INTRAVITREAL INJECTION OF TRIAMCINOLONE ACETONIDE FOR SEROUS MACULAR DETACHMENT IN A PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSUS Chi-Hsien Peng, MD,*†‡ Cheng-Kuo Cheng, MD*†§
Purpose: To report our experience with intravitreal triamcinolone acetonide treatment of serous macular detachment in a patient with active systemic lupus erythematosus (SLE). Methods: Interventional case report. Results: A 38-year-old man who had SLE with bilateral serous macular detachment and retinopathy was treated with a single intravitreal injection of triamcinolone acetonide in one eye and two intravenous injections of a megadose steroid. Serous detachment in the eye injected with intravitreal steroid showed more significant improvement than that in the fellow eye. Conclusion: Our case suggests that intravitreal triamcinolone acetonide injection may be considered for treatment of SLE-related serous macular detachment that does not respond to systemic steroid therapy. RETINAL CASES & BRIEF REPORTS 2:36 –38, 2008
From the *Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial Hospital, the †School of Medicine, Fu Jen Catholic University, the ‡School of Medicine, National Yang-Ming University, and the §School of Medicine, National Taiwan University, Taipei, Taiwan.
not respond well to systemic steroid and immunosuppressive therapy. To our knowledge, this is the first report of IVTA injection to treat serous macular detachment in association with SLE. Case Report
I
ntravitreal triamcinolone acetonide (IVTA) is widely accepted for the treatment of macular edema.1 Recently, it has also been shown to be effective in inducing regression of serous macular detachments associated with advanced diabetic macular edema2 and branch retinal vein occlusion.3 We describe our experience with IVTA injection to treat serous macular edema in a patient with active systemic lupus erythematosus (SLE) complicated with diabetes, hypertension, and lupus nephritis. Serous detachment did
A 38-year-old man with a 3-week history of blurred vision in both eyes presented with bilateral cotton-wool spots, exudates, multiple retinal flame-shaped hemorrhages radiating from the disk, and bullous macular detachments (Fig. 1, A and B). Best-corrected visual acuity was counting fingers in the right eye and 20/600 in the left eye. Fluorescein angiograms showed marked diffuse retinal vascular leakage, microaneurysms, and diffuse darkening of choroidal vasculature (Fig. 1, C and D). Optical coherence tomography images revealed severe serous macular detachments in both eyes. He had a history of diabetes mellitus and poorly controlled hypertension for several years and had undergone hemodialysis for 3 months. He was referred to the rheumatology department where a diagnosis of SLE was established on the basis of renal pathologic findings, constitutional symptoms and signs, anemia, and serological abnormalities. Serological examinations revealed positivity for antinuclear antibody, an elevated level of antibody to doublestranded DNA, decreased levels of complements, and presence of anticardiolipin antibody. He was treated with oral prednisolone
None of the authors have any proprietary or commercial interests related to this report. Reprint requests: Cheng-Kuo Cheng, MD, Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wen-Chang Road, Shih-Lin District, Taipei 11120, Taiwan; email: [email protected]
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IVTA FOR MACULAR DETACHMENT IN SLE
Fig. 1. Fundus color photographs showing cotton-wool spots, exudates, multiple retinal flame-shaped hemorrhages radiating from the disk, and bullous macular detachment: A, right eye; B, left eye. Fluorescein angiograms showing marked diffuse retinal vascular leakage, microaneurysms, and diffuse darkening of choroidal vasculature: C, right eye; D, left eye.
(0.5 mg/[kg·d]) and azathioprine (4 mg/[kg·d]) for 3 months. The autoimmune activity was only moderately controlled. The level of antibody to double-stranded DNA decreased from 51 IU/mL to 41 IU/mL (normal value, ⬍15 IU/mL), and complement levels increased slightly but were still subnormal. Meanwhile, angiotensinconverting enzyme inhibitors and -blockers were administered for control of hypertension, and his blood pressure gradually decreased from 160/100 mmHg to 134/80 mmHg in 1 month. However, serous macular detachment did not improve significantly in both eyes (Fig. 2, A and B). Optical coherence tomography images showed macular thickness of 990 m in the right eye and 781 m in the left eye. An intravitreal injection of 20 mg of crystalline triamcinolone acetonide (Kenacort-A; Bristol-Myers Squibb) was given in the right eye. Vision in the right eye improved gradually, and after 3 months, best-corrected visual acuity became 20/60. Optical coherence tomography showed significant reabsorption of subretinal fluid and attached macula in the right eye (Fig. 2C). Because of active lupus nephritis, two courses of megadose steroid “pulse therapy” (intravenous injections of 1 g of methylprednisolone daily for 3 days) were administered 1 month and 2 months after IVTA injection was given to the right eye. Vision and serous macular detachment of the left eye showed little improvement after the systemic steroid treatment (Fig. 2D). Instead, retinopathy worsened in the left eye. Retinal microangiopathy of increasing severity, neovascular membrane, and preretinal hemorrhages developed 1 month later, prompting treatment with panretinal photocoagulation. The macular thickness measured 189 m in the right eye and 561 m in the left eye 2 months after completion of the second course of megadose steroid injection. He was then treated with IVTA injection in the left eye. Serous macular detachment regressed rapidly. One month after the intravitreal injection, optical coherence tomography images demonstrated complete resolution of serous macular detachments in both eyes (Fig. 2, E and F). Macular thickness was 132 m
in the right eye and 177 m in the left eye. After 3 months of follow-up, the macula remained attached in both eyes. Best-corrected visual acuity was 20/40 in the right eye and 20/400 in the left eye.
Discussion Our patient had newly diagnosed SLE complicated with long-term diabetes, hypertension, and lupus ne-
Fig. 2. Central macular thicknesses in both eyes detected by optical coherence tomography. Preinjection optical coherence tomography showing serous macular detachments: A, right eye; B, left eye. Optical coherence tomography showing significant regression of detachment in the right eye and persisted serous macular detachment in the left eye 3 months after intravitreal injection in the right eye: C, right eye; D, left eye. Optical coherence tomography showing significant regression of detachment in the left eye 1 month after an intravitreal injection in the left eye: E, right eye; F, left eye.
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RETINAL CASES & BRIEF REPORTSℜ
phropathy. The retinal manifestations in our patient— cotton-wool spots, exudates, microangiopathy, and dot and blot retinal hemorrhages—are common features of diabetic retinopathy, hypertensive retinopathy, and lupus retinopathy. However, prominent serous macular detachment is unusual in diabetic retinopathy and is more commonly related to hypertension and SLE. Although choroidopathy is the most common cause of serous macular detachment in patients with accelerated hypertension or active SLE, subretinal fluid may accumulate from severe leakage of retinal vessels.4 In this case, fluorescein angiograms showed extensive retinal vascular leakage without marked choroidal hyperfluorescence, suggesting the source of subretinal fluid was from retinal vessels. IVTA injection has the potential to downregulate intraocular inflammatory cytokines and influence cellular permeability.2 It restores function of the blood–retinal barrier and enhances resolution of the subretinal fluid.2 Although intravenous steroid is generally very effective in the treatment of serous macular detachment due to choroidal inflammation,5 IVTA injection has been reported to be effective for regression of macular detachment due to occlusive retinopathy.3 In our patient, IVTA injection worked rapidly to resolve serous macular detachment after failure of systemic steroid therapy. Serous macular detachment persisted in the left eye after treatments with two intravenous megadose steroid injections. In contrast, the right eye had significant improvement of macular detachment after a single IVTA injection. Prompt improvement of the left eye after IVTA injection further supports the effectiveness of IVTA injection for treating subretinal fluid from a retinal source.
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2008
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VOLUME 2
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NUMBER 1
In conclusion, our case suggests that IVTA injection may be considered in the treatment of SLErelated serous macular detachment that dose not respond to systemic steroid therapy. There is a need for further studies to understand the cause of serous macular detachment in SLE and to compare the safety and efficacy of IVTA injection with those of systemic steroid therapy. Key words: systemic lupus erythematosus, serous detachment, intravitreal injection, triamcinolone acetonide. Acknowledgment The authors thank Professor Chung-May Yang (Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan) for the critical review of this report.
References 1.
2.
3.
4.
5.
Chieh JJ, Roth DB, Liu M, et al. Intravitreal triamcinolone acetonide for diabetic macular edema. Retina 2005;25:828– 834. Ozdemir H, Karacorlu M, Karacorlu SA. Regression of serous macular detachment after intravitreal triamcinolone acetonide in patients with diabetic macular edema. Am J Ophthalmol 2005;140:251–255. Karacorlu M, Ozdemir H, Karacorlu SA. Resolution of serous macular detachment after intravitreal triamcinolone acetonide in patients with branch retinal vein occlusion. Retina 2005;25: 856–860. Otani T, Yamaguchi Y, Kishi S. Serous macular detachment secondary to distant retinal vascular disorders. Retina 2004; 24:758–762. Nguyen QD, Uyl HS, Akpek EK, et al. Choroidopathy of systemic lupus erythematosus. Lupus 2000;9:288–298.
Purpose: To report our experience with intravitreal triamcinolone acetonide treatment of serous macular detachment in a patient with active systemic lupus erythematosus (SLE). Methods: Interventional case report. Results: A 38-year-old man who had SLE with bilateral serous macular detachment and retinopathy was treated with a single intravitreal injection of triamcinolone acetonide in one eye and two intravenous injections of a megadose steroid. Serous detachment in the eye injected with intravitreal steroid showed more significant improvement than that in the fellow eye. Conclusion: Our case suggests that intravitreal triamcinolone acetonide injection may be considered for treatment of SLE-related serous macular detachment that does not respond to systemic steroid therapy. RETINAL CASES & BRIEF REPORTS 2:36 –38, 2008
From the *Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial Hospital, the †School of Medicine, Fu Jen Catholic University, the ‡School of Medicine, National Yang-Ming University, and the §School of Medicine, National Taiwan University, Taipei, Taiwan.
not respond well to systemic steroid and immunosuppressive therapy. To our knowledge, this is the first report of IVTA injection to treat serous macular detachment in association with SLE. Case Report
I
ntravitreal triamcinolone acetonide (IVTA) is widely accepted for the treatment of macular edema.1 Recently, it has also been shown to be effective in inducing regression of serous macular detachments associated with advanced diabetic macular edema2 and branch retinal vein occlusion.3 We describe our experience with IVTA injection to treat serous macular edema in a patient with active systemic lupus erythematosus (SLE) complicated with diabetes, hypertension, and lupus nephritis. Serous detachment did
A 38-year-old man with a 3-week history of blurred vision in both eyes presented with bilateral cotton-wool spots, exudates, multiple retinal flame-shaped hemorrhages radiating from the disk, and bullous macular detachments (Fig. 1, A and B). Best-corrected visual acuity was counting fingers in the right eye and 20/600 in the left eye. Fluorescein angiograms showed marked diffuse retinal vascular leakage, microaneurysms, and diffuse darkening of choroidal vasculature (Fig. 1, C and D). Optical coherence tomography images revealed severe serous macular detachments in both eyes. He had a history of diabetes mellitus and poorly controlled hypertension for several years and had undergone hemodialysis for 3 months. He was referred to the rheumatology department where a diagnosis of SLE was established on the basis of renal pathologic findings, constitutional symptoms and signs, anemia, and serological abnormalities. Serological examinations revealed positivity for antinuclear antibody, an elevated level of antibody to doublestranded DNA, decreased levels of complements, and presence of anticardiolipin antibody. He was treated with oral prednisolone
None of the authors have any proprietary or commercial interests related to this report. Reprint requests: Cheng-Kuo Cheng, MD, Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wen-Chang Road, Shih-Lin District, Taipei 11120, Taiwan; email: [email protected]
36
37
IVTA FOR MACULAR DETACHMENT IN SLE
Fig. 1. Fundus color photographs showing cotton-wool spots, exudates, multiple retinal flame-shaped hemorrhages radiating from the disk, and bullous macular detachment: A, right eye; B, left eye. Fluorescein angiograms showing marked diffuse retinal vascular leakage, microaneurysms, and diffuse darkening of choroidal vasculature: C, right eye; D, left eye.
(0.5 mg/[kg·d]) and azathioprine (4 mg/[kg·d]) for 3 months. The autoimmune activity was only moderately controlled. The level of antibody to double-stranded DNA decreased from 51 IU/mL to 41 IU/mL (normal value, ⬍15 IU/mL), and complement levels increased slightly but were still subnormal. Meanwhile, angiotensinconverting enzyme inhibitors and -blockers were administered for control of hypertension, and his blood pressure gradually decreased from 160/100 mmHg to 134/80 mmHg in 1 month. However, serous macular detachment did not improve significantly in both eyes (Fig. 2, A and B). Optical coherence tomography images showed macular thickness of 990 m in the right eye and 781 m in the left eye. An intravitreal injection of 20 mg of crystalline triamcinolone acetonide (Kenacort-A; Bristol-Myers Squibb) was given in the right eye. Vision in the right eye improved gradually, and after 3 months, best-corrected visual acuity became 20/60. Optical coherence tomography showed significant reabsorption of subretinal fluid and attached macula in the right eye (Fig. 2C). Because of active lupus nephritis, two courses of megadose steroid “pulse therapy” (intravenous injections of 1 g of methylprednisolone daily for 3 days) were administered 1 month and 2 months after IVTA injection was given to the right eye. Vision and serous macular detachment of the left eye showed little improvement after the systemic steroid treatment (Fig. 2D). Instead, retinopathy worsened in the left eye. Retinal microangiopathy of increasing severity, neovascular membrane, and preretinal hemorrhages developed 1 month later, prompting treatment with panretinal photocoagulation. The macular thickness measured 189 m in the right eye and 561 m in the left eye 2 months after completion of the second course of megadose steroid injection. He was then treated with IVTA injection in the left eye. Serous macular detachment regressed rapidly. One month after the intravitreal injection, optical coherence tomography images demonstrated complete resolution of serous macular detachments in both eyes (Fig. 2, E and F). Macular thickness was 132 m
in the right eye and 177 m in the left eye. After 3 months of follow-up, the macula remained attached in both eyes. Best-corrected visual acuity was 20/40 in the right eye and 20/400 in the left eye.
Discussion Our patient had newly diagnosed SLE complicated with long-term diabetes, hypertension, and lupus ne-
Fig. 2. Central macular thicknesses in both eyes detected by optical coherence tomography. Preinjection optical coherence tomography showing serous macular detachments: A, right eye; B, left eye. Optical coherence tomography showing significant regression of detachment in the right eye and persisted serous macular detachment in the left eye 3 months after intravitreal injection in the right eye: C, right eye; D, left eye. Optical coherence tomography showing significant regression of detachment in the left eye 1 month after an intravitreal injection in the left eye: E, right eye; F, left eye.
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RETINAL CASES & BRIEF REPORTSℜ
phropathy. The retinal manifestations in our patient— cotton-wool spots, exudates, microangiopathy, and dot and blot retinal hemorrhages—are common features of diabetic retinopathy, hypertensive retinopathy, and lupus retinopathy. However, prominent serous macular detachment is unusual in diabetic retinopathy and is more commonly related to hypertension and SLE. Although choroidopathy is the most common cause of serous macular detachment in patients with accelerated hypertension or active SLE, subretinal fluid may accumulate from severe leakage of retinal vessels.4 In this case, fluorescein angiograms showed extensive retinal vascular leakage without marked choroidal hyperfluorescence, suggesting the source of subretinal fluid was from retinal vessels. IVTA injection has the potential to downregulate intraocular inflammatory cytokines and influence cellular permeability.2 It restores function of the blood–retinal barrier and enhances resolution of the subretinal fluid.2 Although intravenous steroid is generally very effective in the treatment of serous macular detachment due to choroidal inflammation,5 IVTA injection has been reported to be effective for regression of macular detachment due to occlusive retinopathy.3 In our patient, IVTA injection worked rapidly to resolve serous macular detachment after failure of systemic steroid therapy. Serous macular detachment persisted in the left eye after treatments with two intravenous megadose steroid injections. In contrast, the right eye had significant improvement of macular detachment after a single IVTA injection. Prompt improvement of the left eye after IVTA injection further supports the effectiveness of IVTA injection for treating subretinal fluid from a retinal source.
●
2008
●
VOLUME 2
●
NUMBER 1
In conclusion, our case suggests that IVTA injection may be considered in the treatment of SLErelated serous macular detachment that dose not respond to systemic steroid therapy. There is a need for further studies to understand the cause of serous macular detachment in SLE and to compare the safety and efficacy of IVTA injection with those of systemic steroid therapy. Key words: systemic lupus erythematosus, serous detachment, intravitreal injection, triamcinolone acetonide. Acknowledgment The authors thank Professor Chung-May Yang (Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan) for the critical review of this report.
References 1.
2.
3.
4.
5.
Chieh JJ, Roth DB, Liu M, et al. Intravitreal triamcinolone acetonide for diabetic macular edema. Retina 2005;25:828– 834. Ozdemir H, Karacorlu M, Karacorlu SA. Regression of serous macular detachment after intravitreal triamcinolone acetonide in patients with diabetic macular edema. Am J Ophthalmol 2005;140:251–255. Karacorlu M, Ozdemir H, Karacorlu SA. Resolution of serous macular detachment after intravitreal triamcinolone acetonide in patients with branch retinal vein occlusion. Retina 2005;25: 856–860. Otani T, Yamaguchi Y, Kishi S. Serous macular detachment secondary to distant retinal vascular disorders. Retina 2004; 24:758–762. Nguyen QD, Uyl HS, Akpek EK, et al. Choroidopathy of systemic lupus erythematosus. Lupus 2000;9:288–298.
