Avoiding conjunctival necrosis after periocular depot corticosteroid injection

Corticosteroids in ophthalmology: drug delivery innovations, pharmacology, clinical applications, and future perspectives

Corticosteroids remain the mainstay of the treatment for various ocular conditions affecting the ocular surface, anterior and posterior segments of the eye due to their anti-inflammatory, anti-oedematous, and anti-neovascularization properties. Prednisolone, prednisolone acetate, dexamethasone, triamcinolone acetonide, fluocinolone acetonide, and loteprednol etabonate are amongst the most widely used ophthalmic corticosteroids. Corticosteroids differ in their activity and potency in the eye due to their inherent pharmacological and pharmaceutical differences. Different routes and regimens are available for ocular administration of corticosteroids. Conventional topical application to the eye is the route of choice when targeting diseases affecting the ocular surface and anterior segment, while periocular, intravitreal, and suprachoroidal injections can be potentially effective for posterior segment diseases. Corticosteroid-induced intraocular pressure elevation and cataract formation remain the most significant local risks following topical as well as systemic corticosteroid administration. Invasive drug administration via intracameral, subconjunctival, and intravitreal injection can enhance ocular bioavailability and minimize dose and dosing frequency of administration, yet may exacerbate ocular side effects of corticosteroids. This review provides a critical appraisal of the ophthalmic uses of corticosteroid, routes of administration, drug delivery fundamentals and novel ocular implantable steroid delivery systems, factors influencing side effects, and future perspectives for ocular corticosteroid therapy.

Intralesional corticosteroid injections as treatment for non-infectious orbital inflammation

A retrospective single-center chart review identified 19 patients treated with intralesional corticosteroid injection between 2007 and 2015 for orbital inflammatory disease. Patients were treated in the office, or intraoperatively at the time of orbital exploration and biopsy, with 5-40 mg of triamcinolone acetonide. Average follow up time was 2.44 years. Information recorded included visual acuity and eyelid position measurements, pre-injection treatment, post-injection treatment, complications, and exam findings. Nine of the identified patients received intraoperative injections, 9 in the office setting, and one received an injection in each. Eight patients (42.1%) were on oral corticosteroids prior to the injection. All patients showed initial clinical improvement after 1-2 injections and no more than a 1-2 line difference in visual acuity. Overall, six patients (31.6%) required repeat injections due to recurrence of inflammation, and seven (36.8%) required additional oral corticosteroids beyond the initial taper. Patients pre-treated with oral corticosteroids were more likely to need repeat injections (83.3% vs 16.7% respectively, p = 0.04). Compared to injections performed in the office setting, intraoperative injections were associated with fewer repeat injections (0% vs. 60.0% respectively, p = 0.01) and less need for post-injection oral steroids (0% vs. 58.3% respectively, p < 0.01). There were no systemic or permanent side effects observed from the injections. Two patients (10.5%) had transient post-injection intraocular pressure elevation, which resolved. Intralesional orbital corticosteroid injection is an effective first-line and adjunctive treatment for localized and diffuse non-infectious orbital inflammation.

[Treatment of macular edema: Comparison of efficacy and tolerability of subconjunctival triamcinolone injections, sub-tenon's triamcinolone injections and intravitreal dexamethasone implant]

The area of uveitis is related to numerous pathological entities. One of the main causes of decreased visual acuity in these patients is macular edema. One aspect of the treatment includes cortosteroids used peri- and intra-ocularly.

MATERIALS AND METHODS

The goal of our work was to estimate the criteria of efficacy (on improvement in visual acuity and macular edema, as well as time to recurrence) and safety (on intraocular pressure and cataract) of these various routes of administration of corticosteroid after a single injection. We compared patients treated with Ozurdex^® versus subconjonctival triamcinolone versus sub-tenon's triamcinolone. This is a retrospective study conducted in 2 tertiary centers, the university medical center of Nantes and La Pitié-Salpêtrière hospital from November, 2011 to November, 2013.

RESULTS

At presentation, 25 % of the patients displayed VA better than 5/10. During follow-up, this proportion increased to 45 % at M1, 50 % at M3, 49 % at M6 and 48 % at the end of follow-up. There was no significant difference between the groups with respect to VA gain. The reductions in mean CMT compared with D0 were all statistically significant (improvement of one line in log-OCT). We observed an improvement in macular thickness of 88 % at M1, 86 % at M3, 61 % at M6 and 60 % at the end of follow-up, significant at each time, with no significant difference between the three groups. A comparison of time to anatomic vs. functional recurrence was performed, showing no difference. The largest increase in IOP was observed at M1, statistically different from the other time points.

DISCUSSION

Intra- and periocular injections should be considered as an adjuvant therapy, since the majority of the conditions in question require systemic treatment. They allow for increased intravitreal concentrations with fewer systemic effects.

CONCLUSION

We demonstrated neither any true superiority of any of the 3 treatments nor any difference in tolerability between the 3 groups.

Conjunctival necrosis and scleritis following subtenon triamcinolone acetonide injection

The present study aims to report a case of conjunctival necrosis and scleritis due to a subtenon injection of triamcinolone acetonate. A 15-year-old boy received a subtenon injection of triamcinolone acetonate after a pars plana vitrectomy due to an intraocular foreign body. Seven days later, conjunctival necrosis and scleritis appeared at the site of injection. No improvement was seen after seven days of conservative treatment, and necrotic tissue debridement was performed. Within one week the conjunctiva cleared. Conjunctival necrosis and scleritis are rare complications of periocular corticosteroid injections, but an early diagnosis can be very valuable. Improper dosage and injection site of corticosteroids with insufficient prophylactic antibiotics are predisposing factors. If conservative treatment is not sufficient, debridement should be considered as a potential critical treatment option.

Pharmacological Treatments for Thyroid Eye Disease

Thyroid eye disease (TED), which affects the majority of patients with Grave's disease, is associated with significant ophthalmic morbidity. In patients with mild disease, supportive treatment with lubricating medication can be sufficient. However, in patients with severe TED and disfiguring proptosis or sight-threatening neuropathy, more aggressive medical or surgical interventions are necessary. Corticosteroids remain the preferred pharmacological treatment modality in the majority of patients with an active inflammatory component. Other immunosuppressive drugs in combination with corticosteroids may be helpful in patients with corticosteroid-resistant TED. Newer agents such as somatostatin analogues have not shown to be of significant clinical benefit; however, initial studies on the use of antioxidants and cytokine antagonists are encouraging.

Conjunctival ulceration following triamcinolone injection

PURPOSE

To report conjunctival ulceration as a complication of periocular triamcinolone acetonide injection. Interventional case series.

METHODS

Conjunctival ulceration was found in three patients who had anterior subtenon's or subconjunctival deposition of triamcinolone. Cultures from the ulcer edges were negative.

RESULTS

Most of the triamcinolone extruded, and the conjunctival ulcers healed with minimal scarring.

CONCLUSIONS

Conjunctival ulceration was a potential complication of periocular triamcinolone injection in three patients who had anterior subtenon's or subconjunctival deposition of the corticosteroid.

Lower eyelid herniation of orbital fat may complicate periocular corticosteroid injection

PURPOSE

To report a case of lower eyelid herniation of orbital fat occurring after periocular corticosteroid injection.

DESIGN

Interventional case report.

METHODS

A 44-year-old man with asymmetrical pars planitis complicated by right cystoid macular edema was treated with multiple right orbital floor injections of triamcinolone through the lower eyelid.

RESULTS

Right lower eyelid orbital fat herniation occurred during the course of the treatment.

CONCLUSION

A herniation of orbital fat may complicate the injection of corticosteroid through the lower eyelid.

Ocular complications of topical, peri-ocular, and systemic corticosteroids

Topical ophthalmic, oral, and intravenous corticosteroids have long been associated with ocular side effects. Recent data suggest that inhaled corticosteroids are also associated with the development of cataract and increased intraocular pressure. Thus far, nasally administered steroids have not been associated with the same effects. Local injection of steroids, even at sites far from the eye, have been associated with the development of cataract, glaucoma, and even retinal and choroidal emboli. Any physician prescribing corticosteroids should be aware of these potential ocular side effects and should advise patients accordingly.