Originl Article DOI: 10.17354/ijss/2015/548 Intrvitrel Trimcinolone Acetonide in Mculr Edem due to Retinl Vein Occlusions: A Comprtive Study of 1 mg nd 4 mg Doses Siknder A K Lodhi 1, Sntosh Devulplly 2 1 Assistnt Professor, Deprtment of Ophthlmology, Srojini Devi Eye Hospitl, Osmni Medicl College, Hyderd, Telngn, Indi, 2 Post-grdute, Deprtment of Ophthlmology, Srojini Devi Eye Hospitl, Osmni Medicl College, Hyderd, Telngn, Indi Astrct Introduction: Mculr edem (ME) occurs in wide vriety of oculr situtions like uveitis, trum, vsculr retinopthies, hereditry dystrophies, nd introculr surgery. It is one of the most importnt cuses of visul disturnce in ptients with retinl vein occlusions. Mterils nd Methods: A totl of 43 eyes of 43 ptients with ME due to retinl vein occlusion were rndomized to receive either 1 mg or 4 mg dose of intrvitrel injection of trimcinolone cetonide. Ech ptient hd complete comprehensive ophthlmic exmintion t seline nd t ech susequent visit. Fundus fluorescein ngiogrphy nd opticl coherence tomogrphy were done t seline nd t 1, 3, nd 6 months. Best-corrected visul cuity (BCVA), the sttus of the lens nd introculr pressure (IOP) were recorded t ech follow-up visit. BCVA ws mesured in Snellen s lines nd converted into logrithm of minimum ngle of resolution scle for sttisticl nlysis. The dt were sttisticlly evluted using the Wilcoxon signed rnk test, Mnn-Whitney test, nd t-tests wherever pplicle. A P < 0.05 ws considered significnt. Results: There ws no sttisticlly significnt difference in the men fovel thickness mesurement t seline (P = 0.159) or t the 3 rd month (P =0.605) etween oth the groups. There ws no sttisticlly significnt difference oserved in men BCVA etween the two groups t 1 dy, 1 month, 3 months, nd 6 months. There ws no sttisticlly significnt difference oserved in IOP etween the two groups t ny follow-up visit. Conclusions: The results of our study suggest tht 1 mg dose of IVTA is s effective s 4 mg dose of IVTA in improving the functionl nd ntomicl outcome in ME ssocited with retinl vein occlusions. Key words: Retinl vein occlusion, Mculr edem, Trimcinolone Acetinide INTRODUCTION Mculr edem (ME) is the result of n ccumultion of fluid in the retinl lyers round the fove. It contriutes to vision loss y ltering the functionl cell reltionship in the retin nd promoting n inflmmtory reprtive response. ME is nonspecific sign of oculr disese nd not specific entity. It should e considered s www.ijss-sn.com Access this rticle online Month of Sumission : 10-2015 Month of Peer Review : 11-2015 Month of Acceptnce : 12-2015 Month of Pulishing : 12-2015 specil nd cliniclly relevnt type of mculr response to n ltered retinl environment. In most cses, it is ssocited with n ltertion of the lood-retinl rrier. ME my occur in wide vriety of oculr situtions including uveitis, trum, introculr surgery, vsculr retinopthies, vitreoretinl dhesions, hereditry dystrophies, nd ge-relted mculr degenertion. 1 It is the most commonly seen following venous occlusive disese, dietic retinopthy, nd posterior segment inflmmtory disese. 2 The histopthologicl picture of this condition is n ccumultion of fluid in the outer plexiform (Henle s) nd inner nucler nd plexiform lyers of the retin. The Corresponding Author: Siknder A K Lodhi, 10-3-300/3, Humyun Ngr, Ms Tnk, Hyderd 500 028, Telngn, Indi. Tel.: (0)4023530775, Phone: +91-9848020497. E-mil: siknderlodhi@gmil.com 25 Interntionl Journl of Scientific Study Decemer 2015 Vol 3 Issue 9
increse in wter content of the retinl tissue chrcterizing ME my e intrcellulr or extrcellulr. 1 There re vrious modlities for treting the ME. 2 Intrvitrel trimcinolone cetonide (IVTA) is one of the tretment modlities. 2 However, IVTA is ssocited with significnt complictions like ctrct progression nd rise in introculr pressure (IOP). 3 Decresing the dose of IVTA my reduce the complictions. ME tretment vries, depending on the underlying etiology cusing the edem. 4 Trditionlly, the min tretment options hve included topicl nd systemic steroids, topicl nd systemic non-steroidl nti-inflmmtory gents, orl cronic nhydrse inhiitors, nd lser photocogultion therpy. Despite these tretment modlities, ptients often hve persistent mculredem. 4 Vsculr endothelil growth fctors (VEGF) hve een implicted in mny different mechnisms, which led to ME. Anti-VEGF gents ct y locking the ction of VEGF. Vrious Anti-VEGF gents considered for the tretment of ME include evcizum, rniizum, nd pegptni. Vrious other drugs such s steroid-spring immunosuppressive drugs, interferon α2, cyclosporine A, nti-tumor necrosis fctor therpy, protein kinse inhiitors, nd somtosttin nlogs such s octreotide hve een used in ME due to vrious cuses. 5 Intrvitrel corticosteroid injections hve een used t n incresed rte for treting ME. Corticosteroids hve likely een successful in the tretment of vrious forms of ME, due to its known nti-ngiogenic, nti-edemtous, 6 ntiinflmmtory, 7 nd nti-prolifertive effects. 8 Furthermore, it hs lso een demonstrted tht ctivtion of the glucocorticoid receptor is protective to the retinl photoreceptors due to its nti-poptotic effect. 9 The commonly used intrvitrel steroid is trimcinolone cetonide. In vrious cse reports nd series, IVTA hs een shown to e sfe nd effective when used for the tretment of ME cused y retinl vein occlusion. 10 While studies hve een done using vrying dosges of 1-20 mg, 11 the commonly used dosge is 4 mg. The efficcy, durtion of ction nd risk of side effects could e expected to increse with higher doses of IVTA. 12 The two most common side effects of IVTA re the elevtion of IOP nd ctrct formtion. Decresing the dose of IVTA my reduce complictions. Phrmcokinetics of trimcinolone cetonide fter 4 mg intrvitrel injection for ME in nonvitrectomized eyes showed tht the men elimintion hlf-life ws 18.6 dys, suggesting tht trimcinolone cetonide would e present in mesurle concentrtions for 3 months. 13 Aim To compre the efficcy nd sfety of 1 mg nd 4 mg doses of IVTA injection in the tretment of ME due to retinl vein occlusion. Ojectives of the Study Primry ojectives To compre the est corrected visul cuity (BCVA) nd fovel thickness on opticl coherence tomogrphy (OCT) etween 1 mg nd 4 mg doses of IVTA injections. Secondry ojectives To compre the steroid relted complictions s seen y IOP mesurements nd ctrct progression. This ws prospective rndomized comprtive interventionl study done on ptients who ttended the Vitreo-Retin Deprtment of Srojini Devi Eye Hospitl, Hyderd from Decemer 2010 to My 2012. The study included 43 eyes of 43 ptients with retinl vein occlusion ssocited with ME, rndomly ssigned to receive either 1 mg or 4 mg dose of IVTA. The ptients were explined out the dignosis, prognosis, different tretment options nd the likely complictions. An informed consent ws tken efore enrolment. MATERIALS AND METHODS Inclusion Criteri ME due to retinl vein occlusion BCVA <6/12 ME seen on slit lmp io microscopy Fundus flourescein ngiogrphy showing lekge t mcul OCT showing fovel thickness of >200 μ Exclusion Criteri Reduced visul cuity due to significnt ctrct Posterior cpsulr opcifiction in pseudophkic eyes Intrvitrel or periulr steroids or ny mculr photocogultion 4 months prior to injection Prior prspln vitrectomy Ctrct surgery or yttrium luminum grnet cpsulotomy 4 months prior to injections Any epiretinl memrne or vitreomculr trction on OCT Eyes with thin scler Any glucom or psuedoexfolition. A complete comprehensive oculr exmintion ws done in ll ptients, including BCVA; slit lmp exmintion of nterior segment nd posterior segment (using 90 D lens), indirect ophthlmoscopy, gonioscopy, pplntion tonometry t seline nd t ech susequent visit. FFA Interntionl Journl of Scientific Study Decemer 2015 Vol 3 Issue 9 26
nd OCT were done t seline, 1 month, 3 months, nd t 6 months follow-up. BCVA ws recorded in Snellen s lines nd converted to logrithm of minimum ngle of resolution (log MAR) scle for nlysis. All the ptients were evluted for systemic risk fctors for retinl vein occlusion including dietes, hypertension, nd coronry rtery disese nd were investigted for lood nd urine sugrs, glycted hemogloin (H), H%, Serum lipids, nemi, nd serum homocysteine. A crdiovsculr evlution ws done y physicin/crdiologist including 2 D echo nd Doppler exmintion. Any norml prmeters found on systemic evlution were treted y physicin. Gtifloxcin eye drops 3 times dy were given 1 dy efore nd on the dy of injections. The intrvitrel injections were given in the opertion theter using topicl nesthesi (proprcine hydrochloride 0.5%). Asepsis ws chieved y surfce preprtion of eye including the lshes using 2-3 drops of 5% povidineiodine. 0.1 ml (either 1 mg or 4 mg) of trimcinolone cetonide ws injected, using 1 ml syringe with 30 G needle, t prs pln in the inferotemporl qudrnt 3.5 mm posterior to limus in psuedophkic eyes nd 4 mm posterior to limus in phkic eyes. The ptients were reviewed the next dy nd proper plcement of the drug confirmed. Topicl gtiflox eye drops were used 4 times dy for 1 week fter the injection. Ptients were re-exmined t 1 dy, 1 week, 1 month, 3 months, nd 6 months fter the injection. The minimum period of follow-up ws 6-month. The dt, thus, collected ws sujected to sttisticl nlysis. Snellen s VA ws converted to the log MAR nd verged for the purpose of sttisticl nlysis. Sttisticl nlysis ws performed using commercil sttisticl softwre (IBM SPSS for Windows, Version 20). The dt were sttisticlly evluted using the Wilcoxon signed rnk test, Mnn Whitney test, nd t-tests wherever pplicle. A P < 0.05 ws considered significnt. Age distriution The men ge ws 50.25 ± 14.37 in 1 mg group nd 48.5 ± 13.59 in 4 mg group (Figure 3). Type of retinl vein occlusion Out of 20 eyes in ech group 7 eyes (35%) were dignosed s centrl retinl vein occlusion (CRVO), 2 (10%) with hemi-retinl vein occlusion, 11 (55%) with rnch retinl vein occlusion (BRVO) (Figures 4 nd 5). Durtion of symptoms The men (±stndrd devition [SD]) durtion of symptoms ws 55.3 ± 23.06 (rnge 20-90) dys in 1 mg Tle 1: Gender distriution Gender n=20 1 mg 4 mg Mles 12 14 Femles 8 6 Figure 1: 1 mg group Figure 2: 4 mg group RESULTS AND OBSERVATIONS Out of the totl 43 ptients, two ptients receiving 1 mg of IVTA nd one ptient receiving 4 mg of IVTA were lost to follow-up. 40 ptients completed 6 months follow-up. Therefore, 40 eyes of 40 ptients with minimum followup period of 6-month were included for nlysis. Demogrphic Profile Gender distriution Our study comprised predominntly of mles; totl 40 ptients of which 26 ptients were mle nd 14 ptients were femle (Tle 1 nd Figures 1 nd 2). Figure 3: Age distriution 27 Interntionl Journl of Scientific Study Decemer 2015 Vol 3 Issue 9
group nd 51.25 ± 30.55 (rnge 15-120) dys in 4 mg group. Fovel thickness The men (±SD) fovel thickness ws 423.77 ± 105.45 (n = 13) in 1 mg group nd 502 ± 169.75 (n = 16) in 4 mg group. Men chnge in fovel thickness (Tle 2 nd Figure 6) The men fovel thickness significntly improved from seline in oth the groups. There ws no sttisticlly significnt difference in the men fovel thickness mesurement t seline (P = 0.159) or t 3 rd month (P =0.605) etween oth the groups. Figure 4: Types of retinl occlusion (1 mg) Visul cuity Men chnge in BCVA (Tle 3 nd Figure 7) The men (±SD) seline BCVA ws 1.30 ± 0.33 in 1 mg group nd 1.13 ± 0.44 in 4 mg group. In 1 mg group, the men BCVA ws significntly improved from seline to 1.19 ± 0.26 (P =0.010), 0.95 ± 0.33 (P < 0.0001), 0.71 ± 0.48 (P < 0.0001), 0.62 ± 0.56 (P = 0.001), 0.75 ± 0.56 (P = 0.002) t 1 dy, 1 week, 1 month, 3 months, nd 6 months, respectively. In 4 mg group, the men BCVA ws significntly improved from seline to 0.99 ± 0.46 (P = 0.002), 0.65 ± 0.37 (P < 0.0001), 0.51 ± 0.38 (P < 0.0001), 0.50 ± 0.47 (P = 0.001), 0.48 ± 0.45 (P = 0.003) t 1 dy, 1 week, 1 month, 3 months, 6 months, respectively. There ws no sttisticlly significnt difference oserved in the men seline BCVA etween the two groups (P = 0.166). The men BCVA ws etter in 4 mg group t 1 week (P = 0.026). There ws no sttisticlly significnt difference oserved in men BCVA etween the two groups t 1 dy, 1 month, 3 months, nd 6 months. Visul Acuity Chnge in Snellen s Lines (Tle 4 nd Figure 8) Complictions Increse in introculr pressure (Tle 5 nd Figure 9) Men chnge in IOP during follow-up period: The men (±SD) seline IOP ws 14.9 ± 2.29 in 1 mg group nd Figure 5: Types of retinl occlusion (4 mg) Figure 7: Men chnge in est corrected visul cuity Figure 6: Men chnge in fovel thickness Figure 8: Visul cuity chnge in Snellen s lines Tle 2: Men chnge in fovel thickness Visit 1 mg (n=10) 4 mg (n=15) P etween su-groups Bseline 448.80±94.50 515.67±166.35 0.159 3 months 284.00±160.41 0.037 253.93±169.37 0.001 0.605 Interntionl Journl of Scientific Study Decemer 2015 Vol 3 Issue 9 28
14.8 ± 2.46 in 4 mg group. In 1 mg group, the men IOP ws significntly incresed from seline to 17.7 ± 3.90 (P = 0.007), 18.1 ± 4.17 (P = 0.001), 17.6 ± 4.03 (P = 0.006), Tle 3: Men chnge in BCVA Visit 1 mg 4 mg P etween su-groups Bseline 1.30±0.33 1.13±0.44 0.166 1 st dy 1.19±0.26 0.010 0.99±0.46 0.002 0.107 1 week 0.95±0.33 <0.0001 0.65±0.37 <0.0001 0.026 1 month 0.71±0.48 <0.0001 0.51±0.38 <0.0001 0.192 3 months 0.62±0.56 0.001 0.50±0.47 0.001 0.512 6 months 0.75±0.56 0.002 0.48±0.45 0.003 0.114 BCVA: Best corrected visul cuity Tle 4: Visul cuity chnge in Snellen s lines Chnge in Snellen s lines 1 mg 4 mg 1-3 lines 6 (3.0%) 3 (15%) 4-5 lines 3 (15%) 5 (25%) >5 lines 7 (35%) 10 (50%) Not responded 4 (20%) 2 (10%) Worsening fter initil improvement 3 3 Tle 5: Men chnge in IOP during follow-up period Visit 1 mg 4 mg P etween su-groups Bseline 14.9±2.29 14.8±2.46 0.895 1 st dy 14.5±2.41 0.330 15.0±2.63 0.716 0.536 1 week 17.7±3.90 0.007 17.4±3.50 0.012 0.800 1 month 18.1±4.17 0.001 18.2±6.67 0.029 0.955 3 months 17.6±4.03 0.006 17.6±4.92 0.020 1.00 6 months 16.3±2.36 0.023 17.5±4.34 0.005 0.285 IOP: Introculr pressure Tle 6: Incidence of elevted IOP/glucom Within nd including 6 months n (%) 1 mg 4 mg Increse 5 mmhg from seline 6 (30) 9 (45) Increse 10 mmhg from seline 3 (15) 4 (20) 30% increse from seline 7 (35) 9 (45) IOP-lowering mediction 5 (25) 5 (25) Glucom surgery (treculectomy) 0 1 (5) IOP: Introculr pressure 16.3 ± 2.36 (P = 0.023) t 1 week, 1 month, 3 months, nd 6 months, respectively. In 4 mg group, the men IOP ws significntly incresed from seline to 17.4 ± 3.50 (P = 0.012), 18.2 ± 6.67 (P = 0.029), 17.6 ± 4.92 (P = 0.020), 17.5 ± 4.34 (P = 0.005) t 1 week, 1 month, 3 months, nd 6 months, respectively. There ws no sttisticlly significnt difference oserved in the men seline IOP etween the two groups (P = 0.895). There ws no sttisticlly significnt difference oserved in IOP etween the two groups t ny follow-up visit. Incidence of elevted IOP/glucom (Tle 6) 6 eyes (in 1 mg group) nd 9 eyes (in 4 mg group) hd n elevtion of 5 mmhg of IOP from seline. Three eyes (in 1 mg group) nd 4 eyes (in 4 mg group) hd n elevtion of 10 mmhg of IOP from seline. Seven eyes (in 1 mg group) nd 9 eyes (in 4 mg group) hd 30% elevtion from seline. IOP-lowering mediction required in 5 eyes in ech group. One eye underwent treculectomy in 4 mg group for refrctory elevtion of IOP. Ctrct Aout 18 eyes were phkic nd 2 eyes were pseudophkic t presenttion in 1 mg group. In 4 mg group, 19 eyes were phkic, nd 1 eye ws pseudophkic t presenttion. Out of 18 eyes, 1 ptient showed increse in nucler sclerosis in 1 mg group. Out of 19 eyes, 3 ptients showed increse in nucler sclerosis nd 2 ptients developed posterior sucpsulr ctrct in 4 mg group. In 4 mg group, 2 ptients underwent ctrct surgery 6 months post-injection. Figure 10 shows right eye superotemporl BRVO, nd Figure 10 shows the OCT of the sme eye with incresed fovel thickness nd multiple cystic spces. Figure 11 nd shows the sme eye 3 months post IVTA with decresed ME nd norml fovel contour on OCT. Figure 12 shows the fundus picture of cse of CRVO with Figure 13 showing cystoid ME on OCT of the sme cse. Figures 12 nd 13 show the fundus nd OCT 3 months post IVTA with resolved ME. Figure 9: Men chnge in introculr pressure during follow-up period Figure 10: () ST rnch retinl vein occlusion pre-intrvitrel trimcinolone cetonide (IVTA), () opticl coherence tomogrphy pre IVTA, cystic spces nd incresed fovel thickness 29 Interntionl Journl of Scientific Study Decemer 2015 Vol 3 Issue 9
DISCUSSION Figure 11: () 3 months post-intrvitrel trimcinolone cetonide (IVTA), () opticl coherence tomogrphy shows norml fovel contour with norml thickness, 3 months post IVTA Figure 12: () Centrl retinl vein occlusion, () 3 months postintrvitrel trimcinolone cetonide Figure 13: () Cystoid mculr edem on opticl coherence tomogrphy, () resolved edem post-intrvitrel trimcinolone cetonide In our study, the men durtion etween symptoms nd tretment ws 55.3 dys in 1 mg group nd 51.25 dys in 4 mg group. We oserved tht (Tle 4) in 1 mg group, 15 eyes (75%) showed t lest 1 line improvement in visul cuity, 10 (50%) eyes showed more thn 3 lines improvement nd 6 (30%) eyes showed more thn 5 lines of improvement t the end of 6 months follow-up. In 4 mg group, 16 eyes (80%) showed t lest 1 line improvement, 12 (60%) eyes showed more thn 3 lines improvement nd 9 (45%) eyes showed more thn 5 lines of improvement t the end of 6 months follow-up. Three eyes in ech group showed worsening of visul cuity fter initil improvement. In SCORE-BRVO tril, 14 25.6%, nd 27.2% prticipnts showed gin in visul cuity letter score of 15 or more from seline in 1 mg nd 4 mg trimcinolone groups, respectively. The results of the SCORE-BRVO tril demonstrte no significnt differences mong the 2 tretment groups for gin in visul cuity letter score of 15 or more t 12 months, though n erly positive tretment response of gin in visul cuity letter score of 15 or more ws oserved t month 4 in the 4 mg trimcinolone group compred with the 1 mg trimcinolone. In SCORE-CRVO tril, 15 26.5%, nd 25.6% prticipnts showed gin in visul cuity letter score of 15 or more from seline in 1 mg nd 4 mg trimcinolone groups, respectively. The results of the SCORE-CRVO tril 15 demonstrte no significnt differences mong the 2 tretment groups for gin in visul cuity letter score of 15 or more t 12 months. In our study, oth the groups showed decrese in fovel thickness from seline. At 3 months the decrese in fovel thickness ws similr in oth the groups. In SCORE-CRVO Tril, 15 there ws no difference etween groups in retinl thickness t 12 months. At month 4, there ws greter reduction in OCT-mesured center point thickness in the 4 mg IVTA group thn in the 1 mg group (P < 0.001). SCORE-BRVO tril 14 lso concluded tht t month 4, there ws greter reduction in OCT-mesured center point thickness in the 4 mg IVTA group thn the 1 mg group. In similr study done in dietic ME compring 1 mg IVTA nd 4 mg IVTA, 16 we oserved tht in 1 mg group, 80% showed t lest 1 line improvement, 40% eyes showed more thn 3 lines improvement nd 10% eyes showed more thn 5 lines of improvement t the end of 6 months follow-up. In 4 mg group, 85% showed t lest 1 line improvement, 40% eyes showed more thn 3 lines improvement nd 10% eyes showed more thn 5 lines of improvement t the end of 6 months follow-up. In the present study, the incidence of dverse events were higher in the 4 mg IVTA group compred with the 1 mg group. Six (30%) eyes nd 9 (45%) eyes showed 5 mmhg elevtion of IOP from seline in 1 mg nd 4 mg groups, respectively. Five (25%) eyes in ech group required IOP-lowering mediction. One eye in 4 mg group underwent treculectomy for refrctory elevtion of IOP. In SCORE BRVO tril 14 IOP-lowering, mediction ws initited in more eyes through 12 months in the 4 mg IVTA group (41%) compred with the 1 mg IVTA group (7%). In the 4 mg group, one prticipting underwent treculectomy nd nother received tue shunt to control IOP. In SCORE-CRVO tril, 15 more eyes in the 4 mg IVTA group (35%) initited IOP lowering mediction through 12 months compred with the 1 mg IVTA (20%) group. In our study, the incidence of lenticulr chnges ws more in 4 mg group thn 1 mg group. One (out of 18) eye nd 5 (out of 19) eyes developed lenticulr chnges in Interntionl Journl of Scientific Study Decemer 2015 Vol 3 Issue 9 30
1 mg nd 4 mg groups respectively. Two eyes underwent ctrct surgery in 4 mg group. In SCORE-BRVO tril, 14 the estimte of new-onset lens opcity or progression of n existing opcity sed on clinicl ssessment through month 12 ws 25% nd 35% in the 1 mg nd 4 mg IVTA groups, respectively. More ctrct surgeries were performed in the 4 mg group. CONCLUSION The results of our study suggest tht the functionl nd ntomicl outcome in the mngement of ME due to retinl vein occlusions is s effective with 1 mg IVTA s with 4 mg IVTA with fewer complictions like secondry glucom nd ctrct. REFERENCES 1. Coscs G, Cunh-Vz J, Sourne G. Mculr edem: Definition nd sic concepts. Dev Ophthlmol 2010;47:1-9. 2. Trnos PG, Wickremsinghe SS, Stngos NT, Topouzis F, Tsinopoulos I, Pvesio CE. Mculr edem. Surv Ophthlmol 2004;49:470-90. 3. Ozkiris A, Erkiliç K. Complictions of intrvitrel injection of trimcinolone cetonide. Cn J Ophthlmol 2005;40:63-8. 4. Johnson MW. Etiology nd tretment of mculr edem. Am J Ophthlmol 2009;147:11-21.e1. 5. Wolfenserger TJ, Gregor ZJ. Mculr edem-rtionle for therpy. Dev Ophthlmol 2010;47:49-58. 6. Penfold PL, Wen L, Mdign MC, Gillies MC, King NJ, Provis JM. Trimcinolone cetonide modultes permeility nd intercellulr dhesion molecule-1 (ICAM-1) expression of the ECV304 cell line: Implictions for mculr degenertion. Clin Exp Immunol 2000;121:458-65. 7. Bolnd EW. Nonspecific nti-inflmmtory gents. Some notes on their prcticl ppliction, especilly in rheumtic disorders. Clif Med 1964;100:145-55. 8. Jons JB, Kreissig I, Degenring R. Intrvitrel trimcinolone-lone cetonide for tretment of introculr prolifertive, exudtive, nd neovsculr diseses. Prog Retin Eye Res 2005;24:587-611. 9. Wenzel A, Grimm C, Seeliger MW, Jissle G, Hfezi F, Kretschmer R, et l. Prevention of photoreceptor poptosis y ctivtion of the glucocorticoid receptor. Invest Ophthlmol Vis Sci 2001;42:1653-9. 10. Greenerg PB, Mrtidis A, Rogers AH, Duker JS, Reichel E. Intrvitrel trimcinolone cetonide for mculr edem due to centrl retinl vein occlusion. Br J Ophthlmol 2002;86:247-8. 11. Kim JE, Pollck JS, Miller DG, Mittr RA, Spide RF. For The ISIS Study Group A prospective rndomized, dose- escltion intrvitrel steroid injection study for refrctory dietic mculr edem. Retin 2008;28:735-40. 12. Spndu UH, Derse M, Schmitz-Vlckenerg P, Ppoulis C, Jons JB. Dosge Dependency of intrvitrel trimcinolone cetonide s tretment for dietic mculr oedem. Br J Ophthlmol 2005;89:999-1003. 13. Andrde RE, Muccioli C, Frh ME, Nussenltt RB, Belfort R Jr. Intrvitrel trimcinolone in the tretment of serous retinl detchment in Vogt-Koyngi-Hrd syndrome. Am J. Ohthlmol 2004;137:572-4. 14. Scott IU, Ip MS, VnVeldhuisen PC, Oden NL, Blodi BA, SCORE Study Reserch Group, et l. A rndomized tril compring the efficcy nd sfety of intrvitrel trimcinolone with stndrd cre to tret vision loss ssocited with mculr Edem secondry to rnch retinl vein occlusion: The stndrd cre vs. Corticosteroid for retinl vein occlusion (SCORE) study report 6. Arch Ophthlmol 2009;127:1115-28. 15. Ip MS, Scott IU, VnVeldhuisen PC, Oden NL, Blodi BA, Fisher M, SCORE Study Reserch Group, et l. A rndomized tril compring the efficcy nd sfety of intrvitrel trimcinolone with oservtion to tret vision loss ssocited with mculr edem secondry to centrl retinl vein occlusion: The stndrd cre vs. Corticosteroid for retinl vein occlusion (SCORE) study report 5. Arch Ophthlmol 2009;127:1101-14. 16. Lodhi SA, Reddy S, Devulplly S. Intrvitrel trimcinolone in dietic mculr edem: A comprtive study of 1 mg nd 4 mg doses. J Evol Med Dent Sci 2015;2015:9191-201. How to cite this rticle: Lodhi SAK, Devulplly S. Intrvitrel Trimcinolone Acetonide in Mculr Edem due to Retinl Vein Occlusions: A Comprtive Study of 1 mg nd 4 mg Doses. Int J Sci Stud 2015;3(9):25-31. Source of Support: Nil, Conflict of Interest: None declred. 31 Interntionl Journl of Scientific Study Decemer 2015 Vol 3 Issue 9