Intravitreal triamcinolone could
reduce need for PDT re-treatment in eyes with exudative AMD
ORLANDO, FL - Adjunctive intravitreal triamcinolone acetonide may
improve visual outcomes and minimise the need for photodynamic therapy
(PDT) re-treatment in eyes with exudative age-related macular degeneration
That is according to the results of an open, uncontrolled study
evaluating the use of intravitreal triamcinolone acetonide 4.0 mg
administered immediately after verteporfin (Visudyne) PDT.
Richard F. Spaide MD presented his findings at the annual meeting
of the American Academy of Ophthalmology.
His study included two sub-groups: one comprising 13 eyes with no
previous treatment and the second 13 eyes that underwent repeat
PDT treatment and suffered vision loss before PDT.
Results from clinical and angiographic follow-up at three and six
months indicated that the adjunctive use of triamcinolone might
improve visual outcomes and minimise the need for PDT re-treatment
relative to historical experience with PDT alone.
"Although our study has the limitations of being small and
uncontrolled compared to the responses of eyes treated with verteporfin
PDT in the TAP study, the results are very encouraging," Dr
He explained that interest in using intravitreal triamcinolone to
treat exudative AMD is based on its anti-inflammatory, anti-angiogenic
and anti-vascular permeability effects.
Verteporfin PDT may rapidly close the new vessels in eyes with CNV
secondary to AMD.
But those effects are transient and it also stimulates inflammation
and increases vascular permeability to cause oedema. After three
months, there is typically a one-line loss of vision and most patients
require re-treatment for persistent leakage, he said.
"Triamcinolone persists in the vitreous cavity for months after
injection and based on its pharmacological profile, might be expected
to address the limitations of verteporfin PDT and reduce the need
for repeating this expensive modality," Dr Spaide said.
In his study, mean baseline ETDRS visual acuity was about 20/160
in both the newly and previously treated groups. After three months,
patients in the newly treated group achieved a +1.9 line change,
a statistically significant difference.
Of the 13 patients, four (31%) showed a visual acuity improvement
of three lines or more. Based on an assessment of fluorescein angiograms
at the three-month visit, only two (15%) eyes were treated again
At the six-month visit, there was a further increase in mean acuity
with the change from baseline averaging +2.3 lines. Based on the
repeat angiograms, no eyes required further PDT.
In the previously treated eyes, the mean visual acuity change from
baseline at three months was only +0.3 lines, which was not a statistically
Only one eye had gained three or more lines from baseline vision
and by six months, mean visual acuity was no different from baseline.
However, during the course of follow-up, none of the previously
treated eyes required further PDT.
"These results are in contrast with those achieved in the TAP
study where at the first three-month visit about 90% of patients
required re-treatment and there was on average a one line loss in
"They also compare favourably with outcomes reported for other
anti-angiogenic agents, including anecortave acetate, Eye001 and
rhuFab V2. Compared to those agents, triamcinolone has the advantage
of being a low-cost, generic medication that may potentially require
fewer injections," Dr Spaide said.
Intraocular pressure (IOP) elevation was the most common complication
observed in the series, occurring in five (19%). It was controlled
with medical monotherapy in all. In addition, progression of nuclear
sclerosis was observed in two eyes and a posterior subcapsular cataract
was noted in a third.
Jost B. Jonas MD reported German data on intravitreal treatment
with triamcinolone acetonide 25 mg in 71 eyes of 67 patients with
Almost all eyes, 68 (95%) had totally or predominantly (greater
than 50%) occult choroidal neovascularisation (CNV) membranes and
23 (32%) eyes were pseudophakic. Eyes undergoing simultaneous cataract
surgery were excluded from the study.
The results showed early vision benefits, with significant improvements
from baseline Snellen acuity after one and two months' follow-up.
Acuities remained numerically better than baseline thereafter. While
the effects were not statistically significant, Dr Jonas suggested
a treatment benefit might have been masked by triamcinolone-induced
cataractous changes in the crystalline lens.
"Currently there are no effective modalities for reducing vision
loss in eyes with predominantly occult CNV related to AMD.
"We have experience using the 25 mg dosage of triamcinolone
acetonide in over 300 eyes with a range of proliferative, oedematous
and neovascular ocular diseases and found it to be relatively well
tolerated. We feel this modality merits further study as a treatment
for exudative AMD," Dr Jonas said.
Visual acuity testing showed significant improvements from baseline
after one and two months, increasing from a mean of 0.16 at baseline
At monthly follow-up visits thereafter, mean visual acuities were
not significantly different compared to baseline. At three months,
visual acuity in the majority of eyes was still slightly better
than at baseline, while at six months most had lost vision and were
below their baseline level.
Dr Jonas observed that the decline in vision benefit over time seemed
to coincide with the disappearance of triamcinolone acetonide crystals
from within the eye.
"That raises the issue of whether it might be useful to administer
repeat injections at an appropriate interval to maintain a therapeutic
intraocular concentration but the safety of serial treatment with
a high dose of this steroid also remains a question," Dr Jonas
Repeat injections were administered to six eyes at three to seven
months after the initial treatment. One eye was treated a total
of four times. Those eyes exhibited a positive visual response to
the first intravitreal injection but subsequently lost vision. Transient
vision improvement was noted in three eyes after the repeat injection.
Like Dr Spaide's series, the most common side effects were cataractous
changes in the crystalline lens and ocular hypertension. IOP was
elevated to 22 mm Hg or higher in at least one follow-up measurement
in 40% of eyes and raised to the 50 mm Hg to 60 mm Hg range in two
Those latter cases had pre-existing glaucoma and went on to require
filtering surgery. IOP elevation was treated topically in the remaining
eyes without development of any optic nerve glaucomatous changes
during the available follow-up.
"No cases of post-injection endophthalmitis, rhegmatogenous
retinal detachment or proliferative vitreoretinopathy occurred but
the potential for those risks must also be considered cautiously
with this treatment," he noted.