Persistence of triamcinolone acetonide following macular hole surgery

Editor, Triamcinolone acetonide (TA) is frequently used in vitrectomy for the purpose of visualizing the transparent vitreous (Peyman et al. 2000). We encountered two cases in which TA had accumulated in the area of the macular hole (MH) following TA-assisted MH surgery. A 53-year-old Japanese woman presented with metamorphopsia of the right eye that had started 3 months earlier. Corrected visual acuity (VA) was 0.1 in the right eye and the patient exhibited mild cataract. A full-thickness MH was present in the fundus of the right eye and a Weiss ring was observed. Surgery consisted of cataract surgery followed by three-port vitrectomy. About 0.7 ml of TA suspension was sprayed onto the peripheral vitreous for the purpose of visualizing the peripheral vitreous body. Triamcinolone acetonide solution consisting of 40 mg of TA (Kenakolot-A; Bristol Pharmaceuticals KK, Tokyo, Japan) dissolved in 4 ml balanced salt solution was applied using a Millipore filter. The internal limiting membrane (ILM) was removed and a 20% SF6 gas exchange into the vitreous cavity completed the surgery. The patient remained in the prone position for 10 days after surgery. At 1 week after surgery, the accumulation of TA in the MH prevented ophthalmoscopic confirmation of hole closure (Fig. 1). A highly reflective point suggestive of TA was also depicted in the macula in optical coherence tomography (OCT) and we were unable to confirm the hole closure by OCT (Fig. 2). The TA disappeared from ophthalmoscopic findings 5 weeks after surgery (Fig. 3) and we were able to confirm closure of the MH by OCT (Fig. 4). The final corrected VA at 13 months after surgery was 0.6. Fundus photograph of case 1 at 1 week after surgery. The accumulation of TA in the macular hole prevents ophthalmoscopic confirmation of hole closure. Ocular coherence tomography of case 1 at 1 week postoperatively shows a highly reflective point suggestive of TA in the macula hole. Fundus photograph of case 1 at 5 weeks after surgery shows no residual TA in the macular hole and closure of the hole. Ocular coherence tomography of case 1 at 5 weeks postoperatively shows closure of the macular hole. A 66-year-old Japanese man noticed decreased VA in the left eye. Corrected VA in the left eye was 0.4 and a full-thickness MH was observed. Vitrectomy was performed in the same manner as in case 1, and approximately 1.0 ml of TA was applied during removal of the ILM and peripheral vitrectomy. Ten days after surgery, the TA was adhered within the arcade vessel that contained the macular area. Triamcinolone acetonide had accumulated only in the centre of the macula at 2 weeks after surgery. The TA had disappeared ophthalmoscopically at 10 weeks after surgery and closure of the MH was confirmed by OCT. The final corrected VA at 15 months after surgery was 0.6. Although some reports have indicated that TA remains in the eye following surgery (Enaida et al. 2003; Takeuchi et al. 2003), there are many aspects of TA that remain unclear, including its intraocular kinetics and its toxicity on the retina. Macular hole closure can usually be confirmed ophthalmoscopically about 1 week after surgery, but in the two cases reported here it was difficult to confirm hole closure ophthalmoscopically due to the reflection of the white colour of the TA that had accumulated in the area of the hole. Moreover, a highly reflective point attributable to the TA also obstructed confirmation of hole closure by OCT. Consequently, there was concern that until we were able to confirm hole closure, the TA that had accumulated in the bottom of the hole might delay wound curing in the area of the hole, become a physical obstruction that impaired hole closure, or have an effect on photoreceptor cells or retinal pigment epithelium cells (Yeung et al. 2003). Fortunately, as the holes closed and VA improved in both cases, TA did not have any detrimental effect on hole closure or visual function. Although we cannot verify the longterm safety of injection of TA into the vitreous, we believe that these two cases provide important information.