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T. Yilmaz, C. Weaver, M. Cordero-Coma, M. J. Gallagher, R. A. Cervantes-Castaneda, R. J. Larson; Intravitreal Triamcinolone Acetonide for the Treatment of Refractory Diabetic Macular Edema: An Evidence-Based Systematic Review. Invest. Ophthalmol. Vis. Sci. 2008;49(13):3487.
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Diabetic macular edema (DME) is the leading cause of visual loss in diabetic eye disease. Laser therapy is the gold standard of care for patients with persistent or progressive disease. More recently, intravitreal triamcinolone acetonide (IVTA) has been used to improve visual acuity (VA) and reduce central macular thickness (CMT). We have conducted a systematic review of randomized controlled trials (RCTs) evaluating the efficacy and safety of IVTA versus either placebo or sub-Tenon’s triamcinolone acetonide (STTA) for the treatment of refractory DME. We evaluated outcomes at both short-term and long-term follow-up points.
We searched Medline (1950 - September Week 3 2007), ARVO (2003-2007), The Cochrane Library (Issue 4, 2007) and the TRIP Database (up to October 1, 2007) using no language or other limits. This was supplemented by hand searching the reference lists of selected major review articles. Two reviewers independently abstracted data using a standardized form. Data was analyzed based upon differences in VA, CMT, and intraocular pressure (IOP) at 3 and 6 month follow-up intervals. A sensitivity analysis was performed based upon study quality.
Of the 88 citations retrieved, 6 studies involving 293 eyes met all inclusion criteria. In the 4 RCTs comparing IVTA to placebo or no treatment, IVTA demonstrated greater improvement in visual acuity at 3 months (Weighted Mean Difference (WMD): -0.10, 95%CI: -0.20, 0.00), but the benefit was no longer significant at 6 months (WMD: -0.05, 95%CI: -0.15, 0.05). With regards to side effects, IVTA had significantly higher IOP at 3 months (WMD: 4.33, 95%CI: 2.88, 5.77) and at 6 months (WMD: 2.40, 95%CI: 1.37, 3.44). In the 2 RCTs comparing IVTA to STTA injections, IVTA demonstrated greater improvement in VA at 3 months (WMD: -0.09, 95%CI: -0.16, -0.01) but not at 6 months (WMD: -0.02, 95%CI: -0.10, 0.05). IVTA demonstrated no difference in IOP at 3 months (WMD: 0.74, 95%CI: -0.48, 1.95) or at 6 months (WMD: -0.46, 95%CI: -1.67, 0.76).
IVTA is an effective treatment in improving short-term (3 months) VA and reducing CMT in patients with refractory DME, but the benefits do not appear to persist in the long-term. RCTs evaluating the safety and efficacy of repeated IVTA treatments, long-term IVTA treatment, and anti-VEGF therapy are warranted.
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