Copyright 2002 American Medical Association. All Rights Reserved.
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Central retinal vein occlusion (CRVO) is a common retinal vascular disorder
that can lead to significant visual disability. Persistent macular edema is
one of the major complications associated with CRVO. The Central Vein Occlusion
Study1 evaluated the efficacy of macular
grid laser photocoagulation in patients with macular edema caused by CRVO.
This study did not find a difference in visual acuity between treated and
untreated eyes at any stage during the follow-up period. Therefore, there
is currently no proven management for macular edema in the setting of CRVO.
The purpose of this interventional case report is to describe the clinical
course of 2 patients with macular edema secondary to CRVO who underwent intravitreous
injection of triamcinolone acetonide.
A 57-year-old man had a 2-month history of decreased visual acuity in
his right eye. On initial examination, his best-corrected visual acuity was
20/40 OD and 20/20 OS. Results of anterior segment examination were remarkable
only for 2+ nuclear sclerosis in both eyes. Intraocular pressure was 15 mm
Hg OD and 19 mm Hg OS. A dilated fundus examination revealed findings consistent
with nonischemic CRVO in the right eye. Macular edema was present. Fundus
examination results were normal in the left eye.
Slitlamp biomicroscopy revealed some improvement in the degree of macular
edema in the right eye during the next 2 months. However, 8 months after initial
examination, his visual acuity had decreased further. Examination at that
time revealed a visual acuity of 20/200 OD and 20/20 OS. A dilated fundus
examination of the right eye revealed a nonischemic CRVO with significantly
increased macular edema (Figure 1A).
Optical coherence tomography (OCT) revealed a diffusely thickened retina as
well as cystic foveal changes (Figure 1B).
The patient was observed for an additional month, and when there was no improvement
in the degree of macular thickening or visual acuity, an intravitreous injection
of 4 mg (40 mg in 1.0 mL) of triamcinolone acetonide was given in the right
A, Color fundus photograph of
the right eye shows nonischemic central retinal vein occlusion complicated
by macular edema before intravitreous injection of triamcinolone acetonide.
Visual acuity was 20/200. B, Optical coherence tomogram of the right eye shows
a diffusely thickened retina (to 600 µm) before intravitreous injection
of triamcinolone acetonide.
Follow-up 1 month later showed a return of visual acuity to 20/25 OD,
with complete resolution of macular edema on both clinical examination (Figure 2A) and OCT (Figure 2B). Intraocular pressure was unchanged, and the improvement
in visual acuity and clinical examination results remained at the 6-month
A, Color fundus photograph of
the right eye 1 month following intravitreous injection of triamcinolone acetonide
shows resolution of macular edema. B, Optical coherence tomogram of the right
eye 1 month following intravitreous injection of triamcinolone acetonide shows
restoration of normal foveal architecture. The central foveal thickness measured
A 67-year-old man had a 1-month history of decreased visual acuity in
the left eye. Examination revealed a best-corrected visual acuity of 20/20
OD and 20/200 OS. Anterior segment examination results were remarkable for
2+ nuclear sclerosis in both eyes. His intraocular pressure was 10 mm Hg OU.
A dilated fundus examination revealed a normal fundus in the right eye. Examination
of the left fundus revealed findings consistent with an ischemic CRVO. Foveal
thickness was greater than 600 µm on OCT.
The patient was followed up at 2-month intervals for the next 8 months.
Although the intraretinal hemorrhage cleared significantly, there was neither
improvement in visual acuity nor a decrease in the amount of macular edema
noted on clinical examination or OCT.
Because there was no clinical improvement, an intravitreous injection
of 4 mg of triamcinolone acetonide (40 mg in 1.0 mL) was given. Figure 3 shows the extensive macular edema noted on both slitlamp
biomicroscopy and OCT 5 days before treatment. Three weeks following treatment,
his visual acuity improved to 20/100 OS, and a fundus examination revealed
a significant decrease in macular edema. Foveal thickness measured with OCT
was 100 µm. At the 2-month follow-up, there continued to be a reduction
in macular edema on clinical examination and OCT (Figure 4).
A, Color fundus photograph of
the left eye shows ischemic central retinal vein occlusion complicated by
macular edema before intravitreous injection of triamcinolone acetonide. This
photograph was taken 8 months after initial examination, and although there
was reduction in the amount of intraretinal hemorrhage, significant macular
edema persisted. Visual acuity was 20/200. B, Optical coherence tomogram of
the left eye shows cystic foveal changes and a diffusely thickened retina
(to >600 µm) before intravitreous injection of triamcinolone acetonide.
A, Color fundus photograph of
the left eye 2 months following intravitreous injection of triamcinolone acetonide
shows resolution of macular edema. A reduction in the amount of intraretinal
hemorrhage can also be noted. B, Optical coherence tomogram of the left eye
2 months following intravitreous injection of triamcinolone acetonide shows
resolution of macular edema. The central foveal thickness measured 100 µm.
The patient did well until 3 months following the injection, when his
visual acuity decreased to 20/400. Macular edema was noted on slitlamp biomicroscopy,
and foveal thickness was 500 µm on OCT. No further intervention was
attempted at this point, and the patient has been observed with no change
in his clinical status.
Triamcinolone acetonide is a corticosteroid that is commercially available,
inexpensive, and commonly used as a periocular injection for the treatment
of cystoid macular edema occurring secondary to uveitis or resulting from
intraocular surgery. Intravitreous triamcinolone acetonide has been used experimentally
in the prevention or treatment of proliferative vitreoretinopathy, retinal
neovascularization, choroidal neovascularization, and most recently for macular
edema secondary to diabetic retinopathy.2
In these 2 patients, we attempted to reduce macular edema secondary
to CRVO by injecting triamcinolone acetonide into the vitreous cavity. Intravitreous
injection of triamcinolone acetonide has been shown to have minimal adverse
effects in both animal and clinical studies.3,4
Triamcinolone acetonide may reduce macular edema, possibly by reducing the
breakdown of the blood-retinal barrier, nonspecifically inhibiting the arachadonic
acid pathway, or downregulating vascular endothelial growth factor.
Intravitreous triamcinolone acetonide induced a prompt anatomic and
functional improvement in our patient with nonischemic CRVO (case 1). The
visual acuity of this patient improved from 20/200 to 20/25 in 1 month. Additionally,
the thickness of the central fovea, as measured by OCT, was reduced from 600
µm to 100 µm in 1 month.
In the patient with ischemic CRVO (case 2), intravitreous triamcinolone
acetonide also appeared to produce significant but temporary anatomic benefit.
Visual acuity improvement was noted but was less dramatic than in the patient
with nonischemic CRVO. As in the patient with nonischemic CRVO, the central
foveal thickness was reduced rapidly and dramatically during 1 month following
intravitreous injection. This effect, however, was transient; a decrease in
visual acuity and an increase in macular edema occurred 3 months following
injection. This may be related to the severity of ischemic CRVO. A single
injection of triamcinolone acetonide may remain in the vitreous cavity for
up to 3 months following injection.5 It
is possible that 1 injection of intravitreous triamcinolone lasting 3 months
in the vitreous cavity may be sufficient treatment for macular edema caused
by nonischemic CRVO but not for macular edema caused by ischemic CRVO. A repeated
injection might again have reduced the macular edema and improved visual acuity
in the patient with ischemic CRVO.
In the absence of a definite role for macular laser photocoagulation
in the setting of macular edema from CRVO, intravitreous injection of triamcinolone
acetonide may be a viable treatment option. The 2 patients described previously
had a prompt anatomic and functional response, although the need for repeated
treatment and possible adverse effects should be investigated further. No
adverse effects such as retinal detachment, endophthalmitis, cataract, or
glaucoma occurred in this series. Further study is warranted to evaluate the
safety and efficacy of this promising treatment modality for CRVO complicated
by macular edema.
Corresponding author and reprints: Michael S. Ip, MD, University
of Wisconsin–Madison, Department of Ophthalmology and Visual Sciences,
600 Highland Ave, F4/336, Madison, WI 53792 (e-mail: email@example.com).
Ip MS, Kumar KS. Intravitreous Triamcinolone Acetonide as Treatment for Macular Edema From Central Retinal Vein Occlusion. Arch Ophthalmol. 2002;120(9):1217-1219. doi: