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Evaluation of Sub-Tenon Triamcinolone Acetonide 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 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
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 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.
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
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 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 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 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- 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 triamcinolone acetonide (TA) injection (1 mL of a 40 School—University of Medicine and Dentistry of New Jersey, Newark,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, neously into the sub-Tenon space in the inferior temporal Doctors Office Center, 90 Bergen Street, Suite 6100, Newark, NJ 07103;e-mail: 2010 BY ELSEVIER INC. ALL RIGHTS RESERVED.
Outcome 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 ultimately recurrence took place again. Her regimen sub-sequently was changed to infliximab (Remicade; Horsham,Pennsylvania, USA), methotrexate, and prednisone, and 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 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.
Two patients were excluded because they were lost follow-up. One patient did not meet inclusion criteria of follow-upwithin 5 weeks. At 8 weeks after injection on celecoxib (Celebrex; Pfizer Inc, New York, New York, USA), sheexperienced 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 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 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- TABLE. Sub-Tenon Triamcinolone Acetonide Injections for Anterior Non-necrotizing Scleritis
F ϭ female; M ϭ male; wks ϭ weeks.
Four 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 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 SCI in contrast are well tolerated and and objectively reduced inflammation after 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 SCI with overall favorable results and no serious compli- Our results may be confounded by concomitant systemic 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 might have resulted from a combined or synergistic effect patient required repeat injection in either the treated orfellow eye after a mean of 7.4 months. Cumulatively, these 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 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 THIS STUDY WAS SUPPORTED BY AN UNRESTRICTED GRANT FROM RESEARCH TO PREVENT BLINDNESS INC, NEW YORK, NEWYork. 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 Boardof the University of Medicine and Dentistry of New Jersey in accordance with Health Insurance Portability and Accountability Act regulations.
6. Watson PG. Diseases of the sclera and episclera. In: Tasman W, Jaeger EA, editors. Duane’s Ophthalmology on CD- 1. Fong LP, de la Maza MS, Rice BA, et al. Immunopathology ROM. Philadelphia, Pennsylvania: Lippincott William & of scleritis. Ophthalmology 1991;98:472– 479.
2. Jabs DA, Mudun A, Dunn JP, Marsh MJ. Episcleritis and 7. Jabs DA. Subconjunctival corticosteroids should not be used scleritis: clinical features and treatment results. Am J Oph- in the treatment of scleritis (Discussion). Ophthalmology 3. Akpek EK, Thorne JE, Qazi FA, Do DV, Jabs DA. Evalua- 8. Tu EY, Culbertson WW, Pflugfelder SC, Huang A, Chodosh tion of patients with scleritis for systemic disease. Ophthal- JC. Therapy of nonnecrotizing anterior scleritis with subcon- junctival corticosteroid injection. Ophthalmology 1995;102: 4. Watson PG, Hayreh SS. Scleritis and episcleritis. Brit J 9. Croasdale CR, Brightbill FS. Subconjunctival corticosteroid 5. Watson PG. Treatment of scleritis and episcleritis. Trans injections for nonnecrotizing anterior scleritis. Arch Oph- 10. 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.
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.
12. Sen HN, Ursea R, Nussenblatt RB, Buggage RR. Subconjunc- 15. Shah SS, Lowder CY, Schmitt MA, Wilke WS, Kosmorsky tival corticosteroid injection for the treatment of non-necrotis- GS, Meisler DM. Low-dose methotrexate therapy for ocular ing anterior scleritis. Br J Ophthalmol 2005;89:917–929.
inflammatory disease. Ophthalmology 1992;99:1419 –1423.
The AJO encourages authors to report the visual acuity in the manuscript using the same nomenclature that was used ingathering the data provided they were recorded in one of the methods listed here. This table of equivalent visual acuitiesis provided to the readers as an aid to interpret visual acuity findings in familiar units.
Table of Equivalent Visual Acuity Measurements 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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