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Off-label use of intravitreal triamcinolone acetonide for diabetic macular edema in a pregnant patient


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We present a case of diabetic macular edema in a pregnant patient treated with a single intravitreal injection of triamcinolone acetonomide. Initial presentation and serial examinations after treatment included visual acuity, slit-lamp examination, indirect ophthalmoscopy, and optical coherence tomography. Resolution of visual acuity and macular edema were present six weeks after injection and persisted throughout the duration of the pregnancy without further intervention. No adverse outcomes for either mother or fetus were noted. To our knowledge, this is the first report of intravitreal triamcinolone administration in this patient population to be published in the medical literature.
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DOI: 10.2147/OPTH.S14584
Off-label use of intravitreal triamcinolone
acetonide for diabetic macular edema
in a pregnant patient
Ahad Fazelat
Kameran Lashkari
Schepens Eye Research Institute,
Harvard Medical School,
Boston, MA, USA
Correspondence: Ahad Fazelat
243 Charles Street, Boston,
MA 02114-3096, USA
Tel +1 617 573 4199
Fax +1 617 864 6437
Abstract: We present a case of diabetic macular edema in a pregnant patient treated with a
single intravitreal injection of triamcinolone acetonomide. Initial presentation and serial exami-
nations after treatment included visual acuity, slit-lamp examination, indirect ophthalmoscopy,
and optical coherence tomography. Resolution of visual acuity and macular edema were present
six weeks after injection and persisted throughout the duration of the pregnancy without further
intervention. No adverse outcomes for either mother or fetus were noted. To our knowledge,
this is the first report of intravitreal triamcinolone administration in this patient population to
be published in the medical literature.
Keywords: triamcinolone, macular edema, diabetes, pregnancy
Case report
A pregnant 23-year-old female with a six-year history of Type 1 diabetes presented with
a complaint of increased “blur” in both eyes for the previous two months. Her most
recent hemoglobin A
was measured at 6.4%. She was six months’ pregnant at initial
presentation. On examination her best corrected visual acuity was 20/40 OU. Slit-lamp
examination was entirely unremarkable in both eyes. Dilated funduscopic examination
was significant for flame-shaped, dot, and blot hemorrhages in the posterior segment,
with associated macular edema and exudates bilaterally (Figures 1A and 1B). No retinal
neovascularization was noted. Optical coherence tomography (OCT) revealed a foveal
thickness of 578 ± 5 microns and 667 ± 8 microns in the right and left eye, respectively
(Figures 2A and 2B). All OCT scans were performed with the Stratus
optical coher-
ence tomograph (Zeiss-Humphrey Inc, Dublin, CA).
Examination findings were consistent with bilateral, nonproliferative diabetic retin-
opathy and clinically significant macular edema. After careful deliberation with the patient
and her obstetrician, a decision was made to treat the bilateral macular edema with intra-
vitreal triamcinolone acetonide injection. The patient received 0.05 mL of triamcinolone
acetonide 40 mg/mL in the left eye initially and in the right eye one week later.
The patient returned for re-examination six weeks after treatment. Best-corrected
visual acuity was 20/20 and 20/25 in the right and left eye, respectively. Funduscopic
examination revealed marked reduction in macular edema bilaterally. Repeat OCT
revealed a foveal thickness of 159 ± 5 microns and 202 ± 6 microns in the right and
left eye, respectively (Figures 3A and 3B).
Four months after treatment, the patient’s visual acuity remained stable bilaterally.
Slit-lamp examination and Goldman applanation tonometry did not reveal any
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Fazelat and Lashkari
intraocular hypertension or significant lenticular changes
at this visit or at any point after triamcinolone injection.
Funduscopic examination revealed only mild retinal thicken-
ing in the left eye. The patient delivered a full-term, healthy
baby boy weeks prior to this examination. The patient
reported no complications in pregnancy or parturition.
Progression of diabetic retinopathy during pregnancy has
been described previously by several authors.
impairment in these cases can result from both proliferative
(eg, vitreous hemorrhage, retinal detachment) and nonpro-
liferative etiologies (eg, retinal hemorrhage, papillopathy,
macular edema).
Although macular edema may regress in
some cases after delivery, in other cases edema can persist
and can be associated with severe and persistent visual
Data from large, randomized clinical trials have estab-
lished the benefits of argon laser photocoagulation for clini-
cally significant macular edema.
Focal laser photocoagulation
of actively leaking blood vessels or grid laser for areas of
Figure 1 A) Color fundus photograph of the right eye. B) Color fundus photograph
of the left eye.
Figure 2 A) Optical coherence tomograph of macula at initial presentation, right eye.
B) Optical coherence tomograph of macula at initial presentation, left eye.
Figure 3 A) Optical coherence tomograph of macula at six weeks following
injection, right eye. B) Optical coherence tomograph of macula at six weeks
following injection, left eye.
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Triamcinolone for diabetic macular edema in pregnancy
diffuse permeability can decrease clinically significant edema.
However, laser photocoagulation in close proximity to the
fovea increases the risk of inducing iatrogenic central scotoma
as a result of thermal injury to the tissues, or subsequent glial
There are many reports of off-label use of intravitreal
triamcinolone in cases of persistent and refractory diabetic
macular edema.
Improved visual acuity and decreased
foveal thickness have been documented by serial OCT after
a single injection. However, these effects do not appear to
persist beyond 3–4 months without repeated administration.
A Medline search using keywords “pregnancy”, “pregnant”,
“clinically significant macular edema”, “gestational diabetes”,
and “triamcinolone acetonide” revealed no case reports or
case series documenting the treatment of clinically significant
macular edema with intravitreal corticosteroids in a pregnant
Side effects of systemic corticosteroid administration
are well known. Major ophthalmic complications of intra-
vitreal corticosteroid injection include, but are not limited
to, cataract formation and increased intraocular pressure.
Although corticosteroid equivalents can be measured in the
aqueous three months after a single intravitreal injection, it
is not known how much corticosteroid is released into the
systemic circulation after a single intravitreal injection.
Thus, it is hard to estimate the systemic effects of intravitreal
corticosteroid therapy.
To date, there are no reports of teratogenic outcomes
with systemic corticosteroid use in pregnant human females.
However, teratogenic effects have been observed in many
species receiving equivalent systemic human doses.
authors have noted maxillofacial deformity and, in particular,
cleft palate in mice which have received corticosteroids early
in gestation.
Our patient presented with bilateral clinically significant
diabetic macular edema and diminishing vision. The area of
greatest thickening was within the fovea of both the right and
left eyes, with little edema observed in the extrafoveal area.
Laser photocoagulation to this area carried a significant risk
of inducing a permanent central scotoma. We consulted the
patient’s obstetrician about the possibility of initiating intra-
vitreal corticosteroid therapy. Given the patient’s late stage
of pregnancy, we felt that intravitreal steroid posed little risk
to either mother or fetus. We were able to achieve resolution
of macular edema and improved visual acuity with a single
intravitreal dose to each eye.
In conclusion, we propose that intravitreal triamcinolone
injection may be a viable treatment modality for management
of clinically significant macular edema in pregnant patients.
The safety profile with administration of this medication is
enhanced if the steroid is administered after the first trimester.
We suggest a multidisciplinary approach and consultation
with an obstetrician whenever using corticosteroid therapy
in pregnant patients.
The authors report no conflicts of interest in this work.
1. Sinclair SH, Nessler C, Foxman B, Nicholas CW, Gabbe S. Macular
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2. Moloney JB, Drury MI. The effect of pregnancy on the natural course
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3. Early Treatment Diabetic Retinopathy Study Research Group. Treatment
techniques and clinical guidelines for photocoagulation of diabetic
macular edema. Early Treatment Diabetic Retinopathy Study Report
Number 2. Ophthalmology. 1987;94:761–774.
4. Chieh JJ, Roth D, Liu M, et al. Intravitreal triamcinolone acetonide for
diabetic macular edema. Retina. 2005;25:828–834.
5. Diabetic Retinopathy Clinical Research Network. A randomized trial
comparing intravitreal triamcinolone acetonide and focal/grid photo-
coagulation for diabetic macular edema. Ophthalmology. 2008;115:
6. Furukawa S, Usada K, Abe M, Ogawa I. Histopathological findings of
cleft palate in rat embryos induced by triamcinolone acetonide. J Vet
Med Sci. 2004;66:397–402.
7. Kenalog-40 injection [Package insert]. Princeton, NJ: Bristol-Myers
Squibb Company; 2007.
... CNVM=Choroidal neovascular membrane; PIC=Punctate inner choroidopathy; POHS=Presumed ocular histoplasmosis syndrome; ICNM=Idiopathic choroidal neovascular membrane Fazelat et al. [70] (2 eyes of 1 patient) In cases where there is refractory DME, Diabetic Retinopathy Clinical Research (DRCR) Network showed greater effectivity with steroids than laser after 4 months in terms of visual acuity and retinal thickness, while laser was proved superior to intravitreal triamcinolone at 3 years. [80,81] Though, first-trimester use of systemic steroids has shown formation of oral clefts, [82] low birth weight with topical steroids [83] and craniofacial abnormalities in animal models with triamcinolone, systemic absorption of triamcinolone has been shown to be minimal. ...
Full-text available
Diabetes and gestational diabetes (GD) are areas of concern worldwide. GD can eventually lead to serious development of diabetic retinopathy (DR) during pregnancy or worsening of an already existing DR. GD confers future risk of diabetes, both in the mother and fetus, further complicating their lives. DR in pregnant women has been intriguing in terms of understanding the prevalence, assessing risk factors causing pathogenesis, and problems associated with treating them. Pregnancy itself is a risk factor for progression of DR. Physiological changes such as metabolic, vascular, immunologic, and hormonal changes that occur during pregnancy can cause development as well as worsening of DR. This can eventually lead to permanent visual loss if not addressed on time. Timing of laser, choice of treatment for diabetic macular edema with laser, intravitreal anti-vascular endothelial growth factor agents (VEGF), and intravitreal steroids pose a serious challenge in managing these patients without causing damage to the mother and fetus. This review article showcases the prevalence, risk factors, and pathogenesis, outlines the management of DR in pregnancy, and recommends guidelines based on the available evidence. PubMed and MEDLINE searches were performed pertaining to the prevalence of GD in India, DR in pregnancy, risk factors for progression of DR, role of vasoactive mediators in DR, role of angiopoietic factors in DR, hormonal influence of DR, role of growth factors in DR, use of fluorescein and indocyanine green angiography, retinal lasers, anti-VEGF agents, intravitreal steroids, anesthesia, and retinal surgery, all pertaining to pregnancy and guidelines and recommendations for managing DR in pregnancy.
... Moreover, dexamethasone is known to be used in pregnancy in cases of preterm labour for fetal lung maturation and hence is safe. In literature, the use of dexamethasone and triamcinolone for treatment of macular edema in pregnant female have been reported [5,6]. ...
... In the case of progressive DME needing treatment, the intravitreal injection of steroids is the best option [90][91][92], and no side effects in pregnancy have been reported. ...
Full-text available
Oxidative stress has been postulated as an underlying pathophysiologic mechanism of diabetic retinopathy (DR), the main cause of avoidable blindness in working-aged people. This review addressed the current daily clinical practice of DR and the role of antioxidants in this practice. A systematic review of the studies on antioxidant supplementation in DR patients was presented. Fifteen studies accomplished the inclusion criteria. The analysis of these studies concluded that antioxidant supplementation has a IIB level of recommendation in adult Type 1 and Type 2 diabetes mellitus subjects without retinopathy or mild-to-moderate nonproliferative DR without diabetic macular oedema as a complementary therapy together with standard medical care.
... Apesar do grande volume de injeções intravítreas realizadas anualmente, há pouca evidência no uso dessas substâncias durante a gestação e amamentação. Há relatos de uso de triancinolona intraocular durante a gestação sem intercorrências 34 . A preocupação é maior com uso dos agentes anti-VEGF pelas potenciais alterações no desenvolvimento placentário e do feto, principalmente no início da gestação. ...
A injeção intravítrea é o procedimento oftalmológico mais realizado no mundo. Através dessa técnica é possível administrar medicamentos para o segmento posterior do olho, sendo a via de escolha para o tratamento da maioria das patologias coriorretinianas. O evento ocular adverso mais grave é a endoftalmite pós injeção. Diversas medidas foram sugeridas para diminuição do risco dessa complicação, com evidências variáveis. Tendo em vista o grande número de injeções realizado em nosso serviço de oftalmologia do Hospital de Clínicas de Porto Alegre (HCPA), realizamos uma revisão da literatura com o objetivo de definir as melhores práticas. Nós descrevemos a evidência disponível para os principais aspectos dos diferentes estágios do procedimento (pré injeção, peri injeção e pós injeção) e apresentamos nosso protocolo. A medida com maior evidência científica na profilaxia da endoftalmite é a aplicação de iodopovidona tópica pelo menos trinta segundos antes da injeção.
... After high-dose intravitreal triamcinolone (20-25mg) therapy, systemic serum levels of the drug were practically undetectable [261]. Dexamethasone has been used to accelerate foetal lung maturation in premature labour [262], but intravitreal triamcinolone [263] and dexamethasone [264,265] have also been used to treat DMO with no reported systemic side effects in pregnancy. As dexamethasone (in the form of Ozurdex) is a NICE-approved drug in the UK for the treatment of DMO, it would be appropriate to consider using this in pregnancy, if treatment is deemed necessary. ...
Full-text available
The management of diabetic retinopathy (DR) has evolved considerably over the past decade, with the availability of new technologies (diagnostic and therapeutic). As such, the existing Royal College of Ophthalmologists DR Guidelines (2013) are outdated, and to the best of our knowledge are not under revision at present. Furthermore, there are no other UK guidelines covering all available treatments, and there seems to be significant variation around the UK in the management of diabetic macular oedema (DMO). This manuscript provides a summary of reviews the pathogenesis of DR and DMO, including role of vascular endothelial growth factor (VEGF) and non-VEGF cytokines, clinical grading/classification of DMO vis a vis current terminology (of centre-involving [CI-DMO], or non-centre involving [nCI-DMO], systemic risks and their management). The excellent UK DR Screening (DRS) service has continued to evolve and remains world-leading. However, challenges remain, as there are significant variations in equipment used, and reproducible standards of DMO screening nationally. The interphase between DRS and the hospital eye service can only be strengthened with further improvements. The role of modern technology including optical coherence tomography (OCT) and wide-field imaging, and working practices including virtual clinics and their potential in increasing clinic capacity and improving patient experiences and outcomes are discussed. Similarly, potential roles of home monitoring in diabetic eyes in the future are explored. The role of pharmacological (intravitreal injections [IVT] of anti-VEGFs and steroids) and laser therapies are summarised. Generally, IVT anti-VEGF are offered as first line pharmacologic therapy. As requirements of diabetic patients in particular patient groups may vary, including pregnant women, children, and persons with learning difficulties, it is important that DR management is personalised in such particular patient groups. First choice therapy needs to be individualised in these cases and may be intravitreal steroids rather than the standard choice of anti-VEGF agents. Some of these, but not all, are discussed in this document.
... Both triamcinolone acetonide and Ozurdex have been reported to be used during pregnancy with no adverse effects [54,55]. Use of anti-VEGF agents during pregnancy is more concerning, as the antiangiogenic effect may be hazardous to the placenta and developing fetus, especially in the early stages of pregnancy. ...
Intravitreal injections (IVI) have become the most common intraocular procedure worldwide with increasing numbers every year. The article presents the most up-to-date review on IVI epidemiology and techniques. Unfortunately, important issues related to pre-, peri- and postinjection management lack randomized clinical trials for a final conclusion. Also, a great diversity of approaches exists worldwide. Therefore, expert consensus recommendations on IVI techniques are provided.
Liquid ophthalmic drug products are the most common presentation for pharmacotherapy used to treat a variety of anterior and posterior segment diseases of the eye. Their attributes largely mirror those of parenteral formulations, but specifically consider certain qualities for drug substance and product from a perspective of compatibility and delivery to a biologically and physiologically distinct environment in and around the eye. Features such as formulation pH and osmolarity, or properties of all inactive ingredients, play a critical role when considering the route of ocular administration. This chapter provides an overview of physical chemistry, formulation, and manufacturing considerations as they relate to the anatomical characteristics and physiology of the eye from a pragmatic, historical, case-study-driven, and biosystem-based perspective.
Full-text available
Deep learning (DL) is a subset of artificial intelligence (AI), which uses multilayer neural networks modelled after the mammalian visual cortex capable of synthesizing images in ways that will transform the field of glaucoma. Autonomous DL algorithms are capable of maximizing information embedded in digital fundus photographs and ocular coherence tomographs to outperform ophthalmologists in disease detection. Other unsupervised algorithms such as principal component analysis (axis learning) and archetypal analysis (corner learning) facilitate visual field interpretation and show great promise to detect functional glaucoma progression and differentiate it from non-glaucomatous changes when compared with conventional software packages. Forecasting tools such as the Kalman filter may revolutionize glaucoma management by accounting for a host of factors to set target intraocular pressure goals that preserve vision. Activation maps generated from DL algorithms that process glaucoma data have the potential to efficiently direct our attention to critical data elements embedded in high throughput data and enhance our understanding of the glaucomatous process. It is hoped that AI will realize more accurate assessment of the copious data encountered in glaucoma management, improving our understanding of the disease, preserving vision, and serving to enhance the deep bonds that patients develop with their treating physicians. 深度学习 (Deep learning,DL) 是人工智能的一个分支, 通过模仿哺乳动物视皮层合成影像的能力, 建立多层神经网络模型。 这种技术会在青光眼领域起到变革的作用。自主DL算法能够最大化地收集眼底图像和OCT中包含的信息, 在疾病探查方面甚至能够超越眼科医生。其他的无监管算法例如主成分分析 (纵学习) 和原型分析 (角点学习) 有助于对视野结果进行解释, 并且与传统软件包相比能够更好地检测青光眼功能性进展, 并与非青光眼相鉴别。此外, 如卡尔曼滤波器等预测性工具可收录一系列影响因素后确定维持视力的目标眼压值, 从而彻底改变了青光眼的管理。DL算法通过处理青光眼数据可生成激活图, 引导我们关注高通量数据中嵌入的关键数据元素, 并加强我们对青光眼发展过程的理解。最后, 希望AI能够更加精准地评估青光眼治疗管理过程中的大量数据, 提高我们对青光眼、保护视力的认识, 成为患者与医生之间的深厚纽带。
L’autorisation de mise sur le marché (AMM) permet aux médicaments d’êtrecommercialisés au sein d’un pays ; cette démarche pour les industriels s’avère être longue et coûteuse. Les prescriptions hors AMM sont fréquemment rencontrées, tous les domaines sont concernés. La population infantile, les femmes enceintes ainsi que tous les patients atteints de maladies rares reçoivent fréquemment des médicaments hors AMM. Pour les médecins les prescriptions hors AMM sont une solution en l’absence d’alternative thérapeutique recommandée. Cette thèse s’intéresse aux prescriptions hors AMM dans leur ensemble, l’objectif est de présenter les différents usages des médicaments en dehors de leur résumé des caractéristiques du produit (RCP) et d’évaluer la véracité des informations retrouvées. Pour cela, nous avons réalisé une étude transversale au sein du Centre Hospitalier de l’Ouest Vosgien ; le but de cette étude est d’évaluer le nombre de prescriptions hors AMM au sein de deux services de médecine générale. Ensuite, nous avons réalisé une recherche bibliographique dans deux bases de données différentes Pubmed® et Google Scholar®. Nous avons utilisé des mots clés en anglais tels que « off-label », « drugs », « prescription » dans la base de donnée Pubmed® et des mots clés en français dans la base de donnée Google Scholar® notamment : « médicaments » « prescriptions », « hors AMM ». L’objectif de cette recherche est d’être le plus exhaustif possible afin de retrouver un maximum d’utilisations hors AMM. Les résultats sont ensuite analysés et détaillés dans les différentes parties.
Purpose: To describe the management of active choroidal neovascularization (CNV) during pregnancy with the use of a dexamethasone intravitreal implant (DXI) (Ozurdex). Methods: Case series of active CNV treated with DXI with at least 12-month follow-up retrospectively analyzed at 2 high-volume referral centers in France. Medical records and multimodal macular imaging were evaluated. Results: Three eyes of 3 patients (age 30.0 ± 3.6 years) were included. One case of idiopathic CNV and two cases of CNV secondary to multifocal choroiditis were analyzed. Mean follow-up was 20.6 ± 4.0 months (range, 16-23 months). The DXI was given at second trimester of established pregnancy in all cases. Mean central retinal thickness decreased from 359 ± 53 μm to 301 ± 17 μm 1 month after DXI and remained stable up to 12 months of follow-up. Visual improvement in all cases was observed (mean 10 letters; range, 5-30 letters) 1 month after DXI and remained stable/increased up to 12-month follow-up (mean 22 letters; range, 10-30 letters). All patients had an uneventful prenatal course and delivered a healthy full-term infant. Conclusion: In the authors' experience, a single DXI revealed safe and effective in CNV treatment during pregnancy.
Objective: To evaluate the efficacy and safety of 1-mg and 4-mg doses of preservative-free intravitreal triamcinolone in comparison with focal/grid photocoagulation for the treatment of diabetic macular edema (DME). Design: Multicenter, randomized clinical trial. Participants: Eight hundred forty study eyes of 693 subjects with DME involving the fovea and with visual acuity of 20/40 to 20/320. Methods: Eyes were randomized to focal/grid photocoagulation (n = 330), 1 mg intravitreal triamcinolone (n = 256), or 4 mg intravitreal triamcinolone (n = 254). Retreatment was given for persistent or new edema at 4-month intervals. The primary outcome was evaluated at 2 years. Main Outcome Measures: Visual acuity measured with the electronic Early Treatment Diabetic Retinopathy Study method (primary), optical coherence tomography-measured retinal thickness (secondary), and safety. Results: At 4 months, mean visual acuity was better in the 4-mg triamcinolone group than in either the laser group (P<0.001) or the 1-mg triamcinolone group (P = 0.001). By 1 year, there were no significant differences among groups in mean visual acuity. At the 16-month visit and extending through the primary outcome visit at 2 years, mean visual acuity was better in the laser group than in the other 2 groups (at 2 years, P = 0.02 comparing the laser and 1-mg groups, P = 0.002 comparing the laser and 4-mg groups, and P = 0.49 comparing the 1-mg and 4-mg groups). Treatment group differences in the visual acuity outcome could not be attributed solely to cataract formation. Optical coherence tomography results generally paralleled the visual acuity results. Intraocular pressure increased from baseline by 10 mmHg or more at any visit in 4%, 16%, and 33% of eyes in the 3 treatment groups, respectively, and cataract surgery was performed in 13%, 23%, and 51 % of eyes in the 3 treatment groups, respectively. Conclusions: Over a 2-year period, focal/grid photocoagulation is more effective and has fewer side effects than 1-mg or 4-mg doses of preservative-free intravitreal triamcinolone for most patients with DME who have characteristics similar to the cohort in this clinical trial. The results of this study also support that focal/grid photocoagulation currently should be the benchmark against which other treatments are compared in clinical trials of DME.
To determine the influence of pregnancy on the retinas of insulin-dependent diabetics, we assessed 53 diabetic women by retinal photography every six weeks throughout pregnancy and for six months post partum. Thirty-nine nonpregnant insulin-dependent diabetics of childbearing age served as controls. Of the 39 controls, 18 (46.2%) had retinopathy. Of the 53 pregnant women, 33 (62%) had retinopathy at the first examination and eight others (15%) developed it as pregnancy advanced, significantly increasing the prevalence of retinopathy during pregnancy to 77.4%. Progressive changes occurred as pregnancy advanced; microaneurysms moderately increased, hemorrhages appeared in 30 (56.6%), and soft exudates in 15 (28.3%). Four patients (7.5%) had neovascularization, one for the first time. The condition of all four deteriorated during pregnancy. Six months after delivery the background changes had regressed to control levels. Neovascularization showed some regression. Duration of disease was related to the development and progression of retinopathy; every pregnant patient who had had diabetes for ten years had retinopathy. Retinal hemorrhages or neovascularization were associated with increased infant morbidity. Hemorrhages and exudates behaved independently and were associated with different risk factors, but increased insulin requirements and polyhydramnios were important risk factors in the development of retinal hemorrhages. Low fasting blood glucose levels late in pregnancy were significantly associated with soft exudates.
Seven women with insulin-dependent diabetes (mean age, 26 years; mean duration of diabetes, 15.4 years) had minimal or no retinopathy before becoming pregnant but developed severe macular edema associated with preproliferative or proliferative retinopathy during the course of their pregnancies. The edema was associated with significant macular capillary nonperfusion, and often with significant proteinuria and mild hypertension. Although proliferation was controlled with panretinal photocoagulation, the macular edema continued to worsen until delivery in all cases and was often aggravated by the photocoagulation. Macular edema and retinopathy both regressed after delivery in some patients but persisted in others, causing significant visual loss. Pregnant women with retinopathy, nephropathy, or hypertension should undergo ophthalmoscopy at least once a month. If proliferative retinopathy develops, panretinal photocoagulation should be applied even if the macular edema is aggravated.
Triamcinolone acetonide (TAC), a synthetic glucocorticoid, induces cleft palate resulting from poor development of palatal shelves in mice. However, TAC has no effect on medial edge epithelial cells (MEE cells) in secondary palatal shelves. In the present study, we examined the relationship between the pathogenesis of cleft palate and the effects on MEE cells and palatal mesenchymal cells in rat embryos/fetuses exposed to TAC. Pregnant Wistar Hannover rats were given TAC intramuscularly at 0.5 mg/kg at gestation days (Day) 12, 13, and 14, then embryos/fetuses were harvested on Days 14.5, 15, 16 and 20. The effects of TAC were as follows; an inhibition of palatal mesenchymal cell proliferation on Day 14.5, a decrease in the density of palatal mesenchymal cells and MEE cells, and expression of epidermal growth factor (EGF) receptors in MEE cells on Day 15, and stratified squamous differentiation of MEE cells with expression of cytokeratin and EGF receptors on Day 16. These findings indicated that TAC inhibited the proliferation of mesenchymal cells and affected the differentiation of MEE cells into stratified squamous epithelia in the palatal shelves of rat embryos. However, these stratified squamous MEE cells partially fused with each other. Thus, we suspected that a major contributing factor to the formation of TAC-induced cleft palate might not be the altered differentiation of MEE cells, but the inhibition of mesenchymal cell proliferation.
Intravitreal injection of triamcinolone acetonide has been advocated to treat exudative diabetic macular edema. The purpose of the study was to evaluate the clinical outcome of an intravitreal injection of triamcinolone acetonide as treatment for diffuse diabetic macular edema. This study was a retrospective, interventional, clinical case series examining 210 eyes of 174 patients who received an intravitreal injection of 1 or 4 mg of triamcinolone acetonide for treatment of diffuse diabetic macular edema. Inclusion criteria were clinically significant macular edema, visual acuity loss, and leakage shown by fluorescein angiography. Main outcome measures were visual acuity and intraocular pressure. Mean follow-up time +/- SD was 6.6 +/- 3.1 months. In the study group, visual acuity improved significantly (P < 0.001) from a median of 20/200 (mean logMAR, 0.92) at baseline to 20/80 (mean logMAR, 0.82) at 6 months. Mean intraocular pressure +/- SD increased from 15.4 +/- 3.4 mmHg (median, 16 mmHg; range, 6-26 mmHg) to a maximal value of 20.4 +/- 6.2 mmHg (median, 19 mmHg; range, 12-51 mmHg) during the follow-up period. Complications included culture-negative sterile endophthalmitis in six cases and cataract extraction in five eyes. Intravitreal injection of 1 to 4 mg of triamcinolone acetonide may benefit patients by improving visual acuity in eyes with clinically significant diabetic macular edema. This study did not provide significant evidence to justify its routine use in clinical practice for all patients with diabetic macular edema. A randomized clinical trial on this issue would provide more conclusive evidence and help identify those patients most likely to benefit from intravitreal triamcinolone acetonide.
Treatment techniques and clinical guidelines for photocoagulation of diabetic macular edema. Early Treatment Diabetic Retinopathy Study Report Number 2
Early Treatment Diabetic Retinopathy Study Research Group. Treatment techniques and clinical guidelines for photocoagulation of diabetic macular edema. Early Treatment Diabetic Retinopathy Study Report Number 2. Ophthalmology. 1987;94:761-774.
Diabetic Retinopathy Clinical Research Network. A randomized trial comparing intravitreal triamcinolone acetonide and focal/grid photocoagulation for diabetic macular edema
Diabetic Retinopathy Clinical Research Network. A randomized trial comparing intravitreal triamcinolone acetonide and focal/grid photocoagulation for diabetic macular edema. Ophthalmology. 2008;115: 1447-1459.