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Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 35-37

Importance of careful clinical examination and multimodal imaging before injecting intravitreal steroid


Department of Vitreo-Retinal Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Madurai, Tamil Nadu, India

Date of Submission03-Dec-2019
Date of Decision06-Oct-2020
Date of Acceptance30-Aug-2021
Date of Web Publication3-Feb-2022

Correspondence Address:
Piyush Kohli
Department of Vitreo-Retinal Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Madurai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_102_19

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  Abstract 


Intravitreal injections have now become the most preferred treatment for retinal vascular diseases. Intravitreal steroids are associated with complications such as cataracts, glaucoma, and central serous chorioretinopathy (CSCR). We report a case who developed CSCR after a single injection of intravitreal triamcinolone, given for the treatment of cystoid macular edema (CME) secondary to branch retinal venous occlusion (BRVO). On careful retrospective examination, we found that pachychoroid and a pigment epithelial detachment was present even before the injection was given. Four months postinjection, there was a recurrence of CME due to BRVO while there was no sign of CSCR. We emphasize on the importance of a careful clinical examination and appropriate interpretation of multimodal imaging before injecting intravitreal steroids.

Keywords: Central serous chorioretinopathy, intravitreal triamcinolone acetonide, mineralocorticoid-receptor, pigment epithelial detachment, toxicity


How to cite this article:
Babu N, Kohli P, Shah V, Ramasamy K. Importance of careful clinical examination and multimodal imaging before injecting intravitreal steroid. J Clin Ophthalmol Res 2022;10:35-7

How to cite this URL:
Babu N, Kohli P, Shah V, Ramasamy K. Importance of careful clinical examination and multimodal imaging before injecting intravitreal steroid. J Clin Ophthalmol Res [serial online] 2022 [cited 2022 May 29];10:35-7. Available from: https://www.jcor.in/text.asp?2022/10/1/35/337185



Intravitreal injections have now become the most preferred treatment for retinal vascular diseases.[1] Intravitreal steroids are preferred over antivascular endothelial growth factors injections in certain conditions such as retinal venous occlusions associated with serous retinal detachment (SRD).[2],[3],[4] However, intravitreal steroids are associated with complications such as cataracts, glaucoma, and central serous chorioretinopathy (CSCR).[5],[6]

We highlight the importance of careful clinical examination and multimodal imaging before injecting intravitreal steroid with the help of a case who developed sequential CSCR after a single dose of intravitreal triamcinolone acetonide (IVTA), given for the treatment of cystoid macular edema (CME) secondary to branch retinal venous occlusion (BRVO).


  Case Report Top


A 53-year-old hypertensive male presented with left eye sudden painless decreased vision. His best-corrected visual acuity (BCVA) was 20/40 in the right eye and 20/80 in the left eye. Anterior segment examination was unremarkable in both eyes. The posterior segment showed mild nonproliferative diabetic retinopathy with CME in the right eye and inferotemporal BRVO with CME in the left eye [Figure 1]a. Left eye optical coherence tomography (OCT) showed subfoveal SRD and CME [Figure 2]a. His sugar levels, renal parameters, and lipid profile were normal.
Figure 1: (a) Colored fundus photograph of the left eye 1-month postinjection showing inferotemporal branch retinal venous occlusion; (b-d) fundus fluorescein angiography images (b) 1-month postinjection showing pigment epithelial detachment temporal to fovea, (c) 1-month postinjection showing ink-blot leak temporal to the pigment epithelial detachment; (d) 3-month postinjection showing that pigment epithelial detachment is present while the ink-blot leak disappeared

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Figure 2: Optical coherence tomography of the left eye (a) at presentation showing subfoveal serous retinal detachment and cystoid macular edema due to branch retinal venous occlusion; (b) at 1-month, subfoveal serous retinal detachment and cystoid macular edema due to branch retinal venous occlusion have resolved, while central serous chorioretinopathy has appeared temporal to macula; (c) at presentation (initially missed), pigment epithelial detachment temporal to macula, atrophic choriocapillaris, and dilated choroidal vessels; (d) at 4-month postinjection, a recurrence of serous retinal detachment and cystoid macular edema due to branch retinal venous occlusion, with no sign of central serous chorioretinopathy

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IVTA (4 mg/0.1 ml, Aurocort, Aurolab, India) was injected into his left eye. One-month postinjection, his BCVA improved to 20/20. OCT showed that the subfoveal SRD and CME had resolved, however, another asymptomatic neurosensory detachment (NSD) appeared temporal to the macula [Figure 2]b. Fundus fluorescein angiography (FFA) showed a pigment epithelial detachment (PED) and an ink-blot leak of one and three disc-diameter temporal to fovea, respectively [Figure 1]b and [Figure 1]c. Furthermore, the intraocular pressure (IOP) increased to 28 mmHg.

On careful retrospective examination, we found that this PED was present in the preinjection OCT also but was initially missed [Figure 2]c. The PED was associated with dilated large choroidal vessels and atrophic choriocapillaris. Right eye OCT showed pachychoroid and small PEDs. The ink-blot leak was lasered and the advised to use a combination of two topical antiglaucoma medications, timolol maleate 0.5% and briminonidine tartrate 0.2%.

Three-month postinjection, he maintained a BCVA of 20/20. OCT showed a decrease in NSD due to CSCR, while there was no recurrence of CME due to BRVO. FFA showed the presence of the PED temporal to the fovea, while the ink-blot leak closed [Figure 1]d. The IOP remained well controlled with the drops throughout the follow-up. The medications were stopped after 3 months.

Four months postinjection, his BCVA again decreased to 20/40. OCT showed a recurrence of subfoveal SRD and CME due to BRVO, while there was no sign of CSCR [Figure 2]d. Fortunately, another IOP rise was not noted after stopping the antiglaucoma medications.


  Discussion Top


CSCR is one of the pachychoroid spectra of diseases.[6] The pathophysiology underlying CSCR remains poorly understood. It has been proposed that the elevated tissue hydrostatic pressure due to hyperpermeable pachychoroid leads to the development of PED if the retinal pigment epithelium (RPE) can overcome the fluid overload and CSR if the RPE is unable to overcome the pressure overload.[6],[7],[8] In our patient, PED and pachychoroid were already present and the administration of IVTA may have decompensated the PED into CSCR. This may be either due to a further increase in choroid hydrostatic pressure via mineralocorticoid-receptor or RPE cell cytotoxicity.[6],[7],[8],[9]

Development of CSCR after intravitreal steroids has been reported previously. Kocabora et al. reported exacerbation of CSCR following IVTA injection given for the treatment of CME secondary to BRVO.[10] Imasawa et al. reported the development of CSCR 10 days after vitrectomy for proliferative diabetic retinopathy.[11] Ersoz et al. reported the sequential development of pachychoroid pigment epitheliopathy and CSCR in one eye after five bilateral intravitreal dexamethasone implants given for diabetic macular edema.[12] Georgalas et al. reported the development of CSCR in the contralateral eye after two dexamethasone implants given for the treatment of Irvine-Gass syndrome.[13]

We present a unique case where a patient with preexisting pachychoroid and PED developed CSCR after a single dose of IVTA. It is evident that CSCR developed in the region of preexisting PED. As the use of intravitreal steroids is increasing, especially the dexamethasone implant, we emphasize on the importance of a careful clinical examination and appropriate interpretation of multimodal imaging before injecting them.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Falavarjani KG, Nguyen QD. Adverse events and complications associated with intravitreal injection of anti-VEGF agents: A review of literature. Eye (Lond) 2013;27:787-94.  Back to cited text no. 1
    
2.
Kaldırım HE, Yazgan SA. Comparison of three different intravitreal treatment modalities of macular edema due to branch retinal vein occlusion. Int Ophthalmol 2018;38:1549-58.  Back to cited text no. 2
    
3.
Tsujikawa A, Sakamoto A, Ota M, Kotera Y, Oh H, Miyamoto K, et al. Serous retinal detachment associated with retinal vein occlusion. Am J Ophthalmol 2010;149:291-301.e5.  Back to cited text no. 3
    
4.
Noma H, Funatsu H, Mimura T, Shimada K. Comparison of the efficacy of intravitreal triamcinolone acetonide for cystoid macular edema with versus without serous retinal detachment in branch retinal vein occlusion: Influence on macular sensitivity and morphology. BMC Ophthalmol 2012;12:39.  Back to cited text no. 4
    
5.
Scott IU, VanVeldhuisen PC, Oden NL, Ip MS, Blodi BA, Hartnett ME, et al. Baseline predictors of visual acuity and retinal thickness outcomes in patients with retinal vein occlusion: Standard Care Versus COrticosteroid for REtinal Vein Occlusion Study report 10. Ophthalmology 2011;118:345-52.  Back to cited text no. 5
    
6.
Nicholson B, Noble J, Forooghian F, Meyerle C. Central serous chorioretinopathy: Update on pathophysiology and treatment. Surv Ophthalmol 2013;58:103-26.  Back to cited text no. 6
    
7.
Daruich A, Matet A, Dirani A, Bousquet E, Zhao M, Farman N, et al. Central serous chorioretinopathy: Recent findings and new physiopathology hypothesis. Prog Retin Eye Res 2015;48:82-118.  Back to cited text no. 7
    
8.
Manayath GJ, Shah VS, Saravanan VR, Narendran V. Polypoidal choroidal vasculopathy associated with central serous chorioretinopathy: Pachychoroid spectrum of diseases. Retina 2018;38:1195-204.  Back to cited text no. 8
    
9.
Narayanan R, Mungcal JK, Kenney MC, Seigel GM, Kuppermann BD. Toxicity of triamcinolone acetonide on retinal neurosensory and pigment epithelial cells. Invest Ophthalmol Vis Sci 2006;47:722-8.  Back to cited text no. 9
    
10.
Kocabora MS, Durmaz S, Kandemir N. Exacerbation of central serous chorioretinopathy following intravitreal triamcinolone injection. Graefes Arch Clin Exp Ophthalmol 2008;246:1783-6.  Back to cited text no. 10
    
11.
Imasawa M, Ohshiro T, Gotoh T, Imai M, Iijima H. Central serous chorioretinopathy following vitrectomy with intravitreal triamcinolone acetonide for diabetic macular oedema. Acta Ophthalmol Scand 2005;83:132-3.  Back to cited text no. 11
    
12.
Ersoz MG, Hocaoglu M, Sayman Muslubas I, Arf S, Karacorlu M. Development of pachychoroid pigment epitheliopathy and transformation to central serous chorioretinopathy after intravitreal dexamethasone implantation. Retin Cases Brief Rep 2021;15:386-90.  Back to cited text no. 12
    
13.
Georgalas I, Petrou P, Pagoulatos D, Papaconstantinou D, Tservakis I. Central serous chorioretinopathy in the fellow eye as a complication of intravitreal dexamethasone implant for the treatment of Irvine-Gass syndrome. Clin Exp Optom 2016;99:601-3.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]



 

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