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Clinical Sciences |

Noninfectious Endophthalmitis Associated With Intravitreal Triamcinolone Injection FREE

Daniel B. Roth, MD; Janet Chieh, BA; Marc J. Spirn, MD; Stuart N. Green, MD; David L. Yarian, MD; Nauman A. Chaudhry, MD
[+] Author Affiliations

From the Retina Vitreous Center, Department of Ophthalmology, University of Medicine and Dentistry of New Jersey (Drs Roth, Spirn, Green, and Yarian and Ms Chieh), New Brunswick; and New England Retina Associates (Dr Chaudhry), New London, Conn. The authors have no relevant financial interest in this article.


Arch Ophthalmol. 2003;121(9):1279-1282. doi:10.1001/archopht.121.9.1279.
Text Size: A A A
Published online

Background  Intravitreal injection of triamcinolone has been advocated to treat exudative macular diseases such as macular edema and choroidal neovascularization.

Objective  To describe 7 patients who developed a clinical picture simulating endophthalmitis after intravitreal triamcinolone injection.

Methods  Intravitreal triamcinolone injections were performed to treat refractory cystoid macular edema or diffuse macular edema associated with diabetic retinopathy, macular pucker, branch retinal vein occlusion, or pseudophakia. One patient received an injection in an attempt to treat exudation associated with occult choroidal neovascularization.

Results  Preinjection visual acuity ranged from 20/50 to 20/400. An extensive inflammatory response developed 1 to 2 days after injection in all 7 eyes. Five eyes had previously undergone vitrectomy. Four eyes had a layered hypopyon. All 7 eyes had an anterior chamber cellular reaction and vitritis. Visual acuity ranged from 20/400 to hand movements. The first 6 patients were treated for presumed endophthalmitis with vitreous cultures and intravitreal injections of antibiotics. All 6 cultures were negative for any organisms, and the eyes resolved their inflammatory response, with recovery to preinjection visual acuity or better. The seventh patient was treated with topical prednisolone without antibiotic therapy, and the inflammation resolved, with resolution of the macular edema seen before the intravitreal triamcinolone injection.

Conclusion  It may be appropriate to closely observe noninfectious, toxic endophthalmitis in patients treated with intravitreal triamcinolone before assuming it to be infectious, especially in the absence of eye pain.

CYSTOID MACULAR edema (CME) is a common cause of compromised central vision and is associated with numerous coexisting conditions.14 Initial treatment depends on the underlying cause and includes topical or periocular corticosteroids and nonsteroidal anti-inflammatory medications.5 In cases associated with diabetic macular edema and vascular occlusions, focal laser treatment is often indicated.6,7 In cases of an associated macular pucker or vitreomacular traction, vitrectomy with membrane peeling is necessary.8

However, despite using the previously mentioned therapeutic modalities, many patients have persistent CME. Corticosteroids inhibit prostaglandin and leukotriene synthesis, thereby inducing an anti-inflammatory effect.9 Furthermore, corticosteroids reverse capillary permeability, stabilizing blood vessels and the blood-retinal barrier.1012 Intravitreal triamcinolone acetonide has recently been shown to be nontoxic to the human retina and well tolerated, 13,14 and it has been advocated recently as treatment for refractory CME.1518 Intravitreal triamcinolone is also a potential therapy for choroidal neovascularization associated with age-related macular degeneration, as it decreases capillary permeability and reduces subretinal fluid exudation.1922

As with any therapeutic modality, the benefits must be weighed against the risks. The most common risks associated with intraocular corticosteroid therapy are elevation of intraocular pressure and progression of cataract.23 The risk of endophthalmitis exists with any intraocular injection or penetration. We describe 7 patients who developed a clinical picture simulating endophthalmitis after intravitreal triamcinolone injection that we believe represents a toxic reaction to the material injected.

Intravitreal triamcinolone acetonide (Kenalog; Bristol-Myers Squibb, Princeton, NJ) injection for the treatment of refractory CME or occult choroidal neovascularization has been used as a treatment modality by us since May 2001. The risks and benefits of the procedure were discussed with and written informed consent was obtained from each patient before injection. The eye was prepared with povidone-iodine (Betadine; Purdue Frederick Co, Norwalk, Conn) (5% or 10%) solution and ciprofloxacin hydrochloride (Ciloxan; Alcon Inc, Ft Worth, Tex) drops to obtain sterile conditions. A sterile wire lid speculum was placed in the eye, and sterile topical or subconjunctival lidocaine hydrochloride was used to anesthetize the inferotemporal quadrant of the eye to be injected.

The triamcinolone was injected inferotemporally through the pars plana using a 30-gauge needle on a 1-mL syringe. In 4 eyes, 1 mg of drug was injected from a new, sterile bottle of triamcinolone acetonide, 10 mg/mL, in a volume of 0.1 mL. In 3 eyes, 4 mg of drug was injected from a new, sterile bottle of triamcinolone acetonide, 40 mg/mL, in a volume of 0.1 mL. The suspension was shaken vigorously before drawing it into the syringe to ensure the correct concentration. The supernatant was not removed, and the drug was not resuspended in other diluent. Patients were instructed to instill ciprofloxacin drops for 2 days after injection, and they returned for a follow-up examination either 1 or 2 days after the procedure.

Between May 1, 2001, and June 30, 2002, we performed 104 intravitreal injections to treat cystoid or diffuse diabetic macular edema that did not respond to focal laser photocoagulation; CME associated with retinal vein occlusions, pseudophakia, or preretinal gliosis; and choroidal neovascularization. We encountered 7 cases of atypical inflammation simulating endophthalmitis after triamcinolone injection, all occurring between January 16, 2002, and February 19, 2002.

Four women and 3 men were identified as having a clinical picture simulating endophthalmitis after intravitreal triamcinolone injection (mean age, 67 years; range, 37-84 years). All 7 eyes had previously undergone intraocular surgery. Five eyes were pseudophakic, and 5 eyes had previously undergone vitrectomy(Table 1). Intravitreal triamcinolone injections were performed to treat cystoid or diffuse diabetic macular edema that did not respond to focal laser photocoagulation in 3 eyes, CME associated with a mild macular pucker or with a branch retinal vein occlusion in 1 eye each, pseudophakic CME after a secondary anterior chamber intraocular lens in 1 eye, and exudation associated with choroidal neovascularization in 1 eye.

The dose of triamcinolone injected was either 1 or 4 mg. In patients with their first injection for treatment of CME, 1 mg was typically administered. For patients with an incomplete response to a previous injection or recurrent macular edema after an excellent response to a previous injection, 4 mg was injected. For patients with choroidal neovascularization, 4 mg was administered. Patient 7 is an exception in that he received a 4-mg injection for diabetic CME without any previous intraocular corticosteroid treatment.

Preinjection visual acuity ranged from 20/50 to 20/400. All 7 eyes had acute, painless loss of vision on the first visit after intravitreal injection. Visual acuity after injection ranged from 20/400 to hand movements. Three patients were examined 1 day after injection, and the other 4 were seen 2 days after injection. An extensive inflammatory response was observed in all 7 patients, with anterior chamber cell and flare and posterior segment vitritis(Table 2). The response was distinct from triamcinolone suspension particles. In the 4 eyes with hypopyon, the collection in the angle was distinguished from triamcinolone suspension particles, even in pseudophakic eyes, by its appearance and slightly yellow color. The vitritis obscured the fundus details in all 7 eyes; however, in 4 eyes, the inflammation was so extensive that B-scan ultrasonography was necessary to evaluate the retina, as only the red reflex was visible. B-scan ultrasonography in these cases revealed dense vitritis without retinal detachment.

The first 6 patients were treated for presumed infectious endophthalmitis; they underwent vitreous culture and injection of intraocular antibiotics. Each of these 6 eyes received 1 mg of vancomycin hydrochloride and 2 mg of ceftazidime by intravitreal injection through the pars plana. Four of the vitreous samples were obtained using a vitreous cutter and 2 were obtained via needle aspiration. All vitreous cultures had adequate samples and were plated on blood, chocolate, and Sabouraud agar and on thioglycolate broth. Initial gram stains were not performed routinely. None of the samples were positive for any organisms on these media, and all were thought to be sterile. Owing to a concern that the vials of triamcinolone carried infectious organisms, 3 of the bottles used for injection were cultured. One culture was positive for a presumed contaminant colony of Staphylococcus aureus on blood and chocolate agar, and the other 2 were negative. The lot numbers of the triamcinolone vials used for intravitreal injection were recorded, and samples of each lot number were sent for routine culture; all were negative for any organisms.

Patient 7 had a similar clinical picture of endophthalmitis but was observed closely and was treated with topical prednisolone acetate without topical, intraocular, or systemic antibiotic therapy. The inflammation improved in the initial 2 days and resolved completely during the ensuing 3 weeks, with disappearance of all vitritis and absence of the preexisting macular edema. Visual acuity improved from 20/200 before triamcinolone injection to 20/70 afterward.

In the other 5 eyes with macular edema (patients 1-5), the CME resolved completely in 3 and was reduced on fluorescein angiography in the other 2, despite developing endophthalmitis and undergoing further intervention. The patient with choroidal neovascularization associated with age-related macular degeneration was later enrolled in a clinical trial that involved intravitreal injections of an inhibitor of vascular endothelial growth factor. She mounted a similar inflammatory response to this injection, but her inflammation resolved without sequelae and her visual acuity improved from an initial baseline value of 20/200 to 20/60, with a substantial decrease in subretinal fluid exudation.

Intravitreal triamcinolone injections have been associated with reductions in capillary permeability and resolution of macular edema in patients with CME with multiple causes.1518 Patients with choroidal neovascularization may benefit from intraocular corticosteroid therapy owing to the reduction in subretinal fluid exudation and from the bacteriostatic effect of triamcinolone.2426 However, any invasive intervention has risks. The most common adverse effects of intravitreal triamcinolone injection are a transient elevation in intraocular pressure and potential worsening of a cataract.23 Although endophthalmitis is an obvious potential adverse effect of intraocular injections, it is extremely rare when appropriate sterile technique is practiced. In our review of 104 cases of intravitreal triamcinolone injection, we found 7 cases of endophthalmitis clustered between January 16, 2002, and February 19, 2002. We believe that these cases represent noninfectious endophthalmitis—probably a toxic reaction to the drug, the vehicle in which it is suspended, or a contaminant in the vials involved in this series.

The basis of this assumption derives from multiple facts. (1) All 6 cases that were cultured failed to reveal organisms, and the 1 eye that was observed resolved spontaneously without antibiotic therapy. No cases of culture-positive endophthalmitis have been seen since we began using this therapeutic modality.(2) All 7 cases presented acutely without pain, whereas infectious endophthalmitis typically manifests acutely or subacutely with pain. (3) All 7 patients rapidly recovered to their preinjection levels of visual acuity, typically within days of developing endophthalmitis, suggesting a toxic reaction to the dose of injected material. Most of the patients even recovered to better visual acuity owing to resolution of the macular edema.

All 7 patients experienced severe inflammation within 2 days of intravitreal injection. If a patient develops new symptoms more than several days after injection, infectious endophthalmitis should be presumed and immediate therapy should be initiated.

Many patients in this series were pseudophakic or had previously undergone vitrectomy (n = 5 [71%] for both). It is possible that in eyes that have not undergone vitrectomy, the drug remains more sequestered in the vitreous cavity, diffusing more slowly to the intraocular structures. In eyes that have undergone vitrectomy, the drug has direct access to the ocular coats, allowing any toxic agent to more readily induce a brisk immune response. Similarly, in patients with pseudophakia, the relative unicameral nature of the eye may allow for a more robust immune response.

Furthermore, many patients developed endophthalmitis after receiving a second injection of triamcinolone (n = 4 [57%]). It is possible that the eye is more likely to mount an immune response when receiving a second injection, especially if less than 6 weeks has elapsed since the previous injection.

We did not pinpoint a specific lot number or type of triamcinolone packaging(10 mg/mL, 1-mL vials; 40 mg/mL, 5-mL vials; or 40 mg/mL, 1-mL vials) that was more suspect because these endophthalmitis cases represent varied lot numbers and were administered from all 3 types of newly opened triamcinolone vials. The clustering of cases in a 5-week period raises the suspicion that some toxin existed in the vial that prompted susceptible patients to mount an inflammatory reaction. No modification of the intravitreal injection technique was noted during this period that could explain the incidence of severe inflammation or endophthalmitis. After these cases were noted, we returned all our held stock of triamcinolone to the manufacturer in exchange for new vials, and we have not encountered any other cases of endophthalmitis.

Infectious endophthalmitis can occur after intravitreal triamcinolone injection, with potentially devastating adverse effects, and it is possible that intraocular corticosteroid use blunts the usual ability of the eye to eradicate infectious organisms. However, we believe that in select eyes injected with triamcinolone under sterile conditions, the differential diagnosis includes a sterile, toxic endophthalmitis that may be appropriate to observe closely, perhaps every 8 to 12 hours, to determine whether the inflammation is worsening or improving. Some patients who do not require further surgery can avoid unnecessary intervention and clear their inflammation spontaneously.

Corresponding author: Daniel B. Roth, MD, Retina Vitreous Center, Department of Ophthalmology, University of Medicine and Dentistry of New Jersey, 125 Paterson St, CAB–Fourth Floor, New Brunswick, NJ 08901 (e-mail: rothretina@aol.com).

Submitted for publication August 29, 2002; final revision received April 10, 2003; accepted April 17, 2003.

Ting  TDOh  MCox  TAMeyer  CHToth  CA Decreased visual acuity associated with cystoid macular edema in neovascular age-related macular degeneration. Arch Ophthalmol. 2002;120731- 737
PubMed Link to Article
Freeman  GMatos  KPavesio  CE Cystoid macular oedema in uveitis: an unsolved problem. Eye. 2001;1512- 17
PubMed Link to Article
Smith  SC Nonproliferative diabetic retinopathy and macular edema. Insight. 1999;2459- 62
PubMed
Harbour  JWSmiddy  WERubsamen  PE  et al.  Pars plana vitrectomy for chronic pseudophakic cystoid macular edema. Am J Ophthalmol. 1995;120302- 307
PubMed
Heier  JSTopping  TMBaumann  WDirks  MSChern  S Ketorolac versus prednisolone versus combination therapy in the treatment of acute pseudophakic cystoid macular edema. Ophthalmology. 2000;1072034- 2038
PubMed Link to Article
Early Treatment Diabetic Retinopathy Study Research Group, Early photocoagulation for diabetic retinopathy: ETDRS report number 9. Ophthalmology. 1991;98766- 785
PubMed Link to Article
Clarkson  JG Photocoagulation for ischemic central retinal vein occlusion: Central Vein Occlusion Study. Arch Ophthalmol. 1991;1091218- 1219
PubMed Link to Article
Ito  YTerasaki  HMori  M  et al.  Three-dimensional optical coherence tomography of vitreomacular traction syndrome before and after vitrectomy. Retina. 2000;20403- 405
PubMed Link to Article
Hood  PPCotter  TPCostello  JFSampson  AP Effect of intravenous corticosteroid on ex vivo leukotriene generation by blood leucocytes of normal and asthmatic patients. Thorax. 1999;541075- 1082
PubMed Link to Article
Wilson  CABerkowitz  BASato  Y  et al.  Treatment with intravitreal steroid reduces blood-retinal barrier breakdown due to retinal photocoagulation. Arch Ophthalmol. 1992;1101155- 1159
PubMed Link to Article
Osaki  NKBehany  KDNishihara  KC  et al.  Regulation of retinal vascular endothelial growth factor and receptors in rabbits exposed to hyperoxia. Invest Ophthalmol Vis Sci. 2002;431546- 1557
PubMed
Funatsu  HYamashita  HNoma  H  et al.  Increased levels of vascular endothelial growth factor and interleukin-6 in the aqueous humor of diabetics with macular edema. Am J Ophthalmol. 2002;13370- 77
PubMed Link to Article
McCuen  BWBessler  MTano  YChandler  DMachemer  R The lack of toxicity of intravitreally administered triamcinolone acetonide. Am J Ophthalmol. 1981;91785- 788
PubMed
Young  SLarkin  GBranley  MLightman  S Safety and efficacy of intravitreal triamcinolone for cystoid macular oedema in uveitis. Clin Experiment Ophthalmol. 2001;292- 6
PubMed Link to Article
Greenberg  PBMartidis  ARogers  AHDuker  JSReichel  E Intravitreal triamcinolone acetonide for macular oedema due to central retinal vein occlusion. Br J Ophthalmol. 2002;86247- 248
PubMed Link to Article
Martidis  ADuker  JSPuliafito  CA Intravitreal triamcinolone for refractory cystoid macular edema secondary to birdshot retinochoroidopathy. Arch Ophthalmol. 2001;1191380- 1383
PubMed
Antcliff  RJSpalton  DJStanford  MR  et al.  Intravitreal triamcinolone for uveitic cystoid macular edema: an optical coherence tomography study. Ophthalmology. 2001;108765- 772
PubMed Link to Article
Martidis  ADuker  JSGreenberg  PB  et al.  Intravitreal triamcinolone for refractory diabetic macular edema. Ophthalmology. 2002;109920- 927
PubMed Link to Article
Challa  JKGillies  MCPenfold  PL  et al.  Exudative macular degeneration and intravitreal triamcinolone: 18 month follow up. Aust N Z J Ophthalmol. 1998;26277- 281
PubMed Link to Article
Penfold  PLWen  LMadigan  MC  et al.  Triamcinolone acetonide modulates permeability and intercellular adhesion molecule-1 (ICAM-1) expression of the ECV304 cell line: implications for macular degeneration. Clin Exp Immunol. 2000;121458- 465
PubMed Link to Article
Penfold  PL Intravitreal triamcinolone in recurrence of choroidal neovascularisation. Br J Ophthalmol. 2002;86600- 601
PubMed Link to Article
Ranson  NTDanis  RPCiulla  TAPratt  L Intravitreal triamcinolone in subfoveal recurrence of choroidal neovascularisation after laser treatment in macular degeneration. Br J Ophthalmol. 2002;86527- 529
PubMed Link to Article
Wingate  RJBeaumont  PE Intravitreal triamcinolone and elevated intraocular pressure. Aust N Z J Ophthalmol. 1999;27431- 432
PubMed Link to Article
Wang  YSFriedrichs  UEichler  WHoffmann  SWiedemann  P Inhibitory effects of triamcinolone acetonide on b FGF-induced migration and tube formation in choroidal microvascular endothelial cells. Graefes Arch Clin Exp Ophthalmol. 2002;24042- 48
PubMed Link to Article
Penfold  PLWong  JGGyory  JBillson  FA Effects of triamcinolone acetonide on microglial morphology and quantitative expression of MHC-II in exudative age-related macular degeneration. Clin Experiment Ophthalmol. 2001;29188- 192
PubMed Link to Article
Ciulla  TACriswell  MHDanis  RPHill  TE Intravitreal triamcinolone acetonide inhibits choroidal neovascularization in a laser-treated rat model. Arch Ophthalmol. 2001;119399- 404
PubMed Link to Article

Figures

References

Ting  TDOh  MCox  TAMeyer  CHToth  CA Decreased visual acuity associated with cystoid macular edema in neovascular age-related macular degeneration. Arch Ophthalmol. 2002;120731- 737
PubMed Link to Article
Freeman  GMatos  KPavesio  CE Cystoid macular oedema in uveitis: an unsolved problem. Eye. 2001;1512- 17
PubMed Link to Article
Smith  SC Nonproliferative diabetic retinopathy and macular edema. Insight. 1999;2459- 62
PubMed
Harbour  JWSmiddy  WERubsamen  PE  et al.  Pars plana vitrectomy for chronic pseudophakic cystoid macular edema. Am J Ophthalmol. 1995;120302- 307
PubMed
Heier  JSTopping  TMBaumann  WDirks  MSChern  S Ketorolac versus prednisolone versus combination therapy in the treatment of acute pseudophakic cystoid macular edema. Ophthalmology. 2000;1072034- 2038
PubMed Link to Article
Early Treatment Diabetic Retinopathy Study Research Group, Early photocoagulation for diabetic retinopathy: ETDRS report number 9. Ophthalmology. 1991;98766- 785
PubMed Link to Article
Clarkson  JG Photocoagulation for ischemic central retinal vein occlusion: Central Vein Occlusion Study. Arch Ophthalmol. 1991;1091218- 1219
PubMed Link to Article
Ito  YTerasaki  HMori  M  et al.  Three-dimensional optical coherence tomography of vitreomacular traction syndrome before and after vitrectomy. Retina. 2000;20403- 405
PubMed Link to Article
Hood  PPCotter  TPCostello  JFSampson  AP Effect of intravenous corticosteroid on ex vivo leukotriene generation by blood leucocytes of normal and asthmatic patients. Thorax. 1999;541075- 1082
PubMed Link to Article
Wilson  CABerkowitz  BASato  Y  et al.  Treatment with intravitreal steroid reduces blood-retinal barrier breakdown due to retinal photocoagulation. Arch Ophthalmol. 1992;1101155- 1159
PubMed Link to Article
Osaki  NKBehany  KDNishihara  KC  et al.  Regulation of retinal vascular endothelial growth factor and receptors in rabbits exposed to hyperoxia. Invest Ophthalmol Vis Sci. 2002;431546- 1557
PubMed
Funatsu  HYamashita  HNoma  H  et al.  Increased levels of vascular endothelial growth factor and interleukin-6 in the aqueous humor of diabetics with macular edema. Am J Ophthalmol. 2002;13370- 77
PubMed Link to Article
McCuen  BWBessler  MTano  YChandler  DMachemer  R The lack of toxicity of intravitreally administered triamcinolone acetonide. Am J Ophthalmol. 1981;91785- 788
PubMed
Young  SLarkin  GBranley  MLightman  S Safety and efficacy of intravitreal triamcinolone for cystoid macular oedema in uveitis. Clin Experiment Ophthalmol. 2001;292- 6
PubMed Link to Article
Greenberg  PBMartidis  ARogers  AHDuker  JSReichel  E Intravitreal triamcinolone acetonide for macular oedema due to central retinal vein occlusion. Br J Ophthalmol. 2002;86247- 248
PubMed Link to Article
Martidis  ADuker  JSPuliafito  CA Intravitreal triamcinolone for refractory cystoid macular edema secondary to birdshot retinochoroidopathy. Arch Ophthalmol. 2001;1191380- 1383
PubMed
Antcliff  RJSpalton  DJStanford  MR  et al.  Intravitreal triamcinolone for uveitic cystoid macular edema: an optical coherence tomography study. Ophthalmology. 2001;108765- 772
PubMed Link to Article
Martidis  ADuker  JSGreenberg  PB  et al.  Intravitreal triamcinolone for refractory diabetic macular edema. Ophthalmology. 2002;109920- 927
PubMed Link to Article
Challa  JKGillies  MCPenfold  PL  et al.  Exudative macular degeneration and intravitreal triamcinolone: 18 month follow up. Aust N Z J Ophthalmol. 1998;26277- 281
PubMed Link to Article
Penfold  PLWen  LMadigan  MC  et al.  Triamcinolone acetonide modulates permeability and intercellular adhesion molecule-1 (ICAM-1) expression of the ECV304 cell line: implications for macular degeneration. Clin Exp Immunol. 2000;121458- 465
PubMed Link to Article
Penfold  PL Intravitreal triamcinolone in recurrence of choroidal neovascularisation. Br J Ophthalmol. 2002;86600- 601
PubMed Link to Article
Ranson  NTDanis  RPCiulla  TAPratt  L Intravitreal triamcinolone in subfoveal recurrence of choroidal neovascularisation after laser treatment in macular degeneration. Br J Ophthalmol. 2002;86527- 529
PubMed Link to Article
Wingate  RJBeaumont  PE Intravitreal triamcinolone and elevated intraocular pressure. Aust N Z J Ophthalmol. 1999;27431- 432
PubMed Link to Article
Wang  YSFriedrichs  UEichler  WHoffmann  SWiedemann  P Inhibitory effects of triamcinolone acetonide on b FGF-induced migration and tube formation in choroidal microvascular endothelial cells. Graefes Arch Clin Exp Ophthalmol. 2002;24042- 48
PubMed Link to Article
Penfold  PLWong  JGGyory  JBillson  FA Effects of triamcinolone acetonide on microglial morphology and quantitative expression of MHC-II in exudative age-related macular degeneration. Clin Experiment Ophthalmol. 2001;29188- 192
PubMed Link to Article
Ciulla  TACriswell  MHDanis  RPHill  TE Intravitreal triamcinolone acetonide inhibits choroidal neovascularization in a laser-treated rat model. Arch Ophthalmol. 2001;119399- 404
PubMed Link to Article

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