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   Table of Contents      
BRIEF REPORT
Year : 2003  |  Volume : 51  |  Issue : 2  |  Page : 180-181

Management of iatrogenic intravitreal triamcinolone acetonide.


Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All Institute of Medical Sciences, New Delhi, India

Correspondence Address:
A Kumar
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


PMID: 12831151

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  Abstract 

Intravitreal corticossteroids have been used for therapeutic purposes in optimum doses and adverse reports have not been described. To best of our knowledge, this entity has never been reported as a problem. We report a case of successful management of iatrogenic intravitreal triamcinolone acetonide for intermediate uveitis. This case study highlights the strategy of appropriate and timely surgical management.

Keywords: Triamcinolone, vitrectomy, iatrogenic, intravitreal, pars planitis


How to cite this article:
Kumar A, Prakash G, Nainiwal S. Management of iatrogenic intravitreal triamcinolone acetonide. Indian J Ophthalmol 2003;51:180-1

How to cite this URL:
Kumar A, Prakash G, Nainiwal S. Management of iatrogenic intravitreal triamcinolone acetonide. Indian J Ophthalmol [serial online] 2003 [cited 2019 Aug 26];51:180-1. Available from: http://www.ijo.in/text.asp?2003/51/2/180/14707

Intravitreal triamcinolone acetonide has been used to treat cystoid macular oedema in uveitis[1] and diffuse diabetic macular oedema in a dose of 2 - 4 mg. This corticosteroid has also been used at the end of vitrectomy surgeries in cases of complicated proliferative diabetic retinopathy[2] and proliferative vitreoretinopathy[3] in a dose of 10-20 mg. Crystalline triamcinolone acetonide (0.5 ml of 40 mg/ml) is used as subTenon injection for managing cases of intermediate uveitis. Inadvertent globe perforation is rare with subTenon injection. We report such a case where adequate surgical intervention not only salvaged the eye but also restored good vision.


  Case report Top


A 24-year-old male patient underwent planned subTenon injection of triamcinolone acetonide 0.5 ml (20 mg) in the right eye under topical anaesthesia for diagnosed idiopathic pars-planitis. During the procedure, the patient complained of pain. But this was considered only a procedural discomfort till the patient complained of gross reduction of vision within 6 hours of the procedure.

The patient was referred to us the next day. On examination, he had vision of 6/18 with accurate projection of light in the right eye. The vision in the left eye was 6/6. An intravitreal milky-white substance overlying the temporal retina of the right eye was visible on indirect ophthalmoscopy [Figure - 1]. Organisation of triamcinolone acetonide was indicated by a high reflective, solid appearing mass with irregular internal structure and shape. The left eye did not have evidence of pars-planitis. The rest of the anterior segment, including intraocular pressure, was normal in both eyes.

Immediate pars plana vitrectomy was planned, after detailed discussion with other retinologists. After a temporal 110 scleral buckling procedure (using a 7 mm asymmetrical grooved silicone tire) and encirclement (using a 2.5 mm silicone band), the infusion cannula was placed more inferiorly than the standard pars plana site, because visualisation would have hampered the presence of intravitreal triamcinolone. The vitrectomy probe was placed through a similar, but more superior port. Limited vitrectomy was done to remove the triamcinolone acetonide, taking care to avoid the pale and fragile retina. The peripheral retina was inspected for retinal tears with a wide-angle viewing system. After ruling out any iatrogenic retinal breaks, limited retinopexy was performed using the diode laser endophotocoagulation to isolate the pale, weak-looking retina [Figure - 2]. The sclerotomies were closed with 6-0 vicryl sutures. Conjunctiva was sutured with 8-0 Vicryl. A subconjunctival gentamicin (20 mg) and dexamethasone (2 mg) was injected, and the eye was patched for 12 hours.

Postoperatively the retina was attached, though appeared a bit pale in colour. The patient had a best corrected visual acuity of 6/9 on the seventh postoperative day. At one month follow-up, the vision remained 6/9 and the buckle indent was clearly visible [Figure - 3].


  Discussion Top


Intravitreal triamcinolone acetonide is recommended in a dose of 2-4 mg in formed non-vitrectomised eyes and 20-40 mg at the end of vitrectomy surgeries for a variety of ocular pathologies. Iatrogenic intravitreal triamcinolone in our case was approximately 20 mg in quantity, but it was injected into the formed gel vitreous. Gel vitreous does not allow the triamcinolone to disperse, which makes it even more toxic to the localized retina.

The treatment options available to us were pars plana vitrectomy to remove the steroid, laser delimitation of the involved retina, cryotherapy to enhance resolution or allow a natural course of resolution. Natural clearance of triamcinolone acetonide in such a large dose in a non-vitrectomised eye is either unlikely or could take a very long tine. In an earlier case involving a smaller dose, it took 4 months and the retina became completely necrotic. Laser delimitation or cryotherapy alone was not considered since this would not have addressed the primary problem in the eye.

The general consensus was to perform the standard pars plana vitrectomy along with localised buckling and limited laser delimitation. The former would address the primary problem and the latter two would act as safety measures against future retinal detachment, lest any break was found or any break occurred. Localised 110 buckling was also planned, as preoperative localisation of any break/needle perforation site/vitreous traction/vitreous incarceration was impossible to locate due to the presence of the triamcinolone acetonide inside the eye, which hampered visualisation. The postoperative clearing of the retinal whitening suggested that our timely vitrectomy was indeed the correct decision to prevent retinal necrosis and severe retinal toxicity.

This case highlights the fact that iatrogenic intravitreal triamcinolone (though rare) is possible because of its frequent use as a subTenon injection. We suggest an early vitrectomy to salvage the eye functionally.

 
  References Top

1.
Antcliff RJ, Spalton DJ, Stanford MR, Graham EM, Ffytche TJ, Marshall J. Intravitreal triamcinolone for uveitic cystoid macular edema: An optical coherence tomography study. Ophthalmology 2001;108:765-72  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.
Jonas JB, Hayler JK, Sofker A, Panda-Jonas S. Intravitreal injection of crystalline cortisone as adjunctive treatment of proliferative diabetic retinopathy. Am J Ophthalmol 2001;131:468-71.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.
Jonas JB, Hayler JK, Panda-Jonas S. Intravitreal injection of crystalline cortisone as adjunctive treatment of proliferative vitreoretinopathy. Br J Ophthalmol 2000;84:1064-67.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]


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