A combination of suprachoroidal injection of triamcinolone using a custom-made needle and intravitreal Ziv-aflibercept every eight weeks to manage naïve/denovo central DME: a single-center retrospective case series

Abstract

Background: Previous studies have shown promising effects of combining intravitreal bevacizumab and suprachoroidal injection of triamcinolone acetonide in treating DME. However, further research is needed.

Objective: To assess the efficacy and safety of combining both intravitreal Ziv-aflibercept and suprachoroidal injection of triamcinolone acetonide using a custom-made needle in naïve and de novo central diabetic macular edema (DME) patients every eight weeks for 24 weeks.

Methods: Central macular thickness was measured via spectral domain-optical coherence tomography, and best-corrected visual acuity was measured via a Snellen chart at baseline and at 4, 8, 12, 16, and 24 weeks postinjection. Additionally, cataract progression, intraocular pressure (IOP), and ocular safety were analyzed.

Results: A total of 10 eyes of 6 patients were treated with suprachoroidal injections of triamcinolone acteonid combined with an intravitreal injection of Ziv-aflibercept. Vision improved from 0.69 log minimum angle of resolution (MAR) at baseline to 0.39 log MAR after treatment. Central macular thickness significantly decreased from 462.3 ± 166 μm at baseline to 362.7 ± 77.6 μm at 24 weeks postinjection.

Conclusion: Suprachoroidal injection of triamcinolone using a custom-made needle with the intravitreal agent Ziv-aflibercept to treat de novo/naïve central DME has favorable outcomes and adequate safety results. Moreover, this study demonstrated the benefit of adapting the previous treatment combination for extending the interval between anti-VEGF treatments from 4 to 8 weeks, which could prevent further expenses, especially in low-income countries.However, large multicenter randomized clinical trials with longer follow-up periods are needed to assess this treatment route, especially in low-income and resourced countries.

Keywords: Custom-made needle; DME; Suprachoroidal; Triamcinolone; Ziv-aflibercept.

Fig. 1

The needle used in the injection. Custom-made and developed by the author

Fig. 2

OCT for central diabetic macular edema (DME) treated with a suprachoroidal injection of triamcinolone and intravitreal Ziv-aflibercept. A Central DME with increased central macular thickness (CMT) with intraretinal cystic changes and hard exudates. B Four weeks after suprachoroidal injection of triamcinolone and intravitreal injection, Ziv-aflibercept reduced CMT and partially resolved intraretinal cysts. C Eight weeks after the first injection, the CMT increased, and intraretinal cystic changes reformed. At this point, the injection combination is repeated. D Four weeks after the second injection, a reduction in CMT and resolution of central intraretinal cysts were detected. E Eight weeks after the second injection, the CMT increased, and central intraretinal cystic changes reformed. At this point, the injection combination is repeated for the third time. F Four weeks after the third injection, a reduction in CMT and partial resolution of central intraretinal cysts were detected. G Eight weeks after the third injection, the CMT increased, and there was a slight reformation of the central intraretinal cyst