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Foreign body reaction against
intracameral Triamcinolone:
Clinicopathological case report
Amy L. Wong, MRCSEd;
Hunter K. L. Yuen FRCS;
Christopher K.S. Leung, MD;
Dennis S.C. Lam, MD.
Department of Ophthalmology & Visual Sciences,
The Chinese University of Hong Kong
Introduction
o Triamcinolone acetonide (TA) is a corticosteroid
suspension with potent anti-inflammatory effect.
o Intravitreal TA has been advocated in the treatment
of various conditions including
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refractory macular edemas1-2
choriodal neovascularizations secondary to AMD
pathological myopia3
enhancing visualization of vitreous during vitrectomy4-5 and
ERM peeling operations
o Common adverse effects of intravitreal injection of
TA are
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transient elevated intraocular pressure
cataract progression7
Endophthalmitis is a rare but devastating8-9
Non-infectious endophthalmitis or
pseudoendophthalmitis as a result of toxic reaction1012
o Here, we report a patient who had persistent
pseudohypopyon five weeks after intracameral TA
injection following cataract surgery
Case report
o 72/F; Good past medical health
o Underwent an uneventful phaco + IOL operation of
the right eye in February 2007
o Immediately after the surgery, intracameral injection
of 2 mg triamcinolone (40mg/ml, Kenacort A, BristolMyer, Squibb, Agani, Italy) was given for the control
of postoperative inflammation.
o Post op Day 1:
o On the next day, the TA was noted in the inferior part
of the anterior chamber mimicking a shallow
hypopyon (Fig. 1)
o BCVA: 0.4; IOP: normal; ACQ and no ocular pain
o The patient was managed conservatively with close
observation
Case report
o Post op 4 weeks:
o Pseudohypopyon persisted and anterior segment
optical coherence tomography (Visante OCT, Carl
Zeiss Meditec, Dublin, CA, USA) revealed that the
pseudohypopyon covered 3 clock hours inferiorly
and measured 0.78 mm in height (Fig. 2)
o A similar finding was noted one week later and there
was no change in the extension and height of this
pseudohypopyon
o The anterior chamber washout was performed
because of the persistent of pseudohypopyon
o Intraoperatively, the pseudohypopyon was found to
be a soft mass like lesion instead of liquid
o The patient had an uneventful recovery thereafter
o BCVA: 0.7; IOP: normal; ACQ
Histopathological analysis
o Numerous birefrigence particles consistent
with TA crystals were identified when the
pseudohypopyon was examined under
polarized light (Fig. 3A)
o Microscopic examination disclosed
numerous histiocytes with numerous clear
dropout spaces of different sizes
o These dropout spaces were presumably
caused by removal of TA crystals during
processing (Fig. 3B)
o The histiocytes were highlighted by CD163
immunstaining (Fig. 3C)
o The overall features were compatible with
foreign body reaction against the injected
TA
Fig. 1 Slit-lamp photo showing a shallow
pseudohypopyon (arrow) located at 5 to 7
o’clock region of right eye.
Fig. 2 ASOCT showing hyperreflective signal
with vertical height of 0.78mm at inferior
anterior chamber angle of right eye 4 weeks after
intracameral triamcinolone injection.
Fig. 3 Histopathology of the ‘pseudohypopyon’. (A)
Multiple birefrigence particles compatible with
triamcinolone crystals (polarized light x 40). (B)
The pseudohypopyon is composed of histiocytes
with numerous clear dropout spaces of different
sizes and brownish iris pigment ( H&E, x 400). (C)
The histiocytes are confirmed by CD163
immunostaining (x 400).
Discussion
o Non infectious endophthalmitis or pseudoendophthalmitis is a
condition that mimics infectious endophthalmits and can post
a diagnostic challenge10. It was postulated that
pseudoendophthalmitis was probably an inflammatory
reaction to some substances in the formulation of TA.
o We have, for the first time, demonstrated by histopathology
that intracameral triamcinolone usage can cause foreign
reaction and pseudohypopyon formation in human eye. The
presence of histiocytes surrounding the TA molecules in our
specimen indicated that the intracamerally injected unfiltered
Kenacort could have induced foreign body reaction.
o Theorectically, triamcinolone will suppress inflammation and
the exact reason for the development of foreign body reaction
is unknown. We postulate that such inflammatory response
could be a non infectious reaction to the drug or its vehicle.
Discussion
o To differentiate infectious from noninfectious
endophthalmitis, clinicians should closely
monitor the clinical symptoms and signs,
like eye pain, visual acuity, intraocular
pressure, progression of anterior chamber
reaction and the level of hypopyon
o Anterior segment optical coherence
tomography is also useful in monitoring the
progression of hypopyon as demonstrated
o This can objectively monitor the level,
location and extension of the hypopyon in a
non invasive, non contact manner with high
resolution, cross sectional images of the
anterior segment (18um).
Conclusion
o Intracameral injection of TA
could trigger foreign body
reaction in a healthy human eye
o Using a preservative free
formulation or filtered suspension
for injection could be considered
as an alternative for intraocular
injection in order to prevent the
unwanted inflammatory
response.
References
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