Triamcinolone Injections for Persistent Choroidal Effusions Post Glaucoma Surgery (TRICEPS)

May 3, 2022 updated by: Dr. Catherine Birt, Sunnybrook Health Sciences Centre

Subtenons Triamcinolone Acetonide Injections for Treatment of Persistent Choroidal Effusions Post Glaucoma Surgery

During glaucoma surgery, a new opening is created that allows fluid to drain out of the eye, bypassing the clogged drainage channels that are malfunctioning in patients with glaucoma. In some patients who have had glaucoma surgery too much fluid flows out and this results in a pressure that is too low. This may cause swelling of one layer at the back of the eye called the choroid. The formation of this swelling, called a choroidal effusion or "choroidal", often makes the eye pressure stay too low, and one of the results is a decrease in vision. The treatment for a choroidal effusion is to try to raise the eye pressure somewhat to allow the swelling to subside. In our clinical work, we have found that an injection with an anti-inflammatory drug called triamcinolone appears to be helpful in speeding up healing. We plan to compare two groups of patients with choroidal effusions, one group that gets an injection of triamcinolone and one that gets a "sham" treatment with nothing injected and compare the length of time it takes the choroidal effusions to disappear. Both groups receive the standard treatment with eye drops. We will also assess the outcome of the glaucoma surgery and any other complications that may occur. This research is aimed at studying a new method of improving the outcomes of surgery for glaucoma patients, and further the treatment of glaucoma.

Study Overview

Detailed Description

Glaucoma is the second commonest cause of blindness in our society. The only effective treatment currently involves lowering the intraocular pressure (IOP) by medical, laser, or surgical techniques. Glaucoma surgery is indicated when further IOP lowering is needed despite maximal medical therapy and appropriate laser treatment.

The choroid is a pigmented and vascular structure located between the sclera and retinal pigmented epithelium.

Choroidal effusions are aberrant collections of fluid within the suprachoroidal potential space. There are two types of choroidal effusion, serous and hemorrhagic, depending on the type of fluid that accumulates in the suprachoroidal space. A serous choroidal effusion is composed of a transudate fluid from increased transmural pressure across the capillaries. Their development is usually relatively painless. Hemorrhagic choroidal effusion or suprachoroidal haemorrhage is a sudden and usually very painful accumulation of blood in the suprachoroidal space. 4 Choroidal effusions can be caused by both low IOP and pro-inflammatory conditions. Causes of concomitant low IOP and inflammation include trauma and eye surgery, especially glaucoma surgery. Inflammatory causes include scleritis.

Modern glaucoma surgery has minimized the incidence of postoperative hypotony and resultant choroidal effusion but it is still prevalent. 1 The prevalence of choroidal effusions after glaucoma surgery varies between 10 and 15%, with average of 13% after trabeculectomy (the standard technique of glaucoma surgery). 5 A complication of low-IOP-induced choroidal effusion is hypotony maculopathy, which can cause permanent decline in vision, especially if not resolved in a timely manner. 5 Treatment can be either medical or surgical. Medical treatment includes cessation of any systemic and topical IOP lowering agents and adding cycloplegic agents, topical steroids and eventually systemic steroids. If treatments do not increase the IOP and reduce the choroidal effusion, then surgical management should be considered.

Depending on the particular clinical circumstances of each patient, different surgical approaches can be used, including revision of the trabeculectomy flap, anterior chamber reformation, and surgical drainage of the effusion.

As an alternative to systemic steroids, steroids as triamcinolone acetonide (Kenalog™) can be injected in the subtenons space. This treatment allows for a high local dose of steroids, without exposing the patient to systemic treatment. Not every patient requires steroid injection, and this treatment will be reserved for patients who do not respond to medical management after a few days.

Following the sham or Kenalog injection participants will receive topical prednisolone acetate 1% qid for 4 weeks or PRN Topical atropine 1% qid for one week or PRN.

There are several studies in the literature showing the benefit of a triamcinolone injection for different inflammatory conditions, such uveitis and for the treatment of diabetic maculopaty and cystoid macular edema. 6-9 Recently Shen et al. published the benefit of subtenons triamcinolone acetonide in the management of a combination of retinal detachment and choroidal effusion. 2 However we did not find any studies that assessed the benefit on triamcinolone subtenons injection for choroidal effusion after glaucoma surgery. In a recent retrospective study we performed a chart review of the effect of subtenons triamcinolone injection in patients with choroidal effusions after glaucoma surgery compared to a group of patients who did not receive the injection as part of their management. We found that recovery time in the injection group was significantly shorter than in patients with no injection, 10.6 days versus 27.44 days. (p=0.02). The study showed no difference in final intraocular pressure (IOP), number of medications and visual acuity.

Study Type

Interventional

Enrollment (Anticipated)

20

Phase

  • Phase 4

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Contact Backup

Study Locations

    • Ontario
      • Toronto, Ontario, Canada, M4N 3M5
        • Recruiting
        • Sunnybrook Research Institute
        • Contact:
        • Principal Investigator:
          • Catherine M Birt, MD FRCSC

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

16 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • Age more than 18 years old
  • Patients who have had glaucoma surgery at Sunnybrook Health Sciences Centre and / or Kensington Eye Institute and developed choroidal effusions that do not improve after one week of standard medical treatment. (Trabeculectomy, Combined Phaco-trabeculectomy, Glaucoma tube Shunts, postoperative 5-FU needling, and laser suture lysis are all considered as eligible Glaucoma surgeries/Procedures)
  • Decision makers fluent in English.
  • Decision makers able to understand and read consent form.

Exclusion Criteria:

  • Patients with choroidal effusions with improvement after one week of medical treatment.
  • Patients with choroidal hemorrhage, demonstrated clinically and or with B Scan.
  • Patients with aqueous misdirection and IOP > 10 mmHg.
  • Patients that refuse subtenons injection.
  • Patients with signs of infection.
  • Patients with choroidal effusions who did not have glaucoma surgery.
  • Patients unable to follow up within study schedule.
  • Female patients of childbearing potential who are pregnant of do not agree to use adequate methods of contraception from time of enrollment until 40 days after the last day of Triamcinolone administration.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Triple

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Sham Comparator: Control

Patients placed in a semi supine position. A cotton-tipped applicator saturated with proparacaine 0.5% (Alcaine, Alcon Labs) is placed into the conjunctival fornix of the supero-temporal quadrant for 5 minutes following initial proparacaine drops.

After anaesthetic medication is placed, a 3 ml syringe will be placed into the superotemporal conjunctival fornix but no needle is present and no drug injected.

Patients will be given a sham.
Active Comparator: Injection

Patients placed in a semi supine position. A cotton-tipped applicator saturated with proparacaine 0.5% (Alcaine, Alcon Labs) is placed into the conjunctival fornix of the supero-temporal quadrant for 5 minutes following initial proparacaine drops.

After anaesthetic medication is placed, 1mL of a 40 mg/ml suspension of triamcinolone acetonide is injected through the superotemporal conjunctival fornix using a 25 Gauge needle, 5/8 inch length on a 3 ml syringe, following the contour of the globe with the needle, external to sclera for the full length of the needle such that the needle tip is ultimately positioned immediately posterior to the macula with the bevel down.

After preparation, Triamcinolone Acetonide 1 ml of 40 mg/mL suspension is injected through the superotemporal conjunctival fornix using a 25 Gauge needle, 5/8 inch length on a 3 ml syringe, following the contour of the globe with the needle, external to sclera for the full length of the needle such that the needle tip is ultimately positioned immediately posterior to the macula with the bevel down.
Other Names:
  • Kenalog

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Time to resolution
Time Frame: One week to three months
The time to clinical resolution of the choroidal effusions will be determined
One week to three months

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
IOP
Time Frame: 3 month visit
Intraocular pressure at the final study visit
3 month visit
Vision
Time Frame: 3 month visit
Visual acuity at the final study visit
3 month visit
Medications
Time Frame: 3 month visit
Number of glaucoma medications required at the final study visit
3 month visit
Complications
Time Frame: All study visits
Any intra-operative or post-procedural side effects or complications, including further surgery, will be recorded and compared between the two groups
All study visits

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Investigators

  • Principal Investigator: Catherine M Birt, MD FRCSC, Sunnybrook Research Institute

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

October 14, 2020

Primary Completion (Anticipated)

May 31, 2023

Study Completion (Anticipated)

December 31, 2024

Study Registration Dates

First Submitted

September 23, 2016

First Submitted That Met QC Criteria

September 26, 2016

First Posted (Estimate)

September 28, 2016

Study Record Updates

Last Update Posted (Actual)

May 4, 2022

Last Update Submitted That Met QC Criteria

May 3, 2022

Last Verified

May 1, 2022

More Information

Terms related to this study

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

Undecided

IPD Plan Description

Summary data will be reported, individual participant data will not

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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