Department of Ophthalmology, Faculty of Clinical Medicine Mannheim, Ruprecht-Karls-University of Heidelberg, Germany

Correspondence to:
Dr J Jonas
Universit?ts-Augenklinik, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany: Jost.Jonas@augen.ma.uni-heidelberg.de

Accepted for publication 1 July 2003

Keywords: intravitreal triamcinolone; exudative retinal detachment; retinal pigment epithelium; proliferative vitreoretinopathy; intraocular

Coats’ disease or entities like Coats’ disease are characterised by a marked exudative retinal detachment with leakage of peripheral retinal vessels, pronounced subretinal deposition of lipids, and eventual progression to total retinal detachment. In some situations, iris neovascularisation can occur, suggesting an angiogenetic component in the course of the disease. In view of the subretinal exudation from the leaking retinal vessels and the possibly neovascular aspect in the disease process, the purpose of this study was to evaluate whether intravitreal triamcinolone acetonide may be helpful in the treatment of Coats’ like diseases. Intravitreal triamcinolone acetonide has recently been shown to have a pronounced anti-oedematous and possibly anti-angiogenic effect in diseases such as diffuse diabetic macular oedema, proliferative diabetic retinopathy, chronic pre-phthisical ocular hypotony, chronic uveitis, and persistent pseudophakic cystoid macular oedema.1,2

Case report

The prospective clinical interventional case report included two patients who presented with subtotal exudative retinal detachment. A 39 year old female patient showed an extensive exudative retinal detachment extending from the temporal periphery of the fundus to the macular region. Diagnosed with Coats’ disease in her early teens, she had received multiple xenon arc coagulations as well as argon laser coagulations. Her visual acuity was 0.02. Intraocular pressure measured 13 mm Hg. The second patient was a 75 year old woman presenting with almost total exudative retinal detachment with marked subretinal deposition of lipids. Visual acuity was 0.05. Intraocular pressure measured 21 mm Hg.

Under topical anaesthesia, both patients received an intravitreal injection of 25 mg triamcinolone acetonide, which was transconjunctivally applied through the pars plana. Both patients were fully informed about the experimental character of the treatment and had given informed consent. The technique has already been described in detail.2 Follow up after the injections were 2 years and 10 months, respectively.

After the injection, visual acuity remained unchanged, and intraocular pressure ranged between 10 and 15 mm Hg in the first patient. In the second patient, visual acuity eventually decreased to light perception after the injection. Intraocular pressure ranged between 19 and 25 mm Hg. In both patients, flare in the anterior chamber and in the vitreous cavity, as assessed by slit lamp biomicroscopy, decreased markedly. Upon ophthalmoscopy, the extent of exudative retinal detachment increased slightly, with subretinal strands being stronger and more visible.

Comment

Although intravitreal triamcinolone acetonide can markedly reduce retinal oedema in eyes with diffuse diabetic macular oedema and pseudophakic cystoid macular oedema, intravitreal triamcinolone acetonide was not pronouncedly helpful in reducing subretinal oedema and re-attaching the retina in the two patients presented in this study. This result was unexpected in view of the presumed anti-phlogistic and anti-proliferative effect of steroids such as triamcinolone acetonide.1,2 It may be explained by a previous experimental study in which triamcinolone acetonide inhibited the proliferation of rabbit dermal and conjunctival fibroblasts in cell culture at 150 mg/l, but paradoxically increased proliferation almost twofold at concentrations ranging from 1–30 mg/l under identical culture conditions.3 As long as the influence of steroids on the proliferation of retinal pigment epithelium cells is unclear, intravitreal triamcinolone acetonide may thus cautiously be taken as adjunct treatment of marked exudative retinal detachment in eyes with a Coats’ like disease. A similar conclusion was drawn in a recent study on eyes with proliferative vitreoretinopathy, in which pars plana vitrectomy was combined with an intravitreal injection of 25 mg of triamcinolone acetonide, and in which unexpectedly, the recurrence rate of proliferative vitreoretinopathy was not markedly diminished.4 Future randomised studies as well as investigations evaluating the effect of intravitreal steroids combined with other drugs such as 5-fluorouracil on the proliferation of retinal pigment epithelium cells and retinal detachment rate5 may be warranted.

References

Machemer R, Sugita G, Tano Y. Treatment of intraocular proliferations with intravitreal steroids. Trans Am Ophthalmol Soc 1979;77:171–80.

Jonas JB, S?fker A. Intraocular injection of crystalline cortisone as adjunctive treatment of diabetic macular edema. Am J Ophthalmol 2001;132:425–7.

Blumenkranz MS, Claflin A, Hajek AS. Selection of therapeutic agents for intraocular proliferative disease. Cell culture evaluation. Arch Ophthalmol 1984;102:598–604.

Jonas JB, S?fker A, Hayler J, et al. Intravitreal crystalline triamcinolone acetonide as additional tool in pars plana vitrectomy for complicated proliferative vitreoretinopathy? Acta Ophthalmol 2003; (in press).

Berger AS, Cheng CK, Pearson PA, et al. Intravitreal sustained release corticosteroid-5-fluoruracil conjugate in the treatment of experimental proliferate vitreoretinopathy. Invest Ophthalmol Vis Sci 1996;37:2318–25.

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《英国眼科学杂志》2004年4月第88卷第4期