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Mahjoub A, Ben Abdesslem N, Ben Abderrazek A, Zaafrane N, Mahjoub A, Aoun H, Jabri A, Krifa F, Ghorbel M, Mahjoub H. Sterile endophthalmitis after intravitreal triamcinolone acetonide injection: A case report series. Ann Med Surg (Lond) 2022; 76:103537. [PMID: 35495379 PMCID: PMC9052280 DOI: 10.1016/j.amsu.2022.103537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/10/2022] [Accepted: 03/25/2022] [Indexed: 12/03/2022] Open
Abstract
Corticosteroids have proven their effectiveness in the treatment of cystoid macular edema. Especially after an intravitreal injection. Triamcinolone acetonide is the most commonly used in the treatment of macular edema. Noninfectious endophthalmitis is a form of endophthalmitis that can occur in the absence of a defined germ after an intravitreal injection of triamcinolone acetonide. We report here the case of three diabetic patients, who presented with visual blur, three days after an intra vitreal triamcinolone acetonide injection performed in the right eye. The vitreous inflammation resolved spontaneously in the first two cases after three weeks, and after four weeks for the third. The diagnosis of sterile endophthalmitis was made in view of the spontaneous resolution of the inflammation without the use of intravitreal injection of antibiotics and/or vitreoretinal surgery. Describe the development of sterile endophthalmitis after an intravitreal injection of triamcinolone acetonide in diabetic patients with macular edema. Enhance the differences between infections endophthalmitis and sterile endophthalmitis. Report our ophthalmology team's management in front of a sterile endophthalmitis in comparison to literature.
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Affiliation(s)
- Ahmed Mahjoub
- Department of Ophthalmology, Farhat Hached University Hospital of Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Tunisia
| | - Nadia Ben Abdesslem
- Department of Ophthalmology, Farhat Hached University Hospital of Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Tunisia
| | - Atf Ben Abderrazek
- Department of Ophthalmology, Farhat Hached University Hospital of Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Tunisia
- Corresponding author. Department of Ophthalmology, Farhat Hached University Hospital of Sousse, Tunisia.
| | - Nesrine Zaafrane
- Department of Ophthalmology, Farhat Hached University Hospital of Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Tunisia
| | - Anis Mahjoub
- Department of Ophthalmology, Farhat Hached University Hospital of Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Tunisia
| | - Hichem Aoun
- Department of Ophthalmology, Farhat Hached University Hospital of Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Tunisia
| | - Ahmed Jabri
- Department of Ophthalmology, Farhat Hached University Hospital of Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Tunisia
| | - Fethi Krifa
- Department of Ophthalmology, Farhat Hached University Hospital of Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Tunisia
| | - Mohamed Ghorbel
- Department of Ophthalmology, Farhat Hached University Hospital of Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Tunisia
| | - Hachemi Mahjoub
- Department of Ophthalmology, Farhat Hached University Hospital of Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Tunisia
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Malinowski SM, Wasserman JA. Centrifuged-Concentrated Intravitreal Slurry Triamcinolone Acetonide: An Inexpensive, Easy, and Viable Alternative to Long-Term Steroid Delivery. JOURNAL OF VITREORETINAL DISEASES 2021; 5:15-31. [PMID: 37009586 PMCID: PMC9976047 DOI: 10.1177/2474126420943417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: This work reports the duration, safety, and viability of intravitreal slurry triamcinolone acetonide (TA; 1.0 mL of 40-mg/mL TA centrifuge concentrated into a 0.1-mL pellet) to treat cystoid macular edema (CME). Methods: A retrospective, consecutive review was conducted of patients undergoing intravitreal slurry TA injections, July 2009 to December 2018. Results: In 143 eyes of 120 patients, slurry TA resolved CME for a mean of 327.15 (SD = 213.11) days, or 10.76 (SD = 7.00) months, per intravitreal injection (n = 466). In 100 eyes requiring multiple injections (n = 423), mean duration was 270.95 (SD = 177.14) days, or 8.91 (SD = 5.82) months, between injections. In 43 single-injection eyes, duration was 749.30 (SD = 483.17) days, or 24.63 (SD = 15.88) months. Mean duration decreased from 337.89 (SD = 210.46) days, or 11.11 (SD = 6.92) months, in nonvitrectomized eyes to 279.74 (SD 179.63) days, or 9.20 (SD = 5.91) months, in vitrectomized eyes (n = 74 injections, t = 2.24, P = .014, 1-tailed). Central foveal thickness as shown on optical coherence tomography decreased by 173.89μ (SD = 147.56μ), from 459.16μ (SD = 47.14μ) to 285.27μ (SD = 77.27μ; t = –25.31, P < .001), within 43.41 days (SD = 36.86). Visual acuity improved from 20/100 (logMAR 0.70, SD = 0.33) to 20/74 (logMAR 0.57, SD = 0.31; SD = 0.21; t = –11.01, P < .001), within 33.98 (SD 24.98) days. Fifteen of 31 phakic eyes (48.39%) underwent cataract extraction. Fifty-seven eyes (39.86%) developed a steroid response (> 10 mm Hg increase from baseline) 94.79 days (SD = 85.52 days), or 3.11 (SD = 2.81) months, following injection. Conclusions: A single injection of slurry TA lasted on average 10.76 months with significant improvement of CME and visual acuity. Adverse ocular effects were comparable to currently available, long-term, implantable steroids. Slurry TA appears to be an easily reproducible, safe, and cost-effective alternative to long-term intraocular steroid delivery.
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Affiliation(s)
- Susan M. Malinowski
- Retina Consultants of Michigan, Southfield, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Jason Adam Wasserman
- Department of Foundational Medical Studies and Department of Pediatrics, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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Șuță MC, Karancsi OL, Mușat O, Balica N, Yasar I, Roșca C, Stanca S, Dărăbuş DM. Triamcinolone acetonide induces sterile endophthalmitis in patients with intermediate uveitis: A case report series. Exp Ther Med 2020; 20:2524-2528. [PMID: 32765744 PMCID: PMC7401768 DOI: 10.3892/etm.2020.8883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/22/2020] [Indexed: 12/22/2022] Open
Abstract
Due to their anti-inflammatory, antiangiogenic and antiedematous properties, corticosteroids have been commonly used in the treatment of retinal diseases. Intravitreal administration of steroids offers the maximal drug efficacy and the lowest risk of systemic side effects. The authors report three cases of presumed sterile endophthalmitis induced by triamcinolone acetonide (TA) in three eyes with intermediate non-infectious uveitis. Each patient received a single intravitreal injection of TA of 4 mg. Because of the intense vitreous inflammatory reaction, retina examination and the optical coherence tomography could not be performed, although vitreous opacities were observed on the ocular ultrasound. The dense vitreous opacity is a defining factor, the anterior segment inflammation is mild to moderate and a hypopyon is present, which may be a sterile inflammatory reaction or the triamcinolone material itself. In cases of sterile endophthalmitis, the visual acuity increases progressively as the intraocular inflammation diminishes. Local treatment with topical antibiotics, prednisolone acetate and cycloplegic eyedrops is recommended to control the inflammatory reaction.
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Affiliation(s)
- Marius Cristian Șuță
- Department of Ophthalmology, ‘Victor Babeş’ University of Medicine and Pharmacy, 300041 Timişoara, Romania
| | - Olimpiu Ladislau Karancsi
- Department of Oral Implantology and Prosthetic Restorations on Implants, ‘Victor Babeş’ University of Medicine and Pharmacy, 300041 Timişoara, Romania
| | - Ovidiu Mușat
- Department of Ophthalmology, ‘Dr. Carol Davila’ Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Nicolae Balica
- Department of ENT, ‘Victor Babeş’ University of Medicine and Pharmacy, Timişoara County Emergency Clinical Hospital, 300041 Timişoara, Romania
| | - Iasmina Yasar
- Department of Ophthalmology, Timişoara County Emergency Clinical Hospital, 300041 Timişoara, Romania
| | - Cosmin Roșca
- Department of Ophthalmology, Oculens Clinic, 400501 Cluj-Napoca, Romania
| | - Simona Stanca
- Department of Pediatrics, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Diana-Maria Dărăbuş
- Department of Ophthalmology, ‘Victor Babeş’ University of Medicine and Pharmacy, 300041 Timişoara, Romania
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Mason RH, Ballios BG, Yan P. Noninfectious endophthalmitis following intravitreal triamcinolone acetonide: clinical case and literature review. Can J Ophthalmol 2020; 55:471-479. [PMID: 32702307 DOI: 10.1016/j.jcjo.2020.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 06/03/2020] [Accepted: 06/12/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To review the literature on noninfectious endophthalmitis (NIE) following intravitreal triamcinolone acetonide (IVTA). DESIGN A literature review and case report. PARTICIPANTS Individuals who developed NIE after IVTA injection. METHODS A review of the literature was undertaken using Ovid MEDLINE and EMBASE databases, and articles available up to and including December 30, 2019, were included. A total of 518 articles were identified, of which 27 were selected. We also present an illustrative case report. RESULTS The incidence rate of NIE lies between 0.1% and 7.3% in most studies. Although the etiology of NIE is still the subject of investigation, proposed mechanisms include excipients and rheologic stress caused by small crystals. The time to presentation of NIE is often 1-3 days after IVTA injection, with symptoms of moderate to marked reduction in visual acuity along with signs of anterior chamber inflammatory reaction, hypopyon, and vitritis. Resolution occurs in 1-3 weeks in the majority of patients, and almost all return to their pre-injection visual acuity. Differences in the presentations of NIE, infectious endophthalmitis, and pseudo-endophthalmitis are discussed. We also present an illustrative case report of an 80-year-old woman who developed NIE after an IVTA injection for cystoid macular edema. CONCLUSIONS It is important to distinguish NIE from other forms of endophthalmitis because they have different natural histories and require different interventions and follow-up. NIE is rarely accompanied by significant pain or conjunctival erythema. Visual acuity is inconsistently affected and is therefore not a good criterion for identifying the type of presenting endophthalmitis.
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Affiliation(s)
- Ryan H Mason
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont.; Kensington Vision and Research Centre, Toronto, Ont
| | - Brian G Ballios
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont.; Kensington Vision and Research Centre, Toronto, Ont
| | - Peng Yan
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont.; Kensington Vision and Research Centre, Toronto, Ont..
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London NJS, Garg SJ, Moorthy RS, Cunningham ET. Drug-induced uveitis. J Ophthalmic Inflamm Infect 2013; 3:43. [PMID: 23522744 PMCID: PMC3637087 DOI: 10.1186/1869-5760-3-43] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 03/13/2013] [Indexed: 01/21/2023] Open
Abstract
A number of medications have been associated with uveitis. This review highlights both well-established and recently reported systemic, topical, intraocular, and vaccine-associated causes of drug-induced uveitis, and assigns a quantitative score to each medication based upon criteria originally described by Naranjo and associates.
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Affiliation(s)
- Nikolas JS London
- Retina Consultants San Diego, 9850 Genesee Avenue, Suite 700, La Jolla, CA, 92037, USA
| | - Sunir J Garg
- MidAtlantic Retina, The Retina Service of Wills Eye Institute, Thomas Jefferson University, 840 Walnut Street, Suite 1020, Philadelphia, PA, 19107, USA
| | - Ramana S Moorthy
- Associated Vitreoretinal and Uveitis Consultants, St. Vincent Hospital and Health Services, Indianapolis, IN, 46260, USA
- Associate Clinical Professor of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Emmett T Cunningham
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, CA, 94115, USA
- Department of Ophthalmology, Stanford University School of Medicine, Stanford, CA, 94305-5101, USA
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Abstract
PURPOSE OF REVIEW Over the past few years, the results of many studies have highlighted the risks and benefits of intravitreal injection of a number of medications, the most common being triamcinolone, antivascular endothelial growth factor (VEGF) agents, antibiotics, antivirals, antifungals, and methotrexate. The purpose of this review is to highlight the complications associated with these injections. RECENT FINDINGS Elevated intraocular pressure and glaucoma are the most common complications of intraocular triamcinolone. There is also an increased incidence of cataract formation/progression over time. The immunosuppressive effect of triamcinolone does not appear to increase the risk of endophthalmitis. Recent reports suggest that intravitreal anti-VEGF injections have a low complication rate. Similarly, antimicrobials also have low rates of injection-associated complications. SUMMARY Intravitreal injections play a critical role in daily ophthalmic practice. The overall risk of endophthalmitis and retinal detachment appears to be low and most of the commonly used drugs are well tolerated, even with repeat injection. Further long-term studies need to be performed to elucidate ways of increasing the safety of these procedures and medications.
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