1928
CORRESPONDENCE
Although there was an initial postoperative improvement in CDVA, at 3 weeks the CDVA was HM and cavity hemorrhage and diffuse hyphema were noted (Figure 1). After initial conservative management, cavity washout was performed. The CDVA improved initially, but the patient returned with an IOP of 36 mm Hg, hyphema, and cavity hemorrhage. She was again managed conservatively, but the IOP proved difficult to control and she became confused on acetazolamide. The diagnosis of posterior iris chafing syndrome was considered, and the IOL was removed. This resulted in resolution of the hyphema, cavity hemorrhage, and IOP. At the 6-month follow-up, the CDVA was 6/18 aphakic and the anterior chamber was quiet with a normal IOP on no medication.
DISCUSSION To our knowledge, this is the first report of posterior iris chafing syndrome in a patient with a scleralfixated IOL. Many patients are seen in outpatient clinics after scleral-fixated IOL implantation. Considering posterior iris chafing syndrome in cases of transient visual obscuration, microhyphemas, intermittent spikes in IOP, or pigment dispersion in pseudophakic patients can avoid unnecessary investigations and interventions associated with an incorrect diagnosis. REFERENCES 1. Ellingson FT. Complications with the Choyce Mark VIII anterior chamber lens implant (uveitis-glaucoma-hyphema). Am Intraocular Implant Soc J 1977; 3:199–201
2. Masket S. Pseudophakic posterior iris chafing syndrome. J Cataract Refract Surg 1986; 12:252–256 3. Ferguson AW, Malik TY. Pseudophakic posterior iris chafing syndrome [letter]. Eye 2003; 17:451–452. Available at: http://www.nature.com/eye/journal/v17/n3/pdf/6700322a.pdf. Accessed July 23, 2014 4. Evereklioglu C, Er H, Bekir NA, Borazan M, Zorlu F. Comparison of secondary implantation of flexible open-loop anterior chamber and scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg 2003; 29:301–308 5. Kumar DA, Agarwal A, Jacob S, Prakash G, Agarwal A, Gabor SGB, Prasad S. Sutureless scleral-fixated posterior chamber intraocular lens [letter]. J Cataract Refract Surg 2011; 37:2089–2090
Inadvertent intracorneal triamcinolone injection during cataract extraction Berna Akova-Budak, MD, Sertac¸ Argun Kıvanc¸, MD, Mehmet Baykara, MD Triamcinolone acetonide is currently being used for various purposes in ophthalmology. One purpose is to facilitate the management of posterior segment disorders and vitreous visualization in anterior segment surgery.1–5 Triamcinolone particles are trapped in and on the vitreous gel. The vitreous strands become visible, assisting identification and removal of vitreous in the anterior segment.6 Several complications have been reported with intravitreal and sub-Tenon injection of triamcinolone acetonide.5,7 Although adverse
Figure 1. Six-week clinical course of intracorneal triamcinolone acetonide. A: Brown cataract in the left eye. B: Inadvertent injection of triamcinolone into the corneal stroma. C: Persistence of triamcinolone particles in the corneal stroma. D: Partial dissolution of the particles at 3 weeks. E: Continued dissolution of the particles. F: No particles noted at 6 weeks. J CATARACT REFRACT SURG - VOL 40, NOVEMBER 2014
CORRESPONDENCE
effects of triamcinolone acetonide such as intraocular pressure (IOP) increase have been noted, to our knowledge no complication from intracameral injection of triamcinolone acetonide has been reported. We describe the clinical course of a case in which triamcinolone acetonide was inadvertently injected into the cornea. CASE REPORT An 80-year-old woman presented with nuclear cataract in both eyes. The uncorrected distance visual acuity in the left eye was light perception–projection, and slitlamp examination of the eye showed a brown cataract (Figure 1, A). After nucleus removal through a scleral tunnel, a posterior capsule rupture was noted. For triamcinolone-assisted anterior vitrectomy, 40 mg/mL triamcinolone acetonide (Sinakort-A) was injected through the side port. At the time of injection, the triamcinolone was inadvertently injected into the corneal stroma (Figure 1, B). The patient was left aphakic for secondary intraocular lens implantation because there was no adequate capsule support and visualization of the anterior segment was obstructed by intracorneal triamcinolone particles. On the first day postoperatively, the triamcinolone particles persisted in the corneal stroma with Descemet membrane folds (Figure 1, C). Triamcinolone residue in the cornea partially dissolved by the third week (Figure 1, D). The residue continued to dissolve (Figure 1, E) and was hardly noticeable at 6 weeks (Figure 1, F). At the last follow-up examination, the corrected distance visual acuity was 20/100 with C11.0 diopter correction. Fundoscopy revealed confluent soft drusen at the macula, suggesting age-related macular degeneration. No IOP increase was noted during the 6 weeks. The intrastromal triamcinolone acetonide was completely absorbed within 6 weeks with no complication.
DISCUSSION No complication was encountered following anterior chamber irrigation to remove triamcinolone acetonide after triamcinolone acetonide–assisted anterior vitrectomy. No complication has been reported during injection of triamcinolone acetonide into the anterior chamber.2,3 In our case, the cataract extraction was done with the mini-nucleus technique, as described
1929
by Blumenthal,8 in which the nucleus is expressed through the sclerocorneal tunnel under an anterior chamber maintainer. Frequent use of the side ports during the complicated cataract surgery led to the formation of a secondary corneal tunnel adjacent to the side port. Thus, triamcinolone acetonide was inadventently injected into the corneal stroma through the secondary tunnel. Intracorneal triamcinolone acetonide was absorbed within 6 weeks, resulting in a clear cornea. At the initial visit, fundus examination was unattainable due to a brown cataract. At the last visit, the CDVA was consistent with retinal findings. During this 6-week period, no IOP increase was noted. REFERENCES 1. Wang B, Dong N, Xu B, Liu J, Xiao L. Efficacy and safety of intracameral triamcinolone acetonide to control postoperative inflammation after phacotrabeculectomy. J Cataract Refract Surg 2013; 39:1691–1697 2. Kasbekar S, Prasad S, Kumar BV. Clinical outcomes of triamcinolone-assisted anterior vitrectomy after phacoemulsification complicated by posterior capsule rupture. J Cataract Refract Surg 2013; 39:414–418 3. Bar-Sela SM, Fleissig E, Yatziv Y, Varssano D, Regenbogen M, Loewenstein A, Goldstein M. Long-term outcomes of triamcinolone acetonide–assisted anterior vitrectomy during complicated cataract surgery with vitreous loss. J Cataract Refract Surg 2014; 40:722–727 4. Conway MD, Canakis C, Livir-Rallatos C, Peyman GA. Intravitreal triamcinolone acetonide for refractory chronic pseudophakic cystoid macular edema. J Cataract Refract Surg 2003; 29:27–33 5. Yalcinbayir O, Gelisken O, Kaderli B, Avci R. Intravitreal versus sub-Tenon posterior triamcinolone injection in bilateral diffuse diabetic macular edema. Ophthalmologica 2011; 225:222–227 6. Burk SE, Da Mata AP, Snyder ME, Schneider S, Osher RH, Cionni RJ. Visualizing vitreous using Kenalog suspension. J Cataract Refract Surg 2003; 29:645–651 7. Jalil A, Chaudhry NL, Gandhi JS, Odat TM, Yodaiken M. Inadvertent injection of triamcinolone into the crystalline lens [letter]. Eye 2007; 21:152–154. Available at: http://www.nature.com/ eye/journal/v21/n1/pdf/6702575a.pdf. Accessed June 9, 2014 8. Blumenthal M. Manual ECCE, the present state of the art. Klin Monatsbl Augenheilkd 1994; 205:266–270
J CATARACT REFRACT SURG - VOL 40, NOVEMBER 2014
CORRESPONDENCE
Although there was an initial postoperative improvement in CDVA, at 3 weeks the CDVA was HM and cavity hemorrhage and diffuse hyphema were noted (Figure 1). After initial conservative management, cavity washout was performed. The CDVA improved initially, but the patient returned with an IOP of 36 mm Hg, hyphema, and cavity hemorrhage. She was again managed conservatively, but the IOP proved difficult to control and she became confused on acetazolamide. The diagnosis of posterior iris chafing syndrome was considered, and the IOL was removed. This resulted in resolution of the hyphema, cavity hemorrhage, and IOP. At the 6-month follow-up, the CDVA was 6/18 aphakic and the anterior chamber was quiet with a normal IOP on no medication.
DISCUSSION To our knowledge, this is the first report of posterior iris chafing syndrome in a patient with a scleralfixated IOL. Many patients are seen in outpatient clinics after scleral-fixated IOL implantation. Considering posterior iris chafing syndrome in cases of transient visual obscuration, microhyphemas, intermittent spikes in IOP, or pigment dispersion in pseudophakic patients can avoid unnecessary investigations and interventions associated with an incorrect diagnosis. REFERENCES 1. Ellingson FT. Complications with the Choyce Mark VIII anterior chamber lens implant (uveitis-glaucoma-hyphema). Am Intraocular Implant Soc J 1977; 3:199–201
2. Masket S. Pseudophakic posterior iris chafing syndrome. J Cataract Refract Surg 1986; 12:252–256 3. Ferguson AW, Malik TY. Pseudophakic posterior iris chafing syndrome [letter]. Eye 2003; 17:451–452. Available at: http://www.nature.com/eye/journal/v17/n3/pdf/6700322a.pdf. Accessed July 23, 2014 4. Evereklioglu C, Er H, Bekir NA, Borazan M, Zorlu F. Comparison of secondary implantation of flexible open-loop anterior chamber and scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg 2003; 29:301–308 5. Kumar DA, Agarwal A, Jacob S, Prakash G, Agarwal A, Gabor SGB, Prasad S. Sutureless scleral-fixated posterior chamber intraocular lens [letter]. J Cataract Refract Surg 2011; 37:2089–2090
Inadvertent intracorneal triamcinolone injection during cataract extraction Berna Akova-Budak, MD, Sertac¸ Argun Kıvanc¸, MD, Mehmet Baykara, MD Triamcinolone acetonide is currently being used for various purposes in ophthalmology. One purpose is to facilitate the management of posterior segment disorders and vitreous visualization in anterior segment surgery.1–5 Triamcinolone particles are trapped in and on the vitreous gel. The vitreous strands become visible, assisting identification and removal of vitreous in the anterior segment.6 Several complications have been reported with intravitreal and sub-Tenon injection of triamcinolone acetonide.5,7 Although adverse
Figure 1. Six-week clinical course of intracorneal triamcinolone acetonide. A: Brown cataract in the left eye. B: Inadvertent injection of triamcinolone into the corneal stroma. C: Persistence of triamcinolone particles in the corneal stroma. D: Partial dissolution of the particles at 3 weeks. E: Continued dissolution of the particles. F: No particles noted at 6 weeks. J CATARACT REFRACT SURG - VOL 40, NOVEMBER 2014
CORRESPONDENCE
effects of triamcinolone acetonide such as intraocular pressure (IOP) increase have been noted, to our knowledge no complication from intracameral injection of triamcinolone acetonide has been reported. We describe the clinical course of a case in which triamcinolone acetonide was inadvertently injected into the cornea. CASE REPORT An 80-year-old woman presented with nuclear cataract in both eyes. The uncorrected distance visual acuity in the left eye was light perception–projection, and slitlamp examination of the eye showed a brown cataract (Figure 1, A). After nucleus removal through a scleral tunnel, a posterior capsule rupture was noted. For triamcinolone-assisted anterior vitrectomy, 40 mg/mL triamcinolone acetonide (Sinakort-A) was injected through the side port. At the time of injection, the triamcinolone was inadvertently injected into the corneal stroma (Figure 1, B). The patient was left aphakic for secondary intraocular lens implantation because there was no adequate capsule support and visualization of the anterior segment was obstructed by intracorneal triamcinolone particles. On the first day postoperatively, the triamcinolone particles persisted in the corneal stroma with Descemet membrane folds (Figure 1, C). Triamcinolone residue in the cornea partially dissolved by the third week (Figure 1, D). The residue continued to dissolve (Figure 1, E) and was hardly noticeable at 6 weeks (Figure 1, F). At the last follow-up examination, the corrected distance visual acuity was 20/100 with C11.0 diopter correction. Fundoscopy revealed confluent soft drusen at the macula, suggesting age-related macular degeneration. No IOP increase was noted during the 6 weeks. The intrastromal triamcinolone acetonide was completely absorbed within 6 weeks with no complication.
DISCUSSION No complication was encountered following anterior chamber irrigation to remove triamcinolone acetonide after triamcinolone acetonide–assisted anterior vitrectomy. No complication has been reported during injection of triamcinolone acetonide into the anterior chamber.2,3 In our case, the cataract extraction was done with the mini-nucleus technique, as described
1929
by Blumenthal,8 in which the nucleus is expressed through the sclerocorneal tunnel under an anterior chamber maintainer. Frequent use of the side ports during the complicated cataract surgery led to the formation of a secondary corneal tunnel adjacent to the side port. Thus, triamcinolone acetonide was inadventently injected into the corneal stroma through the secondary tunnel. Intracorneal triamcinolone acetonide was absorbed within 6 weeks, resulting in a clear cornea. At the initial visit, fundus examination was unattainable due to a brown cataract. At the last visit, the CDVA was consistent with retinal findings. During this 6-week period, no IOP increase was noted. REFERENCES 1. Wang B, Dong N, Xu B, Liu J, Xiao L. Efficacy and safety of intracameral triamcinolone acetonide to control postoperative inflammation after phacotrabeculectomy. J Cataract Refract Surg 2013; 39:1691–1697 2. Kasbekar S, Prasad S, Kumar BV. Clinical outcomes of triamcinolone-assisted anterior vitrectomy after phacoemulsification complicated by posterior capsule rupture. J Cataract Refract Surg 2013; 39:414–418 3. Bar-Sela SM, Fleissig E, Yatziv Y, Varssano D, Regenbogen M, Loewenstein A, Goldstein M. Long-term outcomes of triamcinolone acetonide–assisted anterior vitrectomy during complicated cataract surgery with vitreous loss. J Cataract Refract Surg 2014; 40:722–727 4. Conway MD, Canakis C, Livir-Rallatos C, Peyman GA. Intravitreal triamcinolone acetonide for refractory chronic pseudophakic cystoid macular edema. J Cataract Refract Surg 2003; 29:27–33 5. Yalcinbayir O, Gelisken O, Kaderli B, Avci R. Intravitreal versus sub-Tenon posterior triamcinolone injection in bilateral diffuse diabetic macular edema. Ophthalmologica 2011; 225:222–227 6. Burk SE, Da Mata AP, Snyder ME, Schneider S, Osher RH, Cionni RJ. Visualizing vitreous using Kenalog suspension. J Cataract Refract Surg 2003; 29:645–651 7. Jalil A, Chaudhry NL, Gandhi JS, Odat TM, Yodaiken M. Inadvertent injection of triamcinolone into the crystalline lens [letter]. Eye 2007; 21:152–154. Available at: http://www.nature.com/ eye/journal/v21/n1/pdf/6702575a.pdf. Accessed June 9, 2014 8. Blumenthal M. Manual ECCE, the present state of the art. Klin Monatsbl Augenheilkd 1994; 205:266–270
J CATARACT REFRACT SURG - VOL 40, NOVEMBER 2014
