 |
|
Intravitreal Triamcinolone for Refractory Cystoid Macular Edema Secondary to Birdshot Retinochoroidopathy
Arch Ophthalmol. 2001;119:1380-1383.
Birdshot retinochoroidopathy is a chronic, bilateral uveitic disorder.
Originally described by Ryan and Maumenee,1
it is characterized by posterior segment inflammation in the presence of multiple
depigmented choroidal lesions symmetrically scattered throughout the postequatorial
retina. The cause is presumed to be autoimmune and more than 90% of patients
test positive for the HLA-A29 serotype.2
Approximately half of affected eyes develop cystoid macular edema (CME), and
this represents a major cause of considerable visual loss from this condition.3 A rationale for treatment with corticosteroids
has been established based on the inflammatory nature of the disease. However,
systemic and periocular corticosteroids have failed to produce significant
improvement in most treated patients.4 We
report 2 cases of refractory CME secondary to birdshot retinochoroidopathy
that were successfully treated with intravitreal injections of triamcinolone
acetonide.
Report of Cases
Case 1
A 60-year-old woman was diagnosed with birdshot retinochoroidopathy
3 years prior to initial examination. She was positive for HLA-A29 and had
a fundus appearance consistent with this condition (Figure 1). This included multiple creamy yellow choroidal lesions
posterior to the equator bilaterally. The anterior vitreous showed mild cells
with some vitreous debris.
|
|
|
|
Figure 1. Fundus appearance of case 1 is
consistent with a diagnosis of birdshot retinochoroidopathy.
|
|
|
At initial examination, she complained of chronic floaters with occasional
photopsia. However, she noted acute blurring of vision and distortion in the
left eye during the prior 6 weeks. Her best-corrected visual acuity was 20/20
OD and 20/60 OS. Intraocular pressures were 14 mm Hg bilaterally. Anterior
segment examination findings were normal with the exception of mild nuclear
sclerotic cataracts. Indirect ophthalmoscopy and slitlamp biomicroscopy showed
a normal optic disk and retinal vasculature. The right macula was normal,
and the left macula showed intraretinal thickening involving the fovea with
a cystoid appearance. The retinal periphery showed symmetric birdshot lesions
as described.
Fluorescein angiography was obtained and showed leakage in a petalloid
pattern involving the left fovea. Optical coherence tomography (OCT) confirmed
CME with intraretinal thickening measured at 540 µm.
The patient was given ketorolac topical drops 4 times a day. At 3 months,
her visual acuity remained 20/60 OS and OCT showed no improvement in CME (Figure 2). The patient was offered an intravitreal
triamcinolone injection to treat residual edema. Informed consent was obtained,
and the patient underwent injection of 4 mg of triamcinolone acetonide (Kenalog
40; Apothecon, Princeton, NJ) in 0.1 mL. The injection was performed under
topical anesthesia through the pars plana inferiorly using a 27-gauge needle.
Immediately after the injection, the patient described a transient visual
perturbation owing to the opaque corticosteroid compound suspended in the
vitreous cavity. This had resolved over the next 2 days. Within 10 days, OCT
showed reduction of macular thickness to 240 µm with improvement of
visual acuity to 20/50 OS. At 2 months, CME resolved completely with a return
of OCT macular thickness to 190 µm (Figure 3). Her visual acuity improved to 20/25 OS at this interval.
After 6 months of follow-up, the patient maintains this level of acuity and
has shown no recurrence of CME. Macular thickness remains normal at 190 µm
as measured by OCT. The greatest intraocular pressure measured during the
follow-up period was 18 mm Hg. The patient showed no progression of cataract
during this interval.
|
|
|
|
Figure 2. Optical coherence tomograph (OCT)
depicts extensive cystoid macular edema (arrows) that failed conservative
therapy.
|
|
|
|
|
|
|
Figure 3. Optical coherence tomograph (OCT)
after intravitreal corticosteroid injection shows near resolution of cystoid
macular edema (arrows).
|
|
|
Case 2
A 38-year-old woman was diagnosed with birdshot retinochoroidopathy
on initial presentation based on characteristic fundus findings. Findings
from HLA-A29 testing were positive. Slitlamp biomicroscopy showed considerable
neovascularization of the right optic disc along with venous sheathing. Both
maculas showed trace CME. The peripheries were notable for symmetric, creamy
yellow birdshot lesions scattered throughout the postequatorial region. The
vitreous showed 1+ cells bilaterally. Panretinal photocoagulation was performed
on the right eye, and the patient was followed clinically for 3 years with
stable visual acuity at the 20/40 level.
On an emergency visit, the patient reported acute visual loss in the
right eye accompanied by central distortion during the prior week. Her best-corrected
visual acuity measured 20/400 OD and 20/60 OS. Intraocular pressures were
12 mm Hg and 15 mm Hg, respectively. The anterior segments were normal with
the exception of rare cells in each anterior chamber. Examination of the anterior
vitreous revealed 2+ cells on the right and 1+ cells on the left. Fundus examination
of the right eye showed persistent disc neovascularization with a band of
new preretinal hemorrhage beneath the inferotemporal arcade. The right macula
showed considerable CME. Although the left macula showed mild CME, she had
remained essentially stable in this eye and was not symptomatic until visual
loss occurred on the right.
Fluorescein angiography confirmed leakage from disc neovascularization
as well as CME in a petalloid pattern. The OCT measured the intraretinal thickening
at 290 µm. The patient was treated with further panretinal photocoagulation
and a sub-Tenon injection of triamcinolone acetonide (40 mg/mL). At 1-month
follow-up, her visual acuity remained at 20/200 OD. The CME showed no response
to therapy and actually increased to 370 µm on OCT (Figure 4). The patient was followed up for 1 additional month without
a clinical response. At this time, she was offered an intravitreal triamcinolone
injection to treat residual edema. After obtaining informed consent, she was
injected with 0.1 mL of triamcinolone acetonide (40 mg/mL) through the pars
plana inferiorly. She experienced a transient visual perturbation from the
opaque intravitreal corticosteroid suspension lasting 2 days. At 1 month,
her visual acuity improved to 20/100 OD. The macular thickness was reduced
to 220 µm on OCT. Her visual acuity gradually recovered to 20/50 OD
at 3 months with a corresponding macular thickness of 140 µm on OCT
(Figure 5). At 6 months following
intravitreal corticosteroid injection, she maintains a stable macular thickness
of 140 µm and visual acuity measures 20/30 OD without correction. Of
note, neovascularization of the disc has shown regression at 6 months. It
is unclear whether this is an effect of prior photocoagulation and/or antiangiogenic
effect from the corticosteroid. Intraocular pressure never exceeded 16 mm
Hg during the follow-up interval, and there was no evidence of cataract formation
during this time.
|
|
|
|
Figure 4. Optical coherence tomograph (OCT)
confirms intraretinal thickening consistent with cystoid macular edema that
also failed conservative therapy (arrows).
|
|
|
|
|
|
|
Figure 5. Optical coherence tomograph (OCT)
after intravitreal corticosteroid confirms resolution of cystoid macular edema
(arrows).
|
|
|
Comment
Birdshot retinochoroidopathy often is seen with CME, a common cause
of visual loss in this uveitic condition. Current treatments target the inflammatory
nature of the disorder. Corticosteroids represent the mainstay of therapy,
but systemic and periocular routes of administration have produced disappointing
results in controlling inflammation and preserving visual acuity. Cyclosporine
A has shown promise owing to its potent immunosuppressive effect, but its
role has not been fully established in birdshot retinochoroidopathy.4-5 Two patients are described who
had CME that responded promptly to intravitreal administration of triamcinolone
acetonide, an injectable corticosteroid suspension. Both showed marked improvement
in macular thickness with a corresponding dramatic increase in visual acuity
maintained for 6 months of follow-up.
The rationale for intravitreal corticosteroids parallels that established
for other routes of corticosteroid administration, specifically the anti-inflammatory
effect. However, the intravitreal route alleviates the pharmacologic issues
of penetration and bioavailability. A potent dose of medication is delivered
directly to its site of action with a rapid onset. With this more aggressive
approach, concerns arise regarding adverse events associated with the corticosteroid
medication and the injection procedure.
Specifically, corticosteroids have been associated with a rise in intraocular
pressure as well as the development of cataracts. All routes of corticosteroid
administration share these risks, although the risk may be theoretically amplified
with injection into the eye. The injection procedure itself introduces unique
risks of endophthalmitis, retinal detachment, and hemorrhage. Larger studies
of corticosteroid injections for other conditions have not shown significant
morbidity associated with the intravitreal injection procedure.6-7
However, this intervention may best be reserved for those truly refractory
cases that have failed standard topical, regional, and oral routes of delivery.
Of note, neither treated patient experienced any adverse effects related to
the drug or the injection procedure. Both experienced transient visual disturbance
lasting a few days owing to the opaque nature of triamcinolone suspended in
the vitreous cavity. The risks seem justified based on the failure of more
conservative approaches in the presence of progressive visual loss.
Intravitreal corticosteroid injection seems to be a viable optionfor
the treatment of refractory CME owing to birdshot retinochoroidopathy. Preliminary
results show prompt resolution of edema with corresponding improved visual
acuity. Improvement in visual acuity lags resolution of macular edema temporally,
with recovery of retinal function after restoration of structural integrity.
The duration of effect exceeds 6 months in both treated patients. Further
study is warranted to evaluate the long-term risks and benefits associated
with this promising treatment modality for CME complicating birdshot retinochoroidopathy.
AUTHOR INFORMATION
Adam Martidis, MD;
Jay S. Duker, MD;
Carmen A. Puliafito, MD
Boston, Mass
Corresponding author: Jay S. Duker, MD, 750 Washington St, Box 450,
Boston, MA 02111.
REFERENCES
|
1. Ryan SJ, Maumenee AE. Birdshot retinochoroidopathy. Am J Ophthalmol. 1980;89:31-45.
ISI
| PUBMED
2. Nussenblatt RB, Mittal KK, Ryan S. Birdshot retinochoroidopathy associated with HLA-A29 antigen and immune
responsiveness to retinal S-antigen. Am J Ophthalmol. 1982;94:147-158.
ISI
| PUBMED
3. Duker JS. Birdshot retinochoroidopathy. In: Guyer DR, Yannuzzi LA, Chang S, Shields JA, Green WR, eds. Retina-Vitreous-Macula. Philadelphia, Pa: WB Saunders Co;
1999:565-568.
4. Vitale AT, Rodriguez A, Foster CS. Low-dose cyclosporine therapy in the treatment of birdshot retinochoroidopathy. Ophthalmology. 1994;101:822-831.
ISI
| PUBMED
5. LeHoang P, Girard B, Deray G, et al. Cyclosporine in the treatment of birdshot retinochoroidopathy. Transplant Proc. 1988;20(3, suppl 4):128-130.
6. Danis RP, Ciulla TA, Pratt LM, Anliker W. Intravitreal triamcinolone acetonide in exudative age-related macular
degeneration. Retina. 2000;20:244-250.
FULL TEXT
|
ISI
| PUBMED
7. Challa JK, Gillies MC, Penfold PL, Gyory JF, Hunyor AB, Billson FA. Exudative macular degeneration and intravitreal triamcinolone: 18 month
follow-up. Aust N Z J Ophthalmol. 1998;26:277-281.
ISI
| PUBMED
SECTION EDITOR: W. RICHARD GREEN, MD
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Preparation and Characterization of Triamcinolone Acetonide-loaded Poly(3-hydroxybutyrate-co-3-hydroxyhexanoate) (PHBHx) Microspheres
Bayram et al.
Journal of Bioactive and Compatible Polymers 2008;23:334-347.
ABSTRACT
The Role of Topical Antibiotic Prophylaxis for Intravitreal Injections
Scott and Flynn
Arch Ophthalmol 2007;125:974-976.
FULL TEXT
Pars plana vitrectomy with intravitreal triamcinolone: effect on uveitic cystoid macular oedema and treatment limitations
Gutfleisch et al.
Br. J. Ophthalmol. 2007;91:345-348.
ABSTRACT
| FULL TEXT
Intravitreal anti-inflammatory treatment for uveitis
Sugita
Br. J. Ophthalmol. 2007;91:135-136.
FULL TEXT
Photographic estimation of the duration of high dose intravitreal triamcinolone in the vitrectomised eye
Kosobucki et al.
Br. J. Ophthalmol. 2006;90:705-708.
ABSTRACT
| FULL TEXT
Triamcinolone as adjunctive treatment to laser panretinal photocoagulation for proliferative diabetic retinopathy.
Bandello et al.
Arch Ophthalmol 2006;124:643-650.
ABSTRACT
| FULL TEXT
Should corticosteroids be considered as part of the standard care with photodynamic therapy?
Zarbin
Arch Ophthalmol 2006;124:563-571.
FULL TEXT
Predictive Factors for Visual Acuity After Intravitreal Triamcinolone Treatment for Diabetic Macular Edema
Jonas et al.
Arch Ophthalmol 2005;123:1338-1343.
ABSTRACT
| FULL TEXT
Acute Endophthalmitis Incidence: Intravitreal Triamcinolone
Westfall et al.
Arch Ophthalmol 2005;123:1075-1077.
ABSTRACT
| FULL TEXT
Effect of Intravitreal Triamcinolone Acetonide on Susceptibility to Experimental Bacterial Endophthalmitis and Subsequent Response to Treatment
Bucher et al.
Arch Ophthalmol 2005;123:649-653.
ABSTRACT
| FULL TEXT
Diffuse diabetic macular oedema treated by intravitreal triamcinolone acetonide: a comparative, non-randomised study
Jonas et al.
Br. J. Ophthalmol. 2005;89:321-326.
ABSTRACT
| FULL TEXT
Factors influencing visual acuity after intravitreal triamcinolone acetonide as treatment of exudative age related macular degeneration
Jonas et al.
Br. J. Ophthalmol. 2004;88:1557-1562.
ABSTRACT
| FULL TEXT
Intravitreal triamcinolone for the treatment of refractory diabetic macular oedema with hard exudates: an optical coherence tomography study
Ciardella et al.
Br. J. Ophthalmol. 2004;88:1131-1136.
ABSTRACT
| FULL TEXT
Safety of an Intravitreal Injection of Triamcinolone: Results From a Randomized Clinical Trial
Gillies et al.
Arch Ophthalmol 2004;122:336-340.
ABSTRACT
| FULL TEXT
Intravitreal Reinjection of Triamcinolone for Exudative Age-Related Macular Degeneration
Jonas et al.
Arch Ophthalmol 2004;122:218-222.
ABSTRACT
| FULL TEXT
Noninfectious Endophthalmitis Associated With Intravitreal Triamcinolone Injection
Roth et al.
Arch Ophthalmol 2003;121:1279-1282.
ABSTRACT
| FULL TEXT
Trans-Tenon's retrobulbar triamcinolone infusion for the treatment of uveitis
Okada et al.
Br. J. Ophthalmol. 2003;87:968-971.
ABSTRACT
| FULL TEXT
Pseudo-endophthalmitis after intravitreal injection of triamcinolone
Sutter and Gillies
Br. J. Ophthalmol. 2003;87:972-974.
ABSTRACT
| FULL TEXT
Intravitreal triamcinolone acetonide for exudative age related macular degeneration
Jonas et al.
Br. J. Ophthalmol. 2003;87:462-468.
ABSTRACT
| FULL TEXT
Intravitreal injection of triamcinolone acetonide as treatment for chronic uveitis
Degenring and Jonas
Br. J. Ophthalmol. 2003;87:361-361.
FULL TEXT
Intravitreal Injection of Triamcinolone for Diffuse Diabetic Macular Edema
Jonas et al.
Arch Ophthalmol 2003;121:57-61.
ABSTRACT
| FULL TEXT
Modulation of Permeability and Adhesion Molecule Expression by Human Choroidal Endothelial Cells
Penfold et al.
IOVS 2002;43:3125-3130.
ABSTRACT
| FULL TEXT
Intravitreal triamcinolone in recurrence of choroidal neovascularisation
Penfold
Br. J. Ophthalmol. 2002;86:600-601.
FULL TEXT
|
