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Sub-tenon Triamcinolone Acetonide in Age-Related Macular Degeneration as Adjunct to Ranibizumab (STAR)

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ClinicalTrials.gov Identifier: NCT01249937
Recruitment Status : Unknown
Verified January 2011 by University Health Network, Toronto.
Recruitment status was:  Recruiting
First Posted : November 30, 2010
Last Update Posted : February 9, 2011
Information provided by:
University Health Network, Toronto

Brief Summary:
In the Western World, Age Related Macular Degeneration (ARMD) is a leading cause of blindness. This disease was once thought to be a natural part of aging, but recent research has introduced effective treatments. ARMD is related to the body initiating an immune response in the eye, as if responding to an infection. Vision is impacted as ocular tissue becomes inflamed and new blood vessels form at the back of the eye, a process called angiogenesis. In the more severe wet form of ARMD, blood and fluid leak out of the vessels and impair the eye's structure and function. Many studies have shown that ranibizumab, a drug that stops the formation of new blood vessels (an anti-angiogenic agent) can delay damage to the eye and often restore vision. The investigators believe the best drug therapy will also stop the inflammation. Triamcinolone acetonide, a steroid drug, has shown the potential to effectively reduce inflammation in this application. The investigators aim to investigate if patients receiving a combination treatment of ranibizumab and triamcinolone acetonide improve their visual abilities more than those receiving just ranibizumab treatment alone. Secondarily, the investigators will also investigate how often patients receiving each drug therapy regime require re-treatment and how often they experience further vision loss.

Condition or disease Intervention/treatment Phase
Wet Macular Degeneration Drug: Ranibizumab Drug: Triamcinolone Acetonide Phase 2

Detailed Description:

Age Related Macular Degeneration (ARMD or AMD) is the leading cause of blindness in North America. There are two types of ARMD: dry and wet. Both forms of ARMD cause a progressive loss of central vision, the part of your vision that allows you to read, drive and see images in sharp detail directly in front of you. The wet form is typically more severe and is characterized by the growth and leakage of small blood vessels into the choroid layer of the eye, or the back of the eye. These leaking blood vessels disrupt the structure and function of the eye, causing loss of vision, particularly the sharp vision created by the macula area of the eye.

Upon being accepted to the study, participants will be randomly divided into two groups. One group will receive both ranibizumab and triamcinolone acetonide injections and the other group will receive ranibizumab injections and a placebo treatment. To participants in this group, there will be the appearance of a second injection but no actual injection will take place. An individual not connected to the study will assign participants to a group based on a computer-generated system, giving participants at 50% chance of being placed in either group. During the study, participants will not know which group they are in, but will be able to know once the study is finished.

Participants will be asked to come in for an initial assessment to determine their starting visual abilities and medical history. On the next appointment, participants will receive the first treatment injections. They will be asked to come into the clinic every month for six (6) months total for treatment injections and testing. At each appointment, study investigators will take 3-D images of the retina (the back of the eye) using an Optical Coherence Tomography (OCT) imaging device, test eye pressure and determine if there are any signs of infection or inflammation from the injections. On months 1, 3 and 6 investigators will also test vision using Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity charts, contrast sensitivity using a standard contrast sensitivity chart (The Pelli-Robson chart) and take images of the blood vessel growth using a coloured dye (fluorescein) to help see blood vessels. Before every treatment, anesthetic eye drops (proparacaine) will be applied to the eye so participants will not feel the injections. Participants will be given antibiotic eye drops (Zymar®) and will be asked to apply the drops 4 times a day for a few days after the injection to prevent infection.

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 30 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single (Participant)
Primary Purpose: Treatment
Official Title: Sub-tenon Triamcinolone Acetonide in Age-Related Macular Degeneration as Adjunct to Ranibizumab
Study Start Date : January 2011
Estimated Primary Completion Date : July 2011
Estimated Study Completion Date : October 2011

Arm Intervention/treatment
Placebo Comparator: Ranibizumab
Ranibizumab is the current gold standard treatment for wet age-related macular degeneration. This intervention is approved by Health Canada, covered by OHIP (Ontario Health Insurance Plan) and used regularly by ophthalmologists in Canada. Participants will receive intravitreal injections of ranibizumab each month for up to 6 months, with ocular testing at each appointment as prescribed by the study protocol.
Drug: Ranibizumab
Intra-vitreal injections of 0.5mg/0.05 mL dosage, injected at months 0, 1, and 2. For those requiring additional injections, patients will receive monthly treatment up to a maximum of 6 months total.
Other Name: Lucentis

Active Comparator: Ranibizumab and Triamcinolone acetonide

Recent research has discovered that persons with wet or dry ARMD show an immune response, as if the body is fighting off an infection. The body creates a complex immune response to the growth of blood vessels into the eye tissue, which triggers side effects. It is believed that preventing this inflammation can lead to greater visual gains and a need for fewer treatment injections.

Animal studies have shown that Triamcinolone Acetonide, a corticosteroid (class of drugs that reduce inflammation) can prevent damage to vision from this inflammation. The hypothesis is that treatment with both Ranibizumab and Triamcinolone Acetonide will allow even greater vision improvements than Ranibizumab treatment alone for wet age-related macular degeneration.

Drug: Ranibizumab
Intra-vitreal injections of 0.5mg/0.05 mL dosage, injected at months 0, 1, and 2. For those requiring additional injections, patients will receive monthly treatment up to a maximum of 6 months total.
Other Name: Lucentis

Drug: Triamcinolone Acetonide
Sub-tenon injection of 40mg/mL dosage at months 0 and 2 with follow up for a total of 6 months.
Other Name: Kenalog

Primary Outcome Measures :
  1. Gains in visual acuity [ Time Frame: Baseline and months 1, 2, 3, 4, 5, and 6 ]
    Gains in visual acuity will be assessed by comparing best corrected visual acuity at each follow up appointment by the standardized vision testing, early treatment diabetic retinopathy study (ETDRS) visual acuity test. The ETDRS visual acuity test was first developed to effectively evaluate visual changes following panretinal photocoagulation in patients with diabetic retinopathy. This method of measuring visual acuity was more accurate than previous methods, and thus has become the global standard, especially for clinical trials where it is essential to have utmost accuracy.

Secondary Outcome Measures :
  1. Changes in intra-ocular pressure [ Time Frame: Baseline and months 1, 2, 3, 4, 5 and 6 ]
    To be measured by tonometry

  2. Rates of re-treatment [ Time Frame: Months 1, 2, 3, 4, 5 and 6 ]
    To be measured by recording each drug administration date

  3. Rate of vision loss [ Time Frame: Baseline and months 1, 2, 3, 4, 5 and 6 ]
    To be measured by ETDRS visual acuity testing and compared over the course of the study

  4. Rate of cataract progression [ Time Frame: Baseline and months 1, 2, 3, 4, 5, and 6 ]
    Measured at each appointment with a slit lamp examination

  5. • Changes in choroid vessel activity in lesion growth and activity at choroid [ Time Frame: Baseline and months 1, 2, 3, 4, 5 and 6 ]
    The changes in blood vessel lesion growth and activity will be measured by OCT (Ocular Coherence Tomography) and fundus fluoroscein angiography to assess choroidal neovascular leakage

Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • Patients with wet age-related macular degeneration (ARMD) with evidence of sub-foveal choroidal neo-vascularization (CNV)
  • Patients greater than the age 18 years old (male or female)
  • Visual acuity must be between 20/40 and 20/320 in the study eye.

Exclusion Criteria:

  • Patients with CNV from causes other than ARMD
  • Patients having intra-ocular surgery within past 3 months on study eye
  • Patients with medically uncontrolled glaucoma
  • Patients with prior vitreous/retinal surgery
  • Patients with a history of past CNV treatment in study eye
  • Patients with other ocular conditions causing vision loss that could confound the analysis of ARMD
  • Individuals with a disability preventing accurate vision testing

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT01249937

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Contact: Wai-Ching Lam, MD, FRCSC (416) 603-5376 waiching.lam@utoronto.ca

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Canada, Ontario
University Health Network-Toronto Western Hospital Recruiting
Toronto, Ontario, Canada, M5T 2S8
Contact: Wai-Ching Lam, MD, FRCSC    416-603-5376    waiching.lam@utoronto.ca   
Sub-Investigator: Emmanuel Mavrikakis, MD, PhD         
Sub-Investigator: Robert Devenyi, MD, FRCSC         
Sub-Investigator: Sourabh Arora, BSc         
Sub-Investigator: Laura Schneider, BSc         
Sponsors and Collaborators
University Health Network, Toronto
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Principal Investigator: Wai-Ching Lam, MD, FRCSC University Health Network, Toronto Western Hospital
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Responsible Party: Dr. Wai-Ching Lam, University Health Network-Toronto Western Hospital
ClinicalTrials.gov Identifier: NCT01249937    
Other Study ID Numbers: STARP2TWH
First Posted: November 30, 2010    Key Record Dates
Last Update Posted: February 9, 2011
Last Verified: January 2011
Keywords provided by University Health Network, Toronto:
Macular Degeneration
Age-related macular degeneration
Anti-vascular endothelial growth factor (Anti-VEGF)
Triamcinolone Acetonide
Vision loss
Additional relevant MeSH terms:
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Macular Degeneration
Wet Macular Degeneration
Retinal Degeneration
Retinal Diseases
Eye Diseases
Triamcinolone Acetonide
Triamcinolone hexacetonide
Triamcinolone diacetate
Angiogenesis Inhibitors
Angiogenesis Modulating Agents
Growth Substances
Physiological Effects of Drugs
Growth Inhibitors
Antineoplastic Agents
Anti-Inflammatory Agents
Hormones, Hormone Substitutes, and Hormone Antagonists
Immunosuppressive Agents
Immunologic Factors
Enzyme Inhibitors
Molecular Mechanisms of Pharmacological Action