- Email: [email protected]
Cutaneous hypopigmentation following a posterior sub-tenon triamcinolone injection
The patient developed skin hypopigmentation of the upper eyelid adjacent to the site of the sub-Tenon injection. CONCLUSION: Injection of corticosteroids into the subTenon space can cause hypopigmentation of the adjacent tissues, especially in heavily pigmented individuals. (Am J Ophthalmol 2004;137:779 –780. © 2004 by Elsevier Inc. All rights reserved.) RESULTS:
FIGURE 2. The natural recovery interval of ocular motility within 15 or 30 degrees in the nonsurgical patients. Black columns show ocular motility recovery interval within 15 degrees and the gray columns, within 30 degrees.
surgical management: orbital imaging without muscle entrapment; forced duction test findings without strong mechanical restriction; an involved ocular motility range of more than 10 or 20 degrees, respectively, on the Hess chart at 15- or 30-degree movement of the fellow eye. When all these criteria are met, ocular motility will most likely recover naturally even in patients with blow-out fractures. REFERENCES
1. Smith B, Regan WF Jr. Blow-out fracture of the orbit. Am J Ophthalmol 1957;44:733–739. 2. Manson PN, Iliff N. Management of blow-out fractures of the orbital floor: early repair for selected injuries. Surv Ophthalmol 1991;35:280 –292. 3. Putterman AM. Management of blow-out fractures of the orbital floor: the conservative approach. Surv Ophthalmol 1991;35:292–298. 4. Hartstein ME, Roper-Hall G. Update on orbital floor fractures: indications and timing for repair. Facial Plast Surg 2000;16:95–106. 5. Gilbard SM, Mafee MF, Lagouros PA, Langer BG. Orbital blowout fractures: the prognostic significance of computed tomography. Ophthalmology 1985;92:1523–1528.
Cutaneous Hypopigmentation Following a Posterior Sub-Tenon Triamcinolone Injection Mark J. Gallardo, MD, and Daniel A. Johnson, MD
C
UTANEOUS DEPIGMENTATION OR LEUKODERMA AC-
quisitum is a known complication of intralesional corticosteroid injections.1 Skin depigmentation following intralesional corticosteroid injections for the treatment of both chalazia and periocular hemangiomas has been reported.1,2 Reported adverse effects of periocular corticosteroid injections include systemic toxicity, cushingoid responses, globe penetration, retinal and choroidal vascular occlusions, glaucoma, cataract formation, delayed hypersensitivity reactions, and others.1–5 To our knowledge, this is the first reported case of periocular skin hypopigmentation following a posterior sub-Tenon triamcinolone injection for the treatment of Adamantiades-Behcet disease (ABD). The patient was a 28-year-old African American female with ABD whose clinical course had been characterized by recurrent episodes of panuveitis, necrotizing retinitis, and hypopyon uveitis despite varying combinations of systemic corticosteroids, cyclophosphamide, cyclosporine, methotrexate, infliximab, and etanecept. Sub-Tenon injections of triamcinolone acetonide in this patient had proven an effective, albeit temporary, method to reduce ocular inflammation. In the preceding 8 years, the patient underwent 10 such injections in the right eye and six in the left eye. In December 2002, while on a regimen of prednisone 25 mg orally every day and cyclosporine 125 mg orally twice daily, the patient developed recurrent vitreous inflammation in the left eye. One milliliter of triamcinolone acetonide was injected into the superotemporal sub-Tenon space with a 5/8-inch 25-gauge needle on a tuberculin syringe after written informed consent. Follow-up examination 3 weeks later revealed mild cutaneous hypopigmentation with thinning of the upper eyelid temporally, corresponding to the area of the triamcinolone injection (Figure 1). Examination of the globe confirmed placement of the corticosteroid depot in sub-Tenon space in the superotemporal region, posterior to the equator. The patient stated that transient hypopigmentation occurred in
PURPOSE: To report a case of cutaneous skin hypopigmen-
tation following a posterior sub-Tenon triamcinolone acetonide injection for uveitis. DESIGN: Observational case report. METHODS: A 28-year-old African American female with Adamantiades-Behcet disease and panuveitis was administered a posterior sub-Tenon injection of triamcinolone acetonide and developed cutaneous hypopigmentation. VOL. 137, NO. 4
Accepted for publication Sept 16, 2003. From the Department of Ophthalmology, University of Texas Health Sciences Center San Antonio, San Antonio, Texas. All research is, in part, supported by the Lions Eye Institute in an effort to prevent blindness. Inquiries to Mark J. Gallardo, MD, Department of Ophthalmology, University of Texas Health Sciences Center San Antonio, 7703 Floyd Curl Drive, MC 6230, San Antonio, TX 78229-3900; fax: (210) 5676584; e-mail: [email protected]
BRIEF REPORTS
779
pigmentation following sub-Tenon triamcinolone injections and the proposed need to inform patients of this potential complication. REFERENCES
1. Cohen BZ, Ramesh TC. Eyelid depigmentation after intralesional injection of a fluorinated corticosteroid for chalazion. Am J Ophthalmol 1979;88:269 –270. 2. Cogen CS, Frederick EJ. Eyelid depigmentation following corticosteroid injection for infantile ocular adnexal hemangioma. J Pediatr Ophthalmol 1989;26:35–38. 3. Rothova A. Corticosteroids and uveitis. Ophtalmol Clin North Am 2002;15:389 –394. 4. Moshfeghi DM, Lowder CY, Roth DB. Retinal and choroidal vascular occlusion after posterior sub-Tenon triamcinolone injection. Am J Ophtrhalmol 2002;134:132–134. 5. Ozerdem U. Systemic toxicity of topical and periocular corticosteroid therapy in an 11-year-old male with posterior uveitis. Am J Ophthalmol 2000;130:240 –241.
FIGURE 1. External photo of right eyelid showing area of mild cutaneous hypopigmentation on lateral third of the upper lid. Note the prominence of the cutaneous vessels in the area of hypopigmentation.
Retinal Capillary Angioma in Familial Exudative Vitreoretinopathy Treated With Photodynamic Therapy Juan Antonio Grau Javellana, MD, John H. Drouilhet, MD, Gregg T. Kokame, MD, Percival H.Y. Chee, MD, and Byron M.W. Wong, MD To report a case of familial exudative vitreoretinopathy with a retinal capillary angioma and persistent macular exudation treated with photodynamic therapy. DESIGN: Interventional case report. METHODS: A 39-year-old woman with familial exudative vitreoretinopathy presented with an intraretinal capillary angioma temporally with persistent macular exudation despite previous vitrectomy and thermal laser. Photodynamic therapy to the retinal angioma was performed. RESULTS: Three months after photodynamic therapy, vision was stable at 20/200 with a reduction in lesion size on B-scan ultrasonography and no leakage on fluorescein angiography. With 10 months of follow-up there was no recurrence of leakage. CONCLUSION: Retinal capillary angioma may be present in association with familial exudative vitreoretinopathy, and photodynamic therapy may provide a good alternative treatment to decrease exudation. (Am J OphthalPURPOSE:
FIGURE 2. External photo of right eyelid 2 months after corticosteroid injection with resolution of hypopigmentation.
the same eye following an injection given several months earlier that she did not report. On both occasions, the skin changes occurred approximately 2 weeks after injection and resolved approximately 1 month later (Figure 2). Given the temporal relationship between the posterior sub-Tenon triamcinolone injection and her dermal hypopigmentation and known reaction with intralesional injections for chalazia, we believe that her hypopigmentation is related to the triamcinolone injection. It is unclear whether the cutaneous reaction is related to the injection alone, to a cumulative effect of multiple sub-Tenon injections, or to an interaction between the corticosteroid and her other systemic therapy. Although the change was mild, it was significant enough for our patient to bring it to our attention. We report this case to alert the ophthalmologist of the potential risk for developing periocular skin hypo780
AMERICAN JOURNAL
Accepted for publication Oct 3, 2003. From the Division of Ophthalmology, Department of Surgery, University of Hawaii John A. Burns School of Medicine and The Queen’s Medical Center, Honolulu, Hawaii. Inquiries to John H. Drouilhet, MD, Suite 502 Queen’s Physicians Office Building II, 1329 Lusitana Street, Honolulu, Hawaii 96813; fax: (808) 524-1729; e-mail: [email protected] OF
OPHTHALMOLOGY
APRIL 2004
FIGURE 2. The natural recovery interval of ocular motility within 15 or 30 degrees in the nonsurgical patients. Black columns show ocular motility recovery interval within 15 degrees and the gray columns, within 30 degrees.
surgical management: orbital imaging without muscle entrapment; forced duction test findings without strong mechanical restriction; an involved ocular motility range of more than 10 or 20 degrees, respectively, on the Hess chart at 15- or 30-degree movement of the fellow eye. When all these criteria are met, ocular motility will most likely recover naturally even in patients with blow-out fractures. REFERENCES
1. Smith B, Regan WF Jr. Blow-out fracture of the orbit. Am J Ophthalmol 1957;44:733–739. 2. Manson PN, Iliff N. Management of blow-out fractures of the orbital floor: early repair for selected injuries. Surv Ophthalmol 1991;35:280 –292. 3. Putterman AM. Management of blow-out fractures of the orbital floor: the conservative approach. Surv Ophthalmol 1991;35:292–298. 4. Hartstein ME, Roper-Hall G. Update on orbital floor fractures: indications and timing for repair. Facial Plast Surg 2000;16:95–106. 5. Gilbard SM, Mafee MF, Lagouros PA, Langer BG. Orbital blowout fractures: the prognostic significance of computed tomography. Ophthalmology 1985;92:1523–1528.
Cutaneous Hypopigmentation Following a Posterior Sub-Tenon Triamcinolone Injection Mark J. Gallardo, MD, and Daniel A. Johnson, MD
C
UTANEOUS DEPIGMENTATION OR LEUKODERMA AC-
quisitum is a known complication of intralesional corticosteroid injections.1 Skin depigmentation following intralesional corticosteroid injections for the treatment of both chalazia and periocular hemangiomas has been reported.1,2 Reported adverse effects of periocular corticosteroid injections include systemic toxicity, cushingoid responses, globe penetration, retinal and choroidal vascular occlusions, glaucoma, cataract formation, delayed hypersensitivity reactions, and others.1–5 To our knowledge, this is the first reported case of periocular skin hypopigmentation following a posterior sub-Tenon triamcinolone injection for the treatment of Adamantiades-Behcet disease (ABD). The patient was a 28-year-old African American female with ABD whose clinical course had been characterized by recurrent episodes of panuveitis, necrotizing retinitis, and hypopyon uveitis despite varying combinations of systemic corticosteroids, cyclophosphamide, cyclosporine, methotrexate, infliximab, and etanecept. Sub-Tenon injections of triamcinolone acetonide in this patient had proven an effective, albeit temporary, method to reduce ocular inflammation. In the preceding 8 years, the patient underwent 10 such injections in the right eye and six in the left eye. In December 2002, while on a regimen of prednisone 25 mg orally every day and cyclosporine 125 mg orally twice daily, the patient developed recurrent vitreous inflammation in the left eye. One milliliter of triamcinolone acetonide was injected into the superotemporal sub-Tenon space with a 5/8-inch 25-gauge needle on a tuberculin syringe after written informed consent. Follow-up examination 3 weeks later revealed mild cutaneous hypopigmentation with thinning of the upper eyelid temporally, corresponding to the area of the triamcinolone injection (Figure 1). Examination of the globe confirmed placement of the corticosteroid depot in sub-Tenon space in the superotemporal region, posterior to the equator. The patient stated that transient hypopigmentation occurred in
PURPOSE: To report a case of cutaneous skin hypopigmen-
tation following a posterior sub-Tenon triamcinolone acetonide injection for uveitis. DESIGN: Observational case report. METHODS: A 28-year-old African American female with Adamantiades-Behcet disease and panuveitis was administered a posterior sub-Tenon injection of triamcinolone acetonide and developed cutaneous hypopigmentation. VOL. 137, NO. 4
Accepted for publication Sept 16, 2003. From the Department of Ophthalmology, University of Texas Health Sciences Center San Antonio, San Antonio, Texas. All research is, in part, supported by the Lions Eye Institute in an effort to prevent blindness. Inquiries to Mark J. Gallardo, MD, Department of Ophthalmology, University of Texas Health Sciences Center San Antonio, 7703 Floyd Curl Drive, MC 6230, San Antonio, TX 78229-3900; fax: (210) 5676584; e-mail: [email protected]
BRIEF REPORTS
779
pigmentation following sub-Tenon triamcinolone injections and the proposed need to inform patients of this potential complication. REFERENCES
1. Cohen BZ, Ramesh TC. Eyelid depigmentation after intralesional injection of a fluorinated corticosteroid for chalazion. Am J Ophthalmol 1979;88:269 –270. 2. Cogen CS, Frederick EJ. Eyelid depigmentation following corticosteroid injection for infantile ocular adnexal hemangioma. J Pediatr Ophthalmol 1989;26:35–38. 3. Rothova A. Corticosteroids and uveitis. Ophtalmol Clin North Am 2002;15:389 –394. 4. Moshfeghi DM, Lowder CY, Roth DB. Retinal and choroidal vascular occlusion after posterior sub-Tenon triamcinolone injection. Am J Ophtrhalmol 2002;134:132–134. 5. Ozerdem U. Systemic toxicity of topical and periocular corticosteroid therapy in an 11-year-old male with posterior uveitis. Am J Ophthalmol 2000;130:240 –241.
FIGURE 1. External photo of right eyelid showing area of mild cutaneous hypopigmentation on lateral third of the upper lid. Note the prominence of the cutaneous vessels in the area of hypopigmentation.
Retinal Capillary Angioma in Familial Exudative Vitreoretinopathy Treated With Photodynamic Therapy Juan Antonio Grau Javellana, MD, John H. Drouilhet, MD, Gregg T. Kokame, MD, Percival H.Y. Chee, MD, and Byron M.W. Wong, MD To report a case of familial exudative vitreoretinopathy with a retinal capillary angioma and persistent macular exudation treated with photodynamic therapy. DESIGN: Interventional case report. METHODS: A 39-year-old woman with familial exudative vitreoretinopathy presented with an intraretinal capillary angioma temporally with persistent macular exudation despite previous vitrectomy and thermal laser. Photodynamic therapy to the retinal angioma was performed. RESULTS: Three months after photodynamic therapy, vision was stable at 20/200 with a reduction in lesion size on B-scan ultrasonography and no leakage on fluorescein angiography. With 10 months of follow-up there was no recurrence of leakage. CONCLUSION: Retinal capillary angioma may be present in association with familial exudative vitreoretinopathy, and photodynamic therapy may provide a good alternative treatment to decrease exudation. (Am J OphthalPURPOSE:
FIGURE 2. External photo of right eyelid 2 months after corticosteroid injection with resolution of hypopigmentation.
the same eye following an injection given several months earlier that she did not report. On both occasions, the skin changes occurred approximately 2 weeks after injection and resolved approximately 1 month later (Figure 2). Given the temporal relationship between the posterior sub-Tenon triamcinolone injection and her dermal hypopigmentation and known reaction with intralesional injections for chalazia, we believe that her hypopigmentation is related to the triamcinolone injection. It is unclear whether the cutaneous reaction is related to the injection alone, to a cumulative effect of multiple sub-Tenon injections, or to an interaction between the corticosteroid and her other systemic therapy. Although the change was mild, it was significant enough for our patient to bring it to our attention. We report this case to alert the ophthalmologist of the potential risk for developing periocular skin hypo780
AMERICAN JOURNAL
Accepted for publication Oct 3, 2003. From the Division of Ophthalmology, Department of Surgery, University of Hawaii John A. Burns School of Medicine and The Queen’s Medical Center, Honolulu, Hawaii. Inquiries to John H. Drouilhet, MD, Suite 502 Queen’s Physicians Office Building II, 1329 Lusitana Street, Honolulu, Hawaii 96813; fax: (808) 524-1729; e-mail: [email protected] OF
OPHTHALMOLOGY
APRIL 2004