ABSTRACT

A 56 years lady presented with complaint of blurring of vision in her left eye (LE) over 6 months. Her right eye had complicated cataract with glaucomatous optic atrophy. Past history was suggestive of LE recurrent uveitis for which she was on topical prednisolone acetate. On examination of LE, her vision was 6/9 with persistent vitritis and cystoid macular edema. She was subjected to posterior subtenon (PST) injection of 20 mg triamcenolone acetate from the superior fornix. She experienced severe pain dur ing PST injection which was followed by further diminution of vision. On examination, her visual acuity was hand movement with presence of disperse hyphema and no view of posterior segment. Her intraocular pressure (IOP) by Goldman applanation tonometry was 8 mm Hg. Ultrasound B-scan revealed retinal detachment (RD) with subretinal deposition of hyperreflective material. A provisional diagnosis of globe perforation was made. Patient was kept under observation and hyphema disappeared the following day. Vision persisted to be hand movement and IOP remained 10 mm Hg. The patient had RD and choroidal detachment with intravitreal and subretinal triamcinolone deposition involving macula. The patient was then taken for LE pars plana vitrectomy, fluid air exchange and removal of subretinal triamcinolone.

Operative procedure:

Under strict asepsis, a 20 gauge 6 mm infusion cannula was placed at 4 o’clock position. Two 23 gauge cannula were placed at 2 and 10 o’clock position. After core vitrectomy, posterior vitreous detachment was induced with great difficulty and peripheral vitrectomy was done. Drainage retinotomy was made superior to the disc at the site of subretinal triamcinolone deposition. The effort went into vain as there was no drainage of strongly adhered triamcinolone from the retinotomy site inspite of multiple attempts. The situation was very challenging with no clues as to how to remove the adhered drug. Attempts were then made with the help of intraocular forceps. Some of the drug came out in piece meals. Multiple attempts caused the retinotomy to increase in size. Retinotomy was then further enlarged superior to the arcade for further removal of adhered triamcinolone from the outer retinal surface. This lead to some bleeding from the choroidal vessels due to repe ated trauma during manipulation. The drug deposits were eaten up with vitrectomy cutter with difficulty. Finally fluid air exchange was done followed by endolaser of retinotomy site and silicone oil tamponade. Immediate postoperative vision was 1/60 and at 6 months follow up it was 6/24 with normal IOP and an attached retina under oil. Accidental subretinal and intravitreal injection of triamcinolone during posterior subtenon injection is a rarely reported complication in literature. The main topics of argument are- whether to remove the drug, when to remove and how to remove. Considering the side effects of the drug, globe perforation and detached status of retina, the decision to intervene was taken.There is hardly any method suggested by vitreo-retina scholars for removal of such adherent drug from the subretinal space. Wether the decision to remove the drug and the technique used is the best possible method to tackle such a situation is a matter of debate.


CONTACT DETAILS

 

Lalit AGARWAL, Nisha AGRAWAL, Abhishek ANAND
Biratnagar Eye Hospital
Biratnagar, Nepal
Email: doc_lalit1@yahoo.com
Cell Phone: +9779852027817
Work Phone: +9772136360