Conjunctival necrosis following a subconjunctival injection of triamcinolone acetonide in a child.

Conjunctival necrosis is a rare complication following periocular/intraocular triamcinolone acetonide injection and has been reported extensively in adults. We describe a child who developed conjunctival necrosis following subconjunctival injection of triamcinolone acetonide for severe chronic anterior uveitis. Prompt diagnosis and management of this uncommon condition is vital.

INTRODUCTION

Conjunctival ischemia and necrosis following periocular/intraocular injection of methylprednisolone, triamcinolone acetonide, and betamethasone had been reported in adult patients.12345678 Based on a PubMed search, there is one similar complication reported in the pediatric age group recently.9 We described a child who displayed signs of conjunctival necrosis 2 weeks after a subconjunctival injection of triamcinolone acetonide for recurrent attack of anterior uveitis. It is essential to highlight this uncommon complication of periocular corticosteroid injection in children.

CASE REPORT

A mother had noted that her daughter started to have recurrent redness, discomfort, and photophobia in both eyes since she was two and half years of age. Six months after the onset, she was examined in a tertiary hospital and parents were informed that she had severe anterior uveitis in both eyes that had complicated with secondary cataract.

Her visual acuity was 6/60 in both eyes with evidence of posterior subcapsular cataract bilaterally. The conjunctiva was white. The cornea was clear in both eyes with no sign of band keratopathy. The anterior chamber appeared quiet and no iris nodules were documented. The pupil was fairly round with few sites of anterior synechiae observed. The intraocular pressure was within normal. The fundus view was hazy in both eyes. All laboratory investigations including antinuclear antibody and rheumatoid factor were negative. No radiological examination was performed because she was asymptomatic. The parent consented for lens aspiration and intraocular lens implantation in her right eye and followed with the similar operation in her left eye 3-months apart. Both the operations were uneventful.

Subsequently, her visual acuity deteriorated to 6/36 in the right eye and counting fingers in the left eye. Postoperatively, there was persistent anterior uveitis, presence of dense membrane anterior to the intraocular lenses in both eyes, formation of posterior synechiae between the iris and lens, and elevated intraocular pressure. The view of the optic disc and retina was obscured. The B scan ultrasound revealed flat retina in both eyes.

She was treated with syrup prednisolone 1 mg/kg/body weight, gutt predforte every 2 hourly, gutt tropicamide 0.5% every 12 hourly, and gutt timolol 0.5% 12 hourly in both eyes. Her parents agreed for synechiolysis procedure and removal of the membrane covering the pupil in her left eye under general anesthesia. The operation was uneventful. A subconjunctiva triamcinolone acetonide 20 mg (0.5 ml) was injected at the inferonasal aspect of the conjunctiva in the operated eye at the end of the procedure.

At 1 week postoperative review, a subconjunctival hemorrhage was noted that corresponded with the previous site of injection given. A week later, an area of conjunctival necrosis measuring about 5 × 3 mm was observed at the similar site [Figure 1]. The base showed gray-to-white scleral layer with no uveal show. There surrounding conjunctiva was mildly congested. No evidence of scleral inflammation was noted. The patient was started on topical moxifloxacin every 6 hourly in the affected eye.

Figure 1

Anterior segment photograph shows conjunctival necrosis developed 2 weeks after the subconjunctival injection of triamcenolone acetonide

There was a gradual clinical improvement observed 2-weeks later. The new conjunctiva has growing with pinkish appearance. The base of the ulcer appeared clean with evidence of scleral vascularization [Figure 2]. The conjunctival reepithelialization occurred from the edge of the surrounding healthy conjunctiva tissue. The conjunctiva necrosis was completely healed after 10 weeks and overlying conjunctiva was fully restored [Figure 3]. Topical moxifloxacin were discontinued. She has been monitored closely for 9 months and the conjunctiva had healed completely.

Figure 2

Clinical improvement after 2 weeks of medical treatment

Figure 3

A complete recovery of conjunctival necrosis

Her visual acuity remained 6/60 in the right eye and counting finger at 3 feet in the left eye. Both the intraocular lenses were covered by thick membrane that was worse in the left eye. The retina view remained hazy in both eyes. The intraocular pressure remained controlled with gutt timolol 0.5% and trusopt every 12 hourly in both eyes.

DISCUSSION

Triamcinolone acetonide has been used widely in the treatment of pediatric eye diseases. These include triamcinolone-assisted vitrectomy during pediatric cataract operation, intracameral injection in pediatric cataract surgery, intravitreal injection for uveitic macular edema, periocular injection in pediatric uveitis, supratarsal injection in allergic conjunctivitis, intravitreal injections for Coat's disease, and Best vittelliform macula dystrophy.1011121314151617

Conjunctival necrosis in children following injection of triamcinolone acetonide is extremely rare. It was very unfortunate for our patient, a young girl who developed conjunctival necrosis following subconjunctival injection of triamcenolone acetonide for severe anterior uveitis. Recently, Say et al. described a child who developed perilymphatic linear subcutaneous fat atrophy and depigmentation following subtenon injection of triamcinolone acetonide.18

The necrosis appeared localized, hypovascular, and aseptic in our patient. This is probably due to the following explanations. Firstly, corticosteroids are known to potentiate the vasoconstrictive effect of circulating catecholamines, and this may result in an area of localized conjunctiva ischemia.1 Secondly, conjunctival necrosis after a subconjunctival steroid injection may be due to the inactive ingredient benzyl alcohol because of its potential toxicity. Thirdly, improper dosage and injection sites with insufficient prophylactic antibiotic may play important roles in the pathogenesis.9 Eslampour et al. reported that deposition of steroid in the subtenon instead of subconjunctival space may prevent conjunctival toxicity.9 Improper site of administration such as the inferonasal bulbar conjunctiva within the interpalpebral fissure may predispose to conjunctival necrosis due to greater exposure and promixity to the lower lid margin.9 Low dose of topical antibiotic administration despite a high dose of steroid depot may also invite infection. Lastly, fragile conjunctiva that had been exposed to chronic usage of topical corticosteroid perhaps had facilitated the ulceration process in our patient.

Table 1 summarizes published literature on conjunctival necrosis following corticosteroid injection, i.e. triamcinolone acetate, betamethasone, and methylprednisolone. Intensive topical antibiotic, surgical excision, debridement, and suturing have been described to treat the above conditions.2456789 The complete healing was reported ranged from 2-6 weeks in eyes with preexisting inflammatory condition.28 Surgical excision of the necrotic tissues had reported relatively faster recovery.4579

Table 1

Published literatures on conjunctival necrosis following corticosteroid injection

Our observation is parallel with Agrawal et al. who treated their patients conservatively. Their patients showed complete healing with combination of topical antibiotic and antifungal regime after 2-6 weeks.2 Our patient responded to a single topical antibiotic and subsequently showed a complete recovery after 10 weeks. We monitored this patient closely for a possibility of secondary infection.

In conclusion, conjunctival necrosis following subconjunctival triamcinolone acetonide is rare in children. We believe that chronic usage of topical and systemic corticosteroid has probably made her more susceptible to this condition. Administration of subconjunctival triamcinolone acetonide requires proper case selection and counseling as to the potential risks and benefits.