any financial support (grants).
References
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7 Hagimura N, Suto K, Iida T, Kishi S: Optical coherence tomography of the neurosensory retina in rhegmatogenous retinal detachment. Am J Ophthalmol 2000;129:186–190. 8 Theodossiadis PG, Georgalas IG, Emfietzoglou J, et al: Optical coherence tomography findings in the macula after treatment of rhegmatogenous retinal detachment with spared macula preoperatively. Retina 2003; 23:69–75. 9 Wolfensberger TJ, Gonvers M: Optical coherence tomography in the evaluation of incomplete visual acuity recovery after macula-off retinal detachments. Graefes Arch Clin Exp Ophthalmol 2002;240:85–89. 10 Kaga T, Fonesca RA, Dantes MA, Yannuzi LA, Spaide RF: Optical coherence tomography of bleb-like subretinal lesions after retinal reattachment surgery. Am J Ophthalmol 2001;132:120–121. 11 Benson SE, Ratcliffe S, Van Raders P, et al: A randomised comparison of parecoxib/valdecoxib and placebo for the prevention of cystoid macular edema after scleral buckling surgery. Retina 2009;29:387–394.
Ophthalmic Res 2014;52:160–164 DOI: 10.1159/000362882
12 Wu JS, Lin CH, Hwang JF, Chen SN: Influence of systemic steroids on subretinal fluid after scleral buckle surgery for macula-off retinal detachment. Retina 2011;31:99–104. 13 Abouzeid H, Becker K, Holz FG, Wolfensberger TJ: Submacular fluid after encircling buckle surgery for inferior macula-off retinal detachment in young patients. Acta Ophthalmol 2009;87:96–99. 14 Kang SW, Kim JH, Shin WJ, Kim JI: Subretinal fluid bleb after successful scleral buckling and cryotherapy for retinal detachment. Am J Ophthalmol 2008;146:205–210. 15 Koinzer S, Elsner H, Klatt C, et al: Selective retina therapy (SRT) of chronic subfoveal fluid after surgery of rhegmatogenous retinal detachment: three case reports. Graefes Arch Clin Exp Ophthalmol 2008;246:1373–1378. 16 Weene LE: Cystoid macular edema after scleral buckling responsive to acetazolamide. Ann Ophthalmol 1992;24:423–424. 17 Ackerman AL, Topilow HW: A reduced incidence of cystoid macular edema following retinal detachment surgery using diathermy. Ophthalmology 1985;92:1092–1095.
Mirshahi/Karkhaneh/Zamani Amir/ Movassat/Azadi
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1 Woo SJ, Lee KM, Chung H, Park KH: Photoreceptor disruption related to persistent submacular fluid after successful scleral buckle surgery. Korean J Ophthalmol 2011; 25: 380– 386. 2 Hagimura N, Iida T, Suto K, Kishi S: Persistent foveal retinal detachment after successful rhegmatogenous retinal detachment surgery. Am J Ophthalmol 2002;133:516–520. 3 Tunc M, Lahey JM, Kearney JJ, Lewis JM, Francis R: Cystoid macular oedema following pneumatic retinopexy vs scleral buckling. Eye 2007;21:831–834. 4 Wolfensberger TJ: Foveal reattachment after macula-off retinal detachment occurs faster after vitrectomy than after buckle surgery. Ophthalmology 2004;111:1340–1343. 5 Benson SE, Schlottmann PG, Bunce C, Xing W, Charteris DG: Optical coherence tomography analysis of the macula after scleral buckle surgery for retinal detachment. Ophthalmology 2007;114:108–112. 6 Lobes LA Jr, Grand MG: Incidence of cystoid macular edema following scleral buckling procedure. Arch Ophthalmol 1980; 98: 1230– 1232.
Received: February 6, 2014 Accepted: April 12, 2014 Published online: October 18, 2014
Influence of Intravitreal Triamcinolone Acetonide Injection in Scleral Buckling Surgery for Macula-Off Retinal Detachment Ahmad Mirshahi Reza Karkhaneh Javad Zamani Amir Morteza Movassat Pejvak Azadi Tehran University of Medical Sciences, Farabi Eye Hospital, Eye Research Center, Tehran, Iran
Abstract Purpose: To investigate the effect of intravitreal triamcinolone acetonide injection on the resolution of subretinal fluid (SRF), and its correlation with visual outcome after scleral buckle (SB) surgery. Methods: A prospective consecutive case series was conducted in patients who underwent SB surgery for macula-off rhegmatogenous retinal detachment (RRD) at Farabi Eye Hospital from February 1, 2012 to August 30, 2013. Exclusion criteria included previous ocular surgery (e.g. primary surgical failure) except cataract surgery, recurrent retinal detachment, macular hole, epiretinal membrane, proliferative vitreoretinopathy grade C, history of trauma, other retinal diseases, and diabetes mellitus. Patients were assigned to two groups. In group 1, patients received 2 mg of intravitreal triamcinolone acetonide injection at the end of surgery while patients in group 2 received intravitreal balanced saline solution for balancing the intraocular pressure (IOP). Patients were followed up at 1 day, 1 week, 1 month, 2 months and 3 months after the surgery by best-corrected visual acuity (BCVA), slitlamp examination, indirect ophthalmoscopy and optical coherence tomography (OCT). OCT (Heidelberg Engineering, Heidelberg,
© 2014 S. Karger AG, Basel 0030–3747/14/0523–0160$39.50/0 E-Mail [email protected] www.karger.com/ore
Germany) was used at all visits except day 1 after the surgery. Student’s t test and χ2 tests were used for comparisons; p value ≤0.05 was considered significant. Results: Sixty-two eyes of 62 patients were enrolled in the study. There were 33 male patients (53%) and 29 female patients (47%). The average age was 43.8 years (18–72 years). The mean duration of symptoms was 34.7 ± 46.8 days. There were 29 eyes in group 1 and 33 eyes in group 2. Twelve weeks after the operation, 25 patients (40%) had SRF beneath the macula, but there was no significant difference (p = 0.24, χ2 test) between the two groups. Improvement in BCVA in both groups was statistically significant (p ≤ 0.001) but did not differ between the two groups (p = 0.09) apart from week 12, in which the improvement in group 1 was significantly higher (p = 0.03). The incidence of cystoid macular edema did not differ in a statistically significant way between the groups (p = 0.19). IOP in 4 (15%) patients in group 1 rose above 21 mm Hg but responded quickly to 2 weeks of topical antiglaucoma medication. There was no cataract progression in either group. There was no correlation between the incidence of persistent SRF and the extent of detachment in both groups (p = 0.83). There was no surgical failure or redetachment in either group during the study period. Conclusion: Single-dose intravitreal triamcinolone may increase the final BCVA in macula-off RRD patients despite persistent SRF, suggesting the anti-inflammatory role of this drug. © 2014 S. Karger AG, Basel
Pejvak Azadi Fellowship of Vitreoretinal Surgery, Eye Research Center, Farabi Eye Hospital Tehran University of Medical Sciences South Kargar Street, Ghazvin Square, Tehran (Iran) E-Mail azadipe @ yahoo.com
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Key Words Intravitreal injection · Triamcinolone acetonide · Scleral buckling · Subretinal fluid · Visual acuity · Optical coherence tomography
Visual recovery after successful surgery for macula-off rhegmatogenous retinal detachment (RRD) is often not complete [1, 2]. Several preoperative and postoperative factors which could compromise visual outcome have been investigated. The most important predictive risk factors which have been shown to negatively influence visual outcome recovery are low preoperative visual acuity and long duration of macular detachment [3, 4]. When the duration of macular detachment is more than 6 days, the final postoperative best-corrected visual acuity (BCVA) could be worse. However, in a considerable number of patients, final postoperative visual acuity remains poor in spite of having a low-risk profile and a complete follow-up. Postoperatively the macula may seem attached in funduscopy, but assessment with optical coherence tomography (OCT) still shows persistent macular subretinal fluid (SRF) in a substantial number of patients in whom the macula was detached preoperatively [4, 5]. The incidence of persistent SRF at 4–6 weeks after scleral buckle (SB) surgery ranges from 27 to 100% [2–10]. While such fluid is associated with poor vision, by SRF resolution BCVA would improve. OCT studies have revealed that resolution of macular SRF usually takes several months [4, 9]. While delayed absorption of SRF has been shown by some authors to be associated with a worse visual outcome, others did not find such a correlation. Benson et al. [11] reported that the incidence of residual SRF is reduced by cyclooxygenase-2 (COX-2) inhibitor treatment and enhanced anti-inflammatory activity. Wu et al. [12] showed that postoperative systemic steroid treatment may decrease the incidence of SRF and facilitate the absorption of SRF. Patients treated with steroids had greater improvement of BCVA [12]. The purpose of this study was to investigate the effect of intravitreal triamcinolone acetonide injection on the incidence of persistent SRF and its correlation with visual outcome after SB surgery. Because both visual outcome and incidence of persistent SRF are different between macula-on and macula-off RRD, we chose to recruit only macula-off RRD patients in this prospective study.
had recurrent retinal detachment or primary surgical failure, macular hole, epiretinal membrane, proliferative vitreoretinopathy C, history of trauma, retinal diseases other than retinal detachment, previous ocular surgery except cataract surgery and patients with diabetes mellitus. All surgeries were performed by an experienced vitreoretinal specialist (A.M.). Informed consent was obtained from all participants and the study adhered to the tenets of the Declaration of Helsinki. All patients were examined preoperatively including BCVA, slitlamp examination, binocular indirect ophthalmoscopy and checking intraocular pressure (IOP). Cataract severity was recorded based on the Lens Opacities Classification System. Age, gender, duration of symptoms and quadrants of detachment of all patients were recorded. Patients were assigned to one of two groups with simple randomization as follows: patients in group 1 received 2 mg of intravitreal triamcinolone acetonide at the end of surgery while patients in group 2 served as controls and received intravitreal balanced salt solution for balancing the IOP. The surgical procedure including the extent of buckling (place and number of clock hours of buckle) and the site of SRF drainage were recorded in all cases. At each follow-up visit for all patients thorough ophthalmologic examination including BCVA, checking IOP, and status of the lens was performed. OCT of the foveal region was taken at weeks 1, 4, 8 and 12 for each patient and the presence of SRF was assessed. The accumulation of SRF was defined as a clear space between the photoreceptor layer and the retinal pigment epithelium on OCT. For statistical analysis, Snellen visual acuity was transformed into the logarithm of the minimum angle of resolution (logMAR). Comparisons of demographic or clinical variables between two groups were done using the Student’s t test and the χ2 test. Data are presented as mean ± SD, unless stated otherwise. SPSS version 18.0 software (SPSS Inc., Chicago, Ill., USA) was used for statistical analysis; p values of ≤0.05 were considered to be statistically significant.
Results
A prospective consecutive case series was conducted in patients who underwent SB surgery for macula-off RRD at Farabi Eye Hospital from April 1, 2011 to October 31, 2012. Sixty-two eyes of 62 patients were enrolled. Excluded from this study were patients who
Sixty-two eyes of 62 patients were included in this study. All patients underwent SB surgery for primary RRD. There were 33 male patients (53%) and 29 female patients (47%). The average age was 43.8 years, ranging from 18 to 72 years. The mean duration of symptoms was 34.7 ± 46.8 days (26 ± 16 days in group 1 and 42 ± 16 days in group 2; p = 0.17). Forty-two (68%) patients had 2 quadrants of retinal detachment. In 2 patients (3.2%) intravitreal injection of sulfur hexafluoride was done intraoperatively and 23 patients (37%) had external SRF drainage intraoperatively. There were 29 eyes in group 1 and 33 eyes in group 2. The demographic data of groups is presented in table 1. Statistically, there was no significant difference between these groups in the preoperative clinical features, including age, gender, duration of symptoms, preoperative BCVA, extent of retinal detachment, external drainage, and type or extent of buckling. Twelve
Intravitreal Triamcinolone in Scleral Buckling
Ophthalmic Res 2014;52:160–164 DOI: 10.1159/000362882
Material and Methods
161
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Introduction
Group 1
Group 2
Age, years 42.97±14.49 44.3±14.3 Gender Male 14 (48) 19 (57) Female 15 (52) 14 (43) Extent, quadrants One 4 (13) 3 (9) Two 21 (74) 21 (63) Three 4 (13) 6 (18) Four 0 (0) 3 (9) Duration of symptoms, days 26±16 42±16 Preoperative BCVA 1.67±0.65 1.66±0.63 Preoperative IOP 10.14±1.50 9.97±1.53 Type of buckle Segmental 27 (93) 30 (90) Encircling 2 (7) 3 (10) External drainage of SRF 12 (41) 11 (33)
p value 0.71 0.46 0.34
2.0 Case Control 1.5
1.0
0.5
0.17 0.93 0.71
0
0 BCVA
1 BCVA
4 BCVA
8 BCVA
12 BCVA
0.85 0.50
Mean ± SD or number of patients with percentages in parentheses.
Fig. 1. Changes in BCVA in logMAR at follow-up visits in both groups (statistically significant at week 12; p = 0.003). Higher numbers indicate worse visual acuity.
Table 2. Surgical outcome in the two groups at week 12
cept for week 12, which was better in group 1 (p = 0.03; fig. 1). The rate of BCVA ≤0.4 (logMAR) was significantly higher in group 1 (44 vs. 30%, p = 0.03). At week 12, the proportion of patients with persistent SRF who had BCVA better than 0.4 logMAR was 50% (5 of 10 patients) in group 1 and 35% (5 of 15 patients) in group 2 (p = 0.03). In patients who had persistent SRF, the photoreceptor layer was less violated in group 1 compared with group 2 (40 vs. 64%, p = 0.02). Postoperative inflammation such as conjunctival injection was seen in 4 (13%) patients in group 1 and in 10 (30%) patients in group 2 (p = 0.04). IOP in 4 (15%) patients in group 1 rose above 21 mm Hg, which responded to 2 weeks of topical antiglaucoma medication. There was no cataract progression in either group. There was no correlation between the incidence of persistent SRF and extent of the detachment in both groups (p = 0.83). No major systemic or local complications occurred intra- and postoperatively. There was no surgical failure or redetachment in either group during the study period.
PSRF Postoperative CME Patients with PSRF and BCVA better than 0.4 logMAR Patients with PSRF and an intact photoreceptor layer Conjunctival inflammation
Group 1
Group 2
10 (34) 6 (20.7)
15 (45) 11 (33.3)
5 (50)
5 (35)
6 (60) 4 (13)
5 (33) 10 (30)
Figures in parentheses are percentages. PSRF = Persistent subretinal fluid; CME = cystoid macular edema.
weeks after the operation, OCT revealed macular SRF in 25 patients (40%), but there was no significant difference in the incidence of macular SRF (p = 0.24, χ2 test; table 2) between group 1 (10 eyes, 34%) and group 2 (15 eyes, 45%). Improvement in BCVA in both groups was statistically significant (p ≤ 0.001; fig. 1), but the trend between the two groups was not statistically significant (p = 0.09). The incidence of cystoid macular edema was 27% (6 patients in cases and 11 in controls, which was not statistically significant; p = 0.19). The difference in BCVA between the two groups was not statistically significant ex162
Ophthalmic Res 2014;52:160–164 DOI: 10.1159/000362882
Discussion
The incidence of persistent SRF after successful SB surgery varies in the existing literature. It ranges from 47 to 100% for macula-off retinal detachment [2–5] and Mirshahi/Karkhaneh/Zamani Amir/ Movassat/Azadi
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Variable
Color version available online
Table 1. Demographic and clinical data of 62 RRD patients
from 27 to 50% for macula-on retinal detachment [2–6, 8–10]. Our study demonstrates that 41% patients with macula-off RRD have persistent SRF at 12 weeks postoperatively. Although several factors have been postulated to contribute to the chance of persistent SRF formation, such as the height and extent of retinal detachment, clock hours of buckle placement, gender, age, refractive status, and drainage of SRF, little evidence of any association has been shown between these factors and the presence of persistent SRF, except the extent of retinal detachment [5, 9]. SRF is believed to damage the photoreceptor outer segments by blocking the diffusion of oxygen and nutrients [5]. Although Woo et al. [1] reported that the presence and extent of persistent SRF do not affect the final visual acuity or anatomic attachment, Hagimura et al. [2, 7] and Benson et al. [5] suggested that there is an association of poor vision in patients with residual SRF and that resolution of the SRF is followed by vision improvement. According to previous reports, persistent macular SRF often lasts from 5 to 10 months before it is reabsorbed, and most SRF disappears within 1 year after surgery [13]. The long duration of persistent SRF after an SB procedure is probably multifactorial. First, SRF in RRD is composed of hyaluronic acid, various proteins (plasmin, globulin, apoprotein, fibronectin, etc.), lipids and glucides. After water is largely reabsorbed by successful SB procedures, the residual SRF is much more concentrated with respect to hyaluronic acid, protein, and other components, which makes its reabsorption through the outer blood-retinal barrier harder [13]. Besides, surgical trauma induced by SB procedures may further increase the protein concentration of SRF, preventing the SRF from being reabsorbed efficiently. Kaga et al. [10] suggest that a combination of cryopexy and buckling causes a breakdown of the blood-retinal barrier, thus allowing excessive amounts of protein to enter the SRF. In a study, Kang et al. [14] report that indocyanine green angiography reveals choroidal vascular congestion and hyperpermeability near the area with SRF. They presume that the origin of SRF may be associated with choroidal vascular changes resulting from cryotherapy [14]. Several procedures including vitrectomy [4] and scatter laser [15] have been performed to treat the persistent SRF after pneumatic retinopexy but without definite efficacy [16, 17]. Benson et al. [11] found that residual SRF is reduced by COX-2 inhibitor treatment. Because COX-2 inhibitors are anti-inflammatory agents, this indicates that inflammation may
play a part in the pathogenesis of persistent SRF. Steroid and traditional nonsteroidal anti-inflammatory drugs (nonselective COX-1 and COX-2 inhibitors), in addition to their anti-inflammatory role, have been found to reduce the blood-retinal barrier breakdown induced by cryotherapy. Wu et al. [12] reported that systemic steroids could decrease the incidence of persistent SRF and shorten its duration. Based on the possibility that inflammation and blood-retinal barrier breakdown might be one of the possible mechanisms of persistent SRF after retinal detachment surgery, steroids may also be efficacious in reducing the incidence of persistent SRF. In our study the incidence of persistent SRF was at the lower limit of other studies (41% compared with 47–100%), which may be due to the low case number in our study. Although the incidence of persistent SRF was not lower in group 1, the number of patients that had BCVA better than 0.4 logMAR was significantly higher in group 1 compared with group 2 (50 vs. 33%; p = 0.03). The final 12week postoperative BCVA in group 1 was statistically significantly better compared with group 2 (0.52 ± 0.30 vs. 1.06 ± 0.90; p = 0.003). This improvement in BCVA could be attributed to the effect of triamcinolone on the photoreceptor layer, which we found to be less violated in group 1 (fig. 2). We noticed that interruption of the inner section/outer section junction in spite of the small amount of SRF is a contributing factor in incomplete visual recovery in group 2, and preservation of this layer even in the presence of a large amount of SRF could explain the better BCVA in group 1 (fig. 3). In our study we noticed a lower incidence of IOP increase in group 1 comparing with other studies (15 vs.
Intravitreal Triamcinolone in Scleral Buckling
Ophthalmic Res 2014;52:160–164 DOI: 10.1159/000362882
200 μm
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Fig. 2. Week 12 OCT of a patient in group 2 (control group) which shows interruption in the photoreceptor layer. In spite of scant SRF, BCVA remained at 1.00 logMAR.
this condition has been noted elsewhere to occur after 10–12 months postoperatively. The anti-inflammatory effect of triamcinolone acetonide is thought to play a role in reducing postoperative conjunctival inflammation in group 1. Our study had some limitations: (1) the short duration of follow-up which makes it hard to evaluate the duration of persistent SRF and cataract progression, and (2) lack of preoperative OCT to evaluate the level of SRF and its influence on the incidence of persistent SRF.
Conclusion
Fig. 3. Week 12 OCT of a patient in group 1 (cases). The photore-
ceptor layer seems to be intact. BCVA is 0.22 logMAR.
20–53%). The explanation for this result may be the lower concentration of the drug we used (2 mg per 0.5 ml compared with 4 and 8 mg in other studies) and exclusion of diabetic or glaucomatous patients in our study. We did not have any cataract progression in both groups because
Single-dose intravitreal triamcinolone acetonide injection may increase the final BCVA in macula-off RRD patients despite persistent SRF, suggesting that anti-inflammatory drugs could play a role in the good results of SB surgery. Disclosure Statement The authors have no proprietary or commercial interest in the products of companies mentioned in the article and they did not receive any financial support (grants).
References
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