Pseudohypopyon following intravitreal triamcinolone acetonide injection

OBJECTIVE: To report a case of a pseudohypopyon that developed after intravitreal injection of triamcinolone acetonide for choroidal neovascularization from age-related macular degeneration. METHODS: Observational case report. RESULTS: A 62-year-old woman received an intravitreal injection of triamcinolone acetonide for the treatment of a choroidal neovascular membrane that developed as a result of age-related macular degeneration. A layer of yellowish deposits was observed in the anterior chamber 1 day after the injection. The patient denied any pain or reduced vision, and there was no redness noted on examination. The deposits cleared spontaneously on the fourth postoperative day. CONCLUSIONS: Pseudohypopyon may develop after intravitreal injection of triamcinolone acetonide. Distinguishing this from a true hypopyon is important because the treatment and prognosis are very different for the two conditions.     

Resolution of severe macular oedema in adult Coat's syndrome with high-dose intravitreal triamcinolone acetonide

OBJECTIVE: To report the clinical outcome of a patient who received high-dose intravitreal triamcinolone acetonide as treatment for severe macular oedema secondary to adult Coat's syndrome. METHOD: Case report. RESULTS: A 74-year-old Indian man complaining of chronic gradual blurring of vision in the left eye was found to have adult Coat's syndrome with severe macular oedema. He received 25 mg of intravitreal triamcinolone acetonide following unsuccessful resolution with grid laser. Optical coherence tomography (OCT) demonstrated up to 75% decrease in macular oedema that was evident even after 9 months follow-up. However, there was no significant improvement in visual acuity. CONCLUSION: Intravitreal triamcinolone is a reasonable option in reducing severe macular oedema in cases of adult Coat's syndrome.     

Ultrastructure of the trabecular meshwork in secondary glaucoma eyes after intravitreal triamcinolone acetonide

PURPOSE: To study the histology of the trabecular meshwork of eyes with glaucoma by intravitreal injection of triamcinolone acetonide (TA). DESIGN: Two cases report. PARTICIPANTS/METHODS: A 68-year-old Japanese man with branch retinal vein occlusion and a 48-year-old Japanese woman with uveitis were treated by cataract surgery, intraocular lens implantation, and TA-assisted pars plana vitrectomy. At the end of surgery, TA suspension (4 mg) was intravitreously injected. During the follow-up period, the intraocular pressure (IOP) of the patients increased over 30 mm Hg even with full medication. Trabeculectomy was performed at 4 months after TA injection in case 1 and at 6 months in case 2, and intraocular pressure returned to the normal range in both cases. Light and electron microscopic studies of the resected trabecular tissue were carried out. RESULTS: The histology showed minimal deposition of extracellular matrix in the trabecular meshwork in case 1. Case 2 showed the beginnings of deposition of extracellular matrix including fingerprintlike material in the trabecular meshwork with decreased intertrabecular spaces. CONCLUSIONS: The ultrastructural changes in the trabecular meshwork of eyes with glaucoma after treatment with intravitreal TA might resemble those with glaucoma after topical corticosteroid treatment.     

Selective laser trabeculoplasty for intraocular pressure elevation after intravitreal triamcinolone acetonide injection.

PURPOSE: Intravitreal injection of triamcinolone acetonide has increasingly become a therapeutic option for neovascular, inflammatory, and edematous intraocular diseases. A common side effect of this treatment is a steroid-induced elevation of intraocular pressure. In most of these patients, the rise in intraocular pressure can be treated topically. Those cases that cannot be treated medically have been treated with filtering surgery. This report presents a case of intraocular pressure elevation after intravitreal triamcinolone acetonide injection that was successfully treated with selective laser trabeculoplasty. CASE REPORT: A 63-year-old white man presented with brow ache on the right side approximately 3 months after undergoing intravitreal injection of triamcinolone acetonide for diabetic macular edema in the right eye. Applanation tonometry revealed an intraocular pressure of 45 mm Hg in the involved eye. After initial treatment with topical medications, the patient underwent selective laser trabeculoplasty. Now, 6 months postlaser treatment, the intraocular pressure in the involved eye is stable at 15 mm Hg without topical medications. CONCLUSIONS: A steroid-induced elevation of intraocular pressure is a common and widely reported side effect of treatment with intravitreal triamcinolone acetonide. This case report suggests that selective laser trabeculoplasty has potential as first- or second-line therapy for intraocular pressure elevation after intravitreal triamcinolone acetonide injection.     

A case of herpetic keratitis after intravitreal triamcinolone injection

PURPOSE: We report a case of herpetic epithelial keratitis that developed after intravitreal triamcinolone acetonide injection. METHODS: An 81-year-old man with diabetes with severe nonproliferative diabetic retinopathy and diffuse macular edema in both eyes received bilateral intravitreal injections of 0.4 mg/0.1 mL of triamcinolone acetonide. RESULTS: Eighteen days after the injections, the patient presented with redness, tearing, foreign body sensation, and decreased visual acuity in the right eye. The cornea showed dendriform ulcers that exhibited positive fluorescein staining. Diagnosis for herpes simplex epithelial keratitis was made, and topical acyclovir ointment therapy was initiated. The epithelial lesions healed after 7 days of therapy. CONCLUSIONS: Herpes simplex epithelial keratitis can be a possible complication of intravitreal triamcinolone acetonide injection. The course and response to conventional therapy was no different from that of the classical course of the disease.     

Intravitreal triamcinolone acetonide for the management of diabetic papillopathy

PURPOSE: To present a case of severe drop in vision in both eyes caused by diabetic papillopathy that was treated with an intravitreal injection of triamcinolone acetonide. DESIGN: Interventional case report. METHODS: A diabetic patient with bilateral diabetic papillopathy and drop in vision received sequential intravitreal triamcinolone acetonide injections to both eyes. RESULTS: Within 2 weeks of intravitreal injection, vision improved from counting fingers at 1 m to 20/50 OS, and from counting fingers at 4 m to 20/40 OD. This improvement was accompanied by resolution of disk swelling and macular edema. Vision remained stable in both eyes at 20/40 for 8 months of follow-up. No elevation of intraocular pressure beyond 21 mm Hg was noted at any time. CONCLUSION: Diabetic papillopathy with severe drop in vision can be treated with intravitreal triamcinolone acetonide injection.     

Intravitreal triamcinolone acetonide for choroidal granuloma in sarcoidosis

PURPOSE: To report the clinical course of intravitreal triamcinolone acetonide on choroidal granuloma secondary to sarcoidosis that was refractory to systemic prednisolone DESIGN: Interventional case report. METHODS: A 29-year-old Chinese man with sarcoidosis presented with isolated posterior segment involvement in his left eye as retinal periphlebitis, retinal granulomas, and choroidal granuloma. Retinal periphlebitis and retinal granulomas responded well to oral corticosteroid but not the choroidal granuloma. It gradually grew in size and caused a drop in left-eye vision to 20/70. Intravitreal triamcinolone acetonide (4 mg) was injected three times in total. RESULTS: The choroidal mass began to shrink in size after the second injection and completely regressed after the third. The choroidal granuloma became a scar, with no angiographic leakage. The patient's visual acuity improved and remained stable at 20/40 at the last follow-up, 6 months after the last injection. CONCLUSIONS: Given the encouraging results, further study on intravitreal triamcinolone acetonide for macular and peripapillary choroidal granulomas secondary to systemic sarcoidosis is warranted.     

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.     

Vitreous hemorrhage after intravitreal tissue plasminogen activator (t-PA) and pneumatic displacement of submacular hemorrhage

PURPOSE: To report the immediate complication of dense vitreous hemorrhage after intravitreal injection of tissue plasminogen activator and gas for treatment of two cases of sudden submacular hemorrhage associated with retinal arterial macroaneurysm. METHODS: Case reports. RESULTS: Two patients, a 67-year-old woman and a 92-year-old man, presented with sudden vision loss related to submacular hemorrhage from a retinal macroaneurysm. Tissue plasminogen activator at a dose of 50 microg to 75 microg and a sulfur hexafluoride (SF(6)) gas bubble were injected intravitreally under local anesthesia. Dense vitreous hemorrhage was noted on the first postoperative day in both cases, which subsequently required pars plana vitrectomy removal. CONCLUSION: Sudden severe vitreous hemorrhage may be an immediate complication after intravitreal injection of tissue plasminogen activator and gas for treatment of submacular hemorrhage associated with retinal arterial macroaneurysm.     

Infectious and presumed noninfectious endophthalmitis after intravitreal triamcinolone acetonide injection

PURPOSE: To report potentially distinguishing characteristics between bacterial endophthalmitis and presumed noninfectious endophthalmitis associated with intravitreal triamcinolone acetonide injection. METHODS: Records of two patients with culture-proven bacterial endophthalmitis and six patients with presumed noninfectious endophthalmitis from intravitreal triamcinolone acetonide injections were analyzed retrospectively. RESULTS: Two eyes in two patients with culture-proven bacterial endophthalmitis had decreased vision and hypopyon or vitritis, but no pain or conjunctival injection 2 weeks after intravitreal triamcinolone acetonide injection. Seven eyes in six patients with presumed noninfectious endophthalmitis had blurred vision, hypopyon, and variable pain all within 2 days of intravitreal triamcinolone injection. All seven eyes were followed up closely and had rapid resolution of hypopyon and symptoms. CONCLUSION: Bacterial endophthalmitis after intravitreal triamcinolone acetonide injection may present in an atypical, relatively delayed manner with decreased vision but no pain or redness. Presumed noninfectious endophthalmitis presents within 2 days after the injection, may be accompanied by discomfort, and has a hypopyon that may be the triamcinolone material itself or a sterile inflammatory reaction. In these eyes, the hypopyon and symptoms quickly resolve without treatment.     

Intravitreal triamcinolone acetonide as an adjuvant therapy to panretinal photocoagulation for proliferative retinopathy with high risk characteristics in type 1 diabetes: case report with 22 weeks follow-up

PURPOSE: To describe a new treatment protocol to deliver panretinal photocoagulation that may avoid further deterioration of vision in patients with type 1 diabetes mellitus with proliferative retinopathy with high risk characteristics for severe visual loss and cystoid macular oedema. METHODS: Fundus photography, measurement of foveal thickness with optical coherence tomography and best corrected visual acuity (BCVA) determined by Snellen and ETDRS charts were measured before and after treatment in a 28-year-old man. RESULTS: Over 9 weeks, BCVA improved from 0.05 to 0.25 and the number of letters read at 2 metres from four to 39 after panretinal photocoagulation and adjuvant intravitreal triamcinolone injection under intraconal anaesthesia. Foveal thickness decreased from 691 microm to 239 microm and cysts disappeared by 15 weeks. By 22 weeks, foveal thickness had increased to 282 microm and small cysts had reappeared, but BCVA remained at 0.2 and the number of letters read at 30. CONCLUSION: Proliferative retinopathy regressed, cystoid macular oedema disappeared and vision improved after panretinal photocoagulation and adjuvant intravitreal triamcinolone acetonide injection under intraconal anaesthesia. This represents a feasible option in cases where pain during laser treatment and impairment of vision afterwards due to cystoid macular oedema result in poor compliance with standard laser treatment under topical anaesthesia.     

Toxoplasmosis retinochoroiditis after photodynamic therapy and intravitreal triamcinolone for a supposed choroidal neovascularization: a case report

The purpose is to report a complication after photodynamic therapy (PDT) and intravitreal triamcinolone for a presumed choroidal neovascularization in age-related macular degeneration. Photodynamic therapy and intravitreal triamcinolone were used in an 84-year-old man with choroidal neovascularization in the left eye. Forty-five days after therapy, the patient returned with a severe necrotizing uveitis in the posterior pole and vitritis. Laboratory investigation disclosed a high anti-Toxoplasma IgG titer. Therapy with pyrimethamine, sulfadiazine and folinic acid resulted in total lesion healing although central vision was lost. Intravitreal triamcinolone may have had an influence on the exacerbation of retinochoroiditis in the posterior pole of the patient. Although rare, this complication may not be disregarded in the cases that require intraocular corticosteroids for treatment of several conditions, especially in patients who had previously suffered from toxoplasmosis infection.     

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.     

Combined Intravitreal Bevacizumab and Triamcinolone Acetonide Injection for Idiopathic Neuroretinitis

Purpose: To present a case with idiopathic neuroretinitis that was treated with combined intravitreal bevacizumab and triamcinolone. Design: Case report. Methods: Interventional case report. Results: A 31-year-old man presented with a visual acuity of 3/10 and afferent pupillary defect in the right eye. Ophthalmologic examination disclosed papillitis and macular edema. Neurology consultation with cranial computerized tomography scan revealed no abnormality. The patient was injected with bevacizumab and triamcinolone intravitreally. One week later, the vision increased to 10/10, macular edema disappeared. One month later, optic disc edema disappeared. Conclusions: Intravitreal injection of bevacizumab and triamcinolone effectively treated idiopathic neuroretinitis.     

Intravitreal steroid slow-release device replacing repeated intravitreal triamcinolone injections for sympathetic ophthalmia

PURPOSE: To report on the intraocular use of a steroid slow-release device in an attempt to avoid multiple intraocular triamcinolone injections in chronic sympathetic ophthalmia. METHODS: A 47-year-old patient with sympathetic ophthalmia had received 17 intravitreal triamcinolone injections to suppress the uveitis, to increase intraocular pressure, and to reduce systemic anti-inflammatory medication. To avoid the frequent reinjections combined with the temporary reduction in vision and potential risk of infection and a recurrence of sympathetic ophthalmia, a slow-release device of 2.1-mg fluocinolone acetonide was intravitreally implanted. RESULTS: During the follow-up of 11 months after the procedure, intraocular pressure stabilized at 12 to 18 mmHg and visual acuity at 0.40 to 0.50. The systemic immunosuppressive therapy was stopped, and consequently, the insulin treatment could be halted. CONCLUSIONS: Despite the limitations of a single case report, the results suggest that an intravitreal slow-release device of fluocinolone may be an alternative to repeatedly administered intravitreal triamcinolone injection for the long-term treatment of sympathetic ophthalmia. The intraocular slow-release application of steroids has enabled patients to live free from diabetic treatment and immunosuppressive medication after 21 years of systemic immunosuppressive therapy with secondary Cushing disease including diabetes mellitusand arterial hypertension.     

Retinal detachment with macular hole following combined photodynamic therapy and intravitreal bevacizumab injection

PURPOSE: To report a case of retinal detachment with a macular hole following photodynamic therapy (PDT) using verteporfin and intravitreal bevacizumab injection in the treatment of myopic choroidal neovascularization (CNV). METHODS: A 58 -year-old woman was diagnosed with myopic CNV and treated with a combination of PDT with verteporfin and intravitreal bevacizumab injection that same day. She received the second injection of intravitreal bevacizumab four weeks after the initial treatment. RESULTS: The patient developed a sudden decline in vision one week after the second injection; and was subsequently diagnosed with retinal detachment associated with a macular hole. She underwent standard three-port pars plana vitrectomy with internal limiting membrane peeling, fluid-air exchange and silicone oil injection. The retina was still firmly attached at the patient's final follow-up visit. CONCLUSIONS: PDT and intravitreal bevacizumab injection used for the treatment of myopic CNV can be associated with retinal detachment with a macular hole. Patients need to be informed about this potential complication, and a higher index of suspicion may be warranted in patients who report sudden vision loss after the treatment.     

Bartonella henselae infection associated with neuroretinitis, central retinal artery and vein occlusion, neovascular glaucoma, and severe vision loss

PURPOSE: To report a case of Bartonella henselae infection. DESIGN: Observational case report. METHODS: Review of the clinical, laboratory, photographic, and angiographic records of a patient with cat scratch disease associated with central retinal artery and vein occlusion, neovascular glaucoma, and severe vision loss. RESULTS: A 21-year-old man had no light perception in the left eye secondary to concurrent central retinal artery and vein occlusion believed to have resulted from infection with Bartonella henselae. Forty days later, he developed neovascular glaucoma in the left eye. CONCLUSION: Ocular complications associated with Bartonella henselae infection may include central retinal artery and vein occlusion, neovascular glaucoma, and severe vision loss.     

Profound choroidal hypoperfusion after combined photodynamic therapy and intravitreal triamcinolone acetonide

BACKGROUND AND OBJECTIVE: To report a case series of patients with profound choroidal hypoperfusion on fluorescein angiography following combined photodynamic therapy (PDT) and intravitreal triamcinolone acetonide (IVT) for age-related macular degeneration. PATIENTS AND METHODS: A retrospective chart review was performed of all 108 patients (155 treatments) who had combined PDT/IVT between January 2002 and December 2004 at the institution. RESULTS: Fifteen patients were identified with "profound choroidal hypoperfusion." There were no common risk factors identified. Hypoperfusion occurred in some patients after their initial treatment, whereas in others it developed only after repeated treatments. Two patients had severe vision loss associated with profound choroidal hypoperfusion. CONCLUSIONS: Profound choroidal hypoperfusion can be seen after combined therapy with PDT/ IVT. Although adding triamcinolone acetonide to PDT may improve efficacy, it may also change the side effect profile and severe vision loss may occur. Changes in treatment parameters may improve combined therapy.     

Acute stroke after intravitreal bevacizumab to treat choroidal neovascularization due to angioid streaks in pseudoxanthoma elasticum

To report the occurrence of acute stroke after intravitreal bevacizumab administration to treat choroidal neovascularization due to angioid streaks in a patient affected by pseudoxanthoma elasticum. A 54-year-old man with pseudoxanthoma elasticum had vision loss because of choroidal neovascularization due to angioid streaks. He underwent two intravitreal bevacizumab injections. Three days after the second procedure the patient was afflicted by acute stroke. Intravitreal injection of bevacizumab to treat choroidal neovascularization due to angioid streaks in pseudoxanthoma elasticum could lead to severe systemic adverse events.     

Intraocular injection of crystalline cortisone as adjunctive treatment of diabetic macular edema

PURPOSE: To report the clinical outcome of a diabetic patient with macular edema treated with an intravitreal injection of crystalline cortisone. METHODS: Interventional case report. A 73-year-old patient with diabetes mellitus presented with clinically significant diffuse macular edema caused by nonproliferative diabetic retinopathy. Despite grid laser coagulation in the macular region, cystoid macular edema progressed, and within 6 months before the cortisone injection, visual acuity declined from 0.25 to 0.16 and, finally, to 0.10. The patient received a single intravitreal injection of triamcinolone acetonide with topical anesthesia. RESULTS: After the intravitreal injection of triamcinolone acetonide, visual acuity improved from 0.10 to 0.40 during the follow-up period spanning 5 months. Intraocular pressure increased to values up to 30 mm Hg before antiglaucomatous treatment. CONCLUSION: Intravitreal injection of triamcinolone acetonide may be useful for treatment of diabetic macular edema resistant to conventional therapy.