Intravitreal Steroids- A New Tool in the Retina Toolbox

Steroids have been a mainstay of treatment for ophthalmic disease for decades. Systemic administration carries the greatest risk of side effects, some of which are quite serious. While topical administration of steroid is the easiest and has the least risk of side effects, this route of administration is also probably least effective due to limited drug delivery to the retina. Retrobulbar or subTenon’s injections have for many years offered a compromise between better penetration and avoidance of systemic side effects. Intraocular administration of drugs has typically been reserved for vision-threatening conditions such as endophthalmitis. The perceived risk/benefit ratio of intraocular injections for other indications has been influenced by concerns of introducing an infection, detaching the retina, or drug toxicity. However, our experience in managing CMV retinitis with either intraocular antiviral injections or implanted antiviral pellets has shown us that these risks are quite low. In the past two years, the use of in office intraocular injections of steroids for a variety of conditions is being explored by investigators. In one study, chronic refractory CME was treated using a 1 mg intraocular injection of Kenalog. The edema diminished in the majority of patients (89%). Almost one-half the patients had visual improvement of 1 or more lines, and 20% gained 2 or more lines. In a study elsewhere using a 4 mg dose, 75% of patients had improvement, and almost one-half of these had 2 or more lines of improvement. In a prospective study from Germany using a much larger dose of Kenalog (20 to 25 mg), the eyes demonstrated an average vision improvement of 100%. A number of papers presented last year at the Vitreous Society meeting discussed the use of intraocular steroids to treat exudative ARMD, refractory CME from Irvine-Gass syndrome, or diabetic macular edema. There have even been reports of success using such steroid injections for CME associated with branch retinal vein occlusions. Based on surprisingly excellent results in this otherwise refractory group of patients, intraocular steroids are becoming commonplace. While we were aware of these reports, we chose