Subtenon Injection Research Articles

A Comparative Study Between Single Medial Canthus Injection Using 13 x 0.45 mm Needle and Posterior Sub-Tenon Injection as Local Anesthesia Techniques for Strabismus Surgery in Adults

Background: The quality of ophthalmic anesthesia is an important component of the surgical procedure. There is no absolutely well-tolerated local eye anesthetic technique. However, it is important to choose a technique with high efficacy and safety. Objective: This study aimed to compare the efficacy and safety of peribulbar block using medial canthus single injection and posterior sub-tenon injection techniques. Methods: This prospective observational study was carried out at the Research Institute of Ophthalmology, Cairo, Egypt during the period from March to December 2018. Consecutive 60 patients of both sexes, aged >18 years-old, scheduled for bilateral strabismus surgery were enrolled in this study. In one eye of the sixty patients, medial canthus single injection peribulbar anesthesia was used (Group A), whereas posterior sub-tenon technique was applied in the other eye (Group B). Results: The median total ocular akinesia score was significantly higher in group A than in group B when assessed at 1, 3, and 5 min (p < 0.001). Each of the intraoperative (at 5 min) and postoperative pain scores showed no significant differences between the two groups (p > 0.05). However, the median scores of surgeon and patient satisfaction were significantly higher in group A compared with group B (3 vs. 2 each, p < 0.05). No patient developed occulocardiac reflex or postoperative nausea and vomiting. Conclusion: Peribulbar anesthesia by medial canthus single injection showed better akinesia of the globe than sub-tenon injection technique. Otherwise, both techniques were equally effective and safe.

HTLV-1 in Ophthalmology.

Human T-cell leukemia virus type 1 (HTLV-1) was the first retrovirus described as a causative agent for human disease. In the field of ophthalmology, a close relationship between HTLV-1 infection and uveitis was identified through a series of clinical and laboratory studies in the late 1980s–1990s. Since then, HTLV-1-related ocular manifestations such as keratoconjunctivitis sicca, interstitial keratitis, optic neuritis and adult T-cell leukemia/lymphoma (ATL)-related ocular manifestations have continuously been reported. During the three decades since the association between HTLV-1 and ocular pathologies was discovered, ophthalmic practice and research have advanced with the incorporation of new technologies into the field of ophthalmology. Accordingly, new findings from recent research have provided many insights into HTLV-1-associated ocular diseases. Advanced molecular technologies such as multiplex polymerase chain reaction (PCR)/broad-range PCR using ocular samples have enabled rapid and accurate diagnosis. Advanced ophthalmic technologies such as widefield fundus camera and optical coherence tomography (OCT) have clarified various features of HTLV-1-associated ocular manifestations, and identified characteristics such as the “knob-like ATL cell multiple ocular infiltration” (KAMOI) sign. Advanced drug delivery methods such as intravitreal injection and sub-Tenon injection have led to progress in preventing disease progression. This article describes global topics and the latest research findings for HTLV-1-associated ocular diseases, with reference to a large-scale nationwide survey of ophthalmologists. Current approaches and unmet needs for HTLV-1 infection in ophthalmology are also discussed.

A clinical study on the efficacy of posterior subtenon injection of triamcinolone acetonide in patients with post fever retinitis

Aims: The aim of this study was to assess the visual outcome and fundoscopic changes following posterior subtenon (PST) injection of triamcinolone acetonide (TA) in patients with post fever retinitis. Settings and Design: This was a prospective interventional study. Subjects and Methods: A prospective interventional study was conducted on 12 patients with post fever retinitis responding poorly to systemic steroids or with contraindications to systemic steroids. Patients were treated with PST injection of 0.5 ml TA (20 mg). They were followed up for 6 months during which best-corrected visual acuity (BCVA), fundus changes, and intraocular pressure (IOP) were evaluated. Statistical Analysis Used: Descriptive statistics and paired t-test were used in this study. Results: All patients had BCVA

Spontaneous scleral rupture associated with retinochoroidal coloboma

Abstract We reported a case of ocular hypotony due to spontaneous scleral rupture in retinochoroidal coloboma and the treatment which was performed. This is a prospective case report in which a 21-year-old woman complained of abrupt vision loss in her left eye. Ocular hypotony due to spontaneous scleral rupture in retinochoroidal coloboma was identified through tests. An ultrassonography confirmed the scleral lesion but magnetic resonance imaging and fluorescein angiography have also proven to be useful. Due to the posterior location of the perforation, we opted for a sub-tenon injection of autologous blood and intraocular gas tamponade, which were successful, resulting in improved visual acuity and intraocular pressure. In this case, an alternative to invasive surgical procedure in the treatment of spontaneous scleral perforation and retinochoroidal coloboma was presented.

Posterior subtenon injection of triamcinolone acetate in subhyaloid space: A rare complication.

Posterior subtenon injection of triamcinolone acetate in subhyaloid space: A rare complication.

Subtenon Injection of Autologous Platelet-Rich Plasma in Retinitis Pigmentosa: Is It a New Therapeutic Option?

Purpose: Growth factors (GFs) and neurotrophins can decelerate retinal degeneration. This study aimed to investigate the safety, efficacy and durability of subtenon injections of autologous platelet-rich plasma (aPRP) which is a rich source of GFs in retinitis pigmentosa (RP) patients. Methods: 154 eyes of 77 RP patients with various degrees of narrowed visual field were investigated in this study. Each patient received three injections with 4-week intervals and followed for at least 12 months. The examinations and the tests were obtained before the injection, 1 month after the third injection and every 3 months during the study. The primary aim was to evaluate the effects of aPRP on visual acuity (VA) and visual functions, the second aim was to estimate the duration of the therapy effect and the need for additional aPRP injection. Results: Median age of the 77 RP patients was 35.2 ± 13.9 years. All of the eyes received 3 monthly bilateral subtenon aPRP injections. Of these patients 26 received an additional one, 12 received additional two and 1 patient received additional 3 injections with 3-month interval. There were no significant ocular or systemic side effects. The mean baseline VA was 0.22 ± 0.18 Snellen lines. It improved to 0.31 ± 0.19 following three aPRP injections, which was statistically significant. At the end of the study period, the mean VA was 0.27 ± 0.22 Snellen lines. Conclusion: The subtenon injection of aPRP might be an effective therapy and might have a positive influence in the preservation of visual functions and visual acuity of RP patients.

Evaluation of The Effect of Combined Intra-Vitreal Ranibizumab Injection and Sub-Tenon Tri-Amcinolone Acetonide Injection in The Management of Diabetic Macular Edema

Background: to monitor and compare the effect of intravitreal ranibizumab injection alone or with sub-tenon triamcinolone acetonide injection on patients with diabetic macular edema. Aim of the Work: To assess the effect of combined intravitreal ranibizumab injection, and sub-tenon triamcinolone acetonide injection in the management of diabetic macular edema. Patients and Methods: Patients with non-proliferative diabetic retinopathy associated with DME (Central macular thickness over 300 um) which are aimlessly divided into two groups. In group 1, three monthly doses (0.5 mg) of intravitreal ranibizumab are received. In group 2, the anti-VEGF injection was performed 10 days after the sub-tenon steroid injection [triamcinolone acetonide]. All patients’ visual acuity, IOP and CMT were followed up for 3 months. Results: The combined treatment showed improved best corrected visual acuity from baseline 0.24 ± 0.32 log MAR to 0.56 ± 0.18 log MAR (p = 0.023) which was statistically significant. In addition, there was decreased CMT from baseline 420.1 ± 112.84 to 275.73 ± 90.81 which was highly statistically significant (p > 0.001). When comparing the combination treatment with the anti-VEGF treatment alone, recovery of BCVA and CMT was statistically significant (p = 0.041 and p = 0.001, respectively). Conclusion: Steroid addition to the routine anti-VEGF therapy is an effective method of treatment of diabetic macular edema

Evaluation of The Effect of Combined Intra-Vitreal Ranibizumab Injection and Sub-Tenon Tri-Amcinolone Acetonide Injection in The Management of Diabetic Macular Edema

Background: to monitor and compare the effect of intravitreal ranibizumab injection alone or with sub-tenon triamcinolone acetonide injection on patients with diabetic macular edema. Aim of the Work: To assess the effect of combined intravitreal ranibizumab injection, and sub-tenon triamcinolone acetonide injection in the management of diabetic macular edema. Patients and Methods: Patients with non-proliferative diabetic retinopathy associated with DME (Central macular thickness over 300 um) which are aimlessly divided into two groups. In group 1, three monthly doses (0.5 mg) of intravitreal ranibizumab are received. In group 2, the anti-VEGF injection was performed 10 days after the sub-tenon steroid injection [triamcinolone acetonide]. All patients’ visual acuity, IOP and CMT were followed up for 3 months. Results: The combined treatment showed improved best corrected visual acuity from baseline 0.24 ± 0.32 log MAR to 0.56 ± 0.18 log MAR (p = 0.023) which was statistically significant. In addition, there was decreased CMT from baseline 420.1 ± 112.84 to 275.73 ± 90.81 which was highly statistically significant (p > 0.001). When comparing the combination treatment with the anti-VEGF treatment alone, recovery of BCVA and CMT was statistically significant (p = 0.041 and p = 0.001, respectively). Conclusion: Steroid addition to the routine anti-VEGF therapy is an effective method of treatment of diabetic macular edema

Sustained Control from Recurring Non-Infectious Uveitic Macular Edema with 0.19 mg Fluocinolone Acetonide Intravitreal Implant - A Case Report.

In January 2013, a 54-year-old pseudophakic woman was referred to the ocular inflammation clinic with a diagnosis of panuveitis, already on oral cyclosporine (100 mg/day) since 2010. She was a monocular patient, with the left eye eviscerated due to trauma and secondary endophthalmitis in 1995. She had experienced similar recurring episodes between 2010 and 2013. Examination revealed best-corrected visual acuity (BCVA) of 20/200. The anterior segment revealed the presence of flare and absence of cells. Intraocular pressure (IOP) was 11 mmHg. Fundus examination revealed the presence of anterior vitreous organization, exuberant cystoid macular edema (CME) and peripheral Dalen-Fuchs nodules with no activity. Systemic workup showed no changes, and a presumptive diagnosis of sympathetic ophthalmia was made. Initial therapy included topical and systemic corticosteroids. Cyclosporine was replaced with methotrexate (20 mg/week) due to nephrotoxicity. There was marked improvement in anterior inflammation and vitreous organization, but the ME remained exuberant (central ring thickness of 0.7 mm). Over the subsequent 4 years of follow-up, the patient received two intravitreous injections of a dexamethasone extended-release implant (Ozurdex®), with normalization of macular thickness and improvement in visual acuity (VA), but ME recurred around 6 months post-injection. During this period, the patient also underwent three sub-tenon injections of triamcinolone, with marked improvement of ME, but ME recurred between 4 and 6 months after treatment. She was thus recommended for treatment with a fluocinolone extended-release implant (ILUVIEN®). Post-implantation (3-year follow-up), she had controlled anterior inflammation without ME (central macular thickness of 248 µm). This case suggests that sustained control of inflammation enables better control of ME, and benefits may persist even after cessation of the direct anti-inflammatory effect of the implant.FundingAlimera Sciences Ltd funded the Rapid Service Fees.

Comparison of ocular pharmacokinetics of etoposide and its nanoemulsion after subtenon administration in rabbits

Background Subtenon anticancer drugs are given as an adjunct to systemic chemotherapy for conditions like retinoblatoma. This study evaluated the ocular kinetics of nano-emulsion formulation of etoposide (NanoEt) and compared it with an equal dose of commercially available alcohol-based etoposide formulation in healthy rabbits. Methods A nanoemulsion formulation of NanoEt was developed and then evaluated for its ocular kinetics by subtenon administration in healthy rabbits. After the sterile subtenon administration of the drug, the eyes were enucleated after CO2 euthanasia at time intervals of 2 h, 6 h, 12 h, and 24 h, and ocular tissues, blood, and plasma were separated. The concentration of etoposide in the ocular tissues and blood was quantified using liquid chromatography tandem mass spectrometry (LC MS/MS). Results This study found that subtenon injection of NanoEt showed 24 times higher concentration in rabbit retina compared to an equal dose of conventional marketed formulation. Based on the ocular tissue bioavailability calculations (AUC0-24), the present study revealed that the formulation enhanced 90% ocular bioavailability of etoposide, when it was injected in the form of nano-emulsion in most of the tissues. Conclusions NanoEt has better bioavailability compared to the commercial alcohol-based formulation for subtenon injection. Low systemic exposure showed further advantage for its projected use in retinoblastoma (Rb) as an adjunct therapy. Further studies in Rb animal models are required to evaluate its safety and efficacy, for its clinical utility.

Management of Deep Retinal Capillary Ischemia by Electromagnetic Stimulation and Platelet-Rich Plasma: Preliminary Clinical Results.

To investigate the efficacy of retinal electromagnetic stimulation and sub-tenon autologous platelet-rich plasma in the treatment of deep retinal capillary ischemia. The study included 28 eyes of 17 patients aged 15-76years (mean 37.9years) who had deep retinal capillary ischemia. Patients who had acute-onset paracentral scotoma in the last 1month were included in the study between January 2018 and January 2019. The diagnosis of deep retinal capillary ischemia was based on clinical history and typical findings of optical coherence tomography angiography. The eyes were divided into three groups: group 1 (n = 7 eyes) received electromagnetic stimulation alone; group 2 (n = 7 eyes) received electromagnetic stimulation and sub-tenon autologous platelet-rich plasma injection; group 3 had no intervention and served as a control group (n = 14 eyes). The patients underwent ten sessions of electromagnetic stimulation in groups 1 and 2. Sub-tenon autologous platelet-rich plasma injection was performed immediately after the first, fifth, and tenth sessions of electromagnetic stimulation in group 2. The deep retinal capillary density and best corrected visual acuity changes were investigated before and after treatment at the first month. The mean deep retinal capillary density was 52.0% before electromagnetic stimulation and 56.1% after ten sessions of application in group 1; this improvement was statistically significant (p = 0.01). In the combined treatment group (group 2), the mean deep retinal capillary density was 46.9% before the treatment and 56.5% after the treatment; this increase was also statistically significant (p = 0.01). Statistically significant best corrected visual acuity improvement (p = 0.01) could be achieved only in group 2. The combined treatment was significantly superior (p < 0.01) to treatment with only electromagnetic stimulation regarding best corrected visual acuity and deep retinal capillary density. In the control group (group 3), there was no statistically significant change (p = 0.09) in the mean deep retinal capillary density and best corrected visual acuity. Treatment of the underlying cause is a priority in the treatment of deep retinal capillary ischemia. However, in the acute period, local ischemia treatment is necessary to prevent permanent retinal damage and scotomas. In mild cases, only electromagnetic stimulation, which is non-invasive and easy to use, might have a beneficial effect on deep retinal capillary density. In more severe cases, sub-tenon fresh autologous platelet-rich plasma injection together with electromagnetic stimulation may be more effective in the treatment of local ischemia of the retina in order to augment the response. The Rapid Service Fees were funded by the Ankara University Tecnopolis Institute. titck.gov.tr identifier, 2018-136.

Comparison of efficacy between subtenon injection of triamcinolone acetonide and intravitreal injection of ranibizumab for non-arteritic anterior ischenic optic neuropathy

Objective To compare the efficary between posterior subtenon injection of triamcinolone acetonide(TA)and intravitreal injection of ranibizumab for the treatment of non-artertic anterior ischemic optic neuropathy (NAION). Methods Total of 60 eyes of 60 patients who were diagnosed as NAION from Jun. 2016 to Jun. 2018 were randomly divided into two groups.Group A, 30 eyes of 30 patients, received poeterior subtenon injection of triamcinolone acetonide (TA, 20mg). Group B, 30 eyes of 30 cases, received intravitreal injection of ranibizumab. The visual acuity, visual field and optic disc edema were recorded after treatment. Results The visual acuity, visual field and optic disc edema at 15 days after treatment were improved.In group A the vision field improved in 14 eyes (93.33%)among 15 eyes who received visual field examination, unchannged in 1 eye (6.67%). In group B the vision field were improved in 12 eyes(83.33%)among 15 eyes who received visual field examination, and unchannged in 3 eyes(16.67%). Conclusion Triamcinolone acetonide (TA) has the same efficacy as ranibizumab in the treatment of NAION.Triamcinolone acetonide are superior to Ranibizumab in economics and safety. Key words: Neuropathy, optic, ischemic, anterior, non-arteritic; Triamcinolone acetonide, subtenon injection; Ranibizumab, intravitreal injection

Clinical efficacy of subtenon injection of triamcinolone acetonide for anterior ischemic optic neuropathy

Objective To evaluate the efficacy of subtenon injection of triamcinolone acetonide(TA) for non-arteritic anterior ischemic optic neuropathy (NAION). Methods The data of 60 eyes of 60 patients with NAION from Jun. 2015 to May 2017 were analyzed retrospectively. All cases were randomly divided into two groups, 30 eyes of 30 patients in each group. The treatment group underwent injection of compound anisodine around superficial temporal artery combined with subtenon injection of TA(20 mg). The control group underwent injection of compound anisodine around superficial temporal artery. Results The best corrected visual acuity (BCVA), visual field and optic papilla swelling were improved 60 days after treatment. BCVA of treatment group after treatment was better than that of the control group(χ2=17.800, P=0.003). In the treatment group, the visual field was improved in 14 eyes (93.33%) after treatment in 15 eyes with visual field examination.In the control group, the visual field was improved in 3 eyes (16.67%) after treatment in 15 eyes with visual field examination. The difference was significant between the two groups(χ2=18.680, P=0.0025). Conclusion Compound anisodine combined with TA is more effective than compound anisodine separately on the treatment of NAION. Key words: Optic neuropathy, anterior ischemic, non-arteritic; Triamcinolone acetonide; Subtenon injection

Effects of scleral collagen crosslinking with different carbohydrate on chemical bond and ultrastructure of rabbit sclera: Future treatment for myopia progression.

BackgroundMyopia is the most common ocular disorder and is mainly caused by axial elongation of the sclera. If the stiffness of sclera increased, it can inhibit myopia progression. The aim of this study is to compare the effect of the collagen crosslinking with different types and concentrations of carbohydrates on chemical bond and ultrastructural change of rabbit sclera.MethodsNine New Zealand white rabbits were treated with five, sequential sub-Tenon injections of 0.15 mL solutions of ribose, sucrose, and glycogen of 0.1, 0.2 and 0.4 M concentration at the right eye over 14 days. Ten weeks after the last injection, the rabbits were sacrificed and chemical bond and ultrastructural changes were compared with those of the untreated left sclera using Raman spectroscopy, atomic force microscopy (AFM), and histology.ResultsRaman spectroscopy of the control and cross-linked rabbit sclera tissue revealed different types of collagen interactions. Raman shift of 919 cm-1 (C-C stretching and vibration of the proline ring in collagen) was the highest in ribose, followed by sucrose and glycogen. Total energy intensity was also highest in ribose, followed by sucrose and glycogen, and showed a tendency to increase at higher concentrations. AFM revealed interlocking arrangements of collagen fibrils. The collagen fibril diameter was 105.6 ± 21.2 nm, 109.4 ± 28.8 nm, 113.1 ± 30.8 nm and 137.6 ± 25.3 nm for control group, 0.4 M glycogen, sucrose, and ribose, respectively. Histology indicated increased density of the collagen bundle and no increase in inflammatory cell recruitment compared to control at high concentrations of ribose.ConclusionsScleral crosslinking using glycation increased the scleral biomechanical rigidity and these results were particularly pronounced in ribose. Scleral crosslinking using glycation may be a promising method for inhibiting high myopia progression.

Triamcinolone acetonide posterior sub-tenon injection combined with retinal laser photocoagulation for macular edema

Objective To investigate the clinical efficacy of Triamcinolone Acetonide in posterior sub-tenon injection combined with laser photocoagulation for the treatment of macular edema caused by branch retinal vein occlusion(BRVO). Methods Sixty eyes of 60 cases with macular edema caused by BRVO received retinal laser photocoagulation after Triamcinolone acetonide posterior sub-tenon injection.The follow-up time was 6 months. Results At 6 months after treatment, the visual acuity improved in 55 cases(90.16%), the macular edema was reduced significantly in 45 cases(75.20%), and no proliferative vitreoretinopathy or neovascular glaucoma occurred. Conclusion Triamcinolone acetonide in posterior sub-tenon injection combined with laser photocoagulation for the treatment of macular edema caused by BRVO can improve the visual acutiy, promote retinal edema absorption, and also can prevent the formation of neovascular glaucoma. Key words: Occlusion, branch retinal vein; Edema, macular; Triamcinolone acetonide; Injection posterior, sub-tenon; Photocoagulation, laser

Transscleral Delivery of Bevacizumab-Loaded Chitosan Nanoparticles.

Purpose: The aim of this study was to synthesize bevacizumab-loaded nanoparticles and evaluate their effects on the treatment of posterior segment diseases via subtenon injections. Methods: Bevacizumab-loaded chitosan nanoparticles (BLCNs) were synthesized by the ionic gelation method, and their physicochemical characteristics and in vitro release profile were studied. The BLCNs were characterized using atomic force microscopy (AFM), FTIR spectroscopy, dynamic light scattering, and scanning electron microscopy. The BLCNs were delivered into rabbits' eyes via posterior subtenon injections. An immunohistochemical evaluation of the ocular tissues was performed, and the vitreous humor and serum bevacizumab levels were measured by ELISA. Results: Bevacizumab-loaded chitosan nanoparticles with a diameter of 80 to 380 nm were prepared and characterized. In vitro studies showed that after the first 5 days of the experiment, a significant increase in the drug release maintained the desired drug dosage for 3 weeks. Immunohistochemical in vivo studies revealed that there were BLCNs penetrating through the sclera. Furthermore, the intravitreal bevacizumab concentration reached a maximum concentration of 18 μg/ml, and it decreased to 6 μg/ml after only a week. Conclusion: The results revealed that subtenon injection of BLCNs is a promising alternative to intravitreal injections. In addition to the ELISA studies, immunohistochemical experiments confirmed that BLCNs enable transscleral bevacizumab penetration, and BLCN usage may provide the required bevacizumab levels for the treatment of posterior segment diseases.

Assessing “Cell Therapy” Clinics Offering Treatments of Ocular Conditions using Direct-to-Consumer Marketing Websites in the United States

"Cell therapy" is becoming increasingly available to the public via online direct-to-consumer advertisement within the United States (U.S.). The current study investigates the scope of "cell therapy" clinics across the U.S.that advertise and offer "cell therapy" for ocular conditions based on information provided on their websites. Cross-sectional study. The study included companies that are U.S.-based, participate in direct-to-consumer online marketing, have websites that can be data-mined with content analysis, and advertise therapy for ocular conditions. Using a systematic, extensive keyword-based Internet search, content analysis of company websites was utilized to identify, document, and analyze U.S. businesses marketing "cell therapy" for ocular conditions as of September 16,2017. Clinic locations, source of stem cells used, route of administration, marketed ocular conditions, and cost of treatment. Forty companies with 76 clinics use "cell therapy" to treat ocular conditions. California (23), Florida (12), and Illinois (10) contain the most clinics. All 40 companies specified sources of cells, which included autologous adipose-derived stem cells (35; 67%), autologous bone marrow-derived stem cells (8; 15%), amniotic stem cells (2; 4%), peripheral blood-derived stem cells (2; 4%), umbilical cord blood stem cells (2; 4%), allogenic bone marrow-derived stem cells (1; 2%), placental stem cells (1; 2%), and xenocells (1; 2%). The most commonly marketed ocular conditions included macular degeneration (35), optic neuritis (18), retinitis pigmentosa (17), and diabetic retinopathy (16). The most common routes of administration were intravenous (22) and "unspecified" (12); however, other companies listed more ocular-specific routes such as intravitreal injections (2), retrobulbar injections (2), eye injections (2), retrofundal injection (1), sub-Tenon injection (1), intraocular injection with vitrectomy (1), and eye drops (1). The cost of advertised "cell therapy" ranged from $4000 to $10 500. "Cell therapy" for ocular conditions is readily available via direct-to-consumer marketing strategies across the United States. The "cells" are harvested from numerous sources and administered through different methods for multiple ocular conditions at these "cell therapy" clinics. Limited data for these treatments necessitates advocating caution to physicians and patients about treatments offered at commercial "cell therapy" clinics.

Real-world evidence of treatment for relapse of noninfectious uveitis in tertiary centers in Japan: A multicenter study.

Noninfectious uveitis (NIU), which pathogenesis is often autoimmune nature, occurs as a symptom of systemic syndromes or only in the eye. The standard treatment of NIU is local, topical, and oral administration of corticosteroids (CS) in combination with immunomodulatory therapy (IMT). However, additional therapeutic strategies involving topical and systemic administration of CS or others to treat relapse or exacerbation of ocular inflammation in NIU which present as various ocular manifestations have not been established. The aim of this study was to investigate therapeutic strategies used for various ocular inflammations in relapse or exacerbation of NIU and to evaluate factors associated with the treatment pattern in Japan. The subjects were 198 eyes of 156 NIU patients with relapse or exacerbation of ocular inflammation at 6 university hospitals in Japan. The most frequent disease was sarcoidosis in 23.7% of the cases, followed by Behçet disease (BD) in 21.2%, Vogt-Koyanagi-Harada (VKH) disease in 13.6%, acute anterior uveitis (AAU) in 5.6%, tubulointerstitial nephritis and uveitis syndrome (TINU) in 4.0%, and juvenile idiopathic arthritis (JIA)-associated uveitis in 3.0%. Common ocular findings were worsened anterior inflammation (AI) in 67.2% of the cases, vitreous opacity (VO) in 46.5%, macular edema (ME) in 26.8%, retinal vasculitis (RV) in 23.7%, serous retinal detachment (SRD) in 9.1%, and optic perineuritis (OPN) in 4.0%. Reinforcement of betamethasone eye drop (ED) monotherapy for only AI in both unilateral and bilateral AI, sub-tenon injection of triamcinolone acetonide (STTA) for unilateral posterior inflammation including VO and ME, and systemic therapy using CS and/or IMT for bilateral anterior and posterior inflammation were significantly more frequent. Frequencies of exacerbated individual ocular findings in sarcoidosis and BD were similar, and severe ocular inflammation associated with panuveitis required both topical and systemic therapies. These results demonstrate that reinforcement of betamethasone EDs, topical administration of triamcinolone acetonide, and long-term administration of systemic corticosteroids are the major therapeutic strategies, and reinforcement of betamethasone EDs was used for exacerbated AI independently from its use for posterior inflammation. In addition, STTA was preferentially used for VO and ME associated with posterior inflammation.

Ophthalmic Immune-Related Adverse Events of Immunotherapy: A Single-Site Case Series

To report a case of panuveitis and retinal vasculitis associated with pembrolizumab therapy for metastatic lung cancer.A 71-year-old man, who was diagnosed with metastatic lung cancer (squamous cell carcinoma), presented with blurry vision 2 weeks after the initiation of pembrolizumab monotherapy. His best-corrected visual acuity (BCVA) was 20/20 OU, and slitlamp examination revealed fine keratic precipitates, anterior chamber cells (1+) and flare (1+) in both eyes. Dilated fundus examination showed no remarkable finding in the right eye and vitreous haze (2+), perivascular exudates, and vessel sheathing in the left eye. Fluorescence angiography demonstrated dye leakage from the optic disc and both retinal arteries and veins extending from the posterior to the peripheral retina in both eyes. The patient was diagnosed with panuveitis and retinal vasculitis as Grade 3 immune-related adverse event (irAE). Pembrolizumab was discontinued and oral prednisone 70mg/day was given for 1 week. The dose was reduced to 30mg/day for the next 3 weeks and was then stopped. One month after the treatment, intraocular inflammation became quiescent. With a good response to the treatment of irAE, pembrolizumab was restarted. Recurrence of ocular inflammation occurred over the next 1.5 years, but all of which were successfully treated with sub-Tenon's injection of triamcinolone acetonide (STTA). The patient maintained BCVA of 30/20 OU at the latest visit.We showed a case of retinal vasculitis occurred as an irAE of pembrolizumab for metastatic lung cancer. Retinal vasculitis was well managed with transient pembrolizumab discontinuation and oral corticosteroid therapy, and pembrolizumab was restarted with the aid of STTA. As ocular irAEs might be controlled by local corticosteroid therapy, the decision to continue immune checkpoint inhibitor therapy should be made on a case-by-case basis.

Sever inadvertent globe perforation during supplemental peribulbar anesthesia injection

A globe perforation is a well-known serious complication during peribulbar anesthesia. A second supplement injection may further increase the risk of this complication. Retrobulbar hemorrhage and brainstem injection are other serious complications have been reported following peribulbar injections. Although there is an increasing popularity for needle-free procedures of local anesthesia such as sub-tenon's injection and topical anesthesia, peribulbar anesthesia remains one of the favorite techniques for providing anesthesia in ophthalmic procedures. The risk for inadvertent globe perforation is increased if the patient has long axial length or posterior staphyloma. However, careful attention should be done to all patients and not only those with risk factors for globe perforation. Here we report a 69-year-old male patient referred to vitreoretinal surgeon with a vitreous hemorrhage due to a sever globe perforation during peribulbar anesthesia, in which early diagnosis and management helped in achieving a good final visual outcome. Also, in this case we discussed the safety of peribulbar anesthesia supplements, and how to avoid such complication. Using of balloon compression for adequate time to spread the local anesthesia around the globe and giving the injection with a shorter needle syringe may reduce the risk for inadvertent globe perforation following a supplemental peribulbar anesthesia injection.