| Objective: Diabetic macular edema (DME) is a common complication of diabetic retinopathy (DR). It is one of the main reasons leading to visual damage of diabetic patients. Because it severely damage patients'central vision and lack effective treatment , it's an urgent problem in clinical practice now. It is of great clinical significance to treat DME for parients to improve their visual acuity and life quantity. Edema grid photocoagulation is the main measure to treat DME now. Photocoagulation can relieve leakage in macula. It's definite efficiency and benefit have been confirmed in clinical pratice. However, with regard to some refractory diffuse DME, photocoagulation can't play an effective role. Some DME last for a long time and aggrav. Triamcinolone acetonide (TA) is one of an artifically synthesized steroids which have stronge effect on relieving imflammation and proliferation. In recent research, TA can relieve DME significantly and improve central visual acuity. In this study we use intravitreal triamcinolone acetonide (IVTA) or retrobulbar injection of triamcinolone acetonide (RITA) to treat DME which have no response to photocoagulation. We observe it's efficacy and side effect through visual acuity (VA), extent of DME , function of retina in macula and intraocular pressure (IOP) and compare the different administrations. We hope to find an efficient and safe method to treat refractory DME after photocoagulation and provide some directions for the further use of TA in clinical practice.Methods: 1 30 eyes of 30 patients who meet eligibility criteria were enrolled in the study and accept the following examinations and treatments respectively. Select 14 eyes of patients above who have symmetria DME to control group.2 Treatment:15 eyes in the study were selected randomly to receive IVTA treatment of one injection of 4mg/0.1ml TA into vitreous. Other 15 eyes received RITA treatment which include four injections of 20mg/0.5ml TA every two weeks. The control group include 14 eyes which have symmetry DME to the opposite eye treated by IVTA or RITA. The control group have no treatment.3 Follow-up: Every eye was examed VA, ophthalmic routine examination including ophthalmoscopy, slit lamps microscope and intraocular pressure (IOP) in 1 week(W), 2W, 1month(M), 2M, 3M, 6M and 1 year after the treatment.4 Fundus fluorescein angiography(FFA): All the eyes received FFA examination before and 2 months after treatment. We saved every patient's FFA image after 5 minutes and compared the extent of DME before and two months after the treatment.5 Multifocal electroretinogram (mf-ERG) test: All the eyes received mf-ERG before and 2 months after treatment. RETI Scan multifocal ERG version 3.15 system was used to evaluate the retina function in macula which can remove subjective factors.6 Statistical analysis: Analyse all the results including VA, IOP, FFA and mf-ERG using paired T test and chi square test.Results: 1 Compare the VA before and after the treatment in the three groups. In IVTA group, the follow-up average VA of 1W, 2W, 1M, 2M, 3M and half year were better than baseline, which had significant difference (P<0.01). One year after IVTA treatment, the VA declined again, which had no significant difference with the baseline. In RITA group, the follow-up average VA of 2W, 1M, 2M, 3M were better than baseline, which had significant difference (P<0.05), while 1W, half year and 1 year had no significant difference with the baseline. In control group, the follow-up average VA in the first three months had no significant difference with the baseline. But in half and 1 year, the VA declined and had significant difference with the baseline(P<0.05).2 Compare the VA of two eyes of the same patient with symmetria DME who have one eye treated by IVTA or RITA. The VA of the eye treated by IVTA was better than the control one within half year, which had significant difference (P<0.05).But 1 year after the treatment, there were no significant difference between two eyes. The VA of the eye treated by RITA was better than the control one in 2W, 1M, 2M, 3M follow-up time(P < 0.05). But 1W, half year and 1 year after the treatment,there was no significant difference between two eyes.3 FFA results: Compare the DME in FFA image after treatment with before. The constituent ratio of DME extinction have significant difference among the three groups(P<0.01).4 mfERG results: 3 months after IVTA treatment, the latencies of P1 and N1 wave decreased and the amplitude densities advanced at macula, which had significant difference with before(P<0.05). The changes of P1 wave were larger than N1, and the changes of latency were larger than amplitude density. 3 months after RITA treatment, the latency of P1 wave decreased and the amplitude densities of P1 and N1 wave advanced at macula, which had significant difference with before(P<0.05). But the latency of N1 wave had no difference with before.5 In the IVTA group, the follow-up IOP of 1W, 2W had significant difference with baseline (P<0.05). Other follow-up IOP had no significant difference. There are 5 cases'IOP higher than 21mmHg in the IVTA group, accounting 33.3%. All the high IOP can be controlled by anti-glaucoma drugs. The follow-up IOP in the RITA and control group had no significant difference with baseline. In the IVTA group, 2 cases'cataract progressed 1 year after treatment, which showed post-capsule cloudiness. No serious complications were found such as vitreous hemorrhage, retinal detachment and endophthalmitis. There were no complications above in the RITA group. Conclusions: 1 Intravitreal injection of triamcinolone can relieve refractory DME rapidly and effectively and elevate visual acuity in short term.But in a long run its curative effect can't persist. The DME recurre and VA decline.2 The therapeutic effect of IVTA for DME can last for about half a year.Therapeutic effect achieve peak 2 to 3 months after treatment,3 Retrobulbar injection of triamcinolone acetonide can also relieve diffuse DME. But compared to IVTA treatment, RITA play a slower, shorter and poorer effect.4 DME affect retina electrophysical activity apparently. Alone with the relieving of DME, the average amplitude values increase and the average latency values decrease in mf-ERG.5 The common complication of IVTA is rising of IOP. About 33.3% cases have this complication, which often happen in 1 week to 1 month after treatment. But most high IOP can be controlled by anti-glaucoma drugs. TA can also cause cataract progressing, most of which was post-capsule cloudiness. RITA treatment have not above complications.6 On the basis of own control study, TA can only elevate VA in short term, but can't change the prognosis of VA in long term of DME patients. |
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