- Email: [email protected]
Serum levels of triamcinolone acetonide after intravitreal injection
despite markedly decreased vision (20/125) in one patient.3 Recently, Codenotti and associates4 reported intraretinal nonreflective spaces and increased reflectivity at the level of the inner foveal retina in four patients with solar retinopathy up to 1 week after sun exposure; OCT abnormalities were no longer visible at 1 month and 1 year.4 In the current study, evaluation using third generation OCT demonstrated abnormalities in the outer foveal retina in all patients with late solar retinopathy. These findings are consistent with histopathologic studies of solar retinopathy, in which selective retinal pigment epithelium and photoreceptor damage in the fovea has been described.1,5 Decreased acuity was measured in the patient whose OCT demonstrated abnormalities in the reflective layers corresponding to both outer and inner segments of the photoreceptors. Normal acuity and mild Amsler grid abnormalities were noted in two patients whose OCTs demonstrated partial involvement of the photoreceptor reflective layer. No visual complaints were reported by the patient whose OCT demonstrated only a mildly abnormal reflectivity pattern and absence of optically clear spaces within the outer fovea. Further investigations in patients with solar retinopathy are required to determine whether a direct association exists between degree of visual disturbance and OCT abnormalities of the reflective layers corresponding to photoreceptor outer and inner segments.
METHODS: For 20 consecutive patients, venous blood samples were taken before and 13 ⴞ 19 days (range 4 to 92) after an intravitreal injection of 20 to 25 mg triamcinolone acetonide as treatment of edematous macular diseases. RESULTS: Serum levels of triamcinolone acetonide did not differ significantly (P ⴝ .174; t test for paired matches) preoperatively (0 g/l) and postoperatively (0.065 g/l ⴞ 0.21 g/l). In 18 eyes (90%), triamcinolone acetonide could not be detected in serum samples. For two patients (10%), serum samples taken 5 days and 7 days after the injection, respectively, contained 0.5 g/l triamcinolone acetonide and 0.8 g/l triamcinolone acetonide, respectively. CONCLUSION: After an intravitreal high-dose injection of 20 to 25 mg triamcinolone acetonide, triamcinolone acetonide is not, or only marginally, detectable in serum samples obtained within 4 to 92 days after the injection. (Am J Ophthalmol 2004;137:1142–1143. © 2004 by Elsevier Inc. All rights reserved.)
R
of intravitreal injections of triamcinolone acetonide as treatment of edematous macular disorders such as diffuse diabetic macular edema, age-related macular degeneration, and others.1 Main local side effects reported so far are triamcinolone-induced ocular hypertension, cataract, and infectious or sterile endophthalmitis.2 In an attempt to assess possible systemic side effects of intravitreal triamcinolone acetonide injections, it was the purpose of the present study to measure triamcinolone acetonide concentrations in the peripheral blood after an intravitreal highdose injection. The prospective, interventional case series study included 20 consecutive patients (nine women), who received an intravitreal injection of 20 to 25 mg triamcinolone acetonide as treatment of exudative agerelated macular degeneration (n ⫽ 14, 70%), diabetic macular edema (n ⫽ 4, 20%), or other reasons for macular edema (n ⫽ 2, 10%). Mean age was 73.1 ⫾ 11.3 years (range 43.4 to 94.0). Eight patients (40%) had received one to four intravitreal injections of 20 to 25 mg triamcinolone acetonide earlier, for the same reason, into the same or into the other eye. The technique of injection has been described in detail previously.1 All patients were fully informed about the experimental character of the therapy and had signed an informed consent. The Ethics Committee of the university had approved the study following the tenets of the Declaration of Helsinki. For all patients, venous blood was taken from the antecubital vein before and 4 to 92 days after the injection (mean ⫾ SD, 13 ⫾ 19; median, 8). The blood was centrifuged at 3,000 rpm at 15 C for 10 minutes. The supernatant serum was filled into new storage vessels, and stored at ⫺80 C to await final analysis. The blood samples were analyzed by high perfor-
REFERENCES
1. Tso MO, La Piana FG. The human fovea after sungazing. Trans Am Acad Ophthalmol Otolaryngol 1975;79:788 –795. 2. Yeh LK, Yang CS, Lee FL, Hsu WM, Liu JH. Solar retinopathy: A case report [in Chinese]. Zhonghua Yi Xue Za Zh 1999;62:886 –890. 3. Bechmann M, Ehrt O, Thiel MJ, et al. Optical coherence tomography findings in early solar retinopathy. Br J Ophthalmol 2000;84:546 –547. 4. Codenotti M, Patelli F, Brancato R. OCT findings in patients with retinopathy after watching a solar eclipse. Ophthalmologica 2002;216:463–466. 5. Hope-Ross MW, Mahon GJ, Gardiner TA, Archer DB. Ultrastructural findings in solar retinopathy. Eye 1993;7:29 – 33.
Serum Levels of Triamcinolone Acetonide After Intravitreal Injection Robert F. Degenring, MD, and Jost B. Jonas, MD PURPOSE: To evaluate serum levels of triamcinolone acetonide after intravitreal high-dose injection. DESIGN: Prospective, interventional case series study. Accepted for publication Jan 2, 2004. From the Department of Ophthalmology, Faculty for Clinical Medicine Mannheim, Ruprecht-Karls-University, Heidelberg, Mannheim, Germany. Inquiries to Robert F. Degenring, MD, Department of Ophthalmology, Theodor-Kutzer-Ufer 1–3, 68167 Mannheim, Germany; fax: ⫹49-621383-3803; e-mail: [email protected]
1142
AMERICAN JOURNAL
ECENT STUDIES HAVE SHOWN THE POTENTIAL BENEFIT
OF
OPHTHALMOLOGY
JUNE 2004
mance liquid chromatography and tandem mass spectrometry.3 Detection limit of the method was 0.5 g/l. Mean preoperative serum levels of triamcinolone acetonide did not differ significantly (P ⫽ .174; t test for paired matches) from mean postoperative triamcinolone acetonide concentrations in the serum (0 g/l [range 0 g/l to 0 g/l] versus 0.065 g/l ⫾ 0.21 g/l [range 0 to 0.8 g/l]; median 0 g/l). In 18 serum samples (90%), triamcinolone acetonide could not be detected. For two patients (10%), triamcinolone acetonide was detected in the serum samples. One of these samples obtained 7 days after the injection contained 0.8 g/l triamcinolone acetonide. This patient suffering from diffuse diabetic macular edema had not received any previous intravitreal injections of triamcinolone acetonide. The second sample taken 5 days after the injection contained 0.5 g/l triamcinolone acetonide. For treatment of exudative age-related macular degeneration, this patient had received four previous intravitreal injections of triamcinolone acetonide 12, 17, 24, and 29 months before inclusion into the present study. The average serum cortisol levels of healthy men and women aged 65 to 88 years ranged between 70 g/l and 80 g/l.4 The mean daily production rate of cortisol is approximately 9 to 11 mg/(m2 ⫻ day), resulting in a total availability of 15 to 20 mg cortisol each day in an average person.5 Bearing in mind the five times higher potency of triamcinolone compared with hydrocortisone, the highest concentration of triamcinolone acetonide (0.8 g/l) as measured in the present study is likely without systemic effect. Additionally, in 90% of the samples triamcinolone acetonide was not detected. One may infer, therefore, that an intravitreal high-dose injection of triamcinolone acetonide adds clinically insignificant quantities to the physiologic concentration of corticosteroids in the peripheral blood. It may have clinical importance for patients with diabetes mellitus and other diseases who receive an intravitreal injection of triamcinolone acetonide for treatment of diffuse diabetic macular edema, and for whom increased corticosteroid concentrations could deteriorate their metabolic control. Systemic side effects of intravitreal triamcinolone are not expected. REFERENCES
1. Jonas JB, So¨ fker A. Intraocular injection of crystalline cortisone as adjunctive treatment of diabetic macular edema. Am J Ophthalmol 2001;132:425–427. 2. Roth DB, Chieh J, Spirn MJ, et al. Noninfectious endophthalmitis associated with intravitreal triamcinolone injection. Arch Ophthalmol 2003;121:1279 –1282. 3. Jonas JB. Concentration of intravitreally injected triamcinolone acetonide in aqueous humour. Br J Ophthalmol 2002;86: 1066. 4. Gusenoff JA, Harman SM, Veldhuis JD, et al. Cortisol and GH secretory dynamics, and their interrelationships, in healthy aged women and men. Am J Physiol Endocrinol Metab 2001;280:E616 –E625.
VOL. 137, NO. 6
5. Kraan GP, Dullaart RP, Pratt JJ, et al. The daily cortisol production reinvestigated in healthy men. The serum and urinary cortisol production rates are not significantly different. J Clin Endocrinol Metab 1998;83:1247–1252.
Photodynamic Therapy for Choroidal Metastasis From Carcinoid Tumor J. William Harbour, MD To determine the efficacy of photodynamic therapy for the treatment of a choroidal metastasis unresponsive to chemotherapy and radiation therapy. DESIGN: Interventional case report. METHODS: Photodynamic therapy with verteporfin was performed. Visual acuity, local tumor control, and complications were assessed. RESULTS: A 72-year-old woman was diagnosed with bilateral, biopsy-proven choroidal metastasis from a pulmonary carcinoid tumor that was resistant to chemotherapy and radiotherapy. The tumor in the left eye caused a retinal detachment and vision loss to light perception. The smaller lesion in the right eye progressively enlarged toward the fovea despite therapy and was treated with photodynamic therapy with verteporfin. Within 2 months, the exudative detachment resolved, the visual acuity returned to baseline, and the tumor volume decreased by 50%. CONCLUSION: Photodynamic therapy may be an effective treatment option for selected patients with choroidal metastasis. (Am J Ophthalmol 2004;137:1143–1145. © 2004 by Elsevier Inc. All rights reserved.) PURPOSE:
M
ETASTASIS TO THE CHOROID IS THE MOST COMMON
form of intraocular cancer and can lead to significant vision loss.1 Treatment of choroidal metastasis is occasionally indicated to preserve vision and may include laser photocoagulation, cryotherapy, chemotherapy, radiotherapy, and local surgical resection.2 To our knowledge, this is the first report of photodynamic therapy (PDT) with intravenous verteporfin as a treatment for choroidal metastasis that was not amenable to other modalities. In April 2000, a 72-year-old woman presented with 8 weeks of metamorphopsia and visual acuity loss to 20/50 OS. An orange, juxtapapillary choroidal mass was discovered (Figure 1, A). The mass had basal dimensions of 13 ⫻ 8 mm, a height of 4.5 mm, and irregular internal reflectivity on A-scan ultrasonography. These features raised the suspicion of a metastasis, but the patient’s medical history
Accepted for publication Jan 2, 2004. From the Ocular Oncology Service, Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri. Inquiries to J. William Harbour, MD, Campus Box 8069, Washington University School of Medicine, 660 South Euclid Ave, St. Louis, MO 63110; fax: (314) 747-5073; e-mail: [email protected]
BRIEF REPORTS
1143
METHODS: For 20 consecutive patients, venous blood samples were taken before and 13 ⴞ 19 days (range 4 to 92) after an intravitreal injection of 20 to 25 mg triamcinolone acetonide as treatment of edematous macular diseases. RESULTS: Serum levels of triamcinolone acetonide did not differ significantly (P ⴝ .174; t test for paired matches) preoperatively (0 g/l) and postoperatively (0.065 g/l ⴞ 0.21 g/l). In 18 eyes (90%), triamcinolone acetonide could not be detected in serum samples. For two patients (10%), serum samples taken 5 days and 7 days after the injection, respectively, contained 0.5 g/l triamcinolone acetonide and 0.8 g/l triamcinolone acetonide, respectively. CONCLUSION: After an intravitreal high-dose injection of 20 to 25 mg triamcinolone acetonide, triamcinolone acetonide is not, or only marginally, detectable in serum samples obtained within 4 to 92 days after the injection. (Am J Ophthalmol 2004;137:1142–1143. © 2004 by Elsevier Inc. All rights reserved.)
R
of intravitreal injections of triamcinolone acetonide as treatment of edematous macular disorders such as diffuse diabetic macular edema, age-related macular degeneration, and others.1 Main local side effects reported so far are triamcinolone-induced ocular hypertension, cataract, and infectious or sterile endophthalmitis.2 In an attempt to assess possible systemic side effects of intravitreal triamcinolone acetonide injections, it was the purpose of the present study to measure triamcinolone acetonide concentrations in the peripheral blood after an intravitreal highdose injection. The prospective, interventional case series study included 20 consecutive patients (nine women), who received an intravitreal injection of 20 to 25 mg triamcinolone acetonide as treatment of exudative agerelated macular degeneration (n ⫽ 14, 70%), diabetic macular edema (n ⫽ 4, 20%), or other reasons for macular edema (n ⫽ 2, 10%). Mean age was 73.1 ⫾ 11.3 years (range 43.4 to 94.0). Eight patients (40%) had received one to four intravitreal injections of 20 to 25 mg triamcinolone acetonide earlier, for the same reason, into the same or into the other eye. The technique of injection has been described in detail previously.1 All patients were fully informed about the experimental character of the therapy and had signed an informed consent. The Ethics Committee of the university had approved the study following the tenets of the Declaration of Helsinki. For all patients, venous blood was taken from the antecubital vein before and 4 to 92 days after the injection (mean ⫾ SD, 13 ⫾ 19; median, 8). The blood was centrifuged at 3,000 rpm at 15 C for 10 minutes. The supernatant serum was filled into new storage vessels, and stored at ⫺80 C to await final analysis. The blood samples were analyzed by high perfor-
REFERENCES
1. Tso MO, La Piana FG. The human fovea after sungazing. Trans Am Acad Ophthalmol Otolaryngol 1975;79:788 –795. 2. Yeh LK, Yang CS, Lee FL, Hsu WM, Liu JH. Solar retinopathy: A case report [in Chinese]. Zhonghua Yi Xue Za Zh 1999;62:886 –890. 3. Bechmann M, Ehrt O, Thiel MJ, et al. Optical coherence tomography findings in early solar retinopathy. Br J Ophthalmol 2000;84:546 –547. 4. Codenotti M, Patelli F, Brancato R. OCT findings in patients with retinopathy after watching a solar eclipse. Ophthalmologica 2002;216:463–466. 5. Hope-Ross MW, Mahon GJ, Gardiner TA, Archer DB. Ultrastructural findings in solar retinopathy. Eye 1993;7:29 – 33.
Serum Levels of Triamcinolone Acetonide After Intravitreal Injection Robert F. Degenring, MD, and Jost B. Jonas, MD PURPOSE: To evaluate serum levels of triamcinolone acetonide after intravitreal high-dose injection. DESIGN: Prospective, interventional case series study. Accepted for publication Jan 2, 2004. From the Department of Ophthalmology, Faculty for Clinical Medicine Mannheim, Ruprecht-Karls-University, Heidelberg, Mannheim, Germany. Inquiries to Robert F. Degenring, MD, Department of Ophthalmology, Theodor-Kutzer-Ufer 1–3, 68167 Mannheim, Germany; fax: ⫹49-621383-3803; e-mail: [email protected]
1142
AMERICAN JOURNAL
ECENT STUDIES HAVE SHOWN THE POTENTIAL BENEFIT
OF
OPHTHALMOLOGY
JUNE 2004
mance liquid chromatography and tandem mass spectrometry.3 Detection limit of the method was 0.5 g/l. Mean preoperative serum levels of triamcinolone acetonide did not differ significantly (P ⫽ .174; t test for paired matches) from mean postoperative triamcinolone acetonide concentrations in the serum (0 g/l [range 0 g/l to 0 g/l] versus 0.065 g/l ⫾ 0.21 g/l [range 0 to 0.8 g/l]; median 0 g/l). In 18 serum samples (90%), triamcinolone acetonide could not be detected. For two patients (10%), triamcinolone acetonide was detected in the serum samples. One of these samples obtained 7 days after the injection contained 0.8 g/l triamcinolone acetonide. This patient suffering from diffuse diabetic macular edema had not received any previous intravitreal injections of triamcinolone acetonide. The second sample taken 5 days after the injection contained 0.5 g/l triamcinolone acetonide. For treatment of exudative age-related macular degeneration, this patient had received four previous intravitreal injections of triamcinolone acetonide 12, 17, 24, and 29 months before inclusion into the present study. The average serum cortisol levels of healthy men and women aged 65 to 88 years ranged between 70 g/l and 80 g/l.4 The mean daily production rate of cortisol is approximately 9 to 11 mg/(m2 ⫻ day), resulting in a total availability of 15 to 20 mg cortisol each day in an average person.5 Bearing in mind the five times higher potency of triamcinolone compared with hydrocortisone, the highest concentration of triamcinolone acetonide (0.8 g/l) as measured in the present study is likely without systemic effect. Additionally, in 90% of the samples triamcinolone acetonide was not detected. One may infer, therefore, that an intravitreal high-dose injection of triamcinolone acetonide adds clinically insignificant quantities to the physiologic concentration of corticosteroids in the peripheral blood. It may have clinical importance for patients with diabetes mellitus and other diseases who receive an intravitreal injection of triamcinolone acetonide for treatment of diffuse diabetic macular edema, and for whom increased corticosteroid concentrations could deteriorate their metabolic control. Systemic side effects of intravitreal triamcinolone are not expected. REFERENCES
1. Jonas JB, So¨ fker A. Intraocular injection of crystalline cortisone as adjunctive treatment of diabetic macular edema. Am J Ophthalmol 2001;132:425–427. 2. Roth DB, Chieh J, Spirn MJ, et al. Noninfectious endophthalmitis associated with intravitreal triamcinolone injection. Arch Ophthalmol 2003;121:1279 –1282. 3. Jonas JB. Concentration of intravitreally injected triamcinolone acetonide in aqueous humour. Br J Ophthalmol 2002;86: 1066. 4. Gusenoff JA, Harman SM, Veldhuis JD, et al. Cortisol and GH secretory dynamics, and their interrelationships, in healthy aged women and men. Am J Physiol Endocrinol Metab 2001;280:E616 –E625.
VOL. 137, NO. 6
5. Kraan GP, Dullaart RP, Pratt JJ, et al. The daily cortisol production reinvestigated in healthy men. The serum and urinary cortisol production rates are not significantly different. J Clin Endocrinol Metab 1998;83:1247–1252.
Photodynamic Therapy for Choroidal Metastasis From Carcinoid Tumor J. William Harbour, MD To determine the efficacy of photodynamic therapy for the treatment of a choroidal metastasis unresponsive to chemotherapy and radiation therapy. DESIGN: Interventional case report. METHODS: Photodynamic therapy with verteporfin was performed. Visual acuity, local tumor control, and complications were assessed. RESULTS: A 72-year-old woman was diagnosed with bilateral, biopsy-proven choroidal metastasis from a pulmonary carcinoid tumor that was resistant to chemotherapy and radiotherapy. The tumor in the left eye caused a retinal detachment and vision loss to light perception. The smaller lesion in the right eye progressively enlarged toward the fovea despite therapy and was treated with photodynamic therapy with verteporfin. Within 2 months, the exudative detachment resolved, the visual acuity returned to baseline, and the tumor volume decreased by 50%. CONCLUSION: Photodynamic therapy may be an effective treatment option for selected patients with choroidal metastasis. (Am J Ophthalmol 2004;137:1143–1145. © 2004 by Elsevier Inc. All rights reserved.) PURPOSE:
M
ETASTASIS TO THE CHOROID IS THE MOST COMMON
form of intraocular cancer and can lead to significant vision loss.1 Treatment of choroidal metastasis is occasionally indicated to preserve vision and may include laser photocoagulation, cryotherapy, chemotherapy, radiotherapy, and local surgical resection.2 To our knowledge, this is the first report of photodynamic therapy (PDT) with intravenous verteporfin as a treatment for choroidal metastasis that was not amenable to other modalities. In April 2000, a 72-year-old woman presented with 8 weeks of metamorphopsia and visual acuity loss to 20/50 OS. An orange, juxtapapillary choroidal mass was discovered (Figure 1, A). The mass had basal dimensions of 13 ⫻ 8 mm, a height of 4.5 mm, and irregular internal reflectivity on A-scan ultrasonography. These features raised the suspicion of a metastasis, but the patient’s medical history
Accepted for publication Jan 2, 2004. From the Ocular Oncology Service, Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri. Inquiries to J. William Harbour, MD, Campus Box 8069, Washington University School of Medicine, 660 South Euclid Ave, St. Louis, MO 63110; fax: (314) 747-5073; e-mail: [email protected]
BRIEF REPORTS
1143