Intracameral triamcinolone may be viable PKP treatment

November 1, 2008

Topical, periocular, and/or systemic corticosteroids typically are used to treat corneal endothelial graft rejection. When those modalities fail, experience in a series of five eyes suggests intracameral triamcinolone acetonide may be worth considering.

Key Points

New York-Intracameral triamcinolone acetonide may be an additional modality to consider for the treatment of endothelial allograft rejection when corticosteroid therapy administered via traditional routes fails, said Renée Solomon, MD, and Eric D. Donnenfeld, MD, private practitioners in New York.

"Corneal endothelial graft rejection is a common complication after penetrating keratoplasty [PKP]," Dr. Solomon said. "Corticosteroid therapy via the topical, periocular, and/or systemic route represents the accepted treatment for acute allograft rejection. Other immunosuppressive agents, including cyclosporine, mycophenolate mofetil, and tacrolimus, have been used with varying results, but the next line of intervention has not been well established.

"Our experience with intracameral corticosteroid administration is encouraging and suggests further study is warranted, including evaluations of the optimum dose, dilution, timing, and efficacy compared with alternate regimens for the treatment of acute graft rejection," she added.

At 2 weeks after the intracameral injection, partial resolution of microcystic edema and endothelial rejection lines was noted in three eyes. At a follow-up evaluation conducted after 4 months, uncorrected visual acuity had improved in three of the five eyes and was accompanied by complete resolution of endothelial precipitates and stromal edema. No episodes of IOP elevation associated with the intracameral steroid injection were found.

As further illustration of the efficacy of the intracameral steroid, Dr. Solomon described in greater detail the case of one of the five patients, a 32-year-old male who presented 5 weeks after undergoing PKP for post-LASIK ectasia. The patient was receiving prednisolone acetate 1% four times daily and a fourth-generation fluoroquinolone four times daily. He was referred by his transplant surgeon with multiple suture infiltrates. He presented with best-corrected visual acuity (BCVA) of 20/400 and a well-positioned graft but with superficial peripheral neovascularization in three quadrants, along with mild epithelial and stromal edema of the transplant.

The inflammatory response continued to increase, however, so the antibiotics were stopped and the patient was given a subconjunctival injection of triamcinolone acetonide and a 3-week course of oral prednisone starting at 80 mg per day. Intracameral triamcinolone acetonide was given after 3 weeks when the eye's condition continued to worsen.

The topical corticosteroid regimen slowly was tapered to four times daily. During follow-up to 10 months, improvement was noted in the endothelial rejection lines, anterior chamber reaction, and graft edema. IOP ranged from 17 to 22 mm Hg, and at the last visit, BCVA had improved to 20/20-1.

Commercial formulations of ophthalmic triamcinolone now are available.

This study was supported in part by an unrestricted grant from the American Society of Cataract and Refractive Surgery Foundation.