INTRAVITREAL INJECTION OF TRIAMCINOLONE ACETONIDE TO TREAT CYSTOID FOVEAL EDEMA ASSOCIATED WITH COATS’ DISEASE Tetsushi Kimura, MD, Hitoshi Takagi, MD, PHD, Mihori Kita, MD, PHD, Daisuke Watanabe, MD, PHD, Nagahisa Yoshimura, MD, PHD
Purpose: To investigate the efficacy of intravitreal injection of triamcinolone acetonide (TA) for treatment of cystoid foveal edema (CFE) associated with Coats’ disease. Methods and Patient: A 32-year-old man with a 28-month history of Coats’ disease received an intravitreal TA injection (4 mg) in the right eye. Results: Visual acuity improved from 20/200 to 20/50, and foveal thickness decreased from 701 m to 216 m 45 days after treatment. Conclusion: Intravitreal TA injection might temporarily improve visual acuity in eyes with CFE associated with Coats’ disease. RETINAL CASES & BRIEF REPORTS 3:167–169, 2009
From the Department of Ophthalmology and Visual Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
plied to the peripheral retina in the right eye 18 months previously; he reported a substantial visual decrease 8 months later. Baseline bestcorrected visual acuity in the right eye was 20/200. Capillary telangiectasia with hard exudates and laser scars developed in the superior nasal peripheral retina (Fig. 1). CFE developed in the fovea, and foveal thickness was 701 m (Fig. 2). There were no foveal hard exudates or apparent exudative foveal detachment. Fluorescein an-
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oats’ disease is an idiopathic, typically unilateral, retinal vasculopathy that causes telangiectasia accompanied by exudation within the retina and massive lipid deposition.1 Central visual acuity may be affected by cystoid foveal edema (CFE) caused by intraretinal exudation from juxtafoveolar telangiectasia or peripheral retinal telangiectasia.2 We studied the efficacy and safety of intravitreal injection of triamcinolone acetonide (TA) for treatment of CFE associated with Coats’ disease. Case Report A 32-year-old man with a 28-month history of decreased vision in the right eye was referred to us. He had been diagnosed with Coats’ disease at another institution where laser photocoagulation was apSupported by a Grant-in-Aid for Scientific Research from the Ministry of Education, Science and Culture of the Japanese Government. The authors have no financial interest in any aspect of this report. Reprint requests: Hitoshi Takagi, MD, Department of Ophthalmology, Hyogo Prefectural Hospital, 1-1-1 Higashioomonocho, Amagasaki, Hyogo 660-0828, Japan; e-mail: [email protected]
Fig. 1. Fundus photograph at the first visit shows capillary telangiectasia accompanied by hard exudates and laser scars in the superior nasal peripheral retina. Visual acuity is 20/200.
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Fig. 2. A, Baseline optical coherence tomography shows severe cystoid foveal edema (CFE); foveal thickness is 701 m. B, Optical coherence tomography 45 days after treatment shows normal foveal configuration.
Fig. 4. Optical coherence tomography 45 days after treatment shows normal foveal configuration. Visual acuity is 20/50.
giography of the right fundus showed early-phase leakage from telangiectatic vessels in the juxtafoveolar region (Fig. 3) and superior nasal peripheral retina. Because the leakage point was near the foveola and laser photocoagulation might cause a paracentral scotoma, TA (4 mg) was injected intravitreally. The TA preparation (Kenakolt-A; Bristol) and procedures were performed as previously described.3 Ten days after treatment, CFE resolved markedly, and the fovea appeared normal. Foveal thickness decreased to 177 m, and visual acuity improved to 20/50. Intraocular pressure increased to 37 mmHg, and antiglaucoma eyedrops were prescribed. At 45 days after treatment, the fovea appeared normal, with no CFE. Visual acuity, foveal thickness, and intraocular pressure were 20/50, 216 m, and 20 mmHg, respectively (Figs. 4 and 5). Six months later, CFE recurred and worsened. Fourteen months after treatment, visual acuity was 20/150, and foveal thickness was 554 m. TA (4 mg) was reinjected, and visual acuity improved to 20/50; foveal thickness was 530 m 30 days after treatment. Intraocular pressure was 20 mmHg with antiglaucoma medication.
Discussion In the current case, the mechanism of CFE improvement is uncertain but may have resulted from the antiedematous and antiangiogenic effects of TA, which warrants further research. Jonas4 reported that intravitreal injection of TA was ineffective for treatment of Coats’like diseases with extensive exudative retinal detachment. The disparity between the results could be due to the difference in the pathogenesis of CFE and exudative retinal detachment. Jarin et al5 used a 25-mg intravitreal injection of TA for treatment of foveal edema associated with Coats’ disease, but visual acuity did not improve even after edema absorption; the fluorescein angiographic details of juxtafoveolar telangiectasia were unknown. In the current case, the 4-mg dose was sufficient.
Fig. 3. A, Baseline fluorescein angiography shows juxtafoveolar telangiectasia and cystoid foveal edema (CFE). B, Fluorescein angiography 45 days after intravitreal triamcinolone injection shows reduced CFE but persistent telangiectasia.
Fig. 5. Fluorescein angiography 45 days after intravitreal triamcinolone injection shows reduced cystoid foveal edema but persistent telangiectasia.
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Fluorescein angiography demonstrated persistent juxtafoveolar telangiectasia after treatment. Because the primary pathogenesis of CFE in Coats’ disease is leakage from juxtafoveolar telangiectasia, the effects of TA are temporary, and photocoagulation is needed to prevent recurrence. Photocoagulation after TA injection is a potential treatment because the effect is expected to be greater when there is no foveal edema. References 1.
Shields JA, Shields CL, Honavar SG, et al. Clinical variations and complications of Coats’ disease in 150 cases: The 2000
2.
3.
4.
5.
Sanford Gifford Memorial Lecture. Am J Ophthalmol 2001; 131:561–571. Lee ST, Friedman SM, Rubin ML. Cystoid macular edema secondary to juxtafoveolar telangiectasis in Coats’ disease. Ophthalmic Surg 1991;22:218–221. Nishimura A, Kobayashi A, Segawa Y, et al. Isolating triamcinolone acetonide particles for intravitreal use with a porous membrane filter. Retina 2003;23:777–779. Jonas JB. Intravitreal triamcinolone acetonide as treatment for extensive exudative retinal detachment. Br J Ophthalmol 2004; 88:587–588. Jarin RR, Teoh SCB, Lim TH. Resolution of severe macular oedema in adult Coats’ syndrome with high-dose intravitreal triamcinolone acetonide. Eye 2006;20:163–165.
Purpose: To investigate the efficacy of intravitreal injection of triamcinolone acetonide (TA) for treatment of cystoid foveal edema (CFE) associated with Coats’ disease. Methods and Patient: A 32-year-old man with a 28-month history of Coats’ disease received an intravitreal TA injection (4 mg) in the right eye. Results: Visual acuity improved from 20/200 to 20/50, and foveal thickness decreased from 701 m to 216 m 45 days after treatment. Conclusion: Intravitreal TA injection might temporarily improve visual acuity in eyes with CFE associated with Coats’ disease. RETINAL CASES & BRIEF REPORTS 3:167–169, 2009
From the Department of Ophthalmology and Visual Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
plied to the peripheral retina in the right eye 18 months previously; he reported a substantial visual decrease 8 months later. Baseline bestcorrected visual acuity in the right eye was 20/200. Capillary telangiectasia with hard exudates and laser scars developed in the superior nasal peripheral retina (Fig. 1). CFE developed in the fovea, and foveal thickness was 701 m (Fig. 2). There were no foveal hard exudates or apparent exudative foveal detachment. Fluorescein an-
C
oats’ disease is an idiopathic, typically unilateral, retinal vasculopathy that causes telangiectasia accompanied by exudation within the retina and massive lipid deposition.1 Central visual acuity may be affected by cystoid foveal edema (CFE) caused by intraretinal exudation from juxtafoveolar telangiectasia or peripheral retinal telangiectasia.2 We studied the efficacy and safety of intravitreal injection of triamcinolone acetonide (TA) for treatment of CFE associated with Coats’ disease. Case Report A 32-year-old man with a 28-month history of decreased vision in the right eye was referred to us. He had been diagnosed with Coats’ disease at another institution where laser photocoagulation was apSupported by a Grant-in-Aid for Scientific Research from the Ministry of Education, Science and Culture of the Japanese Government. The authors have no financial interest in any aspect of this report. Reprint requests: Hitoshi Takagi, MD, Department of Ophthalmology, Hyogo Prefectural Hospital, 1-1-1 Higashioomonocho, Amagasaki, Hyogo 660-0828, Japan; e-mail: [email protected]
Fig. 1. Fundus photograph at the first visit shows capillary telangiectasia accompanied by hard exudates and laser scars in the superior nasal peripheral retina. Visual acuity is 20/200.
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Fig. 2. A, Baseline optical coherence tomography shows severe cystoid foveal edema (CFE); foveal thickness is 701 m. B, Optical coherence tomography 45 days after treatment shows normal foveal configuration.
Fig. 4. Optical coherence tomography 45 days after treatment shows normal foveal configuration. Visual acuity is 20/50.
giography of the right fundus showed early-phase leakage from telangiectatic vessels in the juxtafoveolar region (Fig. 3) and superior nasal peripheral retina. Because the leakage point was near the foveola and laser photocoagulation might cause a paracentral scotoma, TA (4 mg) was injected intravitreally. The TA preparation (Kenakolt-A; Bristol) and procedures were performed as previously described.3 Ten days after treatment, CFE resolved markedly, and the fovea appeared normal. Foveal thickness decreased to 177 m, and visual acuity improved to 20/50. Intraocular pressure increased to 37 mmHg, and antiglaucoma eyedrops were prescribed. At 45 days after treatment, the fovea appeared normal, with no CFE. Visual acuity, foveal thickness, and intraocular pressure were 20/50, 216 m, and 20 mmHg, respectively (Figs. 4 and 5). Six months later, CFE recurred and worsened. Fourteen months after treatment, visual acuity was 20/150, and foveal thickness was 554 m. TA (4 mg) was reinjected, and visual acuity improved to 20/50; foveal thickness was 530 m 30 days after treatment. Intraocular pressure was 20 mmHg with antiglaucoma medication.
Discussion In the current case, the mechanism of CFE improvement is uncertain but may have resulted from the antiedematous and antiangiogenic effects of TA, which warrants further research. Jonas4 reported that intravitreal injection of TA was ineffective for treatment of Coats’like diseases with extensive exudative retinal detachment. The disparity between the results could be due to the difference in the pathogenesis of CFE and exudative retinal detachment. Jarin et al5 used a 25-mg intravitreal injection of TA for treatment of foveal edema associated with Coats’ disease, but visual acuity did not improve even after edema absorption; the fluorescein angiographic details of juxtafoveolar telangiectasia were unknown. In the current case, the 4-mg dose was sufficient.
Fig. 3. A, Baseline fluorescein angiography shows juxtafoveolar telangiectasia and cystoid foveal edema (CFE). B, Fluorescein angiography 45 days after intravitreal triamcinolone injection shows reduced CFE but persistent telangiectasia.
Fig. 5. Fluorescein angiography 45 days after intravitreal triamcinolone injection shows reduced cystoid foveal edema but persistent telangiectasia.
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Fluorescein angiography demonstrated persistent juxtafoveolar telangiectasia after treatment. Because the primary pathogenesis of CFE in Coats’ disease is leakage from juxtafoveolar telangiectasia, the effects of TA are temporary, and photocoagulation is needed to prevent recurrence. Photocoagulation after TA injection is a potential treatment because the effect is expected to be greater when there is no foveal edema. References 1.
Shields JA, Shields CL, Honavar SG, et al. Clinical variations and complications of Coats’ disease in 150 cases: The 2000
2.
3.
4.
5.
Sanford Gifford Memorial Lecture. Am J Ophthalmol 2001; 131:561–571. Lee ST, Friedman SM, Rubin ML. Cystoid macular edema secondary to juxtafoveolar telangiectasis in Coats’ disease. Ophthalmic Surg 1991;22:218–221. Nishimura A, Kobayashi A, Segawa Y, et al. Isolating triamcinolone acetonide particles for intravitreal use with a porous membrane filter. Retina 2003;23:777–779. Jonas JB. Intravitreal triamcinolone acetonide as treatment for extensive exudative retinal detachment. Br J Ophthalmol 2004; 88:587–588. Jarin RR, Teoh SCB, Lim TH. Resolution of severe macular oedema in adult Coats’ syndrome with high-dose intravitreal triamcinolone acetonide. Eye 2006;20:163–165.
