The Role of Intravitreal Steroids in the Management of Diabetic Retinopathy

Abstract

The use of steroids for the treatment of diabetic macular edema has been a major recent breakthrough in the management of retinal diseases. First studied in animal models in the 1980s, intravitreal triamcinolone acetonide (IVTA) was first used in human eyes at the Save Sight Institute in Sydney for exudative macular degeneration. When early observations suggested that its effect on macular disease was more marked against exudation than neovascularization, it was used for diabetic macular edema with remarkable effects, which could be appreciated particularly using optical coherence tomography. A placebo-controlled randomized clinical trial reported a beneficial effect of IVTA treatment on best-corrected visual acuity and central macular thickness after 3 months that persisted out to 2 years. Glaucoma medication was required in 15/34 (44%) of IVTA-treated eyes, and removal of steroid-induced posterior subcapsular cataract was required in 55%, mostly in the second year of the study. There was one case of infectious endophthalmitis which responded well to prompt treatment. IVTA can be considered, for example, in eyes with macular edema secondary to focal parafoveal or severe diffuse leak, prior to cataract surgery, or in eyes with macular edema and high-risk proliferative diabetic retinopathy for which immediate pan-retinal photocoagulation is required. Further research is warranted to determine the safest and most efficacious dose of IVTA, and into how ocular steroid therapy can be combined with both retinal laser treatment and the new anti-vascular endothelial growth factor treatments for the safest and most efficacious outcomes for patients.