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Sutter and Gillies described in their paper four cases of
endophthalmitis-like reaction after an intravitreal injection of
triamcinolone acetonide (Kenacort A-40, Bristol-Myers Squibb
Pharmaceuticals, Australia) as a distinct clinical entity. We would
like to point out some issues that could help to explain their findings
at least in part.
We strongly believe that the endophthalmitis-like...
We strongly believe that the endophthalmitis-like reaction appeared
as an acute reaction to the preservative of the drug (i.e. benzyl
alcohol). Hida et al. found that the vehicle, and not the crystalline
cortisone itself, could be toxic to the intraocular tissue. Although
no ocular toxicity has been proved in humans, intravenous use of solutions
containing this alcohol are known to have caused a fetal toxic syndrome in
premature infants. Approximately 25 percent of all commercially
available ophthalmic solutions are preserved with chlorobutanol. Benzyl
alcohol is rarely used because of its low activity, irritation, and
capacity for disolving polystyrene. In fact, experience has
demonstrated that many vehicles meet all the criteria to become a suitable
one but do not have the proper feel to make them acceptable to the human
On the other hand, the authors stated that the site of injection was
at the superior-temporal quadrant. It is well-known that this injection
method will completely obscure the view of the fundus and increase the
vitreous reaction (i.e. injected suspension will drop from up to down
throughout the vitreous gel).
We recommend the use of triamcinolone acetonide suspension for
intravitreal injection with most of the vehicle removed as suggested by
others. We also suggest the introduction of the needle into the eye at
the inferior-temporal quadrant in an effort to keep the suspension in the
inferior vitreous region to reduce the vitreous reaction, and out of the
(1) Sutter FKP, Gillies MC. Pseudo-endophthalmitis after intravitreal
injection of triamcinolone. Br J Ophthalmol 2003; 87:972-974.
(2) Hida T, Chandler D, Arena JE, Machemer R. Experimental and
clinical observations of the intraocular toxicity of commercial
corticosteroid preparations. Am J Ophthalmol 1986;101:190-195.
(3) Brown WJ, Buits NR, Cory Gipson,HT, Huston RK, Kennaway NG. Fatal
benzyl alcohol poisoning in a neonatal intensive care unit. Lancet 1982;1(8283):1250.
(4) Mullen W, Shepherd W, Labovitz J. Ophthalmic preservatives and
vehicles. Surv Ophthalmol 1973;17(6):469-483.
(5) Jonas JB, Hayler JK, Söfker A, Panda-Jonas S. Intravitreal
injection of crystalline cortisone as adjunctive treatment of
proliferative diabetic retinopathy. Am J Ophthalmol 2001;131:468-471.