Iatrogenic Subretinal Triamcinolone During Primary Surgical Repair of a Retinal Detachment With a Giant Retinal Tear

Abstract

Purpose:

We describe the outcome of a 23-year-old man undergoing vitreoretinal surgery for a macula-off rhegmatogenous retinal detachment secondary to a giant retinal tear.

Methods:

Patient underwent combined 25- gauge 3-port pars plana vitrectomy with scleral buckle, perfluorocarbon liquid, and perfluoropropane gas tamponade. During surgery, triamcinolone inadvertently entered the subretinal space and was retained.

Results:

The subretinal triamcinolone deposits spontaneously absorbed over a 2-month period. No adverse sequelae were associated with this complication.

Conclusion:

This may support avoiding aggressive mechanical removal of iatrogenic subretinal triamcinolone in the context of retinal detachment repair.

Introduction

Giant retinal tears (GRTs) comprise 1.5% of rhegmatogenous retinal detachments (RDs) ¹ and are at risk for proliferative vitreoretinopathy causing surgical failure and significant loss of vision. Pars plana vitrectomy is considered to be the standard procedure for repair of GRT-associated RD. ² Surgical repair often involves techniques that use perfluorocarbon liquids, membranectomy, silicone oil tamponade, and adjuvant scleral buckle placement. ³

Triesence (Alcon) is a preservative-free triamcinolone formulation that is approved by the Food and Drug Administration for intraocular use, including use for vitreous visualization. As an off-label use, triamcinolone in the form of Kenalog (Bristol Myers Squibb) can be administered for the same indication. We have previously shown the utility of intravitreal triamcinolone in RD repair to ensure complete removal of the posterior hyaloid and vitreoschisis and to aid chromovitrectomy. ^4,5 However, a potential drawback with intravitreal triamcinolone usage for RD repair is that the corticosteroid particulates can gain access to the subretinal space via the retinal breaks. It has been shown that subretinal triamcinolone can be toxic to the outer retina and retinal pigment epithelium in rabbit models. ⁶ In addition, histologic assays reveal potential areas of absence and/or hyperpigmentation of the retinal pigment epithelium and damage to photoreceptors and the outer nuclear layer of the retina. ⁶

Interestingly, other reports have shown subretinal triamcinolone to cause minimal toxicity to the neurosensory retina based on clinical, functional, and histopathologic data. ⁷ Previously, human ocular tissues were shown to tolerate accidental subretinal injection of triamcinolone without toxicity. ⁸ Here, we describe a case of iatrogenic subretinal triamcinolone during surgical repair of RD associated with a GRT.

Methods

Case

A 23-year-old man with a temporal GRT and associated macula-off rhegmatogenous RD underwent combined 25-gauge 3-port pars plana vitrectomy with scleral buckle, perfluorocarbon liquid, and perfluoropropane gas tamponade. The patient’s visual acuity at presentation was hand motion. To optimize visualization, chromovitrectomy with approximately 0.2 mL of undiluted triamcinolone (Triesence, 40 mg/mL) was injected into the midvitreous cavity to stain the vitreous and highlight the posterior hyaloid interface. During the vitrectomy, the white triamcinolone particulates dispersed and inadvertently gained access to the subretinal space via the GRT, which involved the macula (Figure 1). It was readily apparent that it could not be safely removed via aspiration alone, and thus no further attempt was made to mechanically remove the subretinal triamcinolone. The surgery proceeded in the usual fashion and the RD was otherwise repaired, albeit with the triamcinolone particulates left in the subretinal space (Supplemental Video).

Figure 1.

Intraoperative photograph showing extent of subretinal and submacular triamcinolone particulates (arrows) encompassing much of the macula, especially the superotemporal macula, but sparing the fovea.

Results

The patient was closely monitored for 6 months. The subretinal triamcinolone deposits spontaneously absorbed over a 2-month period. At 6 months’ postoperative follow-up, his best-corrected visual acuity improved to 20/40. Color fundus photography and optical coherence tomography imaging confirmed an attached retina without complications (Figure 2). Optical coherence tomography imaging displayed outer retinal attenuation and ellipsoid zone loss, which may be a result of the RD or a consequence of toxicity secondary to subretinal triamcinolone; however, the patient remained asymptomatic after retinal reattachment and denied any metamorphopsia or scotomas. The patient did not develop ocular hypertension in the postoperative period.

Figure 2.

(A) Postoperative color fundus photograph showing subretinal triamcinolone had completely resolved. (B) Optical coherence tomography of the macula showing the attached macula and absence of any hyperreflective material in the subretinal space. VA indicates visual acuity.

Conclusions

We described a patient with iatrogenic subretinal triamcinolone during surgical repair of GRT-associated RD. Our patient had excellent anatomic and visual outcomes and did not show adverse sequelae associated with subretinal triamcinolone; this may support avoiding aggressive mechanical removal of iatrogenic subretinal triamcinolone in the context of RD repair. However, we could not determine whether there was definitive retinal toxicity associated with subretinal triamcinolone in this case because the patient did not have formal perimetric or electroretinogram testing. Further studies are required to assess the tolerance of subretinal triamcinolone.