MULTIPLE REPEATED INTRAVITREAL TRIAMCINOLONE TREATMENTS FOR RADIATION-INDUCED MACULAR EDEMA David A. Eichenbaum, MD, Jeffery S. Heier, MD
Background and Purpose: This report discusses a patient with a predictably and repetitively favorable anatomic and functional response to intravitreal triamcinolone for radiation-induced macular edema. The purpose of this report is to demonstrate a situation where this treatment may have a favorable outcome over time. Method: Retrospective interventional case study. Result: Restoration of normal macular contour as well as maintenance of good vision after several treatments with intravitreal triamcinolone. Conclusion: Intravitreal triamcinolone is a well-established treatment for macular edema. In the vast majority of cases, its effect is transient, and additional treatments are necessary. It is important to realize that, in certain cases which are effectively treated with this modality, it may allow for preservation of good vision over time. One must be vigilant for the known complications of intravitreal triamcinolone, especially increased intraocular pressure and cataract progression. RETINAL CASES & BRIEF REPORTS 1:202–204, 2007
From Ophthalmic Consultants of Boston, Boston, Massachusetts.
was no foveal ischemia at presentation or on any follow-up image. Focal laser treatment was performed at presentation. In August 2001, vision deteriorated to 20/80. After extensive consideration of the anecdotal value, intravitreal triamcinolone acetonide therapy for radiation retinopathy was recommended. After appropriate informed consent, the patient received a 4-mg intravitreal injection of triamcinolone acetonide. Over 1 month, cystoid macular edema resolved angiographically, and visual acuity improved to 20/50-2. Intraocular pressure remained normal. A second injection was administered in March 2002. By October 2002, vision worsened to 20/200 with cystoid macular edema, and we began to monitor macular thickness with optical coherence tomography. Central thickness at that time was 465 m, and a third injection of triamcinolone acetonide was administered. Macular edema resolved. The patient underwent phacoemulsification in January 2003, and a fourth intravitreal injection was administered in May 2003. Vision in June 2003 had improved from 20/100 to 20/60⫹2, and optical coherence tomography findings improved from cystoid macular edema with a central thickness of 590 m to normal contour and a central thickness of 162 m. Repeated treatments with a similar treatment effect were performed in October 2004, January 2004, August 2004, March 2005, and August 2005 (Fig. 1 Fig. 2).
R
adiation retinopathy is a slowly progressive occlusive microangiopathy secondary to endothelial cell loss and capillary closure that occurs after ionizing radiation treatment. It has features similar to those of diabetic retinopathy, including macular edema. Case Report
A 64-year-old woman presented in February 2001 for evaluation of retinal edema of the right eye. She had a history of intracranial metastatic breast cancer treated with 30 Gy of whole-brain radiation with a 20-Gy boost to the right frontal lobe (total dose to the tumor bed, 54 Gy over 42 days) 7 years before presentation. Visual acuity was 20/60 in the right eye and 20/20 in the left eye. Biomicroscopy disclosed bilateral nuclear sclerosis. Fundus examination revealed intraretinal hemorrhages in the right eye with cystic edema. The fundus in the left eye was normal. Angiography showed early punctate and late petaloid hyperfluorescence consistent with radiation retinopathy and cystoid macular edema. There
Discussion Reprint requests: David A. Eichenbaum, MD, Ophthalmic Consultants of Boston, 50 Staniford Street, Suite 600, Boston, MA 02111; e-mail: [email protected]
Because radiation retinopathy and diabetic retinopathy are clinically and histopathologically similar, 202
203
TRIAMCINOLONE FOR RADIATION RETINOPATHY
Fig. 1. Optical coherence tomography of the right eye immediately before the patient’s ninth intravitreal triamcinolone injection. Top, Cross section of the macula, revealing massive cystoid macular edema. Center, Macular thickness in micrometers, revealing marked retinal thickening.
treatment has been based on established therapy for diabetic retinopathy. In 1998, Kinyoun et al1 used photocoagulation to areas of clinically significant macular edema with resultant stabilization of vision. A more recent study by Hykin et al2 addressed photocoagulation in the treatment of macular edema in radiation retinopathy, showing that this treatment had limited success in reducing edema and improving vision. In 2003, Sutter and Gillies3 reported improvement of retinal edema and visual acuity with intravitreal triamcinolone administration; this treatment was repeated once in their case. Intravitreal triamcinolone has been shown to be efficacious for macular edema of several etiologies, including diabetic edema.4 Triamcinolone appears to restore the integrity of a compromised inner blood– retinal barrier.5 At the time of this writing, our patient had received nine intravitreal injections of triamcinolone acetonide and continued to have remarkable anatomical and visual improvement with each treatment. Her treatment result predictably persisted for 5 months to 7 months. Intraocular pressure and results of optic
nerve examination were within normal limits throughout these treatments. As with any case report, the limitations of these data are apparent. There was no measurement of the direct macular dose of radiation in this case, and a low macular dose may have contributed to therapeutic success. In addition, the initial focal laser may have exerted some improved control of the macular edema over time. However, because macular edema recurred consistently in this case, even years after the treatment effect of the focal laser had time to mature, the effect of intravitreal triamcinolone cannot be ignored. Consistent with other reports of this treatment for vasogenic macular edema, repeated injections seem necessary to maintain a therapeutic effect. Key words: intravitreal injections, macular edema, radiation retinopathy, triamcinolone acetonide. References 1.
Kinyoun JL, Chittum ME, Wells CG. Photocoagulation treatment of radiation retinopathy. Am J Ophthalmol 1988;105: 470–478.
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Fig. 2. Optical coherence tomography of the right eye 1 month after the patient’s ninth intravitreal triamcinolone injection. Top, Cross section of the macula, revealing return to normal foveal contour and essentially no intraretinal cystic spaces. Center, Macular thickness in micrometers, revealing normal thickness.
2.
3.
Hykin PG, Shields CL, Shields JA, Arevalo JF. The efficacy of focal laser therapy in radiation-induced macular edema. Ophthalmology 1998;105:1425–1429. Sutter FKP, Gillies MC. Intravitreal triamcinolone for radiation-induced macular edema. Arch Ophthalmol 2003;121: 1491–1493.
4.
5.
Martidis A, Duker JS, Greenberg PB, et al. Intravitreal triamcinolone for refractory diabetic macular edema. Ophthalmology 2002;109:920–927. Gillies MC. Regulators of vascular permeability: potential sites for intervention in the treatment of macular edema. Doc Ophthalmol 1999;97:251–260.
Background and Purpose: This report discusses a patient with a predictably and repetitively favorable anatomic and functional response to intravitreal triamcinolone for radiation-induced macular edema. The purpose of this report is to demonstrate a situation where this treatment may have a favorable outcome over time. Method: Retrospective interventional case study. Result: Restoration of normal macular contour as well as maintenance of good vision after several treatments with intravitreal triamcinolone. Conclusion: Intravitreal triamcinolone is a well-established treatment for macular edema. In the vast majority of cases, its effect is transient, and additional treatments are necessary. It is important to realize that, in certain cases which are effectively treated with this modality, it may allow for preservation of good vision over time. One must be vigilant for the known complications of intravitreal triamcinolone, especially increased intraocular pressure and cataract progression. RETINAL CASES & BRIEF REPORTS 1:202–204, 2007
From Ophthalmic Consultants of Boston, Boston, Massachusetts.
was no foveal ischemia at presentation or on any follow-up image. Focal laser treatment was performed at presentation. In August 2001, vision deteriorated to 20/80. After extensive consideration of the anecdotal value, intravitreal triamcinolone acetonide therapy for radiation retinopathy was recommended. After appropriate informed consent, the patient received a 4-mg intravitreal injection of triamcinolone acetonide. Over 1 month, cystoid macular edema resolved angiographically, and visual acuity improved to 20/50-2. Intraocular pressure remained normal. A second injection was administered in March 2002. By October 2002, vision worsened to 20/200 with cystoid macular edema, and we began to monitor macular thickness with optical coherence tomography. Central thickness at that time was 465 m, and a third injection of triamcinolone acetonide was administered. Macular edema resolved. The patient underwent phacoemulsification in January 2003, and a fourth intravitreal injection was administered in May 2003. Vision in June 2003 had improved from 20/100 to 20/60⫹2, and optical coherence tomography findings improved from cystoid macular edema with a central thickness of 590 m to normal contour and a central thickness of 162 m. Repeated treatments with a similar treatment effect were performed in October 2004, January 2004, August 2004, March 2005, and August 2005 (Fig. 1 Fig. 2).
R
adiation retinopathy is a slowly progressive occlusive microangiopathy secondary to endothelial cell loss and capillary closure that occurs after ionizing radiation treatment. It has features similar to those of diabetic retinopathy, including macular edema. Case Report
A 64-year-old woman presented in February 2001 for evaluation of retinal edema of the right eye. She had a history of intracranial metastatic breast cancer treated with 30 Gy of whole-brain radiation with a 20-Gy boost to the right frontal lobe (total dose to the tumor bed, 54 Gy over 42 days) 7 years before presentation. Visual acuity was 20/60 in the right eye and 20/20 in the left eye. Biomicroscopy disclosed bilateral nuclear sclerosis. Fundus examination revealed intraretinal hemorrhages in the right eye with cystic edema. The fundus in the left eye was normal. Angiography showed early punctate and late petaloid hyperfluorescence consistent with radiation retinopathy and cystoid macular edema. There
Discussion Reprint requests: David A. Eichenbaum, MD, Ophthalmic Consultants of Boston, 50 Staniford Street, Suite 600, Boston, MA 02111; e-mail: [email protected]
Because radiation retinopathy and diabetic retinopathy are clinically and histopathologically similar, 202
203
TRIAMCINOLONE FOR RADIATION RETINOPATHY
Fig. 1. Optical coherence tomography of the right eye immediately before the patient’s ninth intravitreal triamcinolone injection. Top, Cross section of the macula, revealing massive cystoid macular edema. Center, Macular thickness in micrometers, revealing marked retinal thickening.
treatment has been based on established therapy for diabetic retinopathy. In 1998, Kinyoun et al1 used photocoagulation to areas of clinically significant macular edema with resultant stabilization of vision. A more recent study by Hykin et al2 addressed photocoagulation in the treatment of macular edema in radiation retinopathy, showing that this treatment had limited success in reducing edema and improving vision. In 2003, Sutter and Gillies3 reported improvement of retinal edema and visual acuity with intravitreal triamcinolone administration; this treatment was repeated once in their case. Intravitreal triamcinolone has been shown to be efficacious for macular edema of several etiologies, including diabetic edema.4 Triamcinolone appears to restore the integrity of a compromised inner blood– retinal barrier.5 At the time of this writing, our patient had received nine intravitreal injections of triamcinolone acetonide and continued to have remarkable anatomical and visual improvement with each treatment. Her treatment result predictably persisted for 5 months to 7 months. Intraocular pressure and results of optic
nerve examination were within normal limits throughout these treatments. As with any case report, the limitations of these data are apparent. There was no measurement of the direct macular dose of radiation in this case, and a low macular dose may have contributed to therapeutic success. In addition, the initial focal laser may have exerted some improved control of the macular edema over time. However, because macular edema recurred consistently in this case, even years after the treatment effect of the focal laser had time to mature, the effect of intravitreal triamcinolone cannot be ignored. Consistent with other reports of this treatment for vasogenic macular edema, repeated injections seem necessary to maintain a therapeutic effect. Key words: intravitreal injections, macular edema, radiation retinopathy, triamcinolone acetonide. References 1.
Kinyoun JL, Chittum ME, Wells CG. Photocoagulation treatment of radiation retinopathy. Am J Ophthalmol 1988;105: 470–478.
204
RETINAL CASES & BRIEF REPORTSℜ
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2007
●
VOLUME 1
●
NUMBER 4
Fig. 2. Optical coherence tomography of the right eye 1 month after the patient’s ninth intravitreal triamcinolone injection. Top, Cross section of the macula, revealing return to normal foveal contour and essentially no intraretinal cystic spaces. Center, Macular thickness in micrometers, revealing normal thickness.
2.
3.
Hykin PG, Shields CL, Shields JA, Arevalo JF. The efficacy of focal laser therapy in radiation-induced macular edema. Ophthalmology 1998;105:1425–1429. Sutter FKP, Gillies MC. Intravitreal triamcinolone for radiation-induced macular edema. Arch Ophthalmol 2003;121: 1491–1493.
4.
5.
Martidis A, Duker JS, Greenberg PB, et al. Intravitreal triamcinolone for refractory diabetic macular edema. Ophthalmology 2002;109:920–927. Gillies MC. Regulators of vascular permeability: potential sites for intervention in the treatment of macular edema. Doc Ophthalmol 1999;97:251–260.
