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Sub-Tenon Triamcinolone Acetonide Injection in the Treatment of Scleritis
CORRESPONDENCE Sub-Tenon Triamcinolone Acetonide Injection in the Treatment of Scleritis EDITOR: I WOULD LIKE TO THANK DRS JOHNSON AND CHU FOR
their article “Evaluation of Sub-Tenon Triamcinolone Acetonide Injections in the Treatment of Scleritis.1 It brings to our attention the new approach to treatment of nonnecrotizing scleritis, which is characterized by severe pain and a high relapse rate. The authors conclude that sub-Tenon triamcinolone acetonide (TA) may be a useful adjunct to achievement of transient, partial improvement of subjective pain and objective inflammation while waiting for systemic medications to take effect. Although the study is simple and concise, I have the following comments and questions. The authors reported that 10 of 11 patients reported subjective improvement and that 10 patients showed improvement in objective inflammation at the time of the initial follow-up (range, 2 to 5 weeks). All patients received simultaneous systemic medications: prednisone, methotrexate, nonsteroidal anti-inflammatory drugs, celecoxib, and so forth. I am wondering how to conclude that sub-Tenon TA injections may be a useful adjunct for achievement of subjective and objective improvement in patients with scleritis while waiting for systemic medications to take effect without exclusion of the preexisting effect of systemic treatment. In addition, there were wide discrepancies in the time designated for evaluation of initial improvement of symptoms and signs associated with scleritis: minimum 2 weeks and maximum 5 weeks. The authors commented that in the “Results,” 2 patients were excluded because they were lost to follow-up; however, it seemed that the authors included them in their data and in the Table. Furthermore, I found a few instances of missed proofreading; for example, SCI (subconjunctival corticosteroid injections) in the “Results,” line 2, is not correct, and SCI in the “Discussion,” page 80, left paragraph, line 28, may cause misunderstanding among readers. I highly appreciate the report by these authors, which provided us with valuable information on new, challenging treatment methods for retractable nonnecrotizing scleritis. They reported that adverse events from sub-Tenon TA injections were few and manageable: 2 ocular hypertension cases and 1 cataract case. We recently reported in our retrospective analysis that posterior sub-Tenon TA injections for treatment of posterior uveitis, diabetic macular edema, and macular edema secondary to retinal vein occlusion, resulted in no severe complications, such as endophthalmitis or retinal detachment, and relatively less risk of 128
©
2010 BY
complications because of intraocular pressure (11.3%) and cataract progression (2.1%).2 Our study showed a much lower incidence of side effects than this study, because our study included a large case series with more long-term follow-up. In conclusion, sub-Tenon injection is a safe procedure and can be applied repeatedly to eyes, as in this study. Although it involved a small case series, findings from this study demonstrated that sub-Tenon TA injections should be considered as a useful adjunct in treatment of nonnecrotizing scleritis and that further studies are warranted. YOUNG-HOON PARK
Seoul, Korea
REFERENCES
1. Johnson KS, Chu DS. Evaluation of sub-Tenon triamcinolone acetonide injections in the treatment of scleritis. Am J Ophthalmol 2010;149(1):77– 81. 2. Byun YS, Park YH. Complications and safety profile of posterior subtenon injection of triamcinolone acetonide. J Ocul Pharmacol Ther 2009;25(2):159 –162.
REPLY WE WOULD LIKE TO RESPOND TO THE COMMENTS FROM DR
Park in reference to the recently published case series describing sub-Tenon triamcinolone acetonide injections in the treatment of scleritis.1 All patients were receiving systemic therapy at the time of injection; we agree that these medications could have a confounding effect when evaluating the impact of regional corticosteroid treatment. We suggest the injections are helpful as an adjunct therapy, and are not intended to replace systemic approaches. An inherent disadvantage of this case series is the inability to compare regional corticosteroids with no treatment. We selected a short initial follow-up time of 2 to 5 weeks to attempt to capture the rapid effect of the injections. We agree that this time range is variable, but were limited by the retrospective nature and number of patients in the study. In the “Results,” we comment that 2 patients who received injections were excluded because they did not meet inclusion criteria of initial follow-up within 5 weeks. One patient had follow-up at 8 weeks, and 1 patient did not return at all for follow-up. These patients were not included in our data or in the Table. We appreciate the identification of errors in the “Results” (line 2) and “Discussion” (line 28) on the use of subconjunctival corticosteroid injections (SCIs). This may cause misunderstanding among readers, as we intended to mention subTenon injections in these sentences.
ELSEVIER INC. ALL
RIGHTS RESERVED.
0002-9394/$36.00
their article “Evaluation of Sub-Tenon Triamcinolone Acetonide Injections in the Treatment of Scleritis.1 It brings to our attention the new approach to treatment of nonnecrotizing scleritis, which is characterized by severe pain and a high relapse rate. The authors conclude that sub-Tenon triamcinolone acetonide (TA) may be a useful adjunct to achievement of transient, partial improvement of subjective pain and objective inflammation while waiting for systemic medications to take effect. Although the study is simple and concise, I have the following comments and questions. The authors reported that 10 of 11 patients reported subjective improvement and that 10 patients showed improvement in objective inflammation at the time of the initial follow-up (range, 2 to 5 weeks). All patients received simultaneous systemic medications: prednisone, methotrexate, nonsteroidal anti-inflammatory drugs, celecoxib, and so forth. I am wondering how to conclude that sub-Tenon TA injections may be a useful adjunct for achievement of subjective and objective improvement in patients with scleritis while waiting for systemic medications to take effect without exclusion of the preexisting effect of systemic treatment. In addition, there were wide discrepancies in the time designated for evaluation of initial improvement of symptoms and signs associated with scleritis: minimum 2 weeks and maximum 5 weeks. The authors commented that in the “Results,” 2 patients were excluded because they were lost to follow-up; however, it seemed that the authors included them in their data and in the Table. Furthermore, I found a few instances of missed proofreading; for example, SCI (subconjunctival corticosteroid injections) in the “Results,” line 2, is not correct, and SCI in the “Discussion,” page 80, left paragraph, line 28, may cause misunderstanding among readers. I highly appreciate the report by these authors, which provided us with valuable information on new, challenging treatment methods for retractable nonnecrotizing scleritis. They reported that adverse events from sub-Tenon TA injections were few and manageable: 2 ocular hypertension cases and 1 cataract case. We recently reported in our retrospective analysis that posterior sub-Tenon TA injections for treatment of posterior uveitis, diabetic macular edema, and macular edema secondary to retinal vein occlusion, resulted in no severe complications, such as endophthalmitis or retinal detachment, and relatively less risk of 128
©
2010 BY
complications because of intraocular pressure (11.3%) and cataract progression (2.1%).2 Our study showed a much lower incidence of side effects than this study, because our study included a large case series with more long-term follow-up. In conclusion, sub-Tenon injection is a safe procedure and can be applied repeatedly to eyes, as in this study. Although it involved a small case series, findings from this study demonstrated that sub-Tenon TA injections should be considered as a useful adjunct in treatment of nonnecrotizing scleritis and that further studies are warranted. YOUNG-HOON PARK
Seoul, Korea
REFERENCES
1. Johnson KS, Chu DS. Evaluation of sub-Tenon triamcinolone acetonide injections in the treatment of scleritis. Am J Ophthalmol 2010;149(1):77– 81. 2. Byun YS, Park YH. Complications and safety profile of posterior subtenon injection of triamcinolone acetonide. J Ocul Pharmacol Ther 2009;25(2):159 –162.
REPLY WE WOULD LIKE TO RESPOND TO THE COMMENTS FROM DR
Park in reference to the recently published case series describing sub-Tenon triamcinolone acetonide injections in the treatment of scleritis.1 All patients were receiving systemic therapy at the time of injection; we agree that these medications could have a confounding effect when evaluating the impact of regional corticosteroid treatment. We suggest the injections are helpful as an adjunct therapy, and are not intended to replace systemic approaches. An inherent disadvantage of this case series is the inability to compare regional corticosteroids with no treatment. We selected a short initial follow-up time of 2 to 5 weeks to attempt to capture the rapid effect of the injections. We agree that this time range is variable, but were limited by the retrospective nature and number of patients in the study. In the “Results,” we comment that 2 patients who received injections were excluded because they did not meet inclusion criteria of initial follow-up within 5 weeks. One patient had follow-up at 8 weeks, and 1 patient did not return at all for follow-up. These patients were not included in our data or in the Table. We appreciate the identification of errors in the “Results” (line 2) and “Discussion” (line 28) on the use of subconjunctival corticosteroid injections (SCIs). This may cause misunderstanding among readers, as we intended to mention subTenon injections in these sentences.
ELSEVIER INC. ALL
RIGHTS RESERVED.
0002-9394/$36.00