Universidade Federal de São Paulo, Vis Inst, São Paulo, BrazilUniversidade Federal de São Paulo, Vis Inst, São Paulo, BrazilWeb of Scienc

C Muccioli

F B Aggio

JB Jonas

JM Benitez Del Castillo Sanchez

K Kishore

R Belfort

RB Nussenblatt

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Intravitreal triamcinolone acetonide as an adjunct in the treatment of severe ocular toxoplasmosis

Aggio, Fabio Bom

Muccioli, Cristina

Belfort, Rubens Junior

Repositório Institucional UNIFESP

Correspondence: HG Sheth,Medical Eye Unit,St Thomas’ Hospital,Lambeth Palace Road,London SE1 7NH, UKTel: þ 44 20 7188 7188;Fax: þ 44 20 8902 7135.E-mail: drhitensheth@yahoo.co.ukEye (2006) 20, 1078–1080. doi:10.1038/sj.eye.6702109;published online 30 September 2005Sir,Intravitreal ganciclovir injections in aqueouscytomegalovirus DNA positive hypertensive iritisTeoh et al1 suggested that Posner–Schlossman Syndrome(PSS) may represent a spectrum of anterior chamberinflammatory responses to local viral reactivation ofmembers of herpesviridae family such as CMV and HSV.We would like to share a similar case of CMV associatedhypertensive iritis treated with intravitreal ganciclovir.A 42-year-old Chinese man initially presented with a3-day history of right eye redness and pain. Best-corrected visual acuity was 6/9 and intraocular pressurewas 45 mmHg. Right eye slit-lamp examination showedmild corneal oedema, medium-sized stellate keraticprecipitate, and mild anterior chamber reaction.Gonioscopy showed open angle. No glaucomatous opticdisc changes were present and Humphrey visual fieldswere normal. The rest of the ocular examinations of botheyes were normal. On direct questioning, patientadmitted having two mild episodes of visual blurring,discomfort, and redness in his right eye, each lasting 1–2days, over the past 2 years. A tentative diagnosis of PSSwas made. Topical corticosteroids and timolol wereprescribed for ocular hypertension and inflammation.The right eye returned to normal after 2 weeks.After 1 year, he presented with a recurrence. The rightintraocular pressure was again high at 50 mmHg. Thecondition was again controlled with topical steroids andtimolol.A relapse recurred 2 months later when the frequencyof topical steroid was reduced. To exclude an infectivecause, the aqueous was aspirated for polymerase chainreaction (PCR) analysis. The right aqueous had CMVDNA measured at 7.16 103 copies per ml. The leftaqueous was negative for CMV. HIV test on the patientwas negative. His CD4 and CD8 counts were normal. Theserum IgG but not the IgM to CMV was positive, theserum CMV antigen was negative. He was recommendedto take ganciclovir but was unhappy with the diagnosisand the expenses involved. He subsequently agreed totry an intravitreal injection of ganciclovir. Right eyeaqueous was retested 2 weeks later and the CMV DNAcount had been reduced to 1.3 103 copies per ml. Thepatient had a quiet anterior chamber and intraocularpressures were within normal range. We think our caseadds to the evidence of herpesviridae viruses playing asignificant role in the etiology of PSS. We look forward tofurther interesting reports on this subject.AcknowledgementsProprietary/financial interest: None.Reference1 Teoh SB, Thean L, Koay E. Cytomegalovirus in aetiology ofPosner–Schlossman syndrome: evidence from quantitativepolymerase chain reaction. Eye 2004, 29 October [E-pubahead of print].RSH Chung and CN ChuaThe Eye Institute at Alexandra Hospital,National Healthcare Group, 378 Alexandra Road,Singapore 159964,SingaporeCorrespondence: CN Chua,Tel: þ 65 6379 3510;Fax: þ 65 6379 3618.E-mail: Chuaoxford@hotmail.comEye (2006) 20, 1080. doi:10.1038/sj.eye.6702112;published online 30 September 2005Sir,Intravitreal triamcinolone acetonide as an adjunctin the treatment of severe ocular toxoplasmosisToxoplasmosis lesions in the posterior pole are generallytreated with anti-Toxoplasma drugs in association withhigh-dose oral corticosteroids.1 Our standard therapeuticregimen consists of a 6-week course of pyrimethamine,sulphadiazine, folinic acid, and oral prednisone, alongwith topical drops. However, there are situations inwhich systemic corticosteroids are contraindicated.Herein we report two such cases, treated with anti-Toxoplasma drugs and an intravitreal triamcinoloneacetonide (IVTA) injection.Correspondence1080EyeCase reportsA 30-year-old woman had central serouschorioretinopathy OD associated with high-dosecorticosteroid use and active macular toxoplasmosis OS(Figure 1). At 7 days before presentation, she was startedon pyrimethamine 25 mg daily, sulphadiazine 2 g daily,folinic acid 5 mg twice weekly, and prednisone 60 mgdaily. Visual acuity was 20/50 OD and counting fingersOS. Oral prednisone was discontinued and 4 mg oftriamcinolone acetonide was injected via pars plana OSunder topical anesthesia. After 5 days, markedamelioration of the vitritis was seen, with visual acuity of20/200 OS. At 1 month following the injection, visualacuity was 20/20 OD and 20/100 OS. Funduscopy wasnormal OD and disclosed a scarred toxoplasmosis lesionin the superotemporal macula OS (Figure 2). Themedication was switched to oral trimethoprim-sulphamethoxazole (160/800 mg) three times a week for3 months. At 18 months after IVTA injection, no signs ofrecurrence were noted.A 74-year-old difficult controlled diabetic man withactive macular toxoplasmosis, along with severe anteriorchamber reaction and vitritis OS, had visual acuity of20/20 OD and hand movements OS. Pyrimethamine,sulphadiazine, and folinic acid were started. After 1week, the picture was unchanged. In total, 4 mg oftriamcinolone acetonide was injected via pars plana OS.After 7 days, marked diminution of anterior chamberand vitreous cells was noted. Treatment was switched totrimethoprim-sulphametoxazole at the 5th week anddiscontinued 3 months later. At 18 months followingIVTA injection, visual acuity was CF at 3 m and signs ofscarring were seen in the retinochoroidal lesion. Noevidence of recurrence or active inflammation wasdetected.DiscussionKishore et al2 reported treating four patients withclindamycin and dexamethasone given intravitreallyFigure 1 Initial presentation. (Left) Fundus photography of the right eye (OD) revealing a circumscribed neurosensory retinaldetachment in the posterior pole (arrows). (Right) Fundus photography of the left eye (OS) showing a whitish, fluffy lesion in thesuperotemporal macula, as well as marked vitritis. Fundus details are barely visible.Figure 2 At 1 month following IVTA injection. (Left) Fundus photography OD (normal). (Right) Fundus photography OS disclosing ascarred toxoplasmic retinochoroiditis lesion in the superotemporal macula.Correspondence1081Eyeunder general or peribulbar anesthesia. However, up tofour injections were required to control the disease, andrecurrence occurred in one case during a mean follow-uptime of 17.5 months. Three patients, including the onewith recurrence, continued one systemic antitoxoplasmicmedication during follow-up.IVTA has been efficient in rapidly decreasinginflammation in acute sight-threatening noninfectiousuveitis.3,4 In our study, a single injection of IVTA wasused as an adjunct in the treatment of severe oculartoxoplasmosis, with rapid and successful control of theintraocular inflammation in both cases and no signs ofrecurrence during an 18-month follow-up period.Trimethoprim-sulphamethoxazole three times a weekwas used as a prophylactic treatment against the parasitein the period in which some triamcinolone acetonideresidue might still be present in the vitreous cavity,potentially suppressing the immune response.ConclusionWe suggest that IVTA should be considered as a potentialbenefit to patients with severe ocular toxoplasmosis or inwhich the use of systemic corticosteroids iscontraindicated and should be investigated further. Toour knowledge, this is the first report of IVTA in thetreatment of infectious uveitis.4References1 Nussenblatt RB. Ocular toxoplasmosis. In: Nussenblatt RB,Whitcup SM (eds). Uveitis: Fundamentals and Clinical Practice,3rd edn. Mosby: Philadelphia, 2004, pp 214–234.2 Kishore K, Conway MD, Peyman GA. Intravitrealclindamycin and dexamethasone for toxoplasmicretinochoroiditis. Ophthal Surg Lasers 2001; 32: 183–192.3 Benitez Del Castillo Sanchez JM, Garcia Sanchez J.Intravitreal injection of triamcinolone acetonide in noninfectious uveitis. Arch Soc Esp Oftalmol 2001; 76: 661–664.4 Jonas JB, Kreissig I, Degenring R. Intravitreal triamcinoloneacetonide for treatment of intraocular proliferative, exudativeand neovascular diseases. Prog Retin Eye Res 2005; 24:587–611.FB Aggio, C Muccioli and R Belfort JrVision Institute, Federal University of Sa˜o Paulo,Sa˜o Paulo, BrazilCorrespondence: FB Aggio,Alameda Jau´, 150 ap 21 B.,Sa˜o Paulo, SP 01420-000, BrazilTel: þ 55 11 3288 8520;Fax: þ 55 11 6606 6324.E-mail: aggio@oftalmo.epm.brThe authors have no proprietary interest in thedevelopment or marketing of this or any competingdevice.Eye (2006) 20, 1080–1082. doi:10.1038/sj.eye.6702113;published online 30 September 2005Sir,The natural history of Vigabatrin-associated visualfield defects in patients electing to continue theirmedicationWe read with interest the paper by Best and Acheson1regarding the natural history of Vigabatrin-associatedvisual field defects in patients electing to continue theirmedication. The first cases of concentric bilateral visualfield defects in patients taking Vigabatrin were reportedin the late 1990s and since then numerous cases havebeen reported worldwide. The association has grownstronger and is now a well-accepted adverse drug effectof Vigabatrin therapy.2–4In 2001, the Royal College of Ophthalmologists (RCO)published screening guidelines entitled ‘The ocular side-effects of Vigabatrin, information and guidelines forscreening’.5 For adults, they recommend pretreatmentbaseline visual field using either static suprathreshold 2or 3 zone perimetry (Humphrey 120 point or Octopus 07)to at least 45 radius eccentricity, or Goldman kineticperimetry (IIIe and I4e or I2e stimuli, as appropriate). Allpatients should have 6 monthly follow-up assessmentsfor the first 3 years of treatment, which can then beextended to annually in patients in whom no visual fielddefects are found.We used a questionnaire survey in the South-West ofEngland and Wales to investigate views of consultantophthalmologists on the RCO guidelines and to reviewcurrent clinical practice.Out of 97 consultants, 54 contacted responded to thequestionnaire (response rate 56%). Consultantophthalmologists were asked about their experience withVigabatrin-related visual field screening in the year 2002–2003. More than a third (35%) of those surveyed wereunaware that the RCO had published guidelines relatingto Vigabatrin-associated visual field defects. Only 15%had received new referrals for baseline visual fielddocumentation prior to patients starting on Vigabatrinand 41% of respondents had performed or arrangedvisual field screening for patients already on Vigabatrin.With respect to screening intervals, 51% thought that thescreening interval should be 12 months or longer, 45%agreed with a screening interval of 6 months and 4% feltCorrespondence1082Eye

Intravitreal triamcinolone acetonide as an adjunct in the treatment of severe ocular toxoplasmosis

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