Purpose
To suggest that sub-Tenon triamcinolone acetonide (TA) injections may be a helpful supplement in patients with scleritis.
Design
Retrospective, interventional case series.
Methods
A retrospective chart review was conducted of all patients at our institution receiving sub-Tenon TA injections for scleritis between August 2001 and August 2007. Outcome measures included subjective improvement, presence of inflammation, and adverse events.
Results
Eleven patients (12 eyes) were included in this study. The mean age was 50 years; 2 patients were male and 9 female. Six patients had systemic autoimmune disease. All patients were receiving systemic medications for scleritis at the time of injection. Mean initial follow-up time was 3 weeks. Ten of 11 patients reported subjective improvement, and 10 patients had improvement in objective inflammation. Three patients had adverse side effects, including ocular hypertension, worsening of cataract, and subconjunctival hemorrhage with periorbital ecchymosis.
Conclusions
Sub-Tenon TA injections may be a useful adjunct to achieving transient, partial improvement of subjective pain and objective inflammation in patients with scleritis while awaiting systemic medications to take effect. Adverse events were manageable in this small series.
Scleritis is an inflammatory ocular condition with potentially serious complications. It is characterized by severe pain and deep, destructive granulomatous inflammation in the sclera. Approximately 40% to 50% of patients with scleritis have an associated systemic disorder such as rheumatoid arthritis, Wegener granulomatosis, systemic lupus erythematosus, inflammatory bowel disease, or relapsing polychondritis. Rheumatoid arthritis is the most commonly associated condition. The disease is classified as anterior or posterior; anterior scleritis is further subdivided into diffuse, nodular, and necrotizing patterns.
The management of scleritis presents a challenge. Because of the severity and depth of the inflammation, topical agents frequently are ineffective. Systemic administration of nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, nonsteroidal immunosuppressive agents, or a combination, is the mainstay of treatment. These therapies can have serious adverse side effects and morbidity. Although regional steroid injections have been used in the treatment of uveitis, this approach in scleritis generally has been avoided because of concerns about poor efficacy and adverse side effects, including scleral perforation or melt, glaucoma, or cataract. However, a few reports have challenged this paradigm and have described case series of scleritis patients receiving subconjunctival corticosteroid injections (SCI) with positive responses. Local corticosteroid treatment may be an attractive adjunct to systemic therapy by achieving timely improvement while systemic medications begin to take effect. We conducted a retrospective chart review to review our experience using these injections.
Methods
Records were reviewed for all patients with scleritis who underwent sub-Tenon corticosteroid injections from August 2001 through August 2007 by the principal investigator at the University of Medicine and Dentistry of New Jersey. We used Current Procedural Terminology (CPT) code 67515 and identified patients with scleritis. Patients with initial follow-up data within 5 weeks after injection were included, because we wanted to observe the rapid effects of injections. The indications for sub-Tenon injection included active inflammation despite systemic treatment with NSAIDs, corticosteroids, other immunosuppressant agents, or a combination thereof, and nonnecrotizing disease. The risks, benefits, and alternatives of injections were explained to all patients before administration. Patients underwent a detailed evaluation, including systemic and ocular history, slit-lamp examination, intraocular pressure (IOP), dilated fundus examination, and laboratory tests. All patients received sub-Tenon triamcinolone acetonide (TA) injection (1 mL of a 40 mg/mL suspension). The medication was delivered with 3-mL syringe using a 25-gauge 5/8–inch needle transcutaneously into the sub-Tenon space in the inferior temporal aspect of the orbit.
Outcome measures included subjective data such as pain, foreign body sensation, discomfort, or redness, objective inflammation observed on slit-lamp examination, IOPs, and any adverse side effects. Subjective improvement was noted if the patient reported a decrease in symptoms. Objective improvement was defined as external slit-lamp biomicroscopic findings of decreased scleral inflammation on a 4-point grading scale by the principal investigator. Resolution was defined as the absence of inflammation on examination.
Results
Twelve eyes from 11 patients with nonnecrotizing scleritis were treated with SCI between August 2001 and August 2007 and were included in the study ( Table ). The mean age at injection was 50 years; 2 patients were male and 9 female. One patient had bilateral disease. Six patients had a concomitant systemic autoimmune disease, including Wegener granulomatosis, rheumatoid arthritis, celiac sprue, and systemic lupus erythematosus. One patient was a Wegener granulomatosis suspect. All patients were receiving systemic medications before the time of injection. Five patients were receiving NSAIDs, one of whom was concurrently being treated with methotrexate. Six patients were being treated with prednisone. Of these, one was concomitantly receiving methotrexate and another simultaneously was taking mycophenolate mofetil. Two patients were excluded because they were lost follow-up. One patient did not meet inclusion criteria of follow-up within 5 weeks. At 8 weeks after injection on celecoxib (Celebrex; Pfizer Inc, New York, New York, USA), she experienced some discomfort, but the scleritis had resolved.
| Patient No. | Age (years) | Gender | Affected Eye | Systemic Diagnosis | Prior Systemic Therapy | Follow-up (wks) | Subjective Improvement | Objective Improvement | T max | Adverse Effects | Recurrence (wks) | Response to Repeat Injection |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 52 | F | Right | Rheumatoid arthritis | Celecoxib | 2 | Yes | Yes | 19.5 | None | 21 | Resolved, 4 wks |
| 2 | 50 | F | Right | Idiopathic | Prednisone | 3 | Yes | Yes | 17 | None | 18 | Improved, 2 wks |
| 3 | 43 | M | Left | Idiopathic | Prednisone | 5 | Yes | Resolved | 17 | None | 14 | Managed systemically |
| 3 | 43 | M | Left | Idiopathic | Prednisone | 4 | Yes | Yes | 15 | None | 20 | Managed systemically |
| 4 | 56 | M | Right | Celiac sprue | Prednisone | 5 | Yes | Resolved | 20 | None | None | |
| 5 | 42 | F | Right | Wegener granulomatosis | Prednisone | 2 | Yes | Yes | 31 | Worsening of posterior subcapsular cataract and ocular hypertension | 4 | Improved, 3 wks |
| 6 | 45 | F | Right | Rheumatoid arthritis | Prednisone, methotrexate | 3 | No data | Yes | 15 | None | 21 | Managed systemically |
| 7 | 44 | F | Left | HLA-B27+ | Ibuprofen | 3 | Resolved | Yes | 21 | Subconjunctival hemorrhage and ecchymosis | None | |
| 8 | 35 | F | Left | Idiopathic | Rofecoxib, methotrexate | 3 | Yes | Yes | 11 | None | 16 | Improved, 5 wks |
| 9 | 66 | F | Left | Idiopathic | Valdecoxib | 3 | Resolved | Resolved | 26 | Ocular hypertension | 12 | Improved, 4 wks |
| 10 | 59 | F | Left | Systemic Lupus erythematosus | Prednisone, mycophenolate mofetil | 4 | Resolved | Resolved | 19 | None | None | |
| 11 | 63 | F | Left | Wegener granulomatosis suspect | Celebrex | 5 | Yes | No | 15.5 | None | 15 | Improved, 7 wks |
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