A Case of Herpetic Keratitis After Intravitreal Triamcinolone Injection

Novel micellar CB2 receptor agonist with anti-inflammatory action for treating corneal alkali burns in a mouse model

Introduction: Moderate corneal alkali burns such as those sustained from accidental exposure to household chemicals are treated with topical corticosteroids. Side effects include increased intraocular pressure and slowing of wound healing. Here, we compare the effects of a cannabinoid receptor 2 (CB2r) agonist, TA-A001, that is involved in wound healing with that of the corticosteroid, prednisolone. Methods: TA-A001 was encapsulated with a polymeric micelle comprising polyvinylpyrrolidone: polylactide block copolymers referred to as SmartCelle™ to allow delivery of the very hydrophobic drug. Mouse corneas were given moderate alkali burns. Different doses of TA-A001 of 0.125%, 0.25% and 0.5% were used to treat the burns in comparison to the corticosteroid, prednisolone. Results: TA-A001 at 0.25% and 0.5% allowed for faster wound closure. However, the higher 0.5% dose also induced unwanted neovascularization. By comparison, burned corneas treated with prednisolone showed slower healing as well as disorganization of the cornea. Although 0.25% TA-A001 appeared to produce the most-optimal responses, this dose resulted in marked expression of the macrophage chemoattractant protein, MCP-1. However, there was also an increase in CD163 positive stained M2 anti-inflammatory macrophages in the TA-A001 corneas. TA-A001 treated corneas showed the presence of sensory nerve fibers throughout the corneal epithelium including the superficial cell layers as did Substance P staining. Discussion: We found that TA-A001 at the 0.25% doses was able to modulate inflammation resulting from a moderate alkali burn to the cornea. With more extensive testing, TA-A001 might prove to be a potential alternative to corticosteroids for treating alkali burns or other causes of corneal inflammation.

Herpetic Keratouveitis following Intravitreal Ranibizumab Injection in a Case with Diabetic Macular Edema

PURPOSE

The purpose of this study is to report a case of herpetic keratouveitis that developed soon after intravitreal ranibizumab injection.

CASE REPORT

A 54-year-old man with bilateral proliferative diabetic retinopathy and severe macular edema received intravitreal ranibizumab injections in both eyes within 3 days interval. One week after the injection, patient presented with acute vision loss in his right eye. Slit-lamp biomicroscopy revealed diffuse corneal edema and severe flare in the anterior chamber with intraocular pressure (IOP) rise. After epithelial dendritic corneal ulcer was visualized, he was diagnosed with right herpetic keratouveitis that was treated with oral valacyclovir, as well as topical acyclovir ointment and prednisolone acetate drops. However, recalcitrant IOP rise had to be treated with a single session transscleral diode laser cyclophotocoagulation.

CONCLUSION

Herpetic keratouveitis can be seen as a rare complication of intravitreal ranibizumab injection. To our best knowledge, this is the first case with herpes keratouveitis developed following intravitreal ranibizumab injection.

Local delivery of corticosteroids in clinical ophthalmology: A review

Locally administered steroids have a long history in ophthalmology for the treatment of inflammatory conditions. Anterior segment conditions tend to be treated with topical steroids whilst posterior segment conditions generally require periocular, intravitreal or systemic administration for penetration. Over recent decades, the clinical applications of periocular steroid delivery have expanded to a wide range of conditions including macular oedema from retino-vascular conditions. Formulations have been developed with the aim to provide practical, targeted, longer-term and more efficacious therapy whilst minimizing side effects. Herein, we provide a comprehensive overview of the types of periocular steroid delivery, their clinical applications in ophthalmology and their side effects.

Herpes simplex virus keratouveitis recurrence following intravitreal bevacizumab injection

We report a case of recurrence of herpes simplex virus (HSV) keratouveitis following the intravitreal injection of bevacizumab for macular edema secondary to central retinal vein occlusion (CRVO) in a previously adequately treated patient of herpetic keratouveitis. A 47-year-old man with the previous history of HSV keratouveitis was administered 2 doses of intravitreal bevacizumab in the right eye for CRVO, at an interval of 4 weeks. Following the second dose, the patient developed decreased vision, corneal edema, and anterior segment inflammation. Since he was a previously known case of HSV keratouveitis with a positive polymerase chain reaction for HSV from the aqueous, oral valacyclovir was started along with topical steroids and cycloplegics. He showed a good response to treatment with resolution of keratouveitis. This case demonstrates that the recurrence of herpetic keratouveitis can be a possible complication of intravitreal bevacizumab, which may occur even after prior uneventful injections.

Antiviral treatment and other therapeutic interventions for herpes simplex virus epithelial keratitis

BACKGROUND

Eye disease due to herpes simplex virus (HSV) commonly presents as epithelial keratitis which, though usually self-limiting, may persist or progress without treatment.

OBJECTIVES

To compare the relative effectiveness of antiviral agents, interferon, and corneal debridement in the treatment of HSV epithelial keratitis.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 12), PubMed (January 1946 to 31 December 2014), EMBASE (January 1980 to 31 December 2014), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to 31 December 2014), System for Information on Grey Literature in Europe (OpenGrey) (January 1995 to 31 December 2014), BIOSIS (January 1926 to 5 May 2014), Scopus (January 1966 to 31 December 2014), Japan Science and Technology Institute (J-Global) (January 1975 to 31 December 2014), China National Knowledge Infrastructure (CNKI) (January 1979 to 31 December 2014), British Library's Electronic Table of Contents (Zetoc) (January 1993 to 7 May 2014). We looked for trials listed on the the metaRegister of Controlled Trials (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en), Chinese Clinical Trial Registry, the U.S. Food and Drug Administration (FDA) (www.fda.gov/), National Institute for Health and Clinical Excellence (NICE) (www.

EVIDENCE

nhs.uk) and the European Medicines Agency (EMA) (www.ema.europa.eu/ema/) as of 31 December 2014. There were no language or date restrictions in the search for trials. We also culled literature digests and conference proceedings as of 15 April 2014. There were no language or date restrictions in the search for trials.

SELECTION CRITERIA

Randomised and quasi-randomised trials of HSV dendritic or geographic epithelial keratitis were included that reported the proportion of eyes healed at one week, two weeks, or both after enrolment.

DATA COLLECTION AND ANALYSIS

We tabulated data on study characteristics, risk of bias, and outcomes and used direct comparisons to estimate a risk ratio (RR) and, when feasible, a hazard ratio (HR) with a 95% confidence interval (CI). Heterogeneity was assessed by an inconsistency index. A multiple treatment comparison meta-analysis consolidated direct and indirect comparisons of relative healing at 14 days.

MAIN RESULTS

One hundred thirty-seven studies involving 8333 eyes met the inclusion criteria. Placebo-controlled studies were heterogeneous in comparison with idoxuridine (RR 1.74; 95% CI 1.03 to 2.91) and few in number for vidarabine (RR 1.81; 95% CI 1.09 to 3.01), interferon (RR 1.32; 95% CI 1.06 to 1.64), and debridement. Vidarabine (RR 1.13; 95% CI 1.02 to 1.25), trifluridine (RR 1.30; 95% CI 1.18 to 1.43), acyclovir (RR 1.23; 95% CI 1.14 to 1.34), and brivudine (RR 1.34; 95% CI 1.18 to 1.51) were more effective than idoxuridine. Trifluridine (RR 1.17; 95% CI 1.03 to 1.32) and acyclovir (RR 1.11; 95% CI 1.03 to 1.19) were more effective than vidarabine. No significant differences in healing emerged among trifluridine, acyclovir, brivudine, and foscarnet although few studies compared brivudine or foscarnet with other antivirals. Any potential advantage of ganciclovir compared to acyclovir was mitigated by study heterogeneity and possible publication bias. Only one study evaluated the joint use of two topical antivirals. In a limited number of studies, oral acyclovir (RR 0.92; 95% CI 0.79 to 1.07) or the combination of oral acyclovir with a topical antiviral (RR 1.36; 95% CI 0.68 to 2.74) appeared as effective as a single topical antiviral agent. Compared to topical antiviral monotherapy, the combination of an antiviral with either interferon or debridement had inconsistent effects on expediting healing and improving outcome.

AUTHORS' CONCLUSIONS

Placebo-controlled studies of HSV epithelial keratitis are limited to superseded interventions. Trifluridine and acyclovir are more effective than idoxuridine or vidarabine and similar in therapeutic effectiveness. Brivudine and foscarnet do not substantially differ in effectiveness from trifluridine or acyclovir. Ganciclovir is at least as effective as acyclovir. The addition of interferon to a nucleoside antiviral agent and the combination of debridement with antiviral treatment need to be further assessed to substantiate any possible advantage in healing.

Therapeutic effect of intravitreal injection of triamcinolone in the treatment of endothelial graft rejection: a pilot study

PURPOSE

To investigate the efficacy of intravitreal triamcinolone acetonide (IVTA) injection in the treatment of endothelial graft rejection and the expression of T-helper type 1 (Th-1) chemokines in the aqueous humor.

METHODS

Eleven patients (11 eyes) with acute endothelial graft rejection underwent IVTA (4 mg/0.1 mL) injection in addition to conventional treatment, including systemic and topical steroids and cyclosporine A (group A); 13 patients (13 eyes) received conventional treatment only (group B). Clinical characteristics were analyzed. In group A, Th-1 chemokines (CXCL-9, -10, and -11) in aqueous humor were measured by enzyme-linked immunosorbent assay and CXCR3(+) cells were counted by flow cytometry before treatment and at the period of improvement.

RESULTS

There were no significant differences in visual acuity, intraocular pressure, and recurrence rate between the 2 groups. The mean time to improvement was 9.1 ± 3.9 days in group A and 15.4 ± 5.5 days in group B (P = 0.04). The concentrations of CXCL-9, -10, and -11 were 562.7 ± 109.4, 30293.1 ± 12537.1, and 228.3 ± 80.8 pg/mL before treatment and 6.7 ± 6.8 (P < 0.01), 207.5 ± 209.8 (P < 0.01), and 18.9 ± 19.5 (P < 0.01) pg/mL after treatment, respectively. The CXCL-10 level correlated with the time to improvement of graft rejection (P = 0.02). Flow cytometry demonstrated a significantly decreased number of CXCR3(+) and CXCR3(+)CD4(+) cells in the aqueous humor after treatment.

CONCLUSION

IVTA injection was effective in reducing the time to improvement of endothelial graft rejection. Increased expression of CXCL-9, -10, and -11, and their receptors in the aqueous humor of patients with endothelial graft rejection decreased after treatment.

Ultrasound biomicroscopy study of vitreous incarceration subsequent to intravitreal injections

OBJECTIVE

To study the existence of vitreous incarceration by ultrasound biomicroscopy (UBM) at the pars plana after direct intravitreal injection of triamcinolone acetonide ± bevacizumab without anterior chamber paracentesis.

DESIGN

Interventional case series.

PARTICIPANTS

Patients undergoing intravitreal injection of triamcinolone acetonide with or without intravitreal bevacizumab.

METHODS

In 21 eyes, the existence of vitreous incarceration at the pars plana site of intravitreal injection of 0.05 mL of drug was studied by UBM (50 MHz probe of the VUmax, Sonomed, NY), the day after surgery, by 1 technician. The reason for injection was diabetic retinopathy in 12 (57.1%) eyes; age-related macular degeneration in 6 (28.6%) eyes; branch retinal vein occlusion in 2 (9.5%) eyes; and choroiditis in 1 eye (4.8%). In 1 eye, only triamcinolone acetonide was injected, and in the other eyes, bevacizumab mixed with triamcinolone acetonide was injected.

RESULTS

We studied 21 eyes in 13 patients. Of the subjects, 61.5% were male. The mean age of the patients was 62.2 years. On the day after intravitreal injection of the drug, vitreous incarceration into the pars plana site was detected by UBM in 42.9% of the eyes.

CONCLUSION

Vitreous incarceration exists after intravitreal injection of drug, but its clinical importance is still unknown. Further long-term prospective studies are recommended.

A case of herpetic epithelial keratitis after triamcinolone acetonide subtenon injection

BACKGROUND

We report a case of herpes simplex virus (HSV) epithelial keratitis that developed after a subtenon triamcinolone acetonide (TA) injection.

METHOD

A 78-year-old woman with a branch retinal vein occlusion and diffuse macular edema in her left eye received a subtenon injection of 20 mg of TA.

RESULTS

Six days after the injection, the patient presented with a foreign body sensation, tearing, redness, and photophobia in the same eye. Slit-lamp examination revealed multiple corneal dendriform ulcers. She was diagnosed with HSV epithelial keratitis and treated with topical acyclovir ointment. The epithelial lesions healed after 1 week of therapy.

CONCLUSION

HSV epithelial keratitis can be a possible complication of a TA subtenon injection.

Herpetic epithelial keratitis after intravitreal injection of bevacizumab (avastin)

PURPOSE

To report a case of herpetic epithelial keratitis that developed after intravitreal bevacizumab (Avastin) injection.

METHODS

A 63-year-old man with diabetes with proliferative diabetic retinopathy and macular edema received intravitreal injection of bevacizumab (Avastin) in his right eye.

RESULTS

Three days after the injection, the patient presented with foreign body sensation, redness, tearing, photophobia, and decreased visual acuity in the right eye. The cornea showed an arborizing dendritic epithelial lesion with terminal bulb typical of herpes simplex virus (HSV) epithelial keratitis. HSV-DNA was detected in corneal scrapings using polymerase chain reaction. A diagnosis for herpes simplex epithelial keratitis was made. Topical acyclovir ointment therapy was initiated with good resolution of HSV signs and symptoms.

CONCLUSIONS

Herpes simplex epithelial keratitis can be a possible complication of intravitreal bevacizumab (Avastin) injection. To our knowledge, this case is the first report of herpetic epithelial keratitis after intravitreal bevacizumab (Avastin) injection.

Herpetic keratitis after descemet stripping automated endothelial keratoplasty for failed graft

OBJECTIVES

To report a case of herpetic epithelial keratitis after Descemet stripping automated endothelial keratoplasty (DSAEK) for a failed graft.

METHODS

A 31-year-old female patient underwent DSAEK for failed graft in left eye. She previously had undergone penetrating keratoplasty for keratoconus in that eye.

RESULTS

One week after DSAEK, the patient presented with pain in left eye. The cornea showed two epithelial defects with dendritic edges that involved the penetrating keratoplasty graft host junction and showed positive fluorescein staining. Diagnosis of herpes simplex virus keratitis was made and the patient was started on oral acyclovir and topical trifluiridine. The epithelial lesions showed complete resolution in 3 days.

CONCLUSIONS

Herpes simplex virus epithelial keratitis can occur after DSAEK for failed grafts even in the absence of previous history of herpes simplex virus infection and should be considered in the differential diagnosis of postoperative epithelial defects.

Case-control study of subconjunctival triamcinolone acetonide injection vs intravenous methylprednisolone pulse in the treatment of endothelial corneal allograft rejection

PURPOSE

To assess the safety and effectiveness of treating corneal endothelial rejection with a subconjunctival injection of 20 mg triamcinolone acetonide in combination with topical application of 1% prednisolone acetate, as compared to treatment with an intravenous pulse of 500 mg methylprednisolone in combination with topical application of 1% prednisolone acetate.

METHODS

A case-controlled study including a literature review was performed. Patients who presented with an initial episode of corneal endothelial rejection were treated with subconjunctival injection of 20 mg triamcinolone in combination with topically applied 1% prednisolone and were retrospectively matched for age and diagnosis to patients who received a single intravenous injection of 500 mg methylprednisolone in combination with topical 1% prednisolone. Patients were analysed regarding reversion of the rejection episode, intraocular pressure, and visual acuity after 1 year.

RESULTS

Overall, the triamcinolone group had a better outcome regarding reversion of corneal transplant rejection (P=0.025), with 15 of 16 patients in the triamcinolone group having clear grafts, compared to only 10 of 16 patients in the methylprednisolone group. Intraocular pressure (IOP) was increased in both groups at day 30 (P=0.002), although there was no statistically significant difference in IOP between the groups (P=0.433). Visual acuity improved in both groups after 1 year (P=0.049), although slightly more improvement was observed in the triamcinolone group (P=0.002).

CONCLUSIONS

The results observed in this case-controlled study suggest that the use of subconjunctival triamcinolone acetonide may benefit patients with corneal transplant rejection.