Retinal vein occlusion disease is estimated to be the second most common cause of retinal vascular disease in the United States.1 The prevalence of retinal vein occlusion in the Blue Mountains Eye Study was 1.6%, with 69.5%(41of59)oftheseocclusionsclassified as branch retinal vein occlusion (BRVO).2 Retinal vein occlusion was bilateral in 5.1% of cases.2 The 15-year cumulative incidence of BRVO was 1.8% in the Beaver Dam Eye Study.3 In the Beaver Damcohort,centraland branch retinal vein occlusion accounted for 12% of eyes that developed severe vision loss during a 15-year period.4

Macular edema is a frequent cause of visual acuity loss from BRVO.1,5,6 The natural history of macular edema secondary to BRVO was delineated in the Branch Vein Occlusion Study (BVOS).1 One arm of the BVOS demonstrated a benefit with grid photocoagulation.1 Of 43 treated eyes available for follow-up at the 3-year visit, 28 (65%) had gained 2 or more lines of visual acuity from baseline and maintained this gain for at least 8 months compared with the same gain in 13 of 35 untreated eyes (37%). The BVOS also identified a subset of patients who derived limited benefit from grid photocoagulation. In the BVOS, 40% of treated eyes (n=43) had worse than 20/40 visual acuity at 3 years, and 12% of treated eyes had 20/200 or worse visual acuity at 3 years.1

During the last decade, a number of additional treatments for macular edema secondary to BRVO have been investigated. Such treatments include laser chorioretinal anastomosis, vitrectomy, arteriovenous sheathotomy, and intravitreal injection of antibodies targeted at vascular endothelial growth factor (VEGF).7-12 Numerous reports have suggested that intravitreal injection(s) of triamcinolone acetonide (hereafter referred to as intravit-real triamcinolone) is a potentially efficacious therapy for retinal thickening and vision loss in patients with macular edema secondary to BRVO but that some patients may develop steroid-related complications, such as elevated intraocular pressure (IOP) and cataract.13-26 Most of the information concerning intravitreal triamcinolone for macular edema secondary to BRVO is derived from case series that lacked long-term follow-up and adequate numbers of study participants; a randomized and controlled study has not been performed.13-26 Despite the shortcomings of these case series, intravitreal triamcinolone is currently in use as a treatment for BRVO.

The rationale for the use of corticosteroids to treat macular edema secondary to BRVO follows from the observation that the increase in retinal capillary permeability that results in macular edema may be caused by a breakdown of the blood-retina barrier mediated in part by VEGF, a 45-kDa glycoprotein.27-29 Therefore, attenuation of the effects of VEGF may reduce macular edema associated with BRVO.30,31 Corticosteroids have been demonstrated to inhibit the expression of VEGF and therefore may be an effective therapy for macular edema.32,33 Inflammation may also play a role in the pathology of BRVO, and the anti-inflammatory properties of corticosteroids may contribute to the attenuation of the disease process.34

Intravitreal triamcinolone is used by ophthalmologists in the clinical setting as a readily available pharmacologic agent (Kenalog 40; Bristol-Myers Squibb, Princeton, New Jersey, or Triesence; Alcon Inc, Fort Worth, Texas), though use for the treatment of macular edema is off label. Other formulations such as compounded preservative-free triamcinolone acetonide are also used in the clinical setting.

The Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) Study, sponsored by the National Eye Institute, is a clinical trial designed to compare 1-mg and 4-mg doses of intravitreal triamcinolone with standard care for vision loss associated with macular edema secondary to per-fused central retinal vein occlusion (CRVO) and BRVO.35,36 This article describes findings from the SCORE-BRVO trial. A companion article that compares intravitreal triamcinolone with observation for vision loss associated with macular edema secondary to CRVO is published concurrently (the SCORE-CRVOtrial).37 The 2 primary study objectives of the SCORE-BRVO trial are (1) to determine whether intravit-real triamcinolone at 1-mg and 4-mg doses produces greater visual benefit, with an acceptable safety profile,than grid photocoagulation, when appropriate, for the treatment of vision loss associated with macular edema secondary to BRVO; and (2) to compare the efficacy and safety of the 1-mg and 4-mg triamcinolone doses.

A Randomized Trial Comparing the Efficacy and Safety of Intravitreal Triamcinolone With Observation to Treat Vision Loss Associated With Macular Edema Secondary to Central Retinal Vein Occlusion: The Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) Study Report 5

Purpose of review Over the past few years, the results of many studies have highlighted the risks and benefits of intravitreal injection of a number of medications, the most common being triamcinolone, antivascular endothelial growth factor (VEGF) agents, antibiotics, antivirals, antifungals, and methotrexate. The purpose of this review is to highlight the complications associated with these injections. Recent findings Elevated intraocular pressure and glaucoma are the most common complications of intraocular triamcinolone. There is also an increased incidence of cataract formation/progression over time. The immunosuppressive effect of triamcinolone does not appear to increase the risk of endophthalmitis. Recent reports suggest that intravitreal anti-VEGF injections have a low complication rate. Similarly, antimicrobials also have low rates of injection-associated complications. Summary Intravitreal injections play a critical role in daily ophthalmic practice. The overall risk of endophthalmitis and retinal detachment appears to be low and most of the commonly used drugs are well tolerated, even with repeat injection. Further long-term studies need to be performed to elucidate ways of increasing the safety of these procedures and medications.

Complications of intravitreal injections.

Intravitreal injections (IVI) have become the most common intraocular procedure worldwide with increasing numbers every year. The article presents the most up-to-date review on IVI epidemiology and techniques. Unfortunately, important issues related to pre-, peri- and postinjection management lack randomized clinical trials for a final conclusion. Also, a great diversity of approaches exists worldwide. Therefore, expert consensus recommendations on IVI techniques are provided.

/pdf/2018-update-on-intravitreal-injections-euretina-expert-2nmnciumld.pdf

2018 Update on Intravitreal Injections: Euretina Expert Consensus Recommendations.

Conclusions: Serial injections of anti-VEGF agents may lead to persistent IOP elevations that require glaucoma therapy. The clinician should recognize this phenomenon, as it can occur even if the patient has tolerated multiple prior injections without IOP elevation. Further exploration of the relationship between anti-VEGF therapy and IOP is needed.

Sustained increased intraocular pressure related to intravitreal antivascular endothelial growth factor therapy for neovascular age-related macular degeneration

Background:Intravitreal ranibizumab and pegaptanib are registered for neovascular age-related macular degeneration. No formal safety study has been conducted for intravitreal bevacizumab. These anti-vascular endothelial growth factor (anti-VEGF) drugs are being used on a large scale in daily practic

A systematic review of the adverse events of intravitreal anti-vascular endothelial growth factor injections

Purpose To describe the long-term surgical outcomes in a population-based cohort of children with intermittent exotropia. Methods The medical records of all children ( Results Of 184 patients with intermittent exotropia, 61 (33%) underwent surgery at a mean age of 7.6 years (range, 3.2 to 23 years). Twelve of the 61 children (19.7%) underwent a second surgery (10 for recurrent exotropia and 2 for consecutive esotropia), and no patient received 3 or more surgeries during a mean follow-up of 10 years from the first surgery. The final postoperative measurements were recorded in 56 of 61 patients (92%) at a mean of 7.4 years (range, 0 to 18 years) after the first surgery: 31 of the 56 (55%) were within 9 Δ of orthotropia at distance and 25 of 55 (45%) had better than 60 seconds of stereopsis. The Kaplan-Meier rate of developing ≥10 Δ of misalignment after the first surgery was 54% by 5 years, 76% by 10 years, and 86% by 15 years. Conclusions In this population-based study of surgery in children with intermittent exotropia, although only 1 in 5 received a second surgery, after a mean follow-up of 8 years, approximately half were successfully aligned and 45% had high-grade stereopsis.

/pdf/postoperative-outcomes-in-children-with-intermittent-43kd0vryrl.pdf

Postoperative outcomes in children with intermittent exotropia from a population-based cohort

Purpose To present the finding of tiny silicone oil droplets in 15 eyes of 15 patients after intravitreal injections of an anti-vascular endothelial growth factor agent or triamcinolone acetonide and to discuss the likely source of silicone oil. Methods In an observational case series, charts of patients who had undergone intravitreal injections by one surgeon were reviewed retrospectively. The finding of intravitreal silicone oil droplets was noted. The following information was also documented: number and type of injections before the appearance of silicone oil droplets, symptoms and evidence of ocular inflammation, visual acuity before and after silicone oil droplets, length of follow-up, and visual acuity at the last examination. Results Fifteen eyes of 15 patients were found to have silicone oil droplets documented after a various number of injections (range, 1-16). Patients were asymptomatic, and there were no adverse side effects associated with the presence of silicone oil droplets at examination. Conclusions Silicone oil droplets may occur in the vitreous cavity after intravitreal drug injections. There were no adverse effects found associated with silicone oil in the vitreous after injections of anti-vascular endothelial growth factor agents or triamcinolone acetonide. The likely source of silicone oil is the needles and syringes used for the injections.

Intravitreal silicone oil droplets after intravitreal drug injections.

The development of myopia among children with intermittent exotropia.

A novel method for computerized measurement of episcleral venous pressure in humans.

Background The effectiveness of amblyopia therapy can be limited by poor adherence. Dichoptic therapies are a new approach, but recent trials have demonstrated difficulty maintaining high adherence over extended periods of at-home treatment. We evaluated the efficacy and adherence of Luminopia One—a dichoptic treatment that applies therapeutic modifications to streaming content chosen by the patient. Methods This single-arm, multicenter prospective pilot study enrolled children aged 4-12 with anisometropic, strabismic, or mixed amblyopia at 10 pediatric ophthalmic and optometric practices across the United States. The therapeutic was prescribed for 1 hour/day, 6 days/week for 12 weeks of at-home use. The primary endpoint was best-corrected visual acuity (BCVA) at the 12-week follow-up visit. Results In total, 90 participants (mean age, 6.7 ± 2.0 years) were enrolled, and 73/90 participants (81%) had prior treatment beyond refractive correction. For those who completed the 12-week visit, mean amblyopic eye BCVA improved from 0.50 logMAR to 0.35 logMAR (1.5 logMAR lines; 95% CI, 1.2-1.8 lines; P  Conclusions In our study cohort, adherence over the 12-week study period was high, and participants demonstrated clinically and statistically significant improvements in visual acuity and stereoacuity.

Noha S. Ekdawi

Papers

Postoperative outcomes in children with intermittent exotropia from a population-based cohort

Intravitreal silicone oil droplets after intravitreal drug injections.

The development of myopia among children with intermittent exotropia.

A novel method for computerized measurement of episcleral venous pressure in humans.

Digital therapeutic improves visual acuity and encourages high adherence in amblyopic children in open-label pilot study.