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BRIEF REPORTS
Year : 2005  |  Volume : 53  |  Issue : 1  |  Page : 65-66

Persistent Depot of Triamcinolone Acetonide after a Single Intravitreal Injection


Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, India

Date of Submission08-Sep-2003
Date of Acceptance16-Sep-2003

Correspondence Address:
Vasumathy Vedantham
Aravind Eye Hospital & Postgraduate Institute of Ophthalmology, 1, Anna Nagar, Madurai - 625 020, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0301-4738.15291

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  Abstract 

The persistence of depot of triamcinolone at four months following a single intravitreal injection is described.

Keywords: Triamcinolone, intravitreal, depot, pharmacokinetics


How to cite this article:
Vedantham V, Kolluru C, Ramasamy K. Persistent Depot of Triamcinolone Acetonide after a Single Intravitreal Injection. Indian J Ophthalmol 2005;53:65-6

How to cite this URL:
Vedantham V, Kolluru C, Ramasamy K. Persistent Depot of Triamcinolone Acetonide after a Single Intravitreal Injection. Indian J Ophthalmol [serial online] 2005 [cited 2020 Nov 30];53:65-6. Available from: https://www.ijo.in/text.asp?2005/53/1/65/15291

Intravitreal injections of triamcinolone acetonide, a potent corticosteroid are increasingly used in treating exudative age-related macular degeneration (AMD). Various studies, both human [1] and animal [2],[3] have focused on the pharmacokinetics of intravitreal triamcinolone by clinical and laboratory estimations. However, the clinically evident persistence of the corticosteroid 4 months after a single intravitreal injection has hitherto been unreported. To the best of acknowledge this is the first case report to document the persistence of clinically visible depot of intravitreal triamcinolone after 120 days (Medline search).[1]-[4]


  Case report Top


A 76-year-old male was referred to the retina-vitreous service of our tertiary care hospital with complaints of sudden reduction of vision in the right eye. The best corrected visual acuity was counting fingers at half metre and 6/36 in the right and left eyes respectively. Fundus examination revealed moderate non-proliferative diabetic retinopathy and an active large subfoveal choroidal neovascular membrane (CNVM) of five disc diameters (DD) in size in the right eye ([Figure 1a]) and stable lasered proliferative diabetic retinopathy in the left eye. Fluorescein angiography confirmed an occult CNVM. Due to the large size of the CNVM and the poor prognosis the patient was offered the choice of intravitreal injection of corticosteroid after explaining the as yet unproven status and risks of the procedure.

He underwent intravitreal injection of 0.1 ml (4.0 mg) of a commercially available suspension of triamcinolone acetonide (Tricort 40, 40mg/ml, Cadila Pharmaceuticals, Ahmedabad, India) under aseptic conditions in the operating room. The patient was seen one month after the injection. The fundus examination showed a scarring CNVM and the corticosteroid depot was seen inferiorly in the peripheral vitreous. The intraocular pressure was normal. At four months of follow-up, the CNVM was totally scarred ([Figure 1b]) with a persistent depot of triamcinolone seen in the inferior vitreous [Figure - 2]. Fundus fluorescein angiography confirmed the scarred nature of the CNVM [Figure - 3]. There was no improvement in the visual acuity and the intraocular pressure was normal.


  Discussion Top


Triamcinolone acetonide is a potent corticosteroid and is increasingly tried as an intravitreal depot in exudative AMD.[5],[6] The relatively low solubility in water ensures its longer persistence in the vitreous, in contrast to the other more water soluble corticosteroids such as dexamethasone. The pharmacokinetics of intravitreal triamcinolone has been well documented in several conflicting animal [2],[3] and human studies.[1] In a study of rabbit eyes by Scholes et al2 the half-life of intravitreal triamcinolone (determined by high-performance liquid chromatography) was 1.6 days, and no drug was detectable by HPLC analysis at 21 days in five of six eyes.[2] Intravitreal triamcinolone was however clinically observable to an average of 23.3 days.

In another study on rabbit eyes by Schindler et al3 intravitreal triamcinolone was visible up to 41 days and 16.8 days in non-vitrectomised and vitrectomised rabbit eyes respectively. Opinions are divided if the ophthalmoscopically visible triamcinolone correlates with the colorimetric or chromatographically assessed drug volume in rabbit eyes.[2],[3]

In human eyes, the mean elimination half-life of triamcinolone is 18.6 days and 3.2 days in non-vitrectomised and vitrectomised patients respectively,[1] and that after a single intravitreal injection, measurable concentrations of triamcinolone would be expected to last for approximately 3 months (93 ± 28 days) in the absence of a vitrectomy. This conclusion was based on a study aqueous humour samples, where the injected depot was not seen clinically. Jonas et al4, have reported a case of secondary open angle glaucoma following intravitreal triamcinolone injection wherein triamcinolone in both crystalline and soluble forms was found in the vitreous and aqueous humour respectively for more than nine months following the injection. This conclusion was following the laboratory measurements of the steroid levels and the depot was not seen clinically. Based on indirect evidence Gillies et al6 have speculated that significant levels of triamcinolone persisted in the eye for at least four months after a single intravitreal injection of triamcinolone. To the best of our knowledge, this is the first case report to document the persistence of clinically visible depot of intravitreal triamcinolone even after 120 days.

Despite the absence of any complications in our patient this report suggests the need for a careful re-estimation of the pharmacokinetics of intravitreal triamcinolone in humans in order to determine the optimum timing of a re-injection.



 
  References Top

1.
Beer PM, Bakri SJ, Singh RJ, Liu W, Peters GB 3rd, Miller M. Intraocular concentration and pharmacokinetics of triamcinolone acetonide after a single intravitreal injection. Ophthalmology 2003;110:681-86.  Back to cited text no. 1
    
2.
Scholes GN, O'Brien WJ, Abrams GW, Kubicek MF. Clearance of triamcinolone from vitreous. Arch Ophthalmol 1985;103:1567-69.  Back to cited text no. 2
    
3.
Schindler RH, Chandler D, Thresher R, Machemer R. The clearance of intravitreal triamcinolone acetonide. Am J Ophthalmol 1982;93: 415-17.  Back to cited text no. 3
    
4.
Jonas JB, Kreissig I, Degenring R. Secondary chronic open-angle glaucoma after intravitreal triamcinolone acetonide. Arch Ophthalmol 2003;121:729-30.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.
Jonas JB, Kreissig I, Hugger P, Sauder G, Panda-Jonas S, Degenring R. Intravitreal triamcinolone acetonide for exudative age related macular degeneration. Br J Ophthalmol 2003;87:462-68.  Back to cited text no. 5
    
6.
Gillies HC, Simpson JM, Luo W, Penfold P, Hunyor ABL, Chua W, Mitchell P, Billson F. A randomized clinical trial of a single dose of intravitreal triamcinolone acetonide for neovascular age-related macular degeneration. One-year results. Arch Ophthalmol 2003;121:667-73.  Back to cited text no. 6
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]


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