Complications Following Inappropriate Intravitreal Triamcinolone Acetonide Injection

doi:10.4236/ojoph.2012.24024

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Open Journal of Ophthalmology, 2012, 2, 114-115

http://dx.doi.org/10.4236/ojoph.2012.24024 Published Online November 2012 (http://www.SciRP.org/journal/ojoph)

Complications Following Inappropriate Intravitreal

Triamcinolone Acetonide Injection

Yukishige Nakaseko*, Mai Kamatani*, Mineo Kondo, Yukitaka Uji, Masahiko Sugimoto#

The Department of Ophthalmology, Mie University School of Medicine, Mie, Japan.

Email: #[email protected]

Received August 16th, 2012; revised September 23rd, 2012; accepted October 30th, 2012

ABSTRACT

Purpose: Intravitreal Triamcinolone Acetonide (IVTA) is a useful treatment option for various intraocular diseases

such as Macular Edema (ME). The treatment can cause several complications, including tran sient elevation of intraocu-

lar pressure and cataract formation. Here, we describe an atypical complication of IVTA. Case: A 60-year-old Japanese

man presented with ME associated with central retinal vein occlusion. We performed intravitreal injection of 4 mg of

TA. However, the drug spread behind the posterior lens capsule and also flowed into the anterior chamber. Althou gh the

amount of TA particles behind the lens capsule decreased over time, these particles persisted for more than 2 months.

Conclusion: Although IVTA is an easy and effective treatment for ME, TA is harmful when injected into inappropr iate

regions of the eye. Accurate IVTA injection is important for effective treatment.

Keywords: Triamci nol on e Ac et oni de; I nt ra vi treal Inject io n

1. Introduction

Breakdown of the blood-retinal barrier induces capillary

leakage with accumulation of fluid in the intraretinal and

subretinal spaces of the macula, resulting in Macular

Edema (ME); this condition occurs in various diseases.

Corticosteroids reduce intraocular inflammation and

tighten the capillary walls; therefore, these drugs have

been used for treating various ocular diseases. Steroids

are applied topically as eye drops, by subconjunctival

injection, or by sub-tenon injection. However, these me-

thods often cannot induce the high intraocular concen-

tration required for thera peutic effects.

Intra Vitreal Triamcinolone Acetonide (IVTA) is being

used with increasing frequency to treat ME due to vari-

ous diseases, including diabetic retinopathy and venous

occlusion with enough therapeutic concentration [1-3].

Though IVTA is a simple and effective treatment, it

sometimes causes co mplications. The most c ommon com-

plications due to Triamcinolone Acetonide (TA) itself are

transient elevation of intraocular pressure and cataract [4].

Other complications may occur due to technical problems,

as a result of flawed vitreal injection techniques; such

complications include retinal detachment and endo-

phthalmitis. Inappropriate IVTA injection is one of the

causes of these complications, and avoidance of such

complications requires accurate TA delivery to the main

target, the posterior pole. Here, we describe an atypical

complication of IVTA.

2. Case Presentation

A 60-year-old Japanese man presented to our clinic with

vision disturbances in his left eye. Best-corrected visual

acuity was 20/50. Fundus examination and optical co-

herence tomography revealed central retinal vein occlu-

sion associated with ME (Figure 1). We could not iden-

tify any change in anterior vitreous. Fundus fluorescein

angiography showed a wide unperfused area, and we

treated the left eye with laser photocoagulation. Two

months after photocoagulation, when no improvement in

ME was seen, we performed intravitreal injection of 4 mg

of TA. The injection was performed under a microscope,

and the tip of the needle was carefully positioned in the

vitreous cavity during injection. Nevertheless, TA spread

to the compartment behind the po sterior lens capsule and

also flowed into the anterior chamber. After surgery, slit

lamp examination revealed TA dispersion into the ante-

rior chamber and behind the posterior lens capsule (Fig-

ures 2(a) and (b)). The fundus became invisible, and the

patient’s visual acuity decreased to counting fingers. Ten

days after surgery, TA persisted behind the lens and par-

tially in the vitreous cavity. B-mode ultrasonography

revealed high-intensity reflections due to remaining TA

(Figures 2(c) and (d)). Although the amount of TA par-

ticles behind the lens capsule partially decreased, the

*These two authors contributed equally to this work.

#Corresponding author.

Complications Following Inappropriate Intravitreal Triamcinolone Acetonide Injection 115

Figure 1. Fundus image at initial examination. On the first

examination, central retinal vein occlusion was observed (a).

Optical coherence tomography revealed macular edema (b).

Figure 2. TA particles after injection. TA particles are seen

in the anterior chamber ((a) arrow) and posterior lens cap-

sule ((b) asterisk) 1 day after injection. TA particles per-

sisted behind the posterior lens capsule and vitreous cavity

for 10 days after injection ((c) arrowhead), although parti-

cles were partially absorbed ((d) arrow). These particles

remained even after 2 months (e). TA: triamcinolone ace-

tonide.

particles persisted for more than 1 month. Only a small

volume of TA was absorbed after 2 months (Figure 2(e)),

and we suggested surgical removal. The patient preferred

TA elimination through a natural course, so we performed

follow-up in the outpatient clinic without performing su r-

gery.

3. Discussion

Several reports have mentioned TA dispersion to the

posterior lens capsule after injection [5,6]. Conforma-

tional changes in the anterior vitreous, such as Berger’s

space, due to aging may cause such abnormal TA disper-

sion. Previous studies have also mentioned that TA was

localized inhomogeneously in the vitreous area after in-

jection in 53.6% of IVTA cases and that this TA per-

sisted for up to 7 weeks after IVTA, indicating that several

months are required for TA absorption [7]. Moreover,

after IVTA, the TA concentration in the aqueous humor

was above the therapeutic concentration for 150 days,

suggesting that a higher and harmful concentration of TA

persisted much longer than the therapeutic demand [8].

Thus, it is clear that IVTA injected inaccurately can

readily cause undesired effects. TA absorption is slow,

resulting in prolong ed loss of visual acuity due to disrup-

tion of the transparent vitreous. In addition , eye examina-

tions are hindered, precluding detection of pathological

events or progression in the retina. In fact, in previous

cases, 1 to 6 months were required for natural absorption,

and surgical treatments were required in some cases [5,6].

Though IVTA is an easy and effective treatment for

ME, accurate injection of TA is somewhat challenging.

Therefore, it is important to deliv er TA close to the main

target (posterior pole). However, we do not recommend

blind injection into the posterior pole, because a closer

approach to the posterior pole can easily cause direct

injury to the retina. Injection under a surg ical microscope

or using an indirect fundus lens may be a much safer and

effective approach.

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