Intravitreal Triamcinolone (Kenalog, Triesence) Injection

Topical, periocular, and systemic steroids have been used in medicine, and ophthalmology in particular, for over 40 years. We have a long experience with these drugs, and they have been extremely useful in reducing, controlling, and sometimes eliminating intraocular inflammation. The list of side effects, limitations, and potential complications is well known. More recently, we have been using long acting intraocular steroids, i.e., triamcinolone acetate for control of intraocular inflammation, resolution of macular edema, and inactivation of subretinal neovascular membranes. The indications for intraocular steroid injection are growing.

There are potential risks of steroids, however delivered, that accompany their significant potential benefits. The injection of steroids, as with any intraocular procedure, has a chance for significant complications. Intraocular procedures, though common and routine, are never considered trivial. The most common complications of intraocular steroids include limited benefit or failure to work as desired. Also, 20% of patients experience a pressure rise, which can lead to glaucoma. Usually, topical drops are sufficient to control the glaucoma, but surgery is sometimes necessary. The intraocular steroid (triamcinolone acetate) typically wears off in three to four months, and the need for ongoing pressure control medication usually subsides. Other less common, but potentially serious, complications include sterile, or even infectious, endophthalmitis (infection of the eye) with potential devastating vision loss. It is uncertain how frequently this occurs, but it is probably on the order of 1 in 500 or 1 in 1000 injections. Even so, many of these patients can be treated satisfactorily with a significant improvement in vision. Cataracts, and less commonly, retinal detachments, intraocular hemorrhages, and even blindness can occur. Extraocular, subconjunctival, or even lid swelling or bruising commonly occurs, but this is of little or no visual consequence.

The shot itself causes minimal discomfort and is done with topical and local anesthesia. Postoperatively, five days of topical antibiotics are useful to reduce the rate of complications. Follow-up appointments are necessary to look for any potential complications and treat them accordingly. The patient usually returns within a week of the intraocular injection, and then again in about one month to judge the effects and to detect late complications of treatment. The benefits may be seen in a few days, weeks, months, or not at all. Repeat injections may be needed.

There are new drug delivery systems on the horizon that may replace intraocular injections. For now, however, intraocular injection of steroids is often a very useful means of applying the steroid where it is most needed. Typically, this has little or no affect on the blood sugars of diabetics because the steroids are contained within the eye. As mentioned earlier, steroids have been present for many years and have long since gone through the FDA approval process. Unfortunately, however, they were not officially approved for intraocular injection, and though they are commonly used nationally and are a national standard of care, it is an "off-label" use. A new drug, Triesence, is now approved by the FDA for use in and around the eye. It has the same compication rate as Kenalog but costs more and is usually covered by insurance. If you have additional questions or concerns, please feel free to discuss them with me.

David V. Poer, M.D., F.A.C.S.