Retina specialists may have a more targeted option for managing persistent postoperative macular edema after complex retinal detachment repair, according to findings presented by Margaret Runner, MD, of the Retina Center of Texas at Retina World Congress in Fort Lauderdale, Florida.
In a retrospective cohort study, suprachoroidal triamcinolone was associated with greater reductions in retinal fluid and central subfield thickness (CST) than subtenon triamcinolone or dexamethasone implant therapy in eyes undergoing complex retinal detachment repairs.
Dr. Runner’s presentation focused on persistent postoperative macular edema and subretinal fluid following retinal detachment repair, which she attributed to disruption of the blood-retinal barrier. She explained that both the inner and outer blood-retinal barrier depend on tight junction integrity to maintain retinal homeostasis. Inflammatory cytokines released during retinal detachment—including interleukin-6 (Il-6), vascular endothelial growth factor (VEGF), and tumor necrosis factor-alpha—may increase ICAM-1 expression, disrupt tight junctions, and promote fluid accumulation.
The incidence of postoperative macular edema varies depending on surgical setting and ocular comorbidities, according to Dr. Runner. Rates are relatively low after uncomplicated cataract surgery but may increase substantially in diabetic eyes, uveitis, combined cataract-vitrectomy procedures, and retinal detachment repairs.
Dr. Runner retrospectively reviewed 346 consecutive complex retinal detachment repairs performed over a 2-year period. Of these cases, 228 (66%) involved proliferative vitreoretinopathy, while 118 (34%) involved diabetic tractional retinal detachments. Overall, 61 eyes (18%) required postoperative steroid injection for macular edema. Eyes treated for hypotony were excluded from analysis.
Among treated eyes, 31 (51%) received subtenon triamcinolone, 23 (46%) received suprachoroidal triamcinolone, and 2 eyes (3%) received dexamethasone intravitreal implant therapy.
At approximately 6 weeks, suprachoroidal triamcinolone demonstrated the largest mean CST reduction, decreasing thickness by an average of 375 µm. Dexamethasone implants produced an average CST reduction of 69 µm. In contrast, eyes treated with subtenon triamcinolone showed little overall improvement, with the mean CST increasing by approximately 75 µm.
Dr. Runner illustrated the findings with complex surgical cases. In one patient with diabetic tractional retinal detachment, recurrent subretinal fluid developed months after apparently successful retinal detachment repair despite no identifiable retinal breaks. Following suprachoroidal triamcinolone injection, OCT imaging demonstrated gradual resolution of the fluid by postoperative month 5.
Another patient with severe proliferative vitreoretinopathy developed progressive posterior pole subretinal fluid under silicone oil after repair. Following suprachoroidal triamcinolone treatment, imaging showed marked improvement within weeks.
Dr. Runner suggested that the apparent benefit of the suprachoroidal approach may relate to its posterior and circumferential drug distribution, which may improve access to the affected retinal pigment epithelium and choroidal tissues. She added that corticosteroids may act through several complementary mechanisms, including anti-inflammatory activity, VEGF transcriptional suppression, restoration of retinal pigment epithelium pump function, and reinforcement of tight junction integrity.
Most eyes with isolated subretinal fluid required only a single injection, although approximately one-quarter of patients later required repeat suprachoroidal treatment, typically around three months after the initial injection. Eyes with persistent intraretinal fluid were more likely to require additional intervention, including membrane peeling surgery in some cases, according to Dr. Runner. RP