[Downloaded free from http://www.ijo.in on Wednesday, November 29, 2017, IP: 80.3.157.133] May 2015 Letters to the Editor intraocular lens by injector implantation. Indian J Ophthalmol 2014;62:857‑60. Access this article online Quick Response Code:
Website: www.ijo.in DOI: 10.4103/0301-4738.159905 PMID: ***
Sterile endophthalmitis following intravitreal triamcinolone acetonide in July 2010 Dear Editor, Sterile endophthalmitis is defined as true intraocular inflammation following intravitreal injection of triamcinolone acetonide (IVTA) that cannot be attributed to an infectious process.[1] We report three cases of sterile endophthalmitis that occurred in July 2010. A 49‑year‑old male patient was treated with IVTA for diabetic macular edema (DME) in his left eye. Two days after the injection, the patient complained of ocular discomfort. His vision was 20/400, which was the same as before IVTA. Slit lamp examination showed 1 mm hypopyon in the anterior chamber. B‑scan showed vitreous opacities [Fig. 1]. The vitreous
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culture was performed, followed by intravitreal injection of vancomycin and ceftazidime. The result of vitreous culture was negative. Furthermore, he was treated with oral moxifloxacin and topical prednisolone acetate and moxifloxacin. At 2 weeks after IVTA, the anterior chamber become clear and the hypopyon resolved completely, but the diffuse vitreous haze remained. At 2 months follow‑up, visual acuity (VA) had improved to 20/100. A 57‑year‑old male patient was treated with IVTA for panuveitis in his left eye. At the first visit on day 1 after IVTA, corneal edema, a severe anterior chamber reaction with hypopyon, and conjunctival hyperemia were detected in the left eye. His VA had decreased from 20/200 to 20/400, but the patient denied having ocular pain. Because of the vitreous inflammation, he was treated with oral moxifloxacin and topical prednisolone acetate, and moxifloxacin, but no vitreous sample was obtained. The inflammation was completely resolved in 2 weeks with the improvement of VA to 20/100. A 59‑year‑old male patient was seen for a scheduled examination 1‑day after IVTA in the right eye for treatment of DME. His VA dropped from 20/200 to counting fingers. He denied having any pain. He had a 1 mm area of hypopyon with flare. Fundus examination revealed vitreous opacities. Vitreous culture was promptly performed, followed by intravitreal injection of vancomycin and ceftazidime. In addition, oral moxifloxacin and topical prednisolone acetate, and moxifloxacin were started. The results of the vitreous culture were negative. Hypopyon resolved in 3 days, and after the 1st week, the anterior chamber and vitreous reaction had cleared. Intravitreal injection of triamcinolone acetonide was performed in 10 eyes in July 2010, and sterile endophthalmitis
b
a
Figure 1: Slit-lamp photograph and B-scan ultrasonography of case 1. (a) Slit-lamp photograph revealed hypopyon and conjunctival hyperemia. (b) B-scan ultrasonography showed dense vitreous opacities
Figure 2: Change of vial in summer 2010
Table 1: Characteristics of patients with sterile endophthalmitis Case number
Age (years)
Indication for IVTA
Phakic status
Time to presentation (day)
Culture results
Other past ocular history
Recovery to initial VA
1
49
DME
Phakic
2
Negative
Vitrectomy
Yes
2 3
57 59
Panuveitis DME
Phakic Pseudophakic
1 1
‑ Negative
Repeated IVTA Cataract surgery
Yes Yes
IVTA: Intravitreal injection of triamcinolone acetonide, VA: Visual acuity, DME: Diabetic macular edema
[Downloaded free from http://www.ijo.in on Wednesday, November 29, 2017, IP: 80.3.157.133]
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Indian Journal of Ophthalmology
occurred in three eyes among them. We believe that all three cases represent sterile endophthalmitis that may have resulted from a toxic reaction to the drug or a contaminant in the vials.[2] Actually, the vial of triamcinolone acetonide changed in summer 2010 [Fig. 2]. The presence of an endotoxin might have contributed to the development of sterile endophthalmitis in these patients, but this could not be confirmed. The basis of this assumption derives from several facts: (1) All cases feature acute painless manifestation, whereas infectious endophthalmitis typically presents with pain acutely. (2) The results of vitreous culture were negative, although we performed only in two cases. (3) All patients had a well‑known risk factor for sterile endophthalmitis [Table 1]. In summary, we report three cases of sterile endophthalmitis after changes of triamcinolone acetonide vial in July 2010.
Moosang Kim, Seung‑Young Yu1, Hyung‑Woo Kwak1 Departments of Ophthalmology, Kangwon National University Hospital, Chuncheon, 1Kyung Hee University Hospital, Kyung Hee University, Seoul, Korea Correspondence to: Prof. Seung‑Young Yu, #1 Hoegi‑Dong, Dongdaemun‑gu, Seoul 130‑702, Korea. E‑mail:
[email protected]
References 1. Jager RD, Aiello LP, Patel SC, Cunningham ET Jr. Risks of intravitreous injection: A comprehensive review. Retina 2004;24:676‑98. 2. Roth DB, Chieh J, Spirn MJ, Green SN, Yarian DL, Chaudhry NA. Noninfectious endophthalmitis associated with intravitreal triamcinolone injection. Arch Ophthalmol 2003;121:1279‑82. Access this article online Quick Response Code:
Website: www.ijo.in DOI: 10.4103/0301-4738.159906 PMID: ***
Hypermetropia, accommodative and decompensated/partially accommodative esotropia and esotropic Duane’s retraction syndrome in infants: Words impact understanding Dear Editor, We read with interest the article by Kekunnaya et al.[1] and would like to make certain observations. The purpose, to study partially accommodative esotropia (ET) in esotropic Duane’s retraction syndrome (DRS), is skewed to say the least. Partially accommodative ET is that part which is left after full correction of the accommodative
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component, implying that partially accommodative component and eso DRS could be the same. Authors have not clarified as to how they have segregated the two, thereby congealing the entire study and attendant inferences. Terms hypermetropia and accommodative ET are not synonymous, certain criteria have to be met for the latter. By preoperative data, only cases 1, 3 and 6 fall in accommodative category, only case 1 had vertical rectus transposition (VRT), other two did not. Both cases (2 and 4) that ended up with exotropia (XT) lacked a proven accommodative component, so also case 5 with VRT. Accordingly, it is misleading to use the term partially accommodative ET in such cases as the deviation was ostensibly due to eso DRS. We don’t know how many were refractive/nonrefractive accommodative, high/low AC/A ratio, how many went in for deteriorated/decompensated accommodative ET, were decompensated monofixational esotropes, developed intermittent XT with accommodative component or simply passed from eso DRS to exo DRS due to long variable follow‑up.[1,2] Hypermetropia does not increase with the passage of time, it may only decrease due to the process of emmetropization. It is not clear why, at last follow‑up, accommodative component worsened de novo after VRT surgery in cases 3 and 5. Refraction at last follow‑up and change vis‑a‑vis preoperative values is not known to draw any logical conclusions regarding induced (non) refractive accommodative component. Most patients are 1‑year old, one being just 6 months; ocular deviation, motility cannot be assessed reliably, including the effect of glasses on the deviation. Most patients with DRS achieve alignment and fusion with abnormal head posture (AHP) and develop good binocularity. Moderate AHP in a 1‑year old with fusion does not call for surgical intervention, larger AHP in an older child with symptoms like neck pain/cosmetic blemish may earn it. Operating on DRS without clear indications is not in order as a lot of negative planning is involved. Full muscle VRT with Foster augmentation as an alternative to lateral rectus/medial rectus recessions for eso DRS in 1‑year olds may raise ethical issues. VRT may only add to globe retraction[3] (which was core criterion to diagnose DRS in this study), induce a vertical deviation (case 2), and limit adduction. The study does not address these issues, neither documents improvement in abduction if any. There is absolutely no controversy that correction of refractive errors is a prerequisite before other surgical/ nonsurgical measures are contemplated in treatment of strabismus, neither that ortho DRS may adopt AHP if deviation is induced by other concurrent factors. However, reasons for AHP in DRS are legion. XT after years could be due to diverse factors as stated above, words hypermetropia and accommodative ET have been used interchangeably, partially accommodative ET and ET due to DRS have not been pigeonholed, accordingly inferences drawn lack legitimacy.
Pramod Kumar Pandey, Vishaal Bhambhwani, Shagun Sood, Kartik Rana, Poonam Gupta, Ranjith P C Department of Ophthalmology, Guru Nanak Eye Centre and Maulana Azad Medical College, New Delhi, India
