Herpes simplex keratitis after intravitreal triamcinolone acetonide

PURPOSE: To report a case of recurrent herpes simplex virus (HSV) epithelial keratitis after intravitreal triamcinolone acetonide injection for the treatment of diabetic macular edema. METHODS: Case report. RESULTS: We describe a case of a 59-year-old woman with a history of ocular HSV disease and severe proliferative diabetic retinopathy. She received an intravitreal injection of triamcinolone acetonide for macular edema in the right eye. One week later, she developed foreign body sensation, redness, and photophobia in the same eye. Slit-lamp examination revealed a corneal epithelial dendritic lesion. She was diagnosed with a recurrence of HSV epithelial keratitis and was treated with oral acyclovir 400 mg, 5 times a day, with good resolution of HSV signs and symptoms. CONCLUSIONS: Intravitreal triamcinolone acetonide injection may result in reactivation of HSV keratitis.     

Pseudo-endophthalmitis after intravitreal injection of triamcinolone

AIMS: To describe an unusual endophthalmitis-like reaction after an intravitreal injection of triamcinolone acetonide in four patients. METHODS: Retrospective case series. RESULTS: Four patients are reported with an endophthalmitis-like reaction following an intravitreal injection of triamcinolone acetonide. There was a dense vitreous haze with severe reduction of fundus view in all cases. One case was treated as an infectious endophthalmitis but the vitreous tap showed no evidence of an endophthalmitis and no bacterial or fungal growth in culture. In all four cases, the vitreous haze cleared without specific treatment. The anterior chamber remained quiet in all cases but one, which was examined 30 minutes after the injection, and there was no periorbital inflammation or pain. CONCLUSION: Pseudo-endophthalmitis after an intravitreal injection of triamcinolone acetonide seems to be a distinct clinical entity that may resolve without specific treatment.     

Cataract progression after intravitreal triamcinolone injection

PURPOSE: To assess cataract progression after intravitreal triamcinolone injection. DESIGN: Retrospective, interventional, case-control study. METHODS: Forty-two phakic eyes of 37 patients were injected one, two, or three times with intravitreal triamcinolone for various indications. Noninjected phakic fellow eyes served as the control. The mean follow-up time for single injection was 12 months, for multiple injections was 14 months, and for control group was 13 months. Lens status, best-corrected visual acuity, and refractive errors were recorded at baseline and at each follow-up examination. RESULTS: At the last follow-up, changes in posterior subcapsular cataract and refractive error from baseline were significantly different between single triamcinolone-injected eyes and the control group [0.7 +/- 0.2 (mean +/- SEM [arbitrary unit] vs 0.2 +/- 0.1, P = .02; and -0.5 +/- 0.1 diopter vs -0.2 +/- 0.1 diopter, P = .01, respectively). For multiple-injected eyes and control eyes, change from baseline in corticonuclear cataract (1.1 +/- 0.2 vs 0.2 +/- 0.1), posterior subcapsular cataract (1.1 +/- 0.2) and refractive error (-1.8 +/- 0.4 diopters) were significantly different (P < .001, P < .001, and P < .001, respectively). Visual acuity did not change after single injection (P = .83) and in control group (P = .19) but decreased after multiple injections (P = .006). Eleven study eyes and two control group eyes underwent cataract extraction during study period. Corticonuclear and posterior subcapsular cataract progression significantly correlated with follow-up time (P = .003 and P = .02, respectively) and number of injections (P = .01 and P = .04, respectively). CONCLUSIONS: Single intravitreal triamcinolone injection induces posterior subcapsular cataract development, whereas multiple injections result in all-layer cataract progression.     

Presumed necrotizing viral retinitis after intravitreal triamcinolone injection: case report

A 56-year-old man presented with anterior chamber inflammation, increased intraocular pressure, peripheral retinal infiltration, and generalized retinal arterial obstruction suggesting acute retinal necrosis five months after intravitreal triamcinolone acetonide injection (IVTA). He was treated with intravenous antiviral agents and aspirin. Shortly after treatment, retinal infiltrations were resolved, and partial recanalization of the obstructed vessel was observed. Viral retinitis may occur as an opportunistic infection following IVTA due to the local immune modulatory effect of the steroid; hence, close observation following IVTA is necessary.     

Intraocular pressure after intravitreal injection of triamcinolone acetonide

AIM: To investigate the intraocular pressure (IOP) response after intravitreal injections of triamcinolone acetonide as treatment of intraocular neovascular or oedematous diseases. METHODS: The prospective consecutive non-comparative interventional case series study included 71 patients (75 eyes) with progressive exudative age related macular degeneration (n = 64 eyes) or diffuse diabetic macular oedema (n = 11 eyes), who received an intravitreal injection of 25 mg triamcinolone acetonide. Mean follow up time was 6.86 (SD 2.52) months (range 3.1-14.47 months). RESULTS: IOP increased significantly (p<0.001) from 15.43 (3.26) mm Hg preoperatively to a mean maximum of 23.38 (8.37) mm Hg (range 13-64 mm Hg) postoperatively. An IOP rise to values higher than 21 mm Hg was observed in 39 (52%) eyes. Elevation of IOP occurred about 2 months after the injection. Preoperative predictive factor for the rise in IOP was younger age (p=0.013). It was statistically independent of refractive error, presence of diabetes mellitus, and indication for the injection. In all but one eye, IOP could be lowered to the normal range with topical medication, without development of glaucomatous optic nerve head changes. In the eyes with an elevation of IOP, IOP normalised about 6 months after the injection, without further medication. Eyes undergoing repeatedly intravitreal injections of triamcinolone acetonide showed only an elevation of IOP, if after the first injection a rise of IOP had occurred. CONCLUSIONS: After intravitreal injections of 25 mg of triamcinolone acetonide, an IOP elevation can develop in about 50% of eyes, starting about 1-2 months after the injection. In the vast majority, IOP can be normalised by topical medication, and returns to normal values without further medication about 6 months after the injection.     

Cataract surgery after intravitreal injection of triamcinolone acetonide

PURPOSE: To report the clinical outcome of patients undergoing cataract surgery after one or repeated intravitreal injections of triamcinolone acetonide as treatment of intraocular neovascular or oedematous diseases. METHODS: The interventional clinical case series study included all patients (n=22) who presented with cataract which had progressed after a single or repeated intravitreal injection of 25 mg of triamcinolone acetonide as treatment of exudative age-related macular degeneration (n=18) or diffuse diabetic macular oedema (n=4). Duration of the follow-up period was 3.76+/-4.99 months. With topical anaesthesia, the patients underwent standard cataract surgery including clear cornea incision, phakoemulsification and aspiration of the lens nucleus and cortex, and implantation of a foldable posterior chamber lens. The main outcome measures were frequencies of capsular rupture, vitreous loss, postoperative infectious endophthalmitis, secondary cataract, and decentration of the intraocular lens, visual acuity and intraocular pressure. RESULTS: Intraoperative dialysis of the lens zonules occurred in one (4.5%) eye and resulted in a loss of vitreous. Secondary cataract leading to Nd : YAG laser capsulotomy was observed in one (4.5%) eye. An optically significant decentration of the IOL or infectious endophthalmitis was not encountered in any patient. Visual acuity increased from 0.11+/-0.10 to 0.13+/-0.94 during the follow-up. Within 1 week after surgery, intraocular pressure was in the normal range in all the eyes. CONCLUSIONS: Cataract surgery after single or repeated intravitreal injection of 25 mg of triamcinolone acetonide does not harbour a markedly elevated frequency or a markedly changed profile of surgical complications.     

Intraocular availability of triamcinolone acetonide after intravitreal injection

BACKGROUND: To evaluate the intraocular concentration of triamcinolone acetonide after intravitreal injection. METHODS: The prospective clinical interventional case series study included 17 patients who had received a 20 to 25-mg intravitreal injection of triamcinolone acetonide as treatment for exudative age-related macular degeneration, diffuse diabetic macular edema, or retinal vein occlusions. During a secondary intraocular surgery taking place 4.1 weeks to 25.7 months after the intravitreal injection, aqueous humor samples were obtained. None of the eyes were vitrectomized. RESULTS: In the aqueous humor samples, triamcinolone acetonide was in low, but measurable, concentrations detected up to 1.5 years after the intravitreal injection. Concentrations found in samples obtained during the first 6 months, or 7 to 12 months, respectively, after the injection ranged between 3.0 microg/l and 436 microg/l, and between 0.0 microg/l and 11.2 microg/l, respectively. CONCLUSIONS: After injection of triamcinolone acetonide, triamcinolone can be present in measurable concentrations up to 1.5 years after the application.     

Serum levels of triamcinolone acetonide after intravitreal injection

PURPOSE: To evaluate serum levels of triamcinolone acetonide after intravitreal high-dose injection. DESIGN: Prospective, interventional case series study. METHODS: For 20 consecutive patients, venous blood samples were taken before and 13 +/- 19 days (range 4 to 92) after an intravitreal injection of 20 to 25 mg triamcinolone acetonide as treatment of edematous macular diseases. RESULTS: Serum levels of triamcinolone acetonide did not differ significantly (P =.174; t test for paired matches) preoperatively (0 microg/l) and postoperatively (0.065 microg/l +/- 0.21 microg/l). In 18 eyes (90%), triamcinolone acetonide could not be detected in serum samples. For two patients (10%), serum samples taken 5 days and 7 days after the injection, respectively, contained 0.5 microg/l triamcinolone acetonide and 0.8 microg/l triamcinolone acetonide, respectively. CONCLUSION: After an intravitreal high-dose injection of 20 to 25 mg triamcinolone acetonide, triamcinolone acetonide is not, or only marginally, detectable in serum samples obtained within 4 to 92 days after the injection.     

Filtering bleb rupture after intravitreal triamcinolone acetonide injection

Intravitreal triamcinolone acetonide is effective in treating various ocular disorders associated with inflammation and swelling of the retina. Unfortunately, the use of intraocular steroids is also associated with several side effects, including increased intraocular pressure and the development of cataracts. This article describes a case of intravitreal steroid injection resulting in filtering bleb rupture due to an acute rise of intraocular pressure, expands on the mechanism, and provides possible ways to avoid such an occurrence in thin, cystic filtering blebs.     

Intraocular pressure elevation after intravitreal triamcinolone acetonide injection

PURPOSE: This study investigated firstly the change of intraocular pressure (IOP) after injection of intravitreal triamcinolone acetonide (IVTA) for the treatment of macular edema and secondly the factors that influence these changes. METHODS: A prospective, non-comparative study was performed in 60 patients at Kangnam Sacred Heart Hospital from October 2003 to September 2004. All the patients received 4-mg IVTA injection. RESULTS: Mean IOP was elevated from the day after injection and peaked at 20.5 mmHg after 2 months (p=0.000). Twenty-six eyes (43.3%) showed significant IOP elevation. IOP was not controlled despite full glaucoma medication in 7 (11.7%) eyes. Two eyes underwent filtering surgery. Younger age was a statistically significant predictive factor for IOP elevation (p=0.009). CONCLUSIONS: In this study, patients who needed filtering surgery developed an IOP spike within one week after the injection. Therefore, clinicians should consider checking IOP at the end of the first week. Furthermore, greater cautions is mandatory with relatively younger patients.     

Short-term intraocular pressure trends after intravitreal triamcinolone injection

PURPOSE: To report the trends in intraocular pressures (IOP) within the first week after intravitreal injection of triamcinolone acetonide (Kenalog) for the treatment of retinal disease. DESIGN: Retrospective chart review. METHODS: Review of 43 consecutive patients and 50 intravitreal injections of 4 mg triamcinolone acetonide. Analysis of the effect on IOP was performed. RESULTS: The mean preinjection IOP was 14.60 +/- 3.71 mm Hg (mean +/- SD) (range, 9 to 26 mm Hg). The mean postinjection IOP (30 minutes after injection) was 19.64 +/- 7.43 mm Hg (range, 5 to 45 mm Hg). Mean IOP change before and after injection was 4.83 +/- 7.10 mm Hg. The mean IOP one to two days after injection was 15.32 +/- 4.41. mm Hg (range, 6 to 27 mm Hg). The mean IOP five to seven days after injection was 15.94 +/- 4.86 mm Hg (range, 5 to 28 mm Hg). CONCLUSIONS: Intravitreal triamcinolone acetonide injection in this limited series does not cause a marked increase in IOP within the first week after the procedure.     

Efficacy of anterior chamber paracentesis after intravitreal triamcinolone injection

PURPOSE: To investigate the efficacy of anterior chamber paracentesis for intravitreal triamcinolone acetonide injection (IVTA). METHODS: A prospective, randomized clinical trial was conducted on 30 eyes from 30 patients scheduled for IVTA (4 mg/0.1 mL). Eyes were randomly divided into two groups: eyes that had undergone anterior chamber paracentesis (Group 1, 15 eyes) and eyes that did not have anterior chamber paracentesis (Group 2, 15 eyes). Intraocular pressure (IOP) was measured by Goldmann applanation tonometry at a baseline of 2, 15, 30, and 60 minutes at 1 day and 1 week after the injection. The authors analyzed the short-term postoperative changes of the IOP in each group. RESULTS: For Group 1, the mean preoperative IOP was 15.33+/-1.72 mmHg, and the postoperative IOP at 2 and 15 minutes were 7.80+/-1.47 and 11.73+/-1.67 mmHg, respectively. For Group 2, there was a significant elevation of IOP (46.73+/-8.26 mmHg) 2 minutes after the injection, which decreased to the normal range (16.13+/-2.61 mmHg) by 15 minutes after the injection. There were no significant differences between the two groups in IOP at 15 minutes postsurgery compared with the distinct difference in IOP at 2 minutes post surgery (Student t-test, p=0.01). CONCLUSIONS: The findings suggest that routine anterior chamber paracentesis is inappropriate due to the brief immediate postoperative IOP elevation with IVTA.     

Pseudohypopyon immediately after intravitreal injection of triamcinolone acetonide--case reports

Report on the development of pseudohypopyon immediately after intravitreal injection of triamcinolone acetonide (TAAC). Two phakic patients presenting with a transient pseudohypopyon after having been treated with intravitreal triamcinolone. One had a clinically significant macular edema with cystoid component (CSME with CMS) and the other, active Vogt-Koyanagi-Harada (VKH) with serous retinal detachment of the macula. One eye from each patient developed a pseudohypopyon with crystal deposits adherent to the corneal endothelium. In one case it appeared right after the injection and disappeared spontaneously in 24 hours. In the other patient it appeared on day 3 and disappeared also spontaneously within 2 days. The pseudohypopyon is an important sign that can be observed after intravitreal injection of TAAC, in phakic patients, with spontaneous resolution and without complication. The pseudohypopyon caused by the deposition of TAAC in the anterior chamber immediately after its injection into the vitreous should be differentiated from other forms of hypopyon associated with this type of treatment.     

Refractory severe ocular hypertension after intravitreal triamcinolone acetonide injection

PURPOSE: To report a serious complication following intravitreal triamcinolone acetonide injection. METHODS: Observational case report. RESULTS: In 2 patients, secondary intractable severe ocular hypertension occurred 2 months after a single 4-mg intravitreal injection of triamcinolone acetonide for macular edema. Both patients required trabeculectomy intervention to control intraocular pressure (IOP). CONCLUSION: We highlight the occurrence of intractable high IOP elevation as a serious complication 2 months after intravitreal triamcinolone acetonide. Cautious monitoring of IOP for several months after this therapy is recommended. The risks of this potentially devastating complication need to be weighed against the benefits of intravitreal triamcinolone in the individual patient.     

Diabetic macular edema before and after intravitreal triamcinolone injection

PURPOSE: To compare intravitreal triamcinolone acetonide (IVT) versus natural course in refractory diabetic macular edema. METHODS: In a prospective interventional case series, twenty five eyes with refractory DME which had been allocated to the sham group of a previous clinical trial underwent new examination and optical coherence tomography about 9 months after their first enrollment. Twenty eyes that met the inclusion criteria, visual acuity (VA) < 20/50 and central macular thickness (CMT) > 200 microm, were treated by 4 mg IVT. Evaluations were repeated at 2 and 4 months post-injection to imitate the similar examination intervals after sham injection. Corrected visual acuity and macular thickness changes following IVT were compared to the corresponding changes after sham injection (the natural course). RESULTS: Visual acuity changes within and between each period were not statistically significant. Visual acuity decreased 0.08 & 0.09 logMAR by 2 months and 0.06 & 0.04 logMAR by 4 months after sham and IVT injections, respectively. The changes of macular thickness after IVT and sham intervention were not meaningful either. However, the difference between thickness changes by 4 months (52+/-50 microm increase after sham vs. 262+/-115 microm reduction after IVT) was significant (P=0.014). CONCLUSIONS: Concerning macular thickness, IVT has beneficial effect on refractory diabetic macular edema as opposed to observation. However, considering visual acuity, it does not induce significant difference in comparison to the natural course of the disease.     

Persistent depot of triamcinolone acetonide after a single intravitreal injection

The persistence of depot of triamcinolone at four months following a single intravitreal injection is described.