Viral retinitis after intravitreal triamcinolone injection in patients with predisposing medical comorbidities

Abstract

Purpose: To review the cases of viral retinitis after intravitreal steroid administration at a single center, to estimate the incidence, and to propose risk factors for its occurrence.

Design: Retrospective, observational case series.

Methods: Seven hundred thirty-six intravitreal triamcinolone (IVTA) injections were administered in the clinic and operating room by 3 retina specialists at a single academic medical center between September 2002 and November 2008. Inclusion criteria were simply a history of 1 or more IVTA injections during the period. The overall incidence of viral retinitis after IVTA injection was calculated. Subsequently, a chart audit was performed to estimate the number of patients with immune-altering conditions who had received IVTA during the period, and the incidence within this subgroup was calculated.

Results: Viral retinitis developed after IVTA injection in 3 patients, yielding an overall incidence of 3 in 736 or 0.41%. An estimated 334 injections were administered to patients with an immune-altering condition, including diabetes. All 3 of the patients in whom viral retinitis developed after IVTA injection possessed abnormal immune systems, yielding an incidence rate of 3 in 334 or 0.90% within this subgroup.

Conclusions: Our high reported incidence for this potentially devastating complication can be attributed to multiple factors, including coexisting medical immunocompromising comorbidities, a higher dose with a longer duration of local immunosuppression in the vitreous, multiple injections, as well as previous viral retinitis. Caution with a high index of clinical suspicion and frequent follow-up is advised in patients receiving IVTA injection with potentially immune-altering conditions, even after apparent immune recovery.

FIGURE 1

Patient 1 with active CMV retinitis. (Top left) The patient's fundus is shown, with active CMV retinitis and hemorrhage in the superotemporal periphery twenty-six weeks after a second intravitreal triamcinolone (IVTA) injection. (Top right) The view of the macula is obstructed due to vitritis. Active CMV retinitis is visible in the superotemporal and inferotemporal periphery. (Bottom left) A wide angle view of the fundus shows a large area of inferotemporal CMV retinitis and a smaller focus superotemporally.

FIGURE 1

Patient 1 with active CMV retinitis. (Top left) The patient's fundus is shown, with active CMV retinitis and hemorrhage in the superotemporal periphery twenty-six weeks after a second intravitreal triamcinolone (IVTA) injection. (Top right) The view of the macula is obstructed due to vitritis. Active CMV retinitis is visible in the superotemporal and inferotemporal periphery. (Bottom left) A wide angle view of the fundus shows a large area of inferotemporal CMV retinitis and a smaller focus superotemporally.

FIGURE 1

Patient 1 with active CMV retinitis. (Top left) The patient's fundus is shown, with active CMV retinitis and hemorrhage in the superotemporal periphery twenty-six weeks after a second intravitreal triamcinolone (IVTA) injection. (Top right) The view of the macula is obstructed due to vitritis. Active CMV retinitis is visible in the superotemporal and inferotemporal periphery. (Bottom left) A wide angle view of the fundus shows a large area of inferotemporal CMV retinitis and a smaller focus superotemporally.

FIGURE 2

Patient 2 with reactivated CMV retinitis. (Top left) The patient's fundus shows an area of healed CMV retinitis inferior to the optic nerve prior to IVTA and subsequent reactivation. (Top right) Thirteen weeks following IVTA, the fundus shows multiple areas of retinal whitening involving the posterior pole and periphery. The original healed CMV scar is visible inferior to the optic nerve.

FIGURE 2

Patient 2 with reactivated CMV retinitis. (Top left) The patient's fundus shows an area of healed CMV retinitis inferior to the optic nerve prior to IVTA and subsequent reactivation. (Top right) Thirteen weeks following IVTA, the fundus shows multiple areas of retinal whitening involving the posterior pole and periphery. The original healed CMV scar is visible inferior to the optic nerve.

FIGURE 3

Patient 3 with triamcinolone and ARN from VZV. (Top left) Residual triamcinolone is visible ten weeks following IVTA injection, along with inferior active retinitis due to ARN. (Top right) Healed ARN with chorioretinal scarring remains ten weeks later, following treatment.

FIGURE 3

Patient 3 with triamcinolone and ARN from VZV. (Top left) Residual triamcinolone is visible ten weeks following IVTA injection, along with inferior active retinitis due to ARN. (Top right) Healed ARN with chorioretinal scarring remains ten weeks later, following treatment.