Sir,

Herein we describe a case report of a child operated for bilateral congenital cataract receiving identical treatment in both eyes, where glaucoma developed in the eye with long-term retained-triamcinolone, but not in the eye without it.

Case report

A 6-week-old infant presented to one of us (MEW) with bilateral cataract. Cataract surgery with limbal approach primary posterior capsulectomy and vitrectomy, and intraocular lens (IOL) implantation (30 D Rayner 570C, East Sussex, UK) were performed for both eyes. Two milligrams (0.05 ml) of intracameral preservative-free triamcinolone acetonide (Triesence, Alcon, Fort Worth, TX, USA) was used in both eyes. In addition to being an anti-inflammatory agent, triamcinolone acetonide helps to identify any residual vitreous strands in the anterior chamber,1 an important advantage in younger children who routinely undergo planned vitrectomy.

Residual anterior chamber triamcinolone was noted in both eyes on the first postoperative day and at 1 week after surgery. However, at the 3-week postoperative visit, triamcinolone was not detected. Surgical removal of visual axis opacification (VAO) was required in both eyes (3 and 8 weeks postoperatively in left and right eyes, respectively). Triamcinolone was not used during the surgical removal of VAO.

Six months after surgery, the patient was noted to have an asymmetric myopic shift, greater in the left eye than in the right eye. As IOP measurement was not possible in the clinic, timolol eye drops were prescribed and examination under anesthesia (EUA) was scheduled. Axial elongation and myopic shift of refraction was documented in the left eye at the time of EUA (Table 1). Phospholine iodine 0.125%, b.i.d., was added as a topical drop for left eye. One month later (7 months post surgery), a 360-degree suture trabeculotomy ab externo was performed in left eye along with an IOL exchange (21 D Rayner 570C, East Sussex, UK). No residual triamcinolone was detected and no additional triamcinolone was used. An additional EUA was performed at 10 months after cataract surgery because the IOP could not be obtained in the office. Retained-triamcinolone was detected in the vitreous cavity of the left eye. None was found in the right eye. The left eye underwent a pars plana vitrectomy and removal of triamcinolone. Several large ‘chunks’ of triamcinolone were cut and aspirated without difficulty. IOP remained under control in both eyes until last follow-up at 3 years after cataract surgery.

Table 1 Preoperative and postoperative examinations
Full size table

Comment

In the case reported here, intracameral triamcinolone acetonide made its way into the vitreous cavity in the left eye and escaped detection for >10 months. In the many of our pediatric cataract and IOL surgeries, the triamcinolone acetonide remained in the anterior chamber and disappeared over a 3- to 14-day period. The lack of spread into the vitreous cavity in most cases is likely due to the capsular-fixated IOL that acts as a sufficient barrier to migration from the anterior chamber into the vitreous cavity. We do not routinely use intracameral triamcinolone when a child is left aphakic because the triamcinolone immediately mixes with the formed vitreous of the child and may be retained for many months. In this case, the IOL was placed in the ciliary sulcus of both eyes instead of in the capsular bag. It was felt that the family would not likely comply with the wearing of glasses, and the sulcus placement was chosen to make the lens easier to exchange later. It is likely that this ciliary sulcus placement allowed the triamcinolone to more easily migrate into the vitreous space. This happened in one eye and not in the other. A portion of it lodged in a location that escaped detection at EUA and at glaucoma surgery. Glaucoma has been reported to occur in children who have intravitreal injection of triamcinolone,2 but this complication is thought to be very rare when intracameral placement is used.3, 4, 5, 6 This single-case report cannot establish a cause and effect relationship, meaning it is difficult to say if retained-triamcinolone led to glaucoma. However, it is important to note that in the case described herein, other risk factors for glaucoma (eg, age at surgery) were identical in both eyes, and glaucoma developed in the eye with retained-triamcinolone, but not in the eye without it. We now place triamcinolone intracamerally only when an IOL has been placed into the capsular bag. We have not, to date, had another incident of long-term retained-intravitreal triamcinolone following pediatric cataract surgery.