Clinical Review of Glaucoma Resulting from Intravitreal Triamcinolone Steroid Injection Dustin J Cou

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Clinical Review of Glaucoma Resulting from
Intravitreal Triamcinolone Steroid
InjectionDustin J Coupal MDAlan S Crandall
MDJason Goldsmith MDNorm A Zabriskie MDMoran
Eye CenterASCRS 2006
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Steroid Induced Glaucoma

• Purpose
• We undertook our study to review our clinical
  experience and treatment success in the
  management of glaucoma that had occurred
  secondary to intravitreal steroid injection.

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Steroid Induced Glaucoma

• Introduction
• Steroid induced glaucoma over the past 10 years
  has become a more common management dilemma. As
  intravitreal depot steroids have become more
  useful in the management of various retinal
  diseases the secondary complications, such as
  elevated intraocular pressure, have become more
  prevalent. In our practice, we were curious to
  better understand the significance of
  intravitreal triamcinolone on intraocular
  pressure (IOP) and whether our management was
  effective or could be optimized.

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Steroid Induced Glaucoma

• Methods
• A retrospective chart review was performed on
  patients who underwent intravitreal triamcinolone
  acetonide (4mg) injections for the management of
  chronic macular edema or subretinal
  neovascularization from 2001-2005. Data was
  collected from all case records including patient
  age, sex, IOP, visual acuity, number of
  injections, number of glaucoma medications and
  systemic health factors. Cases of neovascular or
  angle closure glaucoma were excluded. Cases of
  steroid induced glaucoma were further analyzed
  with regard to the treatment performed and the
  associated treatment response.

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Steroid Induced Glaucoma

• Results
• Population
• 52 patients
• 24 males, 28 females
• 63 eyes
• 34 right, 29 left
• 95 intravitreal injections
• Mean baseline intraocular pressure was found to
  be 15.77 (SD 2.87)

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Steroid Induced Glaucoma

• Results
• In terms of patient age, sex, visual acuity,
  refraction, personal glaucoma history, number of
  injections and systemic health we were not able
  to find any statistically significant
  characteristics of our study population that
  would predict steroid responsive patients.
• Only two patients had documented first degree
  family history of glaucoma and both of those
  patients did develop significant intraocular
  pressure response however this was not
  statistically significant (p0.93).

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Steroid Induced Glaucoma

• Results
• Following review of 95 intraocular injections we
  found
• 37 cases of rise in IOP to 22mmhg or greater
• 11 cases of rise in IOP to 30mmhg or greater
• 2 cases of rise in IOP to 40mmhg or greater
• One of these 2 cases required trabeculectomy
• Complications
• One case of culture positive (S.Viridans)
  endophthalmitis was documented 2 days following
  injection
• 6 patients required cataract surgery during the
  follow-up period however this may not be directly
  related to the steroid injection

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Steroid Induced Glaucoma

• Results
• Analysis showed that there was a statistically
  significant average rise in IOP for each of the
  first 3 post-injection visits.
• Period 1 Avg follow-up 33.01 Days /- 23.5
• Mean IOP Increase from baseline 2.5 mmhg
  (plt0.0001)
• Period 2 Avg follow-up 92.0 Days /- 53
• Mean IOP Increase from baseline 3.1 mmhg
  (plt0.0001)
• Period 3 Avg follow-up 189.3 Days /- 114
• Mean IOP Increase from baseline 3.2 mmhg
  (p0.0007)
• Period 4 Avg follow-up 293.2 Days /- 182
• Mean IOP Increase from baseline 1.2 mmhg
  (P0.11)
• Period 5 Avg folow-up 387 Days /- 245
• Mean IOP Increase from baseline 1.1 mmhg
  (P0.09)
• Period 6 Avg follow-up 434 Days /- 237
• Mean IOP Increase from baseline 0.95 mmhg
  (P0.12)

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Steroid Induced Glaucoma

• Results
• Scatter plot of all patients (Figure 1 Next
  Slide) shows substantial individual patient
  variability with regard to IOP response.
• Trend line analysis to the 4th order shows a
  trend toward higher IOPs in the first 296 days
  following intravitreal injection. Maximal mean
  IOP response by trend line is found to be 4mmhg
  with a peak at 95 days

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Steroid Induced Glaucoma

• Figure 1

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Steroid Induced Glaucoma

• Conclusions
• Steroid response following 4mg of intravitreal
  triamcinolone occurred following 38.9 of
  injections which is similar to previously
  published reports1-3.
• All patients with steroid response in our
  preliminary review were easily manageable with
  standard topical anti-glaucoma therapy and only
  one patient required trabeculectomy which was
  also successful using our routine surgical
  technique

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Steroid Induced Glaucoma

• Conclusions
• We are continuing our review of patients that
  received intravitreal triamcinolone at our
  institution and perhaps with a larger database of
  patients will we be able to identify further
  subtle features of these patients that will help
  us better predict and treat steroid responses

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Steroid Induced Glaucoma

• References
• Jonas JB, Degenring RF, Kreissig I, Akkoyun I,
  Kamppeter BA. Intraocular pressure elevation
  after intravitreal triamcinolone acetonide
  injection. Ophthalmology. 2005 Apr112(4)593-8
• Park HY, Yi K, Kim HK. Intraocular pressure
  elevation after intravitreal triamcinolone
  acetonide injection. Korean J Ophthalmol. 2005
  Jun19(2)122-7.
• Agrawal S, Agrawal J, Agrawal TP. Vitrectomy as a
  treatment for elevated intraocular pressure
  following intravitreal injection of triamcinolone
  acetonide. Am J Ophthalmol. 2004
  Oct138(4)679-80.