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RESULTS
The present study includes 21 eyes of 21 consecutive patients with macular edema due to CRVO or BRVO. The mean age of patients was 53.76±12.88, ranged 2374 years. 15 were males and 6 were females. The duration from diagnosis of retinal vein occlusion with macular edema to treatment was 4.23±3.23 (116) months. All patients had nonischemic retinal vein occlusion at baseline. None of patients had other ocular diseases such as high myopia, central or diffuse retinal degeneration. The conventional treatment group included 12 patients (9 CRVO, 3 BRVO) and Kenalog group included 9 patients (7 CRVO, 2 BRVO). The mean duration of followup was 14.76±10.63 months(436 months).
The average age was 53.75±14.34 years in conventional group and 53.77±11.49 years in Kenalog group (P=0.9).The average duration of RVO prior to treatment in conventional treatment group was 4.8±3.8 months, while the average duration of RVO prior to treatment in Kenalog group was 3.4±2.1 months (P=0.3).
Before treatment, logMAR visual acuity in conventional group was 1.20±0.38 and in Kenalog group it was 1.64±0.31. One month after treatment the logMAR visual acuity improved to 0.98±0.54 in conventional group and 0.87±0.61 in Kenalog group.
There was a significant difference in visual acuity improvement between conventional treatment group and Kenalog group (0.22 vs 0.76) (P=0.01).
At the last followup the logMAR visual acuity was 0.96±0.64 in conventional treatment group and 0.92±0.43 in Kenalog group. There was no significant difference in visual acuity changes between conventional treatment group and Kenalog group (12.67 vs 11.44) (P=0.8). In Kenalog group the logMAR visual acuity at one month after treatment was 0.87±0.61 and at the last followup it was 0.92±0.43 (Table 1). But this difference was not statistically significant (P=0.7).
Temporary mild elevation of IOP occurred in some patients after Kenalog injection, which was controlled with Timohol eyedrops. No eye required cataract surgery during the followup. Also no serious side effects such as postoperative endophthalmitis or retinal detachment occurred.
DISCUSSION
In our study Kenalog was more effective than conventional treatment in macular edema due to RVO and this improvement was permanent till the last followup. No proved treatment exists for macular edema secondary to central retinal occlusion despite the potential for significant visual loss in affected eyes[13]. Many studies showed that triamcinolone acetonide was effective in macular edema due to CRVO. Park et al[14] injected 4mg TA in 10 eyes with nonischemic CRVO, without evidence of neovascularization and visual acuity of 4/10 or less. After an average of 4.8 months followup, a statistically significant improvement was seen. In this study three eyes (30%) without previous history of glaucoma required initiation of topical aqueous suppressant therapy for IOP elevation at the last followup[15]. Ip et al[16] in a retrospective review of 8 patients with macular edema from CRVO who were treated with an intravitreal injection of triamcinolone acetonide concluded that this therapeutic treatment may be safe and effective in some patients with macular edema due to CRVO.
Williamson et al[17] enrolled 18 patients with nonischemic CRVO and cystoid macular edema.He injected 2mg TA into the vitreous and patients were followed up for 12 months. IVTA injection is very effective in reversing cystoid nonischemic CRVO in the first 6 months, but this is unfortunately not sustained at 1 year. Cekic et al[18] injected 4mg TA for treatment of ME due to CRVO (n=21) and HRVO (Hemi RVO)(n=3). The average time between onset of symptoms and first injection was 5.4 months. Mean followup time was 10 months. All injections resulted in reduction in central foveal thickness. But the difference between mean baseline and mean final visual acuity was statistically significant. None of the eyes of diabetic patients or patients with ischemic CRVO improved in visual acuity Some studies evaluated the effect of IVTA on visual acuity (VA) in BRVO. Jonas et al[19] injected 2025mg TA in 28 eyes with BRVO.The experimental group and control group(did not receive IVTA)were compared with each other, and the gain in VA was significantly higher in the study group at 1 month and 2 months after baseline.In Yepremyan et al[20]study early treatment of severe cystoid ME secondary to BRVO with IVTA was effective in reducing foveal thickness and improving VA. Ozkiris et al[21] enrolled 19 patients with persistent ME due to BRVO that failed to respond to previous laser photocoagulation. They injected 8mg IVTA. The differences of VA were statistically significant when compared with baseline values after 1 month, 3 months and last visits. IOP elevation exceeding 21mmHg was observed in 26.3% of eyes at 1 month, 15.7% at 3 months and 5.2% at the last visit.Table 1 Baseline and after treatment visual acuity in Kenalog treatment group and conventional treatment group（略）
Some studies suggested that intravitreal injection of triamcinolone aceonide may not be effective for treatment of macular edema in all CRVO patients or all nonischemic CRVO patients[22] and in some studies IVTA caused an increase in IOP. Gelston et al[23] injected 4mg TA in 9 patients and compared with 10 control patients. No significant difference in visual acuity between CRVO treatment group and control group was observed at the final 6month visit. There was a significant increase in IOP at the 2month visit.
In Avitabile et al[24] study, fiftysix patients (63 eyes) affected by cystoid macular edema due to diabetes or retinal vein occlusion. Of them 22 eyes received 4mg intravitreal TA; 21 eyes underwent MLG (macular laser grid); and 20 eyes received 4mg intravitreal TA, and after 3 months, MLG. Mean followup duration was 9±2 months (ranged 6 to 12 months). After the treatment, at 45 days, 3, 6, and 9 months in the TA group, visual acuity had improved. In the MLG group, visual acuity was unchanged although central macular thickness had decreased by 5%, 13%, 14%, and 16%. In the TA+MLG group, visual acuity had improved. The groups receiving TA had better visual acuity and lower central macular thickness values at all time points. This study concluded that IVTA could be used as primary treatment in patients with cystoid macular edema.
Results from some studies showed that IVTA can substantially improve vision in some patients, but most patients have stable visual acuity compared with baseline at 1 year despite repeated injections[25].
Also TA is effective as a shortterm treatment for macular edema due to retinal vein occlusion. In Moschos et al[26] study, 15 eyes with macular edema due to nonischemic CRVO were injected 4mg TA and followed up for 1 year. In this study visual acuity increased to a significant degree at 3 months, to a smaller degree at 6 months but at 12 months there was no significant improvement. In a prospective interventional study including 13 eyes with RVO and ME, patients received an intravitreal injection of 4mg TA. Followup time was 1 year with repeated injections where appropriate. 8 eyes responded well at 13 months post injection. All 8 eyes developed recurrent ME and 5 received injections. No improvement in visual acuity or OCT macular thickness decrease was seen after the second injection with visual acuity returning to baseline levels at oneyear followup[27]. In Krepler et al[28] study , 13 patients received 4mg IVTA. A significant improvement in visual acuity was observed until 3 months and 6 months.
However, the significant effect was not permanent and persisted for a maximum of 6 months[28]. Whereas in our study no significant difference was observed in visual acuity at the last followup compared to one month after treatment.
Our results showed that although visual acuity improvement was seen in both groups but Kenalog was more effective than conventional treatment for ME due to RVO. In addition, no serious side effects such as postoperative endophthalmitis or retinal detachment occurred.
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