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Triamcinolone acetonide-assisted Epiretinal Membrane Peeling

Chen SDM, Patel CK
Oxford Eye hospital, Oxford UK
 

Correspondence to: Mr Simon Chen, Oxford Eye hospital, Woodstock rd, Oxford OX2 6HE, UK. Email: s-chen{at}rocketmail.com
Accepted for publication:  August 1, 2004

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Introduction

Surgery to remove an epiretinal membrane (ERM) is a common and technically challenging vitreoretinal procedure. The principal indication for ERM surgery is visual disturbance resulting from decreased visual acuity or metamorphopsia. Approximately 70% of patients experience an improvement of vision in the operated eye.¹

ERM’s may be difficult to visualise if fibrosis or pigment deposition is absent. Wrinkling of the underlying retina and associated sheen are indirect markers of their presence. Operative risks associated with poor visualisation of an ERM include inadvertent retinal trauma and incomplete removal of the ERM, potentially leading to persistent or recurrent membranes.

Recently, trypan blue dye has been used to selectively stain ERM’s and facilitate their visualization without noticeable adverse effects.² However, the long term safety of trypan blue is unknown and its availability is limited in some countries.

Another technique described to enhance ERM visualisation is the use of indocyanine green (ICG) dye to ‘negatively stain’ the ERM by selectively staining the surrounding internal limiting membrane.³ The long term safety after intravitreal use of ICG is unknown and concerns have been raised regarding possible toxicity as ICG tends to accumulate in the optic nerve and pigment epithelium⁴, which may be associated with atrophic retinal pigment epithelial changes.⁵

We present a case in which triamcinolone acetonide was successfully used to aid the per-operative visualisation and surgical peeling of an ERM in a 55-year-old pseudophakic male suffering from distortion.

 

Technique

Preservative free triamcinolone solution was prepared by aspirating the contents of a commercially available triamcinolone acetonide (40mg) suspension with its vehicle (Kenalog, Bristol-Myers Squibb, Middlesex, England) into a 2.5 ml syringe and attaching a Millipore filter connected to a three-way tap, which was also attached to a 5 ml syringe containing balanced salt solution (Alcon Laboratories, Fort Worth, Texas, USA). The triamcinolone suspension was passed through the filter and discarded leaving the triamcinolone particles trapped on the filter in the 2.5 ml syringe. The cock on the three-way tap was then turned and the filter was back flushed with 2.5 ml balanced salt solution from the 5ml syringeto resuspend the triamcinolone particles. This procedure was repeated three times to reduce the preservative load to negligible levels.

A standard three-port pars plana vitrectomy was performed. Following core vitrectomy and separation of the posterior hyaloid from the optic disc and posterior retina, 0.1ml of the preservative free triamcinolone suspension was injected over the macula and ERM using a blunt-tipped needle. Excess triamcinolone was aspirated with a back flush needle. Separation of the ERM from retina was performed using a MVR blade to incise and create an edge to the ERM, followed by peeling of the ERM using intraocular forceps. The peeled area was clearly observed as an area devoid of white triamcinolone particles. The peeled ERM was coated with triamcinolone particles. Following removal of the ERM, the residual triamcinolone particles were aspirated from the retinal surface using a back flush needle. Small numbers of triamcinolone particles were left behind on the retina. Postoperatively, no adverse effects of the intraoperative use of triamcinolone were observed with symptomatic improvement noticed 1 day following surgery. Two weeks following surgery his vision had improved from 6/24 to 6/12.

 

Comment

Intravitreal administration of triamcinolone has been shown to be safe and effective when used for the treatment of cystoid macular oedema due to uveitis⁶, diabetic maculopathy⁷, central retinal vein occlusion⁸ and post-cataract surgery.⁹ More recently, triamcinolone has been used to improve visualisation of the transparent vitreous gel during vitrectomy¹⁰ and facilitate visual confirmation of separation of the posterior hyaloid from the optic nerve head and posterior retina. Additional potential benefits associated with the intraoperative use of triamcinolone in vitrectomy surgery include a reduction in postoperative inflammation and intraocular proliferation.¹¹ During ERM surgery triamcinolone tends to stick to residual vitreous and the ERM itself. The peeled area of the ERM is clearly outlined by an absence of white triamcinolone particles surrounded by visible triamcinolone particles on the surface of the surrounding retina.

Although the long-term safety of intraocular administration of triamcinolone is unknown, no clinically observable toxic effects on the retina have been observed following intravitreal injection of triamcinolone for the treatment of macular oedema or intraoperative use during vitrectomy surgery.¹¹Furthermore, no toxic effect has been observed following submacular deposition of triamcinolone. ¹²

Because of concerns that the vehicle and preservatives in commercially available triamcinolone suspension may be toxic to intraocular tissues,¹³ a technique for the elimination of the vehicle in triamcinolone suspension has been recommended by Kumagai before intraocular use, and was used in the case reported above.¹⁴

In conclusion, this case demonstrates that triamcinolone-assisted ERM peeling may be an effective and safe technique for macular surgery. Further studies are needed to evaluate the long term safety of intraoperative use of TA.

 

References

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