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ORIGINAL ARTICLE
Year : 2013  |  Volume : 5  |  Issue : 1  |  Page : 23-27

Visual outcome after macular grid laser and intravitreal triamcinolone acetonide in diabetic macular edema


1 Department of Ophthalmology, Sher-e-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
2 Department of Ophthalmology, Government Medical College, Srinagar, Jammu and Kashmir, India
3 Department of Fellow Paediatric Ophthalmology, Aravind Eye Care System, Coimbatore, Tamil Nadu, India
4 Department of Dental Surgery, Government Medical College, Srinagar, Jammu and Kashmir, India
5 Department of Fellow Cornea And Refractive Surgery, Aravind Eye Care System, Coimbatore, Tamil Nadu, India

Date of Web Publication21-Sep-2013

Correspondence Address:
Omar Rashid
77, Osman Abad, Ashpeer, Sopore - 193 201, Jammu and Kashmir
India
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DOI: 10.4103/1858-540X.118643

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  Abstract 

Introduction: Macular edema affects approximately 29% of diabetic patients and constitutes the primary cause of visual impairment in this population. The combination therapy of grid laser and intravitreal triamcinolone acetonide (IVTA), the reaction mechanism of each therapy to macular edema is different; hence, not only greater effects on the reduction of macular edema can be anticipated, but also the stimulation of inflammatory reaction induced by grid laser could be prevented by anti-inflammatory reaction of steroids as investigated in several studies. Purpose:The purpose of this study was to assess the best corrected visual acuity after IVTA and macular grid laser in combination in cases of diabetic macular edema. Materials and Methods: A total of 50 patients of diabetic macular edema were enrolled in our prospective, randomized clinical trial study, grid laser, and IVTA was given to each patient in combination. The pre-intervention and post-intervention best corrected visual acuity was studied. Results: We observed 35 (70%) patients improved by 1 or more line on Snellen's chart, 12 (24%) remain unchanged and 3 (6%) deteriorated from baseline. The overall mean improvement in visual acuity was 1.08 with SD of ± 0.16. Conclusion: The results of present study showed a favorable influence of grid laser and intravitreal triamcinolone acetonide in diabetic macular edema. It improves and stabilizes the visual acuity in patients with the diabetic macular edema.

Keywords: Intravitreal, laser, macular edema, visual acuity


How to cite this article:
Raja W, Qureshi ST, Sarosh R, Bhat AA, Rafia, Rashid O. Visual outcome after macular grid laser and intravitreal triamcinolone acetonide in diabetic macular edema. Sudanese J Ophthalmol 2013;5:23-7

How to cite this URL:
Raja W, Qureshi ST, Sarosh R, Bhat AA, Rafia, Rashid O. Visual outcome after macular grid laser and intravitreal triamcinolone acetonide in diabetic macular edema. Sudanese J Ophthalmol [serial online] 2013 [cited 2019 Dec 8];5:23-7. Available from: http://www.sjopthal.net/text.asp?2013/5/1/23/118643


  Introduction Top


Diabetic retinopathy is a micro-angiopathy, which primarily affects the pre-capillary arterioles, capillaries, and post-capillary venules although larger vessels may also be involved. It is a progressive dysfunction of retinal vessels caused by chronic hyperglycemia. [1] Diabetic retinopathy is the commonest cause of blindness in the population of working age in developed nations and is of increasing importance in developing nations. [2],[3] Diabetic retinopathy has features of both microvascular occlusion and microvascular leakage. Changes in macular region need special mention, owing to their effect on vision. These changes may be associated with non-proliferative diabetic retinopathy or proliferative diabetic retinopathy. The diabetic macular edema occurs due to increased permeability of the retinal capillaries. It is termed as clinically significant macular edema (CSME). [4],[5] Triamcinolone acetonide is a crystal type steroid that has been widely used in ophthalmology and has been reported by several studies that intravitreal injection is effective in the reduction of macular thickness in diabetic macular edema and the improvement of visual acuity. [6],[7] Diverse dosage of Triamcinolone for intravitreal injection from 1 mg to 25 mg have been attempted. Nonetheless when comparing treatment outcomes, the minimum dosage could minimize side-effects; thus, the 4 mg presently utilized most often in clinics. [8],[9],[10] However, Triamcinolone injected into vitreous body disappears in 3-6 weeks after absorption of drug and the recurrence of macular edema afterward have been reported in several studies. [11],[12] Laser treatment for CSME consists of direct focal treatment, grid treatment or a combination of both. If the edema is diffuse grid laser is applied. If the leakage affects a small part of the macula as in circinate retinopathy, focal laser is applied. Laser produces thinning of retina and choroidal vasculature helps in reducing edema by the autoregulatory constriction of retinal vasculature in the leaking area. In the combination therapy of grid laser and triamcinolone injection the reaction mechanisms of each therapy to macular edema is different hence not only greater effects on the reduction, but also the stimulation of inflammatory reaction induced by the grid laser could be prevented by the anti-inflammatory reaction of steroids.


  Purpose Top


The purpose of this study was to assess the best corrected visual acuity and the angiographic changes after the combination therapy of intravitreal triamcinolone acetonide (IVTA) and macular grid laser.


  Materials and Methods Top


This prospective, randomized clinical study was carried out for a period of 2 years on 50 patients on an out-patient basis in ophthalmology department of Sri Maharaja Hari Singh hospital of Government Medical College, Srinagar, Jammu and Kashmir, India. All the patients with diabetic macular edema were taken for the study. Patients with ischemic diabetic maculopathy, prior intraocular surgery, prior photocoagulation, cases of corneal diseases, inflammatory eye diseases, advanced cataract, optic neuropathy, cystoid macular edema, and age related macular degeneration were excluded from the study. Patients enrolled for the study underwent test for visual acuity (Snellen's), slit lamp examination, dilated fundus examination, applanation tonometry and fluorescein fundus angiography (FFA). After taking consent for the procedure from the patient and going through the basic work-up, first grid laser and then IVTA were given.

Grid Laser Therapy

The affected eye was dilated with Tropicamide (used 3 times after every 15 min) and then anesthetized with 2% topical lignocaine hydrochloride. Using Rodenstock contact lens with spot size of 50-200 m 6 and 0.1-0.2 s exposure time, double frequency Neodymium Ytterium Aluminium Garnet (Nd: YAG) laser was applied at one laser burn interval. The laser irradiated on the area 500-3000 micro meter from the macular center at thickened retina, produces gentle reaction of retina to the area of leakage as shown by FFA.

The same eye was anesthetized again with lignocaine 2% and palpebra and globe were sterilized with 0.05% povidine iodine drops. A vial of triamcinolone acetonide (40 mg/ml) was taken, 0.1 ml (4 mg) of loaded into an insulin syringe (30 gauges). After separating the lid with a wire speculum 0.1 ml of triamcinolone acetonide was injected into the vitreous cavity through the infero-temporal pars plana, 3.5-4.0 mm from the limbus. The globe was fixed with a swab stick, topical antibiotic drops instilled, and tamponade applied for some time. The patient was followed-up subsequently at 1, 2, 4, and 3 months, and then a repeat angiography was carried out at 3 months.


  Observations and Results Top


Data were described as mean ± SD as well as mean ± standard error and percentage. The inter group comparisons for metric/non-metric data were carried out by Mann Whitney 'U' test and Chi-square test, besides intra-group comparison were carried out by Wilcoxon signed rank test and Fredman test. All the variances were measured at 95% confidence interval. Statistical Package for Social Sciences and Microsoft Excel Software were used for data analysis.

The sample consisted of 50 patients, out of which 22 were males and 28 were females. Males were in the mean age group of 56.7 years with SD of ±8.9 years (range 40-75 years). Females were in mean age group of 53.9 years with SD of 7.1 years (range 38-65 years). The difference between the two was not clinically significant [Table 1].
Table 1: Age and gender distribution of the studied subjects

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[Table 2] depicts that there were 2 males (9.1% of total male patients) and 1 female (3.6% of total female patients) with type I diabetes mellitus. There were 20 males (90.9% of total male patients) and 27 females (96.4% of total female patients) with type 2 diabetes mellitus.
Table 2: Type of diabetes mellitus in the studied subjects

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[Table 3] shows that there were 24 patients (48%) with left eye affected and 26 patients (52%) with right eye affected. Baseline Intra Ocular Pressure (IOP) was normal in 50 patients (100%), pre-intervention Slit Lamp Examination was normal in 26 (52%), and minimal cataractous changes seen in 24 (48%) of patients. Pre-intervention fundus was Non Proliferative Diabetic Retinopathy (NPDR) with CSME in 37 patients (74%) and CSME in 13 patients (26%). Pre-intervention FFA was NPDR with diffuse leakage at macula in 37 patients (74%) and diffuse leakage at macula in 13 (26%).
Table 3: Examination of the affected eye

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We observed that 35 (70%) patients showed improvement by 1 or more lines on Snellen's chart, 12 (24%) remains unchanged and 3 (6%) deteriorated from baseline visual acuity. The overall mean improvement was 1.08 on Snellen's chart with SD of ±0.16 [Table 4].
Table 4: Baseline to final visit line improvement

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[Table 5] shows raised IOP in 10 patiens (20%) and persistant macular edema in three patients (6%).
Table 5: Post-intervention complications

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[Table 6] shows that 27 (54%) had Best Corrected Visual Acuity (BCVA) in 6/6 to 6/18 after intervention as compared to 13 (26%) prior to intervention. 23 (46%) patients had BCVA in 6/24 to 6/60 after intervention as compared to 36 (72%) patients prior to intervention although 0 (0.0%) had BCVA ≤6/60 after intervention as compared to 1 (2%) prior to therapy.
Table 6: Pre- and post-intervention BCVA

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  Discussion Top


Diabetic retinopathy is the most common cause of blindness in the developed nation and is of increasing importance in developing nations and the prevalence increases with age. [2],[13] The prevalence of diabetic retinopathy of any severity in the diabetic population as a whole is approximately 30%. [14 ] The purpose of our study was to examine one eye each of 50 cases of diabetic macular edema and to find out the visual outcome after combination of grid laser and IVTA in diabetic macular edema. In the present study, 50 diabetic patients were analyzed in which three patients were having type I diabetes mellitus and 47 patients were having type II diabetes mellitus. The age range was between 38 years and 75 years with mean age of 55.2 years with standard deviation of ± 7.9 years, 22 (44%) were males and 28 (56%) were females. Duration of diabetes was between range of 3 years and 26 years with mean duration of 12.7 years with standard deviation of ±5.8 years. Hypertension was present in 66% of patients, which shows a strong correlation with systemic hypertension. This result is similar to the study carried out by Knowler et al. on increased incidence of retinopathy in diabetes with elevated blood pressure; a 6 year follow-up study in Pima Indians. [15] Grid laser and IVTA was given in combination to all 50 patients of our study group. Choi et al. have reported that in patients of diabetic macular edema the combination therapy of laser and IVTA has better results. [16] Jeong et al. have reported that in diabetic macular edema cases without definite leakage points, laser therapy, and steroid therapy alone showed comparable effects on the improvement of visual acuity and for these cases, the combination of two therapies was thought more effective. [17] In the combination therapy of grid laser and triamcinolone injection the reaction mechanism of each therapy to macular edema is different; hence, not only greater effects on the reduction of macular edema can be anticipated, but also the stimulation of inflammatory reaction induced by grid laser could be prevented by anti-inflammatory reaction of steroids as investigated in several studies. For CSME, the early treatment of diabetic retinopathy shows that immediate laser photocoagulation reduces the risk of moderate visual loss by at least 50%, which is in tally with our study. [18] Following grid laser and IVTA BCVA improved in 70% of the patients, unchanged (static) in 24% patients and deteriorated in 6% of the patients. Similar results were found by Sutter et al.[19] Our study was also in close tally with the study carried out by Kaderli et al. who found BCVA acuity improved in 69% patents after combination therapy. [20] A similar study carried out by Tunc et al. found that visual acuity improved in 80% of patients. [21] In our study, we found that 54% patients have visual acuity in group 6/6 to 6/18 after combination therapy, which was only 26% before therapy, 46% patients have in group 6/24 to 6/60, which was 72% before and 0% patients in group <6/60 which was 2% prior to intervention. This was statistically significant (P = 0.000). This is in agreement with the study carried out by Lee et al.[22] In our study, we found 20% of patients have raised intraocular pressure after therapy, which is in agreement with the study carried out by others. It is in close tally with Lee et al. who found raised intraocular pressure in 25% of patients. [22]


  Conclusion Top


Combined laser treatment with triamcinolone targets two different mechanisms supposed to cause macular edema in diabetics. No extra sittings are required and the procedure is minimally invasive. Encouraging results in terms of improving the visual acuity and decreasing macular edema suggest combination therapy of grid laser and IVTA for diabetic macular edema should be tried as one of the modalities of treatment.

 
  References Top

1.Foulds WS, Maccuish AC, Barrie T. The cost effectiveness of screening for diabetic retinopathy. Semin Ophthalmol 1987;2:45-50.  Back to cited text no. 1
    
2.National Society to Prevent Blindness. Vision problems in the US: Facts and figures. Preferred Practice Patterns Series: Diabetic Retinopathy. Am Acad Ophthalmol 1993;1:19-20.   Back to cited text no. 2
    
3.Ghafour IM, Allan D, Foulds WS. Common causes of blindness and visual handicap in the west of Scotland. Br J Ophthalmol 1983;67:209-13.  Back to cited text no. 3
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4.Patz A, Schatz H, Berkow JW, Gittelsohn AM, Ticho U. Macular edema - An overlooked complication of diabetic retinopathy. Trans Am Acad Ophthalmol Otolaryngol 1973;77:OP34-42.  Back to cited text no. 4
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5.Early Treatment Diabetic Retinopathy Research Group. Photocoagulation for diabetic macular edema: EIDRS Report-1. Arch Ophthalmol 1985;103:1796-806.  Back to cited text no. 5
    
6.Early Treatment Diabetic Retinopathy Study Research Group. Focal photocoagulation treatment of DME. Relationship of treatment effect of fluorescein angiographic and other retinal characteristics at baseline. Early Treatment Diabetic Retinopathy Study Report No. 19. Arch Ophthalmol 1995;113:1144-55.  Back to cited text no. 6
    
7.Micelli Ferrari T, Sborgia L, Furino C, Cardascia N, Ferreri P, Besozzi G, et al. Intravitreal triamcinolone acetonide: Valuation of retinal thickness changes measured by optical coherence tomography in diffuse diabetic macular edema. Eur J Ophthalmol 2004;14:321-4.  Back to cited text no. 7
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8.Martidis A, Duker JS, Greenberg PB, Rogers AH, Puliafito CA, Reichel E, et al. Intravitreal triamcinolone for refractory diabetic macular edema. Ophthalmology 2002;109:920-7.  Back to cited text no. 8
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9.Jonas JB, Kreissig I, Söfker A, Degenring RF. Intravitreal injection of triamcinolone for diffuse diabetic macular edema. Arch Ophthalmol 2003;121:57-61.  Back to cited text no. 9
    
10.Antcliff RJ, Spalton DJ, Stanford MR, Graham EM, ffytche TJ, Marshall J. Intravitreal triamcinolone for uveitic cystoid macular edema: An optical coherence tomography study. Ophthalmology 2001;108:765-72.  Back to cited text no. 10
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11.Schindler RH, Chandler D, Thresher R, Machemer R. The clearance of intravitreal triamcinolone acetonide. Am J Ophthalmol 1982;93:415-7.  Back to cited text no. 11
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12.Beer PM, Bakri SJ, Singh RJ, Liu W, Peters GB 3 rd , Miller M. Intraocular concentration and pharmacokinetics of triamcinolone acetonide after a single intravitreal injection. Ophthalmology 2003;110:681-6.  Back to cited text no. 12
    
13.Klein R, Klein BE, Moss SE, Cruickshanks KJ. The Wisconsin Epidemiologic Study of diabetic retinopathy. XIV. Ten-year incidence and progression of diabetic retinopathy. Arch Ophthalmol 1994;112:1217-28.  Back to cited text no. 13
    
14.Kohener EM, Stratton IM, Aldinton SJ. Prevalence of diabetic retinopathy at diagnosis of NIDDM in the UKPDS. Invest Ophthalmol Vis Sci 1993;34:713.  Back to cited text no. 14
    
15.Knowler WC, Bennett PH, Ballintine EJ. Increased incidence of retinopathy in diabetics with elevated blood pressure. A six-year follow-up study in Pima Indians. N Engl J Med 1980;302:645-50.  Back to cited text no. 15
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16.Choi KS, Chung JK, Lim SH. Laser photocoagulation combined with intravitreal triamcinolone acetonide injection in proliferative diabetic retinopathy with macular edema. Korean J Ophthalmol 2007;21:11-7.  Back to cited text no. 16
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17.Jeong YC, Bae SH, Kim JW. Comparison of effects of IVTA and photocoagulation depending on types of diabetic macular edema. J Korean Ophthalmol Soc 2007;48:655-64.  Back to cited text no. 17
    
18.Neubauer AS, Ulbig MW. Laser treatment in diabetic retinopathy. Ophthalmologica 2007;221:95-102.  Back to cited text no. 18
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19.Sutter FK, Simpson JM, Gillies MC. Intravitreal triamcinolone for diabetic macular edema that persists after laser treatment: Three-month efficacy and safety results of a prospective, randomized, double-masked, placebo-controlled clinical trial. Ophthalmology 2004;111:2044-9.  Back to cited text no. 19
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20.Kaderli B, Avci R, Gelisken O, Yucel AA. Intravitreal triamcinolone as an adjunct in the treatment of concomitant proliferative diabetic retinopathy and diffuse diabetic macular oedema. Combined IVTA and laser treatment for PDR with CSMO. Int Ophthalmol 2005;26:207-14.  Back to cited text no. 20
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21.Tunc M, Onder HI, Kaya M. Posterior sub-Tenon's capsule triamcinolone injection combined with focal laser photocoagulation for diabetic macular edema. Ophthalmology 2005;112:1086-91.  Back to cited text no. 21
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22.Lee HY, Lee SY, Park JS. Comparison of photocoagulation with combined intravitreal triamcinolone for diabetic macular edema. Korean J Ophthalmol 2009;23:153-8.  Back to cited text no. 22
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