Evaluation of Sub-Tenon Triamcinolone Acetonide Injections in the Treatment of Scleritis
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Evaluation of Sub-Tenon Triamcinolone Acetonide
Injections in the Treatment of Scleritis
KEEGAN S. JOHNSON AND DAVID S. CHU
● PURPOSE: To suggest that sub-Tenon triamcinolone The management of scleritis presents a challenge. Because
acetonide (TA) injections may be a helpful supplement in of the severity and depth of the inflammation, topical agents
patients with scleritis. frequently are ineffective. Systemic administration of nonste-
● DESIGN: Retrospective, interventional case series. roidal anti-inflammatory drugs (NSAIDs), corticosteroids,
● METHODS: A retrospective chart review was conducted nonsteroidal immunosuppressive agents, or a combination,
of all patients at our institution receiving sub-Tenon TA is the mainstay of treatment.2 These therapies can have
injections for scleritis between August 2001 and August serious adverse side effects and morbidity. Although re-
2007. Outcome measures included subjective improve- gional steroid injections have been used in the treatment
ment, presence of inflammation, and adverse events. of uveitis, this approach in scleritis generally has been
● RESULTS: Eleven patients (12 eyes) were included in avoided because of concerns about poor efficacy and
this study. The mean age was 50 years; 2 patients were adverse side effects, including scleral perforation or melt,
male and 9 female. Six patients had systemic autoimmune glaucoma, or cataract.5–7 However, a few reports have
disease. All patients were receiving systemic medications challenged this paradigm and have described case series of
for scleritis at the time of injection. Mean initial fol- scleritis patients receiving subconjunctival corticosteroid
low-up time was 3 weeks. Ten of 11 patients reported injections (SCI) with positive responses.8 –11 Local corti-
subjective improvement, and 10 patients had improve- costeroid treatment may be an attractive adjunct to sys-
ment in objective inflammation. Three patients had temic therapy by achieving timely improvement while
adverse side effects, including ocular hypertension, wors- systemic medications begin to take effect. We conducted a
ening of cataract, and subconjunctival hemorrhage with retrospective chart review to review our experience using
periorbital ecchymosis. these injections.
● CONCLUSIONS: Sub-Tenon TA injections may be a
useful adjunct to achieving transient, partial improvement
of subjective pain and objective inflammation in patients
with scleritis while awaiting systemic medications to take METHODS
effect. Adverse events were manageable in this small series. RECORDS WERE REVIEWED FOR ALL PATIENTS WITH SCLERI-
(Am J Ophthalmol 2010;149:77– 81. © 2010 by Elsevier
tis who underwent sub-Tenon corticosteroid injections
Inc. All rights reserved.)
from August 2001 through August 2007 by the principal
investigator at the University of Medicine and Dentistry of
S
CLERITIS IS AN INFLAMMATORY OCULAR CONDITION
New Jersey. We used Current Procedural Terminology
with potentially serious complications. It is charac- (CPT) code 67515 and identified patients with scleritis.
terized by severe pain and deep, destructive granu- Patients with initial follow-up data within 5 weeks after
lomatous inflammation in the sclera.1 Approximately 40% injection were included, because we wanted to observe the
to 50% of patients with scleritis have an associated rapid effects of injections. The indications for sub-Tenon
systemic disorder such as rheumatoid arthritis, Wegener injection included active inflammation despite systemic
granulomatosis, systemic lupus erythematosus, inflammatory treatment with NSAIDs, corticosteroids, other immuno-
bowel disease, or relapsing polychondritis. Rheumatoid ar- suppressant agents, or a combination thereof, and nonne-
thritis is the most commonly associated condition.2,3 The crotizing disease. The risks, benefits, and alternatives of
disease is classified as anterior or posterior; anterior scleritis is injections were explained to all patients before adminis-
further subdivided into diffuse, nodular, and necrotizing tration. Patients underwent a detailed evaluation, includ-
patterns.4 ing systemic and ocular history, slit-lamp examination,
intraocular pressure (IOP), dilated fundus examination,
Accepted for publication Jul 28, 2009. and laboratory tests. All patients received sub-Tenon
From the Department of Ophthalmology, New Jersey Medical
School—University of Medicine and Dentistry of New Jersey, Newark, triamcinolone acetonide (TA) injection (1 mL of a 40
New Jersey. mg/mL suspension). The medication was delivered with
Inquiries to David S. Chu, Department of Ophthalmology, New Jersey 3-mL syringe using a 25-gauge 5/8 –inch needle transcuta-
Medical School—University of Medicine and Dentistry of New Jersey,
Doctors Office Center, 90 Bergen Street, Suite 6100, Newark, NJ 07103; neously into the sub-Tenon space in the inferior temporal
e-mail: chuda@umdnj.edu aspect of the orbit.
0002-9394/10/$36.00 © 2010 BY ELSEVIER INC. ALL RIGHTS RESERVED. 77
doi:10.1016/j.ajo.2009.07.035Outcome measures included subjective data such as mation. At the most recent examination 9 weeks later, he
pain, foreign body sensation, discomfort, or redness, objec- had mild inflammation in both eyes while receiving
tive inflammation observed on slit-lamp examination, prednisone (Deltasone; Pfizer Inc) and methotrexate. Pa-
IOPs, and any adverse side effects. Subjective improve- tient 6 had a history of refractory scleritis and rheumatoid
ment was noted if the patient reported a decrease in arthritis. She experienced a recurrence 21 weeks after
symptoms. Objective improvement was defined as external injection while being treated with methotrexate and pred-
slit-lamp biomicroscopic findings of decreased scleral in- nisone. The methotrexate was changed to adalimumab
flammation on a 4-point grading scale by the principal (Humira; Abbott Laboratories, Parsippany, New Jersey,
investigator. Resolution was defined as the absence of USA) with which she initially achieved quiescence, but
inflammation on examination. ultimately recurrence took place again. Her regimen sub-
sequently was changed to infliximab (Remicade; Horsham,
Pennsylvania, USA), methotrexate, and prednisone, and
RESULTS her disease was quiet on most recent examination approx-
imately 2 years after her initial presentation.
TWELVE EYES FROM 11 PATIENTS WITH NONNECROTIZING Three patients had adverse side effects. In Patient 5,
scleritis were treated with SCI between August 2001 and ocular hypertension and worsening of her posterior sub-
August 2007 and were included in the study (Table). The capsular cataract developed. The maximum IOP across all
mean age at injection was 50 years; 2 patients were male injections of 31 mm Hg was well controlled with topical
and 9 female. One patient had bilateral disease. Six medications, and neither glaucoma nor optic nerve
patients had a concomitant systemic autoimmune disease, changes developed. The topical medications were discon-
including Wegener granulomatosis, rheumatoid arthritis, tinued after 14 months, and her IOPs remained normal.
celiac sprue, and systemic lupus erythematosus. One pa- Visual acuity resulting from the posterior subcapsular
tient was a Wegener granulomatosis suspect. All patients cataract was 20/30 at the most recent follow-up 14 months
were receiving systemic medications before the time of after injection. Patient 9 had ocular hypertension with a
injection. Five patients were receiving NSAIDs, one of maximum pressure of 26 mm Hg, including all injections.
whom was concurrently being treated with methotrexate. Patient 7 had subconjunctival hemorrhage and periorbital
Six patients were being treated with prednisone. Of these, ecchymosis, which resolved spontaneously. There were no
one was concomitantly receiving methotrexate and an- cases of perforation or clinically detectable scleral
other simultaneously was taking mycophenolate mofetil. thinning.
Two patients were excluded because they were lost follow-
up. One patient did not meet inclusion criteria of follow-up
within 5 weeks. At 8 weeks after injection on celecoxib DISCUSSION
(Celebrex; Pfizer Inc, New York, New York, USA), she
experienced some discomfort, but the scleritis had resolved. SCLERITIS IS AN UNCOMMON BUT SEVERE OCULAR INFLAM-
The initial follow-up visit after injection ranged from 2 mation that often is associated with complications. Stan-
to 5 weeks (mean, 3 weeks). Ten (90%) of 11 patients dard treatments include systemic NSAIDs, steroids, and
reported subjective improvement in symptoms, 3 of whom systemic nonsteroidal immunosuppressive agents. Sub-
experienced complete resolution of their pain. In one Tenon corticosteroid injections have been used in other
patient, subjective information was not available. In terms ocular inflammatory conditions. However, they generally
of objective signs of inflammation, 10 (90%) of 11 patients have been avoided in the treatment of scleritis because of
improved after injection. In 4 eyes, complete resolution of concerns about poor efficacy and the risk of scleral thin-
scleral inflammation was achieved. One of these eyes was ning or perforation. The literature supporting this notion is
from the patient with bilateral scleritis; the contralateral comprised of a few case reports. Watson reported that
eye had partial resolution of inflammation. perforation and acute thinning can occur because of local
During follow-up, 8 patients had recurrent scleritis steroid injection in scleritis patients and warned against
(73%). The mean time to recurrence was 18 weeks (range, SCI. However, detailed case descriptions were not pro-
4 to 21 weeks); median time was 16 weeks. The rate of vided. Furthermore, the steroid suspension used is un-
recurrence was 3.3 cases per person-year. Six of these known.5 In a response discussion to a prospective study by
patients received and responded favorably to repeat TA Zamir and associates, Jabs briefly described one patient
injections. The other 2 patients were managed with with scleral melting that was believed to be secondary to
systemic medications. Patient 3 had recurrent scleritis in prior subconjunctival steroid injection.7,10 A literature
both eyes (20 weeks after injection in the right eye, 14 review revealed a few cases of scleral thinning in scleritis
weeks after injection in the left eye). He required an patients attributed to subconjunctival steroid injections.
increase in baseline prednisone dose and initiation of However, reports of rare events like scleral melts are
methotrexate (Trexall; Duramed Pharmaceuticals Inc, circumstantial by nature and preclude an accurate assess-
Woodcliff Lake, New Jersey, USA) to control the inflam- ment of a true occurrence rate.
78 AMERICAN JOURNAL OF OPHTHALMOLOGY JANUARY 2010VOL. 149, NO. 1
TABLE. Sub-Tenon Triamcinolone Acetonide Injections for Anterior Non-necrotizing Scleritis
Patient Age Affected Follow-up Subjective Objective Recurrence Response to Repeat
No. (years) Gender Eye Systemic Diagnosis Prior Systemic Therapy (wks) Improvement Improvement Tmax Adverse Effects (wks) Injection
1 52 F Right Rheumatoid arthritis Celecoxib 2 Yes Yes 19.5 None 21 Resolved, 4 wks
REGIONAL STEROID INJECTIONS
2 50 F Right Idiopathic Prednisone 3 Yes Yes 17 None 18 Improved, 2 wks
3 43 M Left Idiopathic Prednisone 5 Yes Resolved 17 None 14 Managed systemically
3 43 M Left Idiopathic Prednisone 4 Yes Yes 15 None 20 Managed systemically
4 56 M Right Celiac sprue Prednisone 5 Yes Resolved 20 None None
5 42 F Right Wegener granulomatosis Prednisone 2 Yes Yes 31 Worsening of posterior 4 Improved, 3 wks
subcapsular cataract
and ocular
hypertension
6 45 F Right Rheumatoid arthritis Prednisone, methotrexate 3 No data Yes 15 None 21 Managed systemically
7 44 F Left HLA-B27⫹ Ibuprofen 3 Resolved Yes 21 Subconjunctival None
hemorrhage and
IN
ecchymosis
SCLERITIS
8 35 F Left Idiopathic Rofecoxib, methotrexate 3 Yes Yes 11 None 16 Improved, 5 wks
9 66 F Left Idiopathic Valdecoxib 3 Resolved Resolved 26 Ocular hypertension 12 Improved, 4 wks
10 59 F Left Systemic Lupus Prednisone, 4 Resolved Resolved 19 None None
erythematosus mycophenolate mofetil
11 63 F Left Wegener granulomatosis Celebrex 5 Yes No 15.5 None 15 Improved, 7 wks
suspect
F ⫽ female; M ⫽ male; wks ⫽ weeks.
79Four published uncontrolled case series have suggested and scleral inflammation. No cases of perforation or
efficacy and a low rate of side effects of SCI in scleritis observable scleral thinning were encountered. Adverse
treatment. One report was a prospective series by Zamir events included ocular hypertension, worsening of poste-
and associates, later expanded on retrospectively by Albini rior subcapsular cataract, and subconjunctival hemorrhage
and associates.10,11 In their group, 36 (95%) of 38 eyes and periorbital ecchymosis. One patient with worsened
experienced complete resolution of scleral inflammation cataract and ocular hypertension also was receiving sys-
within 6 weeks of injection, without any cases of scleral temic prednisone, which might have contributed to these
necrosis or thinning over a median follow-up of 29 side effects. Given the side effect profile of systemic
months. SCI also reduced the requirement for systemic prednisone including hyperglycemia, osteoporosis, and
therapy from 94% to 49%. Tu and associates reported 18 psychiatric disturbance observed in approximately 22% of
(90%) of 20 patients achieving subjectively improved pain patients combined,2 SCI in contrast are well tolerated and
and objectively reduced inflammation after SCI.8 Nine may be a useful supplement to systemic therapy. Recent
patients (45%) had a recurrence of symptoms. No cases of studies have shown methotrexate has a favorable side
progressive scleral thinning were observed. Croasdale and effect profile, good efficacy, and corticosteroid-reducing
associates retrospectively described 8 patients undergoing effect in scleritis treatment.13–15
SCI with overall favorable results and no serious compli-
Our results may be confounded by concomitant systemic
cations.9 One patient had a poor response. This same
medications before injection. NSAIDs have an analgesic
patient had bilateral scleromalacia that occurred gradually
effect and may influence reports of clinical symptoms, and
over several years. Finally, Sen and associates published a
systemic treatment likely continued to take effect on
retrospective case series of 4 patients receiving SCI, all of
inflammation after the injections. Our described efficacy
whom achieved rapid reduction in inflammation.12 Each
patient required repeat injection in either the treated or might have resulted from a combined or synergistic effect
fellow eye after a mean of 7.4 months. Cumulatively, these of systemic and local treatment.
reports describe a total of 65 (93%) of 70 cases with a In conclusion, this study describes in our small population
beneficial response to SCI and no evidence of perforation that sub-Tenon corticosteroid injections in nonnecrotizing
or observable thinning resulting from the local injection. scleritis can provide a rapid, transient improvement in
Our retrospective, interventional case series was in- subjective pain and scleral inflammation with a high
tended to add further data on SCI in the treatment of relapse rate. Adverse events were manageable, but our
scleritis. We did not have patients with necrotizing scle- series is too small to evaluate the risk of severe adverse
ritis. Our group of 11 patients (12 eyes) had roughly similar events such as scleral melting. The general avoidance of
characteristics compared with a large series describing 97 SCI in scleritis patients seems based on limited reports in
scleritis patients.2 Our group had fewer males and a slightly the literature, rather than convincing evidence suggesting
larger percentage diagnosed with systemic rheumatic dis- a causal relationship. Our series adds to the limited body of
ease compared with the large series. data that this technique may have value and should be
At median follow-up of 3 weeks after injection, 10 considered a useful adjunct in the treatment of nonnecro-
(90%) of 11 patients had improvement in subjective pain tizing scleritis.
THIS STUDY WAS SUPPORTED BY AN UNRESTRICTED GRANT FROM RESEARCH TO PREVENT BLINDNESS INC, NEW YORK, NEW
York. The authors indicate no financial conflict of interest. Both authors were involved in design and conduct of study; collection of data; management,
analysis, and interpretation of data; and preparation, review, and approval of the manuscript. This study was approved by the Institutional Review Board
of the University of Medicine and Dentistry of New Jersey in accordance with Health Insurance Portability and Accountability Act regulations.
REFERENCES 6. Watson PG. Diseases of the sclera and episclera. In: Tasman
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tion of patients with scleritis for systemic disease. Ophthal- JC. Therapy of nonnecrotizing anterior scleritis with subcon-
mology 2004;111:501–506. junctival corticosteroid injection. Ophthalmology 1995;102:
4. Watson PG, Hayreh SS. Scleritis and episcleritis. Brit J 718 –724.
Ophthal 1976;60:163–191. 9. Croasdale CR, Brightbill FS. Subconjunctival corticosteroid
5. Watson PG. Treatment of scleritis and episcleritis. Trans injections for nonnecrotizing anterior scleritis. Arch Oph-
Ophthal Soc UK 1974;94:76 –79. thalmol 1999;117:966 –968.
80 AMERICAN JOURNAL OF OPHTHALMOLOGY JANUARY 201010. Zamir E, Read RW, Smith RE, Wang RC, Rao NA. A 13. Jachens AW, Chu DS. Retrospective review of methotrexate
prospective evaluation of subconjunctival injection of triam- therapy in the treatment of chronic, noninfectious, nonne-
cinolone acetonide for resistant anterior scleritis. Ophthal- crotizing scleritis. Am J Ophthalmol 2008;145:487– 492.
mology 2002;109:798 – 807. 14. Kaplan-Messas A, Barkana Y, Avni I, Neumann R. Metho-
11. Albini TA, Zamir E, Read RW, Smith RE, See RF, Rao NA. trexate as a first-line corticosteroid-sparing therapy in a
Evaluation of subconjunctival triamcinolone for nonnecrotizing cohort of uveitis and scleritis. Ocul Immunol Inflamm
anterior scleritis. Ophthalmology 2005;112:1814 –1820. 2003;11:131–139.
12. Sen HN, Ursea R, Nussenblatt RB, Buggage RR. Subconjunc- 15. Shah SS, Lowder CY, Schmitt MA, Wilke WS, Kosmorsky
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REPORTING VISUAL ACUITIES
The AJO encourages authors to report the visual acuity in the manuscript using the same nomenclature that was used in
gathering the data provided they were recorded in one of the methods listed here. This table of equivalent visual acuities
is provided to the readers as an aid to interpret visual acuity findings in familiar units.
Table of Equivalent Visual Acuity Measurements
Snellen Visual Acuities
4 Meters 6 Meters 20 Feet Decimal Fraction LogMAR
4/40 6/60 20/200 0.10 ⫹1.0
4/32 6/48 20/160 0.125 ⫹0.9
4/25 6/38 20/125 0.16 ⫹0.8
4/20 6/30 20/100 0.20 ⫹0.7
4/16 6/24 20/80 0.25 ⫹0.6
4/12.6 6/20 20/63 0.32 ⫹0.5
4/10 6/15 20/50 0.40 ⫹0.4
4/8 6/12 20/40 0.50 ⫹0.3
4/6.3 6/10 20/32 0.63 ⫹0.2
4/5 6/7.5 20/25 0.80 ⫹0.1
4/4 6/6 20/20 1.00 0.0
4/3.2 6/5 20/16 1.25 ⫺0.1
4/2.5 6/3.75 20/12.5 1.60 ⫺0.2
4/2 6/3 20/10 2.00 ⫺0.3
From Ferris FL III, Kassoff A, Bresnick GH, Bailey I. New visual acuity charts for clinical research. Am J Ophthalmol 1982;94:91–96.
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