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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 110  |  Issue : 1  |  Page : 1-7

Evaluation of intraocular inflammation after intracameral injection of triamcinolone acetonide during pediatric cataract surgery


Ophthalmology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Date of Submission15-Feb-2017
Date of Acceptance21-Mar-2017
Date of Web Publication17-May-2017

Correspondence Address:
Ahmed G Elmahdy
Ophthalmology Department, Faculty of Medicine, Al-Azhar University, Cairo, 11563
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejos.ejos_13_17

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  Abstract 

Purpose The aim of this study was to evaluate the efficacy and safety of intracameral triamcinolone acetonide (TA) to control inflammation in pediatric cataract eyes undergoing cataract extraction.
Patients and methods This prospective clinical study included 60 eyes of 47 patients who underwent elective cataract extraction with irrigation–aspiration under general anesthesia and were randomized to three groups. Eyes in group A were injected with 0.1 ml of 2 mg TA into the anterior chamber. Eyes in group B were injected with 0.05 ml of 1 mg TA into the anterior chamber, and eyes in group C were not administered TA. Postoperatively, in group C, topical prednisolone acetate 1% eye drops were administered six times per day for 7 days, followed by four times per day for 3 weeks, to control postoperative inflammation. In groups A and B, topical corticosteroids were not used. To evaluate the efficacy of intracameral TA, anterior chamber cells were measured on postoperative days 1, 7, and 30 using slit-lamp biomicroscopy.
Results Both treatments were equally effective in controlling postoperative inflammation following irrigation–aspiration in congenital cataract. No statistically significant differences between groups were observed.
Conclusion This study concluded that the use of TA as an intracameral injection during pediatric cataract surgery reduces aqueous cells, the main clinical findings in postsurgical inflammation.

Keywords: Irrigation–aspiration, postoperative inflammation, prednisolone acetate, triamcinolone acetonide


How to cite this article:
Elmahdy AG. Evaluation of intraocular inflammation after intracameral injection of triamcinolone acetonide during pediatric cataract surgery. J Egypt Ophthalmol Soc 2017;110:1-7

How to cite this URL:
Elmahdy AG. Evaluation of intraocular inflammation after intracameral injection of triamcinolone acetonide during pediatric cataract surgery. J Egypt Ophthalmol Soc [serial online] 2017 [cited 2017 Oct 23];110:1-7. Available from: http://www.jeos.eg.net/text.asp?2017/110/1/1/206314


  Introduction Top


Pediatric cataracts are not just cataracts in smaller eyes. Their presentation, surgery, and follow-up differ markedly from adult cataracts. There is decreased scleral rigidity and increased vitreous upthrust, which makes surgical manipulation more difficult, and there are more chances of increased postoperative inflammation [1].

Congenital cataracts usually are diagnosed at birth. If a cataract goes undetected in an infant, permanent visual loss may occur [2].

One of the largest differences between pediatric and adult cataract surgery is the postoperative course. The postoperative period in adults most often follows an uneventful course. In children, however, high uveal reactivity is the major cause of certain postoperative complications such as uveitis, fibrinous reaction, synechiae formation, pupillary block, and attacks of glaucoma. These complications are less common in adults [3].

Primary intraocular lens implantation provides a stable retinal image with minimal aniseikonia and offers a permanent method of optical correction [4]. Cataract surgery in children is challenging, particularly in the youngest due to the elastic tissues and the shallow anterior chamber (AC). Dense congenital cataract often causes severe visual impairment because of form deprivation during the sensitive period of visual development. Cataract surgery is the treatment of choice and should be performed when patients are younger than 17 weeks to ensure minimal or no visual deprivation. Most ophthalmologists prefer surgery much earlier, ideally when patients are younger than 2 months, to prevent irreversible amblyopia and sensory nystagmus in the case of bilateral congenital cataracts [5].

Unilateral cataracts have a worse prognosis compared with bilateral ones. Visual acuity is usually worse in the affected eye, because of the lack of an appropriate stimulation, poor accommodative stimulus, and a lower eye growth. Age limits to achieve satisfactory visual acuity are also smaller in unilateral congenital cataracts. There is some controversy in the literature as regards the optimal age for surgical removal. Surgery up to 6 weeks of life is believed to provide good outcomes, with a maximum limit until 12 weeks of age [6].

Since the early 1950s, corticosteroids have been used in ophthalmology to suppress intraocular inflammation by reducing inflammatory exudation and inhibiting the proliferation of fibroblasts and formation of granulation tissue [7]. They have been applied either topically as eye drops, locally by means of subconjunctival or peribulbar and retrobulbar injections, or systemically as oral medications or intravenous or intramuscular injections [7].

Topical corticosteroids are used for the prevention or suppression of postoperative inflammation [8].

The aim of this clinical study was to evaluate the efficacy of intracameral triamcinolone acetonide (TA) to control inflammation in eyes undergoing cataract extraction with irrigation–aspiration, followed by posterior chamber intraocular lens implantation.


  Patients and methods Top


Sixty eyes of 47 patients indicated to undergo elective uncomplicated irrigation–aspiration under general anesthesia were enrolled in this prospective study. Eyes with all causes of cataract were included − congenital, traumatic, or complicated. Patients were randomized to three groups. Group 1 included 20 children who received intracameral injection of 0.1 ml of TA 2.0 mg intraoperatively after successful cataract removal. Group 2 included 20 children who received intracameral injection of 0.05 ml of TA 1.0 mg intraoperatively after successful cataract removal. Group 3 included 20 children who served as a control group and received the classic regimen of topical prednisolone acetate 1% eye drops postoperatively, in the form of eye drops six times daily for 7 days and then four times daily for 3 weeks.

General procedure

  1. TA was injected into the AC through a side port using a 27-G syringe in 40 eyes.
  2. The remaining 20 eyes did not receive this injection (group 3). Postoperatively, in group 3, topical prednisolone acetate 1% eye drops were administered six times per day for 7 days, followed by four times per day for 3 weeks. Group 1 and group 2 patients did not use topical prednisolone acetate during the postoperative period.
  3. All patients received postoperative topical antibiotic one drop administered four times per day for 7 days. No other treatments were allowed. All parents of children were informed about the design of the study and the procedure involved.


Intracameral triamcinolone injection

Sterilizing triamcinolone particles

Triamcinolone has significant preservatives when taken straight from the bottle. For this reason, the liquid carrier is removed as follows:
  1. Step 1: 1 ml of Kenacort (Bristol-Myers Squibb S.p.A, Fontana del Ceraso, Anagni, Italy) was taken in a 5 ml syringe.
  2. Step 2: Thereafter, 0.22 μm filter was placed on the syringe.
  3. Step 3: The fluid was then expelled through the filter and discarded.
  4. Step 4: Thereafter, 4 ml of sterile balanced salt solution was drawn into the syringe again.
  5. Step 5: The fluid was then expelled and discarded again and the Kenacort particles were resuspended by drawing up 4 ml of balanced salt solution again.
  6. We removed the filter and the needle and attached a blunt cannula for intraocular use. The Kenacort was then washed and each dose was prepared.


Postoperative evaluation

All postoperative examinations were performed to obtain consistent grading scores and all scores were recorded for each visit and compared between the three groups.

The first dressing was carried out after 24 h and the notes were recorded in the examination and follow-up sheet.

All patients were followed up for 1 month. The follow-up schedule was as follows:
  1. First day postoperative.
  2. First week postoperatively.
  3. First month postoperatively.


On each follow-up visit, AC cells were graded from 0 to 4 as follows:
  1. Grade 0: less than five cells.
  2. Grade 1: 5–10 cells.
  3. Grade 2: 11–20 cells.
  4. Grade 3: 21–50 cells.
  5. Grade 4: more than 50 cells.


AC cell and flare scores were determined using the narrowest slit beam (0.5 mm) at a height of 8 mm, with maximal luminance and magnification of the slit lamp.


  Results Top


Sixty cases were included in this study. The cases were divided into three groups.

Group 1 included 20 eyes of 16 patients who received intracameral injection of 0.1 ml of TA 2.0 mg intraoperatively after successful cataract removal. The average age was 3.2±2.05 (ranging from 0.5 to 9) years. Seven (43.75%) patients were female and nine (56.25%) patients were male ([Table 1]).
Table 1 Demographic data of all patients

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Group 2 included 20 eyes of 16 patients who received intracameral injection of 0.05 ml of TA 1.0 mg intraoperatively after successful cataract removal. The average age was 3.04±1.85 (ranging from 0.75 to 8) years. Seven (43.75%) patients were female and nine (56.25%) patients were male.

Group 3 included 20 eyes of 15 patients who constituted the control group and received the classic regimen of topical prednisolone acetate postoperatively, in the form of eye drops six times daily for 7 days, and then four times daily for 3 weeks. The average age was 3.35±2.24 (ranging from 1 to 10) years. Seven (46.7%) patients were female and eight (53.3%) patients were male.

There were no statistically significant differences between the three groups as regards age (P=0.446) or sex (P=0.846).

The follow-up schedule was as follows:
  1. First postoperative day.
  2. First postoperative week.
  3. First postoperative month.


First postoperative day

  1. In group 1, five (25%) cases did not develop any reaction, 10 (50%) cases were reported to have AC cells of grade 1, three (15%) cases were reported to have AC cells of grade 2, and two (10%) cases were reported to have AC cells of grade 3 ([Table 2]).
  2. In group 2, four (20%) cases did not develop any reaction, 11 (55%) cases were reported to have AC cells of grade 1, three (15%) cases were reported to have AC cells of grade 2, and two (10%) cases were reported to have AC cells of grade 3 ([Table 3]).
  3. In group 3, three (15%) cases did not develop any reaction, nine (45%) cases developed AC cells of grade 1, six (30%) cases were reported to have AC cells of grade 2, and two (10%) cases were reported to have AC cells of grade 3.
Table 2 Comparison between group 1 and group 3 as regards anterior chamber cells on the first postoperative day

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Table 3 Comparison between group 2 and group 3 as regards anterior chamber cells at the first postoperative day

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There was no statistically significant difference between group 1 and group 3 as regards AC cells on the first postoperative day (P=0.670) ([Table 2]).

There was no statistically significant difference between group 2 and group 3 as regards AC cells on the first postoperative day (P=0.719) ([Table 3] and [Figure 1]).
Figure 1 Comparison between all studied groups as regards anterior chamber cells on the first day.

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First postoperative week

  1. In group 1, 10 (50%) cases did not have AC cells (grade 0), nine (45%) cases were reported to have AC cells of grade 1 in the first week, and one (5%) case was reported to have AC cells of grade 2 ([Table 4]).
  2. In group 2, 10 (50%) cases did not have AC cells (grade 0), eight (40%) cases were reported to have AC cells of grade 1, and two (10%) cases were reported to have AC cells of grade 2 ([Table 5]).
  3. In group 3, nine (45%) cases did not have AC cells (grade 0), eight (40%) cases were reported to have AC cells of grade 1, and three (15%) cases were reported to have AC cells of grade 2.
Table 4 Comparison between group 1 and group 3 as regards anterior chamber cells at the first postoperative week

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Table 5 Comparison between group 2 and group 3 as regards anterior chamber cells at the first postoperative week

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There was no statistically significant difference between group 1 and group 3 as regards AC cells at 1 week postoperatively (P=0.349) ([Table 4]).

There was no statistically significant difference between group 2 and group 3 as regards AC cells at 1 week postoperatively (P=0.675) ([Table 5] and [Figure 2]).
Figure 2 Comparison between all studied groups as regards anterior chamber cells at first week.

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First postoperative month

All cases of all groups had no AC cells (grade 0) with no signs of intraocular inflammation ([Figure 3] and [Figure 4]).
Figure 3 A case of bilateral posterior polar congenital cataract. (a) Right congenital posterior polar cataract. (b) Left congenital posterior polar cataract. (c) First postoperative day (group 1) with no inflammatory signs. (d) First postoperative day (group 3) with grade 1 iritis. (e) At 1 week post-operatively (group 1) with no inflammatory signs. (f) At 1 week post-operatively (group 3) with no inflammatory signs.

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Figure 4 A case of right post-operative congenital cataract extraction (group 2) with no inflammatory signs. (a) On the first postoperative day. (b) At 1 week post-operative.

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  Discussion Top


Surgical trauma (or manipulation) elicits a cascade of ocular inflammatory reactions in eyes undergoing cataract surgery. This inflammatory response seems to be necessary for wound healing. However, uncontrolled inflammation may cause unwanted complications such as cystoid macular edema, increased intraocular pressure, and excessive cicatrization [9].

Prostaglandins cause miosis, increase the vascular permeability of the blood–ocular barriers, and affect intraocular pressure; the lesser degree of tissue injury caused by the surgery technique is associated with a reduced inflammatory response [10].

The use of topical steroids as postoperative medication to control inflammation has been the standard practice in most ocular surgeries. Generally, this entailed instillation of drops several times a day plus other concomitant eye drops. Uncontrolled ocular inflammation can affect not only visual recovery but also the surgical outcome. The need for frequent instillation of eye drops can also affect compliance with postoperative treatment. Intracameral injection of triamcinolone at the close of surgery is aimed at reducing postoperative medications [11].

Clinical studies have correspondingly revealed that a single intraocular injection of TA may be a therapeutic option as adjunctive treatment of exudative age-related macular degeneration, diabetic cystoid macular edema, and proliferative diabetic retinopathy [12].

Although corticosteroids are potent anti-inflammatory agents that interfere with inflammation at various points, they have several disadvantages [13].

Corticosteroids have also been applied locally as subconjunctival, sub-Tenon, or intravitreal injections [14]. Complications of sub-Tenon’s injection included globe perforation, subconjunctival hemorrhage, scleral melt, inadvertent injection into the retinal or choroidal circulation, central retinal artery occlusion, blepharoptosis, proptosis, orbital fat atrophy, strabismus, chemosis, and infection [15].

Intracameral injection of 1 mg TA can effectively be used to control postoperative inflammation after uncomplicated cataract surgery with phacoemulsification. This makes it possible to decrease the dosage and duration of use of topical eye drops [16].

Aqueous cells and flare are the main clinical findings in postsurgical inflammation. For this reason, this study assessed the degree of AC cells, to evaluate postoperative inflammation.

Group 1 [intracameral injection of 2.0 mg (0.1 ml)]

Three (15%) cases had inflammatory reaction (AC cells of grade 2) on the first day postoperatively. This coincides with the results of Gills and Gills [17] because in their study they used a mean age of around 3 years, which is the same as this study. However, it is lesser than that in the study by Danis et al. [18] (16%) because in their study they used a mean age of more than 7 years, but in our study the mean age was around 3 years.

After 1 week postoperatively, one of two (50%) cases in group 1 still had AC cells of grade 2. This coincides with the results of Gills and Gills [17].

Group 2 [intracameral injection of 1.0 mg (0.05 ml)]

Three of 20 (15%) cases had inflammatory reaction (AC cells of grade 2) on the first postoperative day. This result coincides with the results of Gills and Gills [17] and Jonas et al. [12]. However, it was lesser than that reported by Danis et al. [18] (23%).

After 1 week postoperatively, two cases still had inflammatory reaction (AC cells of grade 2), which coincides with the results of Danis et al. [18].

Group 3 (classic regimen of topical prednisolone acetate 1% eye drops postoperatively)

In group 3, six of 20 (30%) cases had inflammatory reaction (AC cells of grade 2) on the first day postoperatively, which coincides with the results of Gills and Gills [17] (30%) and was higher than the results of Jonas et al. [12], which was 28%.

After 1 week postoperatively, four (20%) cases in group 3 still had inflammatory reaction (AC cells of grade 2); this result was lesser than the results of Gills and Gills [17] (27%) and Jonas et al. [12] (23%).

Gills and Gills [17] added TA to an AC solution for controlling inflammation after cataract surgery. As they did not find the appropriate dose, they began conservatively with 0.25 mg and gradually increased doses to 3.0 mg and up to 4.0 mg in diabetic patients. The authors suggested that, as the TA dose was gradually increased, the number of eyes requiring postoperative steroid treatment reduced from 45% at the lowest dose to 2% at a dose of 1.8–2.1 mg, which coincided with this study.

Catherina and George [19] also reported that 1 mg of TA injected intracamerally at the end of the surgery effectively suppressed postoperative inflammation.

Similar to the result of this study, Aylin et al. [16] reported that intracameral injection of 1 mg of TA can effectively be used to control postoperative inflammation after uncomplicated cataract surgery with phacoemulsification. This makes it possible to decrease the dosage and duration of use of topical eye drops.


  Conclusion Top


This study concluded that the use of TA as intracameral injection during pediatric cataract surgery reduces aqueous cells, the main clinical findings in postsurgical inflammation and helps patients with compliance with the use of postoperative eye drops, and may also prevent the side effects of corneal melts, conjunctival irritation, and dry eye that occur with frequent use of multiple numbers of topical eye drops. Because of the limited number of patients in this sample, larger studies are needed to confirm these results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
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Fabio E, Solange RS, Adriana B, Mauro W, Marcia BT, Paula YS, Josenilson MP. Amblyopia after unilateral infantile cataract extraction after six weeks of age. Arq Bras Oftalmol 2009; 72:645–649.  Back to cited text no. 6
    
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Yaylalı V, Ozbay D, Tatlipinar S, Yildirim C, Ozden S. Efficacy and safety of rimexolone 1% versus prednisolone acetate 1% in the control of postoperative inflammation following phacoemulsification cataract surgery. Int Ophthalmol 2004; 25:65–68.  Back to cited text no. 9
    
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Eakins KE, Whitelocke RAF, Perkins ES, Bennett A, Unger WG. Release of prostaglandins in ocular inflammation in the rabbit. Nat New Biol 1972; 239:248–249.  Back to cited text no. 10
    
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Moshfeghi AA, Flynn HW. Complications of IVTA injection. Rev Ophthalmol 2004; 11:2–5.  Back to cited text no. 11
    
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Jonas JB, Sofker A. Intraocular injection of crystalline cortisone as adjunctive treatment of proliferative diabetic retinopathy. Am J Ophthalmol 2001; 132:425–427.  Back to cited text no. 12
    
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Ichigashira N, Yamaga N. Intraocular fate of dexamethasone disodium phosphate topically applied to the eyes of rabbits. Steroids 1978; 32:615–628.  Back to cited text no. 13
    
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Gopal L, Bhende M, Sharma T. Vitrectomy for accidental intraocular steroid injection. Retina 1995; 15:295–299.  Back to cited text no. 14
    
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Gupta OP, Boynton JR, Sabini P, Markowitch WJ, Quatela CV. Proptosis after retrobulbar corticosteroid injections. Ophthalmology 2003; 110:443–447.  Back to cited text no. 15
    
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Aylin K, Mehmet B, Yonca AA. Intracameral triamcinolone acetonide to control postoperative inflammation following cataract surgery with phaecoemulsification. Acta Ophthalmol 2008; 86:183–187.  Back to cited text no. 16
    
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Gills JP, Gills P. Effect of intracameral triamcinolone to control inflammation following cataract surgery. J Cataract Refract Surg 2005; 31:1670–1671.  Back to cited text no. 17
    
18.
Danis RP, Ciulla TA, Pratt LM, Anliker W. Intravitreal triamcinolone acetonide in exudative age-related macular degeneration. Retina 2000; 20:244–250.  Back to cited text no. 18
    
19.
Catherina G, George N. Safety and efficacy of intracameral triamcinolone in postcataract inflammation. Philipp J Ophthalmol 2008; 33:22–26.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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