Dr. Revathy Subramany, S14321 Dr. Shivcharan Lal Chandravanshi, C11551, Dr. Dwivedi P C, Dr. Shashi Jain (Agarwal), Dr. Eva Rani Tirkey
Introduction
In 1972 Nozik first described periocular injection of corticosteroids for the management of uveitis.1Sub-tenons space is a potential space between Tenon’s capsule and sclera. Triamcenolone acetonide is frequently administered via posterior sun-tenon’s (injection) route. Posterior sub-Tenon’s injection (PSTI) of Triamcenolone acetonid (TA) has certain complication such as pain at injection site, whitish discoloration, pseudoptosis and aponeurotic ptosis, subconjunctival hemorrhage, retinal vascular occlusion such as BRVO, CRVO, CRAO, cataract formation and glaucoma.2-5
In this study we review our experience of posterior sub-Tenon injection of triamcinolone acetonide fortreatment intraocular inflammation and focus on theindications, complications and safety of injection.
Material and Methods
This is a retrospective case series of a single consultant. The duration of study was from 2007 to 2016. The study was done at department of ophthalmology, Shyam Shah Medical College, Rewa, MP. The patients with minimum 1 year after PSTI of TA follow up were included in study. All complications of injection procedure and drug itself were included. All injections were performed by the chief authors under aseptic precaution. Informed consent was taken before injection.
Inclusion criteria:
- Patients above the age of 16 years receiving PSTI of TA.
- Patients with recurrent anterior uveitis, pars planitis, panuveitis, posterior uveitis, diabetic macular edema (DME), post cataract surgery cystoids macular edema (CME).
- Patients having base line evaluation for glaucoma, ptosis and cataract.
- All patents willing for signing informed consents.
Exclusion criteria:
- Patients with preexisting lenticular opacity.
- Patients with preexisting glaucoma.
- Patients with preexisting blepharoptosis.
- Patients under the age of 16 years
- Patients having coexisting mental disorders and possibly not cooperative during injection.
- Patients with traumatic macular edema, subconjunctival hemorrage and traumatic uveitis.
- Patients with postoperative uveitis
- Patients with retinal vascular occlusive disorder
Injection technique
After explaining the procedure, patient is asked to lying down on couch. 4% zylocaine eye drops is instilled in conjunctival sac tominimized pain at injection site. 0.5 cc (20 mg)of triamcinolone acetonide suspention is loaded in 2 cc disposable syringe. 26 G needle of ½ inch length is used to deliver drug. Patient is asked to look down in inferior and nasal direction. Upper eyelid is retracted either with finger or lid retractor and needle is inserted in posterior subtenon’s space and drug is delivered. Eye is patched for 2-4 hours with antibiotic eye ointment. Patients were followed on post injection day 1, 1week, 2 week, 4 week, 2 months and 6 month interval. On day one vision, slit lamp examination fundus examination is re-carried out to look for possible complications as standard institutional protocol. Intraocular pressure measurement was done with applanation tonometer on every follow up visit. Automated visual field analyses, Gonioscopy, were done in glaucoma patients at 3 month interval. Ocular hypertension is considered if IOP was more than 21 mm Hg in two visits.
Out of 370 PSTI of TA (300 patients) during the study period, only 110 eye (of 100 patients) fullfilled the inclusion criteria and were included in study analysis. Data regarding age, sex, indication of PSTI of TA, immediate complication, late complication and treatment outcome were entered in excel sheet for analyzing.
Results
A total 112 eyes of 110 patients were treated with PSTI of TA. The mean age was 50±8.4 years. Out of 110 patients 80 were females and 30 males. The recurrent anterior uveitis was most common indication (44.64%), followed by acute anterior uveitis (21.42%), Panuveitis (12.50%), Posterior uveitis (8.92%), Diabetic macular edema (8.92%), Pars planitis (1.78%),and post cataract surgery cystoids macular edema (1.78%) . Out of 112 eyes, 100 eyes (89.28%) injected once, 10 eye (8.92%) twice, and 2 eyes (1.78%) thrice. Following PSTI of TA, 14 eyes (12.5%) develop ocular hypertension, 6 eyes (5.35%) ptosis, and 3 eyes (2.67%) cataract. Ten out of fourteen eyeswho developed glaucoma had received PSTI of TA more than once. Raised IOP was observed within 4 month after PSTI of TA. Mean intraocular pressure was 34.20 mm hg in patients with glaucoma complications. Only two patients developed field defect. All three eyes received PSTI twice. Glaucoma and cataract both developed in one patient. All three patients who developed cataract underwent cataract surgery. Post PSTI glaucoma and ocular hypertension were managed with topical anti-glaucoma medicines and none patient required surgery. All patients who developed ptosis underwent ptosis correction.Majority of patients received topical and oral steroid for up to 6 weeks. Patient with DME and post cataract surgery CME resolved inflammation in all cases and regain vision in 6/6 in all patients.
Discussion
Posterior sun-tenons’ injection of of triamcinolone acetonide is a widely used mode of drug delivery for corticosteroids for the treatment of intraocular inflammation such as acute anterior uveitis, recurrent uveitis, posterior uveitis, pars planitis, pan uveitis, diabetic macular edema, post cataract surgery cystoids macular edema, cystoid macular edema following retinal vascular occlusive disorders and retinal vasculitis. PSTI of TA is associated with complications such as cataract formation, subconjunctival hemorrhage, posterior subcapsular cataract, raised intraocular pressure, ptosis, and rarely central retinal artery occlusion and retinal and choroidal vein occlusion. Vascular occlusionsare mainly seen due to intraocular injections. Globe perforation is extremely rare but associated with risk of retinal detachment. Cataract formation is the most frequent reported complication of PSTI of TA. In the 1960, Black et al. described the relationship of long term corticosteroid therapy and cataract formation. Cataractogenic effect of corticosteroids depends upon individual body response, dose, mode of delivery and duration. In this study 3 eyes developed cataract. Byun et al reported cataract formation in 2.1% cases after PSTI of TA.5In addition to a PSTI of TA ocular inflammation and topical steroids might have contributed to the formation of cataracts.
Ocular hypertension and glaucoma is another complication of PSTI of TA. Reported mechanisms are: deposition an excess accumulation of glycosaminoglycans in the aqueous outflow system, inhibition of the synthesis of PGE2 and PGF2 and suppression of the phagocytic activity of trabecular endothelial cells. Hsi-Kung Kuo, et al reported glaucoma incidence following PSTI of TA.6
.Ptosis is rare complication of PSTI of TA.7 No exact incidence reported in literature. In our study 5.35% cases develop ptosis following PSTI of TA. Dehiscence of LPS due to injection might be a possible etiology.
In conclusion,
PSTI of TA has higher risk of steroid induced glaucoma hence these patients should to be monitored for intraocular pressure. Repeated posterior subtenon’s injections of TA have more risk of complications such as glaucoma and cataract.
References
1.Nozik RA. Periocular injection of steroids. Trans Am Acad Ophthalmol Otolaryngol 1972;76:695-705.
2. Ellis PP. Occlusion of the central retinal artery after retrobulbar corticosteroid injection. Am J Ophthalmol1978;85:352-6.
3.Shorr N, Seiff SR. Central retinal artery occlusion associated with periocular corticosteroid injection for juvenilehemangioma. Ophthalmic Surg 1986;17:229-31.
4.Moshfeghi DM, Lowder CY, Roth DB, Kaiser PK. Retinal and choroidal vascular occlusion after posterior sub-Tenon triamcinolone injection. Am J Ophthalmol 2002;134:132-4.
5. Byun YS, Park YH. Complications and safety profile of posterior subtenon injection of triamcinolone acetonide. J Ocul Pharmacol Ther. 2009 Apr;25(2):159-62.
6.Kuo KH, Lai IC, Fang PC, Teng MC. Ocular Complications after a Sub-Tenon Injection of Triamcinolone Acetonide for UveitisChang Gung Med J2005;28:85-9
7.Chew EY, Glassman AR, Beck RW, Bressler NM, Fish GE, Ferris FL, Kinyoun JL;Diabetic Retinopathy Clinical Research Network. Ocular side effects associatedwith peribulbar injections of triamcinolone acetonide for iabetic macular edema.Retina. 2011 Feb;31(2):284-9.
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