The Role of Intravitreal Triamcinolone Acetonide in AMD Management
Within the last five years, the intraocular injection of medications as a treatment modality for posterior segment diseases has increased exponentially. Intravitreal injection of triamcinolone acetonide has been used for the treatment of intraocular edematous, proliferative and neovascular diseases such as diabetic macular edema, macular edema associated with retinal vein occlusion, proliferative diabetic retinopathy, uveitis including sympathetic ophthalmia, pre-phthisical chronic ocular hypotony, and exudative age-related macular degeneration (AMD).(1) When photodynamic therapy was demonstrated in randomized clinical trials to have a beneficial effect for the treatment of predominantly classic subfoveal neovascularization,(2) an evidence-based therapy was not available for all other types of exudative AMD. Based on findings from experimental studies, as well as a randomized study in patients with occult subfoveal neovascularization by Ron Danis and colleagues,(3) intravitreal triamcinolone was increasingly used for the treatment of exudative AMD if photodynamic therapy could not be applied. Case series, non-randomized comparative investigations, and intra-individual inter-eye comparisons of patients with unilateral treatment and bilateral disease suggested that intravitreal triamcinolone was associated with better visual results than the natural course of minimally classic and occult lesions associated with AMD.(1) In contrast, in a randomized study by Mark Gillies including patients with subfoveal neovascularization with any classic component, intravitreal triamcinolone acetonide was not associated with a better visual outcome compared to no therapy.(4) Intravitreal triamcinolone was used more frequently for the treatment of exudative AMD when it was combined with verteporfin-associated photodynamic therapy, since case series showed an improvement in visual acuity in most of the treated patients and since the improvement in vision was maintained during a two-year follow-up period with relatively low retreatment numbers.(5) Side effects such as increased intraocular pressure in about 40% of patients and cataractogenesis in combination with relatively meager results in terms of vision improvement led to an almost complete replacement of intravitreal triamcinolone monotherapy by intravitreal injections of anti-vascular endothelial growth factor (VEGF) drugs, such as pegaptanib, ranibizumab and bevacizumab. Compared with intravitreal triamcinolone monotherapy, these anti-VEGF drugs were associated with markedly better improvement in visual acuity in patients with exudative AMD. Since the effect duration of these intravitreally injected anti-VEGF drugs is limited to several weeks, further research of combination treatment strategies (such as the combination of anti-VEGF agents with intravitreal triamcinolone) is needed to investigate whether intravitreal steroids such as triamcinolone acetonide may re-gain a role in the treatment of AMD.
1. Jonas JB. Intravitreal triamcinolone acetonide: a change in a paradigm. Ophthalmic Res 2006;38:218-245.
2. Miller JW, Schmidt-Erfurth U, Sickenberg M, et al. Photodynamic therapy with verteporfin for choroidal neovascularization caused by age-related macular degeneration: results of a single treatment in a phase 1 and 2 study. Arch Ophthalmol 1999;117:1161-73. Erratum in: Arch Ophthalmol 2000;118:488.
3. Danis RP, Cuilla TA, Pratt LM, Anliker W. Intravitreal triamcinolone acetonide in exudative age-related macular degeneration. Retina 2000;20:244-250.
4. Gillies MC, Simpson JM, Luo W, et al. A randomized clinical trial of a single dose of intravitreal triamcinolone acetonide for neovascular age-related macular degeneration: one-year results. Arch Ophthalmol 2003;121:667-673.
5. Augustin AJ, Schmidt-Erfurth U. Verteporfin therapy combined with intravitreal triamcinolone in all types of choroidal neovascularization due to age-related macular degeneration. Ophthalmology 2005;113:14-22.