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Editor,

Cystoid macular oedema (CME) is the most significant cause of visual loss associated with uveitis (Rothova et al. 1996). Intravitreal triamcinolone (IVTA) has been used successfully as a primary treatment, particularly in unilateral disease, but a single injection lasts only approximately 3 months, and 15–30% of patients develop cataract and 25–45% of patients develop elevated intraocular pressure (IOP) (Kok et al. 2005; van Kooij et al. 2006). Studies investigating repeat IVTA injections in other conditions such as diabetic macular oedema have suggested that they become less effective with time and generate increasing problems with IOP (Chan et al. 2006; Gillies et al. 2007), but there is little evidence regarding the outcome of repeat injections in uveitis. This study was designed to address these issues and to determine whether repeated IVTA injections are a viable treatment option for recurrent uveitic CME.

We report a retrospective, consecutive case series of 41 eyes of 35 patients with uveitis recruited from two tertiary referral uveitis clinics. Included eyes had CME proven on optical coherence tomography or fluorescein angiography, were given at least two IVTA injections and were followed up for at least 3 months following their last injection. All injections were given as 4 mg/0.1 ml triamcinolone acetonide (Kenalog), taken straight from the vial. Repeat injections were given in responsive patients if CME recurred, but were not repeated in patients with a marked steroid response. The study was approved by the Research Governance Committee of Moorfields Eye Hospital (LIGS1021) and the Institutional Review Board of Sydney Eye Hospital.

Following the first IVTA injection, CME resolved in 36 of 41 eyes (88%) in a mean of 5 weeks (range 1–14 weeks), but recurred in all eyes at a mean of 7 months (range 2–23 months). After the second injection, CME improved in 31 of 41 eyes (76%), but recurred in 25 eyes at a mean of 5 months (range 1–13 months). Twenty patients had a third IVTA injection, and 10 patients had more than three injections. There was a statistically significant improvement in visual acuity after each injection (p < 0.01), with no evidence of reducing efficacy (Fig. 1A).

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Figure 1.  Response to repeat intravitreal injections of triamcinolone acetonide. In (A) mean ± SEM improvement in logMAR visual acuity is shown, indicating no reduction in effect with repeat injections. In (B), the number of patients with IOP which increased to >21 and ≥30 mmHg is indicated. Note that patients with a marked steroid response were not offered further injections, so the number of patients with a steroid response declines over time.

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Nineteen of 41 eyes (46%) had an IOP increase of 10 mmHg or more from baseline, and 10 eyes (25%) developed an IOP >30 mmHg. However, no eyes required IOP-lowering surgery, and the magnitude of IOP changes did not increase with repeat injections, although patients with a marked steroid response were not offered further injections (Fig. 1B). As expected, repeat IVTA injections were associated with cataract (p < 0.01), and by the time of the fifth IVTA injection, all phakic patients had undergone cataract surgery (Fig. 2). IVTA injection otherwise had a good safety profile: from a total of 118 IVTA injections, only one eye developed IVTA-induced sterile endophthalmitis, and there were no other severe adverse events.

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Figure 2.  Cataract surgery following repeat intravitreal triamcinolone (IVTA) acetonide injections. Kaplan–Meier survival to cataract surgery is shown, indicating that all phakic patients developed visually significant cataract requiring surgery by the fifth IVTA injection.

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Nineteen patients were being treated with systemic therapy at the start of the study. The mean dose of systemic prednisolone required to control the disease decreased significantly over the course of the study to <7.5 mg/day (Fig. 3), and 11 patients were able to reduce significantly or stop their second-line agents.

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Figure 3.  Systemic immunosuppression. Doses of systemic corticosteroids are indicated (mean ± SEM) and indicate a significant reduction over time to long-term sustainable levels of ≤7.5 mg prednisolone per day.

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This study demonstrates the effects of repeated intravitreal triamcinolone injections in patients with uveitic CME: best corrected visual acuity (BCVA) improves, with no evidence of tachyphylaxis, and systemic immunosuppressive therapy can be withdrawn in some patients. However, all patients eventually develop cataract, and IOP-lowering medication is needed in nearly 50% of eyes. In summary, repeat IVTA treatment in patients with recurrent uveitic CME is associated with a repeatable improvement in visual acuity and is thus a viable treatment option for recurrent disease.

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