4.1 Strengths and limitations
Although there is a substantial body
of literature reporting the efficacy and safety of intravitreal
injection triamcinolone, retrobulbar injections triamcinolone,
suprachoroidal triamcinolone, and sub-Tenon’s infusion of triamcinolone
in the treatment of macular edema, there have been no network
meta-analysis comparisons of these four commonly used therapies. The
strengths of our review include the most comprehensive synthesis of
evidence to date on the saftey of triamcinolone acetonide by different
routes of administration therapies for macular edema, including all
recent publications. To the best of our knowledge, this is the first
network meta-analysis to compare the efficacy of triamcinolone acetonide
by different routes of administration for macular edema. In addition,
this study has a higher standard, due to accurate experimental types of
randomized trials, identifying interventions outside of laser
interference, unity of follow-up time. We used state-of-the-art
approaches to categorize and present the findings using GRADE
frameworks.
Limitations of our review include the limited quality of evidence, which
may be caused by the limited number of RCTs. It had further influence on
indirect comparisons of some network estimates. This problem would be
resolved with the augmentation of high-quality RCTs. Second, the test
results of triamcinolone acetonide by different routes of injection
therapy showed that statistical heterogeneity was limited in randomized
controlled trials, which provides limited confidence in the findings.
The third limitation is that our inclusion criteria for disease were not
highly strict. Macular edema from various diseases, such as diabetes and
branch retinal vein occlusion were included in our network
meta-analysis.The fourth limitation is the small sample size of some
RCTs included in the present study. However, The results did not change
when sensitivity analyses for all interventions on the outcomes excluded
studies with non diabetic macular edema and excluded studies with fewer
than 20 eyes.