Foreign body reaction against intracameral Triamcinolone: Clinicopathological case report

1
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

2
Introduction

• Triamcinolone acetonide (TA) is a corticosteroid
  suspension with potent anti-inflammatory effect.
• Intravitreal TA has been advocated in the
  treatment of various conditions including
• refractory macular edemas1-2
• choriodal neovascularizations secondary to AMD
• pathological myopia3
• enhancing visualization of vitreous during
  vitrectomy4-5 and ERM peeling operations
• Common adverse effects of intravitreal injection
  of TA are
• transient elevated intraocular pressure
• cataract progression7
• Endophthalmitis is a rare but devastating8-9
• Non-infectious endophthalmitis or
  pseudoendophthalmitis as a result of toxic
  reaction10-12
• Here, we report a patient who had persistent
  pseudohypopyon five weeks after intracameral TA
  injection following cataract surgery

3
Case report

• 72/F Good past medical health
• Underwent an uneventful phaco IOL operation of
  the right eye in February 2007
• Immediately after the surgery, intracameral
  injection of 2 mg triamcinolone (40mg/ml,
  Kenacort A, Bristol-Myer, Squibb, Agani, Italy)
  was given for the control of postoperative
  inflammation.
• Post op Day 1
• On the next day, the TA was noted in the inferior
  part of the anterior chamber mimicking a shallow
  hypopyon (Fig. 1)
• BCVA 0.4 IOP normal ACQ and no ocular pain
• The patient was managed conservatively with close
  observation

4
Case report

• Post op 4 weeks
• 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)
• A similar finding was noted one week later and
  there was no change in the extension and height
  of this pseudohypopyon
• The anterior chamber washout was performed
  because of the persistent of pseudohypopyon
• Intraoperatively, the pseudohypopyon was found to
  be a soft mass like lesion instead of liquid
• The patient had an uneventful recovery thereafter
• BCVA 0.7 IOP normal ACQ

5
Histopathological analysis

• Numerous birefrigence particles consistent with
  TA crystals were identified when the
  pseudohypopyon was examined under polarized light
  (Fig. 3A)
• Microscopic examination disclosed numerous
  histiocytes with numerous clear dropout spaces of
  different sizes
• These dropout spaces were presumably caused by
  removal of TA crystals during processing (Fig.
  3B)
• The histiocytes were highlighted by CD163
  immunstaining (Fig. 3C)
• The overall features were compatible with foreign
  body reaction against the injected TA

6
Fig. 1 Slit-lamp photo showing a shallow
pseudohypopyon (arrow) located at 5 to 7 oclock
region of right eye.
7
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.
8
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 ( HE,
x 400). (C) The histiocytes are confirmed by
CD163 immunostaining (x 400).
9
Discussion

• 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.
• 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.
• 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.

10
Discussion

• 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
• Anterior segment optical coherence tomography is
  also useful in monitoring the progression of
  hypopyon as demonstrated
• 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).

11
Conclusion

• Intracameral injection of TA could trigger
  foreign body reaction in a healthy human eye
• 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.

12
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