Sir,

Ptosis is a recognized complication of posterior sub-Tenon's (PST) triamcinolone injection. It is usually mild and thought to arise from trauma to the levator aponeurosis.1 However, we present a case of complete myopathic ptosis associated with florid granulomatous inflammation and thickening of the levator muscle following such an injection.

Case report

A fit 74-year-old Caucasian lady with previously controlled bilateral idiopathic panuveitis received her first routine PST triamcinolone injection for right cystoid macular oedema. Her only systemic medications were bendrofluazide and quinine. The procedure involved the application of topical tetracaine to the superior fornix, followed by the injection of 1 ml (40 mg) of triamcinolone (Kenalog) into the superotemporal sub-Tenon's space using a 16 mm 25-gauge needle. A lid speculum was not used. Two days later, she developed a complete right ptosis with an absent skin crease and a levator function of 8 mm. Extraocular movements and pupils were normal. Following 6 months of unchanging ptosis, she underwent repair. At surgery, the inferior 15 mm of levator muscle was grossly thickened with a whitish appearance and woody texture (Figure 1). The aponeurosis was normal. A 12 mm levator resection with hang-back sutures was successfully performed. Histological examination of the excised muscle showed marked granulomatous inflammation with some fibrosis (Figure 2). This was consistent with a foreign-body-type reaction, although no micro-organisms or residual exogenous material were identified.

Figure 1
figure 1

Intraoperative photographs taken (a) after exposing the levator muscle and (b) following levator resection, showing it to be grossly thickened.

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Figure 2
figure 2

Composite photograph of the histological specimen showing granulomatous inflammation of the levator muscle with Langhan's type giant cells and granulomas. (a) × 20 (b) × 100.

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Comment

The above case differs from recent studies on ptosis following PST triamcinolone injection. These describe a delayed, milder ptosis, with normal levator tissues on histology.1 Steroid-induced myopathy has been documented elsewhere but is typically chronic and degenerative. However, two studies involving intracameral triamcinolone and dexamethasone (Decadron) injection have implicated the vehicle used in steroid preparations in causing mild myopathic ptosis.2, 3 Furthermore, specimens taken of orbital fat, prolapsed after PST triamcinolone injection, have demonstrated histiocytes containing phagocytosed particulate material.4 We, therefore, hypothesize that in our patient, inadvertent delivery of triamcinolone directly into the levator muscle induced a fibrotic foreign body response, possibly to the vehicle. This is an unusual complication of a common procedure and cautions us regarding the contentious ‘off-label’ use of triamcinolone acetonide.5