147 Vol. 30, No. 3, Jul – Sep, 2014 Pakistan Journal of Ophthalmology

Original Article

Control of Raised Intraocular Pressure after
Intravitreal Triamcinolone Acetonide

P. S. Mahar, A. Sami Memon

Pak J Ophthalmol 2014, Vol. 30 No. 3

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See end of article for
authors affiliations

…..………………………..

Correspondence to:
P. S. Mahar
Isra Postgraduate
Institute of Ophthalmology,
Al-Ibrahim Eye Hospital, Malir,
Karachi
Cell: 03008284837

…..………………………..

Purpose: To determine the various treatment options including anti-glaucoma
medication, laser and surgery to control the intraocular pressure (IOP) rise after
Intravitreal triamcinolone acetonide (IVTA).

Material and Methods: This prospective, interventional case series was carried
out at Isra Postgraduate Institute of Ophthalmology, Karachi from May 2007 to
April 2009. Patients with various choroidal and retinal vascular disorders, who
were given IVTA in a dose of 4 mg / 0.1 ml and developed raised IOP ( > 21 mm
Hg) were included in the study and followed up for one year.

Results: Two hundred thirty seven eyes of 180 patients received IVTA during
the study period. The mean age of patients was 50.86 ± 10.62 years with gender
distribution of 99 male and 81 female. One hundred seventeen (49.36%) out of
237 eyes showed raised IOP after IVTA. Fifty two (21.94%) eyes showed an IOP
between 25-30 mmHg while 65 (27.42%) had IOP of > 30 mm Hg. Successful
control of IOP was defined as an IOP of less than 21 mm Hg. Thirty-four
(29.05%) eyes were controlled with single beta-blocker therapy (Timolol maleate
0.5%) and 69 (58.97%) eyes were brought into control with combination therapy
(Timolol maleate 0.5% + Dorzolamide 2%). Additional 4 (3.41%) eyes required
Prostaglandin analogue (Latanoprost 0.005%) along with combination therapy
for IOP control. Another 4 (3.41%) eyes were controlled with Argon laser
trabeculoplasty and full medical treatment and remaining 6 (5.12%) eyes settled
down with trabeculectomy with adjunctive mitomycin-C.

Conclusion: Although IVTA is a cost-effective therapeutic agent against various
choroidal and retinal disorders, 50% of the patients developed raised IOP > 21
mm Hg. Half of these patients required multiple drugs and almost 5% needed
surgical intervention to control IOP under 21 mm Hg.

Key words: Triamcinolone acetonide, Intraocular pressure, Glaucoma.

riamcinolone acetonide is a major therapeutic
agent given intravitrealy in various retinal and
choroidal vascular disorders.1-7 The raised

intraocular pressure (IOP) is a major concern of this
procedure. The reported incidence of increase in IOP
varies from 27-50% in various studies published in
literature.8-12 Intravitreal triamcinolone acetonide
(IVTA) causes secondary open angle type of
glaucoma. The exact mechanism of rise in IOP is not
known but it can be caused by cortisone crystals
blocking the trabecular meshwork or steroid related
decreased phagocytosis of extracellular matrix in

meshwork by macrophages. Corticosteroids are
believed to decrease aqueous outflow by inhibiting
degradation of extracellular matrix material in
trabecular meshwork, leading to an excessive amount
of debris within the outflow channels with subsequent
increase in outflow resistance.13,14 Steroid induced
glaucoma after IVTA is usually of transient nature but
can run a chronic course in certain patients. Patients
having IOP of more than 16 mm Hg, with family
history of glaucoma or having diabetes mellitus are at
increased risk of developing full – fledged disease15, 16.
An increase in IOP after IVTA may take up to six

CONTROL OF RAISED INTRAOCULAR PRESSURE AFTER INTRAVITREAL TRIAMCINOLONE ACETONIDE

Pakistan Journal of Ophthalmology Vol. 30, No. 3, Jul – Sep, 2014 148

months to present12. The rise in IOP can be variable
after IVTA, ranging from 22 mm Hg to more than 40
mmHg, failing to control with medical therapy and
eventually requiring drainage surgery.

We undertook this study to determine the various
treatment options and their effectiveness in controlling
IOP in cohort of patients who received IVTA because
of their choroidal and retinal vascular problems and
developed raised IOP > 25 mm Hg.

MATERIAL AND METHODS

This was a prospective interventional case series
conducted at Isra Postgraduate Institute of
Ophthalmology/Al-Ibrahim Eye Hospital, Karachi.
Permission to conduct the research was taken by the
ethics committee of the Hospital. The study design
and details of the procedures are described
elsewhere12. Briefly, 237 eyes of 180 patients received
IVTA (4 mg / 0.1 ml) from May 2007 to April 2009
with various choroidal and retinal vascular disorders
(Table 1). Patients having IOP of > 20mm Hg and
already receiving anti-glaucoma medication were
excluded from the study.

After informed consent, a detailed ocular
examination was carried out, including best corrected
visual acuity, anterior segment biomicroscopy, IOP
measurement, gonioscopy and fundus examination
using +90 DS lens.

All intravitreal injections were given under sterile
conditions in operating theatre with patients receiving
ciprofloxacin 0.3% drops (Ciloxin – Alcon, Belgium)
one day prior to injection and continuing for 3 days
afterwards. All patients were followed at day 1, 1
week, 1 month, 3 months and 6 months subsequently
with mean follow up of one year. At each follow up
visit, patients had charting of vision, IOP
measurement and fundus examination.

A major aim of this study was to determine the
proportion of eyes that had uncontrolled IOP (> 21
mm Hg) after the injection and the type and
effectiveness of the IOP – lowering treatment they
received.

The rise in IOP was noticed at 1 week of post
injection period but peaked to highest level at 3
months and continued to show an increase up to 6
months.

Statistical analysis

For data analysis, SPSS (Statistical Package for Social
Sciences) version 17.0 was used. The frequency and

percentages were computed for categorical variables
including gender and diagnosis. For continuous
variable IOP, data was shown in mean ± standard
deviation.

RESULTS

Two hundred thirty seven eyes of 180 patients
received IVTA during the study period. The mean age
of patients was 50.86 ± 10.62 years with gender
distribution of 99 male and 81 female. Out of 237 eyes,
117 (49.36%) eyes showed an increase in IOP > 21
mmHg (Fig. 1). The IOP increased from 13.76 ± 2.79
mmHg to a mean of 15.73 ± 4.5 mm Hg post injection
after 1 week. At 1 month, IOP was increased to 17.3 ±
6.8 mm Hg. After 3 months, IOP increased to 19.08 ±
8.6 mm Hg and after 6 months IOP was 14.38 ± 4.9 mm
Hg (p < 0.0001). Fifty two (21.94%) eyes showed an
IOP of 21-30 mm Hg. All these eyes were commenced
on Timolol maleate 0.5% (Betalol – Sante, Pak), one
drop twice a day. Thirty four (14.34%) eyes had
controlled IOP < 21 mm Hg, while 18 (7.59%) eyes still
had uncontrolled eye pressure.

Sixty five (27.42%) eyes out of 117 eyes had an

initial IOP measured > 30 mm Hg. These eyes along
with 18 eyes not controlled on single beta blocker
therapy (65 + 18 = 83 eyes) were initiated on
combination therapy of Timolol maleate 0.5% +
Dorzolamide 2% (Co-dorzal – Sante, Pak). Out of total
85 eyes, 69 (29.11%) eyes responded well on
combination therapy bringing IOP < 21 mm Hg while
14 eyes (5.90%) still had an elevated IOP of > 25 mm
Hg. Four (1.68%) eyes had a further drop in IOP < 21
mm Hg with addition of Latanoprost 0.005% (Vislat –
Sante, Pak). Out of remaining 10 (4.21%) eyes, Argon

P. S. MAHAR, et al

149 Vol. 30, No. 3, Jul – Sep, 2014 Pakistan Journal of Ophthalmology

laser trabeculoplasty (ALT) was performed,
controlling IOP in further 4 (1.68%) eyes. The
remaining 6 (2.53%) eyes with uncontrolled IOP of >
25 mm Hg with combination therapy, prostaglandin
analogue and ALT were subjected to trabeculectomy
with adjunctive use of mitomycin-C. All these eyes
remained within range of normal IOP between 10-20
mmHg at mean follow up of one year (Table 2).

1st Week 1st Month 3rd Month 6th Month

Fig. 1: Raised IOP in total number of eyes following
intravitreal triamcinolone acetonide. Total eyes 237,
raised IOP in 117 (49%) eyes.

In essence, out of 117 eyes showing raised IOP

after IVTA, 34 (29.05%) eyes were controlled with
single beta-blocker therapy, 69 (58.97%) eyes were
brought into control with combination therapy.
Additional 4 (3.41%) eyes required Prostaglandin
analogue along with combination therapy for IOP
control. Another 4 (3.41%) eyes were controlled with
ALT and full medical treatment and remaining 6
(5.12%) eyes settled down with drainage surgery.

DISCUSSION

Intravitreal triamcinolone acetonide (IVTA) can be a
therapeutically option for the treatment of various
intraocular pathologies including neovascular,
oedematous and proliferative disease involving
choroid and retina. It can also be used as an
angiostatic agent in eyes with iris neovascularization,
proliferative diabetic retinopathy and Wet age related
macular degeneration. An increase in IOP is a
common side effect with the use of IVTA. The rise in
IOP can occur from one week to 6 months post
injection. The amount of IOP increase can range from
22-40 mm Hg. (The raise in IOP can be between 22 and
40 mm Hg) There are certain number of patients who
cannot be controlled on medical therapy and go on to
have drainage surgery. An IOP elevation after IVTA
was reported in 40% of 305 eyes by Jonas and
coworkers17. Thirty nine percent of these eyes were
controlled below 21 mm Hg on topical anti-glaucoma
medication and systemic carbonic anhydrase
inhibitors with 1% (03) eyes required drainage
surgery. Kocaboraet al8 reported 40 (27%) eyes out of
147 eyes, showing an increase in IOP of > 25 mm Hg
after IVTA. Thirty – three (22.44%) eyes were
controlled below 21 mm Hg on combination treatment
of Timolol maleate and Dorzolamide drops, while 7
(4.7%) eyes required drainage surgery. Park10 and
colleagues reported 26, out of 60 (43.3%) eyes having
elevated IOP after 4mg of IVTA. Intraocular pressure
was not controlled despite full anti-glaucoma
medication in 7 (11.7%) eyes. These eyes underwent
filtering surgery. In another study Bashshur18 reported
59 (26.1%) of 226 eyes having IOP higher than 21 mm
Hg after IVTA in 4mg dosage. Fifteen eyes (6.63%) had
IOP of > 25 mm Hg treated with combination therapy
of Dorzolamide and Timolol maleate, while 3 (1.32%)

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CONTROL OF RAISED INTRAOCULAR PRESSURE AFTER INTRAVITREAL TRIAMCINOLONE ACETONIDE

Pakistan Journal of Ophthalmology Vol. 30, No. 3, Jul – Sep, 2014 150

eyes required surgery.

Compared to these studies, in our cohort of
patients receiving IVTA, 117 out of 237 eyes showed
raised IOP of > 21 mm Hg. Out of these, 34 (29.05%)
eyes were controlled with single beta-blocker, 69
(58.97%) eyes were brought in to control with
combination therapy, while 4 (3.41%) eyes required
Prostaglandin analogue along with combination
therapy for IOP control. Another 4 (3.41%) eyes were
controlled with additional ALT and remaining 6
(5.12%) eyes settled down with drainage surgery.

Severe and intractable IOP elevation can occur
even with full medical treatment after IVTA, with
certain patients necessitating trabeculectomy. This,
therefore requires careful indication of IVTA and long
follow up.

CONCLUSION

The benefit of intravitreal triamcinolone acetonide
therapy should be weighed against the risk of
increased IOP, as 50% of our patient receiving IVTA
developed raised IOP > 21 mm Hg. Half of these
patients required multiple drugs and almost 5%
needed drainage surgery to control IOP.

Author’s Affiliation

Prof. P. S. Mahar
Isra Postgraduate Institute of Ophthalmology
Al-Ibrahim Eye Hospital, Karachi

Dr. A. Sami Memon
Isra Postgraduate Institute of Ophthalmology
Al-Ibrahim Eye Hospital, Karachi

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