Posterior sub-Tenon's triamcinolone in choroidal granuloma due to probable ocular sarcoidosis.

A 35-year-old female presented with painless decreased vision OD (20/1200). There were mutton fat keratic precipitates and 4+ cells in the anterior chamber. Fundus showed a solitary choroidal granuloma temporally at the macula, disc edema [Figure 1a and b] and vitreous snowballs inferiorly [Figure 1c]. Spectral-domain optical coherence tomography (OCT) demonstrated choroidal elevation with intraretinal [Figure 1d] and subretinal fluid. Ultrasound B scan confirmed the presence of choroidal granuloma. The left eye was unremarkable (20/20).

Figure 1

(a) Colour fundus photograph of the right eye showed the presence of a choroidal granuloma temporal to the fovea with disc edema. (b) The fluorescein angiogram showed intense hyper fluorescence in the region of the choroidal granuloma and disc leakage. (c) The inferior retina demonstrated vitreous snowballs. (d) Optical coherence tomography scan through the granuloma revealed choroidal elevation and intraretinal edema

Detailed systemic work up revealed raised erythrocyte sedimentation rate (ESR), raised angiotensin-converting enzyme (ACE) and serum calcium levels. Mantoux was nonreactive; chest X-ray showed no lymphadenopathy. With a diagnosis of probable ocular sarcoidosis[1] , 40 mg (1 ml) of posterior sub-Tenon's triamcinolone acetonide (TA) was administered in the right eye alongwith topical steroids and cycloplegic agents. Best corrected visual acuity (BCVA) improved to 20/200 at three weeks and 20/30 at six weeks following the injection with dramatic resolution of fundus and SD-OCT features [Figures 2 and 3]. Retinal pigment epithelial changes persisted temporal to the fovea, however there was excellent restoration of the macular architecture on SD-OCT. There was no recurrence till eight months follow-up. The patient was referred to a physician for further evaluation for sarcoidosis.

Figure 2

At 3 weeks following posterior subtenon Triamcinolone administration, the colour photograph. (a) Marked flattening of the granuloma and decrease in disc edema. (b) A corresponding optical coherence tomography scan showed marked resolution of the intraretinal edema and sub foveal fluid

Figure 3

At 6 weeks following posterior subtenon Triamcinolone administration colour photograph. (a) Complete resolution of the choroidal granuloma and disc edema. Residual pigmentary changes were present in the area of the granuloma. (b) An optical coherence tomography scan confirmed resolution of intraretinal and subretinal fluid

Comment

The estimated incidence of ocular involvement in systemic sarcoidosis is 25-80%.[23] While anterior segment involvement occurs in the form of granulomatous uveitis, posterior segment involvement encompasses vitritis, retinal vasculitis, chorioetinitis and granulomas involving choroid, optic nerve and retina. Posterior segment involvement is seen in up to 14-28% of patients with ocular sarcoidosis.[45] The international workshop on ocular sarcoidosis (IOWS) recently laid down the criteria for diagnosis of ocular sarcoidosis[1] Since trans-bronchial lung biopsy required for the definitive diagnosis of sarcoidosis may not be possible in all suspected cases, four diagnostic categories of sarcoid uveitis were described.[1] Based on these criteria we made a diagnosis of probable ocular sarcoidosis.

The use of systemic steroids has been found to be effective in the setting of choroidal granulomas.[6] However since the ocular involvement was unilateral in the present patient, we administered posterior subtenon Triamcinolone Acetonide as it avoids the potential systemic side effects of the drug. This resulted in excellent resolution of ocular lesions and restoration of visual acuity. The use of posterior subtenon TA has been rarely described in posterior uveitis in ocular sarcoidosis.[7] While the risk of systemic side effects is minimal with this route of steroid administration, some local side effects may occur, the most common being rise in intraocular pressure. Rarely, globe perforation has been reported.[8] The choice of treatment should therefore be tailored according to each patient. To conclude, periocular administration of steroids in the form of posterior subtenon injection is a viable and effective option in choroidal granulomas due to ocular sarcoidosis. It allows a high concentration of the drug to be delivered to the posterior segment via trans scleral absorption, with minimal systemic side effects.