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.