|Year : 2020 | Volume
| Issue : 2 | Page : 148-153
A clinical study on the efficacy of posterior subtenon injection of triamcinolone acetonide in patients with post fever retinitis
Parvathy Prabhakaran Sreelatha, Pavana Krishnaraj Acharya, Kavitha Chikkanayakanahalli Venugopal, Renuka Sivakiran
Department of Ophthalmology, Hassan Institute of Medical Sciences, Karnataka, India
|Date of Submission||06-Jan-2020|
|Date of Decision||03-Feb-2020|
|Date of Acceptance||23-Feb-2020|
|Date of Web Publication||25-Aug-2020|
Dr. Pavana Krishnaraj Acharya
Department of Ophthalmology, Hassan Institute of Medical Sciences, Hassan, Karnataka
Source of Support: None, Conflict of Interest: None
Aims: The aim of this study was to assess the visual outcome and fundoscopic changes following posterior subtenon (PST) injection of triamcinolone acetonide (TA) in patients with post fever retinitis. Settings and Design: This was a prospective interventional study. Subjects and Methods: A prospective interventional study was conducted on 12 patients with post fever retinitis responding poorly to systemic steroids or with contraindications to systemic steroids. Patients were treated with PST injection of 0.5 ml TA (20 mg). They were followed up for 6 months during which best-corrected visual acuity (BCVA), fundus changes, and intraocular pressure (IOP) were evaluated. Statistical Analysis Used: Descriptive statistics and paired t-test were used in this study. Results: All patients had BCVA <6/60 at presentation. Three patients (25%) had retinitis patch alone, five patients (41%) had retinitis with macular edema, and four patients (34%) had retinitis and macular edema in the presence of other features such as vasculitis or disc edema at the time of presentation. On a 6-month follow-up after PST with TA, nine patients (75%) improved to a BCVA of 6/12 or more. One patient improved to 6/18 and two patients improved to 6/24. The mean logMAR visual acuity before PST was 1.349 which improved to a mean logMAR of 0.248 following PST injection with TA (P < 0.001). Six patients (50%) had a total resolution at 6 months, four patients (34%) had a total resolution with atrophic scars, and two patients (16%) had an incomplete resolution. None of the patients had a significant increase in IOP. Conclusions: PST with TA can be considered as an alternative treatment for post febrile retinitis, especially when the response to systemic steroids is poor or in the presence of contraindications to systemic steroids.
Keywords: Post fever retinitis, posterior subtenon injection, triamcinolone acetonide
|How to cite this article:|
Sreelatha PP, Acharya PK, Venugopal KC, Sivakiran R. A clinical study on the efficacy of posterior subtenon injection of triamcinolone acetonide in patients with post fever retinitis. Kerala J Ophthalmol 2020;32:148-53
|How to cite this URL:|
Sreelatha PP, Acharya PK, Venugopal KC, Sivakiran R. A clinical study on the efficacy of posterior subtenon injection of triamcinolone acetonide in patients with post fever retinitis. Kerala J Ophthalmol [serial online] 2020 [cited 2020 Oct 29];32:148-53. Available from: http://www.kjophthal.com/text.asp?2020/32/2/148/293287
| Introduction|| |
An episode of febrile illness caused by various pathogens such as bacteria, viruses, or protozoa can produce a myriad of manifestations in the eye. Ocular manifestations that follow a febrile illness range from mild conjunctivitis, episcleritis, anterior uveitis, or posterior segment inflammation such as retinitis, neuroretinitis, macular edema, retinal vasculitis, vitritis, and serous retinal detachment. These retinal manifestations can be either unilateral or bilateral and can lead to significant impairment in the vision. The mechanism of these ocular features can be either a direct invasion of the pathogen or an immune-mediated reaction.
Neuroretinitis and retinitis following an episode of fever are assumed to be due to retinal infiltration of immune origin. These immunologic effects may be due to homology between retinal antigens and microbial peptides or an immune response that reacts to self-antigens or a molecular mimicry leading to autoimmunity. Ultimately, these reactions cause an increased vascular permeability of the retinal vasculature leading to retinal edema.
Post fever retinitis and neuroretinitis typically manifest 4–6 weeks following an episode of febrile illness. Patients usually present with sudden-onset painless diminution of vision. Ocular lesions occurring 4–6 weeks following the onset of fever, significant improvement without any antimicrobial or antiviral therapy in an immunocompetent individual, and good response to systemic steroids make an immune-mediated inflammation to be the mechanism of these retinal manifestations.
Systemic corticosteroids are used as the mainstay of treatment in post fever retinitis owing to the immune-mediated inflammatory nature of the pathology. Often, patients need prolonged treatment with corticosteroids which can produce various systemic side effects such as hypertension, impaired glucose tolerance, osteoporosis, obesity, and peptic ulcer. Moreover, there are various absolute contraindications to systemic steroids as in uncontrolled hypertension, poorly controlled diabetes, active peptic ulcer disease, and relative contraindications such as pregnancy and lactation. These factors can cause a major obstacle for the management of post fever retinitis. In spite of adequate therapy with systemic corticosteroids, the response may be either very slow or poor in a few patients.
Posterior subtenon (PST) injection is a method of delivering the desired drug in the PST space, commonly in the superotemporal quadrant. This will facilitate the maximum concentration of the drug in the desired area with minimal systemic side effects.
The aim of our study was to assess the efficacy and safety of PST injection of triamcinolone acetonide (TA) in treating post fever retinitis.
| Subjects and Methods|| |
A prospective interventional study was conducted on 12 eyes of 12 patients with post fever retinitis. The study was conducted during the study period from January 2017 to August 2017. Prior approval from the institutional ethical committee was obtained for conducting the study, and informed consent was obtained from patients in writing before enrollment. Among the 12 patients, 9 patients had shown a poor response to adequate dose of systemic steroids, 2 patients were in the first trimester of pregnancy, and 1 patient was lactating.
The objectives of the study were to assess the visual outcome and fundoscopic changes following PST with TA in post fever retinitis. Patients were included in the study by applying the following inclusion and exclusion criteria.
Patients presented with retinitis following a febrile illness within 3-6 weeks of visual symptoms were included in the study using the following inclusion criteria
- Absence of clinical response to adequate dose of systemic steroids for a period of 4 weeks
- Intolerance or side effects to systemic steroid therapy
- Contraindications for systemic steroid therapy.
In cases with bilateral retinitis, the eye with poor vision was considered for the study.
Patients with preexisting ocular conditions such as uveitis, elevated intraocular pressure (IOP), glaucomatous disc changes, and retinitis due to other causes such as toxoplasmosis, Cytomegalovirus retinitis, and tuberculosis were excluded from the study.
A detailed history emphasizing on visual symptoms and the episode of fever following which the symptoms started was noted followed by detailed ocular examination that included best-corrected visual acuity (BCVA), color vision, anterior chamber examination, dilated fundus examination using indirect ophthalmoscope with 20D, slit-lamp biomicroscopy with 90D, fundus photography, and measurement of IOP with Perkins applanation tonometer.
Hematological examinations such as complete hemogram, erythrocyte sedimentation rate, C-reactive protein, venereal disease research laboratory test, human immunodeficiency virus ELISA, Widal test, and random blood sugar were done for all patients. ELISA for toxoplasma, chest X-ray, and Mantoux skin test for tuberculosis were done to rule out retinitis due to the respective causes.
Technique of posterior subtenon
Following topical instillation of anesthetic agent (4% lignocaine), the eye was painted and draped. Ample exposure was obtained by placing an eye speculum. 0.5 ml of TA (20 mg) was taken in 1 ml syringe with a 26G needle after proper shaking of the vial. A patient was asked to look down, and the upper bulbar conjunctiva was penetrated with the tip of the needle, bevel toward the globe, slightly on the bulbar side of the superotemporal fornix. The needle was advanced posteriorly keeping it as close to the globe following the contour of the globe taking care not to pierce the sclera, and 0.5 ml of TA was injected.
After PST injection, patients were followed up at the 2nd week, 1st month, 3rd month, and 6 months post injection. During each follow-up visit BCVA, dilated fundus examination and IOP measurement were done. Data were analyzed using descriptive statistics. Statistical significance was assessed using paired t-test. P < 0.005 was considered statistically significant.
| Results|| |
Of 12 patients who were treated with PST injection with TA, nine patients (75%) were female and three (25%) were male [Figure 1]. Three patients had bilateral disease, and in them, the eye with poor vision was given PST injection. The age of the patients was in the range of 18–56 years. Majority of the patients were in the age group of 20–40 years [Figure 2]. The mean age was 32.1 years. Two patients were diagnosed to have an episode of enteric fever around 6 weeks before the onset of diminution in vision. In ten patients, the etiology of fever was not found, presumed to be viral in origin.
At presentation, the BCVA of all the 12 patients was ≤6/60 by the Snellen visual acuity chart [Figure 3]. Fundoscopy showed retinitis patches in three patients (25%), retinitis patches with macular edema in five cases (41%), retinitis patch with macular edema and vasculitis in two patients (17%), and retinitis patch with macular edema and disc edema in two patients (17%) [Figure 4]. All the 12 patients had IOP in the normal range.
|Figure 3: Comparison of visual acuity before and after posterior subtenon injection|
Click here to view
Following PST injection, patients were on regular follow-up, and the final outcome was measured at 6 months post PST injection. BCVA improved to 6/6 in three patients, 6/9 in four patients, 6/12 in two patients, 6/18 in one patient, and 6/24 in two patients. The mean logMAR visual acuity before PST was 1.349 which improved to a mean logMAR of 0.248 following PST injection with TA (P< 0.01).
Fundoscopic features 6 months post PST injection revealed complete resolution of retinal lesions in 6 patients (50%) [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], resolution of with atrophic scars in 4 pateints(34%)and incomplete resolution with few hadr exudates and macular edema in 2 patients (16%).
|Figure 8: Fundoscopic image of the second patient before posterior subtenon injection|
Click here to view
|Figure 9: Fundoscopic image of the second patient after posterior subtenon injection|
Click here to view
None of the patients had a significant rise in IOP. The mean IOP before procedure was 13.6 mmHg, and after PST, the mean IOP was 15.8.
| Discussion|| |
Post fever retinitis usually manifests approximately 3 weeks after the onset of fever, irrespective of etiology. The usual manifestations include focal or multifocal patches of retinitis which could be unilateral or bilateral and may be associated with anterior uveitis, macular edema, and serous detachment at the macula. The immunological nature of post fever retinitis and neuroretinitis and its favorable response to systemic steroids is reported by Vishwanath et al.
Even though post fever retinitis is a self-limiting inflammatory process with good spontaneous recovery as suggested by Hosamani et al., potentially blinding inflammation of intraocular contents warrants prompt therapy to reduce inflammation and to salvage the vision.
Many studies have reported the success rate of PST with TA in treating various intraocular inflammations, diabetic macular edema, and pseudophakic cystoid macular edema.,, Lafranco Dafflon et al. conducted a study on PST injection of steroid for treating posterior intraocular inflammation such as panuveitis and uveitis with continuing medical education and found it to be effective in restoring visual acuity. According to this study, visual acuity improved significantly, with 59.4% of eyes having a gain of 2–5 Snellen lines and 18.7% eyes having a gain of >5 lines. Our study also found a significant improvement in visual acuity following PST, where all eyes had an improvement of five or more lines in the Snellen visual acuity chart.
Post fever retinitis being an immune-mediated condition responds well with systemic steroids. This favorable outcome following systemic steroid therapy was studied by Vishwanath et al. The study was conducted on 21 eyes of 14 patients with post fever retinitis, with an average visual acuity of 2/60. Patients were treated with oral steroids. All patients showed improvement in vision, with unilateral cases improving to an average of 6/12 and bilateral cases improving to an average of 6/24. Patients also showed resolution of retinitis, macular edema, and serous detachment. The results of the above study are similar to our study with PST with TA. The major limitation of systemic steroid therapy is its systemic side effects and relative contraindications in certain systemic conditions such as uncontrolled diabetes and hypertension which can be worsened with the therapy. Local delivery of steroids such as subtenon injection or intravitreal injection can overcome this limitation with more drug concentration at the desired area with a minimal systemic side effect.
Intravitreal injection of TA is a proven effective method of delivering anti-inflammatory medications to the posterior segment in case of inflammatory disorders affecting the posterior segment such as noninfectious posterior uveitis and diabetic macular edema. According to a study conducted by Ozkiris. where effectiveness of intravitreal injection of TA was compared with systemic steroids in cases of posterior uveitis, a significant improvement in the visual acuity following intravitreal injection was noted, where the mean visual acuity improved significantly (P< 0.001) from a mean LogMAR value of 2.05 ± 0.82 at baseline to a maximum of 0.33 ± 0.22. In the group treated with systemic steroids, the mean LogMAR visual acuity before therapy was 1.82 ± 0.78, and it has reached a maximum of 0.40 ± 0.22 after treatment. Therefore, local steroid treatments may be as effective compared to systemic steroids.
A rise in IOP following PST injection and intravitreal injection of TA is a complication reported in various studies., The incidence of increase in IOP following intravitreal injection of TA was reported to be as high as 50% in a study conducted by Jonas et al. The incidence of IOP rise after PST injection with TA was found to be 22.06% in the study done by Iwao et al. Hence, the incidence of IOP rise may be less in PST injection than following intravitreal injection TA. However, PST with TA can lead to a delayed rise in IOP when compared to intravitreal injection of TA, which was studied by Jea et al. According to their study, IOP rise following intravitreal TA may be around 3.1 weeks and following PST with TA may have a delayed rise in IOP by around 5.9 weeks. Hence, long-term monitoring of IOP is needed in cases with PST injection of TA. We found no significant elevation in intraocular tension following the procedure and found the procedure a safe one. Our results were comparable to the results of Bui Quoc et al., who found IOP rise in <21.3% of patients after PST with TA, which was well responding to antiglaucoma measures. None of our patients had cataract progression which was similar to the study done by Kim et al. regarding the effect of PST injection of TA in cases of diabetic macular edema, where no significant cataract progression was noted.
Limitations of the study
Small sample size is the major limitation of the study, and OCT analysis of the resolution of macular edema is another factor that is lacking in the study. However, further studies regarding this treatment modality are required with a larger sample size and looking into long-term issues such as cataract incidence following post injection.
| Conclusions|| |
PST injection with TA can be considered as an effective and safe treatment for post fever retinitis. This is particularly useful in patients with contraindications for systemic steroid therapy or if the patient develops intolerance to systemic steroid therapy. PST with TA can be considered as an effective alternate when the patient has poor clinical response to adequate dose of systemic steroids.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Vishwanath S, Badami K, Sriprakash KS, Sujatha BL, Shashidhar SD, Shilpa YD. Post-fever retinitis: A single center experience from south India. Int Ophthalmol 2014;34:851-7.
Relhan N, Pathengay A, Albini T, Priya K, Jalali S, Flynn HW. A case of vasculitis, retinitis and macular neurosensory detachment presenting post typhoid fever. J Ophthalmic Inflamm Infect 2014;4:23.
Purvin V, Sundaram S, Kawasaki A. Neuroretinitis: Review of the literature and new observations. J Neuroophthalmol 2011;31:58-68.
Goldberg RA. Orbital steroid injections. Br J Ophthalmol 2004;88:1359-60.
Kanski JJ, Bowling B. Kanski's clinical ophthalmology-a systemic approach.8th
Hosamani SA, Bhomaj S, Vallabha K, Biradar S, Warad VG. Spontaneous resolution of severe neuroretinitis following a febrile illness. Al Ameen J Med Sci 2015;8:164-7.
Helm CJ, Holland GN. The effects of posterior subtenon injection of triamcinolone acetonide in patients with intermediate uveitis. Am J Ophthalmol 1995;120:55-64.
Qamar RM, Saleem MI, Saleem MF. Comparison of the efficacy between an intravitreal and a posterior subtenon injection of triamcinolone acetonide for the treatment of diffuse diabetic macular edema. Eurasian J Med 2013;45:185-90.
Pfaff AJ, Wirosko WJ. Management of cystoid macular edema resistant to topical medications. Investigative Ophthalmology and Visual Science. 2004;45:1994.
Lafranco Dafflon M, Tran VT, Guex-Crosier Y, Herbort CP. Posterior sub-Tenon's steroid injections for the treatment of posterior ocular inflammation: Indications, efficacy and side effects. Graefes Arch Clin Exp Ophthalmol 1999;237:289-95.
Ozkiris A. Intravitreal triamcinolone acetonide injection for the treatment of posterior uveitis. Ocul Immunol Inflamm 2006;14:233-8.
Jonas JB, Kreissig I, Degenring R. Intraocular pressure after intravitreal injection of triamcinolone acetonide. Br J Ophthalmol 2003;87:24-7.
Iwao K, Inatani M, Kawaji T, Koga T, Mawatari Y, Tanihara H. Frequency and risk factors for intraocular pressure elevation after posterior sub-Tenon capsule triamcinolone acetonide injection. J Glaucoma 2007;16:251-6.
Jea SY, Byon IS, Oum BS. Triamcinolone-induced intraocular pressure elevation: Intravitreal injection for macular edema and posterior subtenon injection for uveitis. Korean J Ophthalmol 2006;20:99-103.
Bui Quoc E, Bodaghi B, Adam R, Burtin T, Cassoux N, Dreifuss S, et al
. Intraocular pressure elevation after subtenon injection of triamcinolone acetonide during uveitis. J Fr Ophtalmol 2002;25:1048-56.
Kim MW, Moon H, Yang SJ, Joe SG. Effect of Posterior Subtenon Triamcinolone Acetonide Injection on Diabetic Macular Edema Refractory to Intravitreal Bevacizumab Injection. Korean J Ophthalmol 2016;30:25-31.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]