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I thank Drs Degenring and Jonas for their thoughtful comments on ourstudy of a single injection of intravitreal triamcinolone acetonide for exudativeage-related macular degeneration, any part of which was classic. Althoughit is true that we might have found an effect of the drug on the primary outcome(loss of 30 logMAR letters) if we had treated the patients every 4 to 6 months,we were as surprised as everyone else when we did not find a beneficial effecton severe or moderate (15 letters) vision loss even at the 3- or 6-month timepoints. Whatever the reason for this might be (apart from the possibilitythat it is simply not particularly efficacious for classic subretinal neovascularization),incorrect preparation of the injection is not it. We can confirm that theinjections were performed using a standardized technique by an experiencedretinal fellow. This entailed drawing up at least 0.2 mL of the drug aftershaking the ampoule, then expressing air and the drug to leave 0.15 mL ofthe drug in the syringe before attaching a 27-gauge needle. The plunger wasadvanced until the 0.05-mL dead space was eliminated, after which a full 0.1mL was injected into the vitreous. In our article, we compared the outcomesof treated eyes that exhibited an intraocular pressure response, which werethus marked as having received a significant dose of steroid, with those thatdid not, and we found no difference.
I am aware that our results directly contradict a number of other reports.Painful experience during the last 5 years that is so widely recognized itneed not be mentioned here has shown that only a limited amount can be inferredfrom clinical trials of treatments for neovascular macular degeneration, unlessthey include masked randomization to treatment and control groups with measurementof best-corrected logMAR visual acuity. I believe that an effect of intravitrealsteroids on macular edema, in which Jonas' group has played a prominent role,may have contributed to the impression that the treatment was working forsubretinal neovascularization in the short term. We have confirmed in a randomizedclinical trial of 65 eyes with diabetic foveal edema that intravitreal triamcinoloneacetonide results in a significant reduction in edema with an improvementof visual acuity 3 months after the injection.1 Iam confident that further careful basic and clinical research will identifythe clinical situations in which intravitreal steroids will benefit our patients.
Correspondence: Dr Gillies, Save Sight and Eye Health Institute,University of Sydney, GPO Box 4337, Sydney NSW 2001, Australia (mark@eye.usyd.edu.au).
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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