INTRAVITREAL TRIAMCINOLONE ACETONIDE IN THE TREATMENT OF MACULAR RETINAL DETACHMENT ASSOCIATED WITH MORNING GLORY ANOMALY Annie C. Lee, MD,* Julia A. Haller, MD,† Kenneth R. Jaegers, Sr., MD,‡ Brooks W. McCuen II, MD*

Purpose: To report the successful treatment of a case of recurrent macular retinal detachment associated with morning glory anomaly using intravitreal triamcinolone acetonide. Methods: A 53-year-old man with a history of bilateral morning glory anomaly and recurrent macular detachment of the left eye refractory to multiple surgical interventions, including 3 vitrectomies with endolaser photocoagulation, gas tamponade, and fibrin glue, underwent an intravitreal injection of 4 mg triamcinolone acetonide. Results: A single treatment with intravitreal triamcinolone acetonide resulted in resolution of a macular retinal detachment and intraretinal fluid within 2 weeks. Conclusion: Treatment with intravitreal triamcinolone acetonide may be beneficial in cases of macular retinal detachment associated with morning glory anomaly. RETINAL CASES & BRIEF REPORTS 3:333–335, 2009

From the *Vitreoretinal Service, Duke Eye Center, Durham, North Carolina; †Retina Service, Wills Eye Institute, Philadelphia, Pennsylvania; and ‡Ophthalmology Associates, Louisville, Kentucky.

surgery on the left eye. A recurrence of the macular detachment led to an additional vitrectomy procedure with application of fibrin glue to the optic nerve and posterior pole along with an SF6 gas tamponade. On examination at the time of his referral, nystagmus was present in both eyes with no anterior segment abnormalities. Visual acuity in the affected left eye was 20/400. Retinal examination of the left eye showed a classic morning glory appearance to the optic disk with surrounding subretinal scarring (Figure 1). Shallow neurosensory retinal elevation of the posterior pole was present with no visible retinal breaks. Optical coherence tomography (OCT) showed the presence of neurosensory retinal elevation adjacent to an area of inner retinoschisis (Figure 2). Ophthalmologic examination of the right eye showed a visual acuity of 20/640 with a similar morning glory appearance to the optic disk and macular scarring secondary to a previous resolved retinal detachment. The patient underwent an intravitreal injection of 4 mg triamcinolone acetonide. Perioperatively, he had a steroid-induced intraocular pressure elevation, which

A

53-year-old man with a history of congenital bilateral morning glory optic disk anomaly was referred to the Duke Eye Center for vitreoretinal consultation regarding recurrent macular retinal detachment in his left eye. The patient developed the macular detachment 1 year before this presentation and was initially treated with pars plana vitrectomy, SF6 gas tamponade, and endolaser photocoagulation. A recurrence of the detachment led to a second vitrectomy procedure 2 months later with additional endolaser photocoagulation and C3F8 gas tamponade. Two months after this, the patient underwent cataract None of the authors have a proprietary interest in the materials presented. Reprint requests: Brooks W. McCuen II, MD, Duke Eye Center, Durham, NC 27710; e-mail: [email protected]

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Fig. 3. OCT 2 weeks after treatment showing resolution of subretinal and intraretinal fluid.

Fig. 1. Morning glory appearance of the left optic nerve with adjacent macular retinal detachment before intravitreal injection of triamcinolone acetonide.

was treated with a limited course of topical medications. Two weeks after the injection, vision in the affected eye was 20/400 with improvement of the macular appearance. Repeated OCT imaging at this time revealed resolution of his subretinal and intraretinal fluid (Figure 3). On examination 20 weeks after treatment, vision was count fingers with intraocular pressure of 19 mmHg. Fundus examination (Figure 4) and OCT imaging (Figure 5) showed sustained reattachment of the macular detachment with a measured central foveal thickness of 211 ␮m (compared with 516 ␮m pretreatment) and a total macular volume of 6.2 mm3 (compared with 11.47 mm3).

38% among reported cases2; however, some controversy exists over the etiology of the subretinal fluid. Some authors have suggested that the retinal detachments are rhegmatogenous or tractional in nature and that fluid from the vitreous cavity passes through slit-like retinal breaks3 or holes resulting from taut fibroglial tissue around the optic nerve.4 Others have postulated that the detachments are of the serous variety and that cerebrospinal fluid accumulates beneath the retina through an abnormal communication between the two spaces.5 Chang et al6 reported a case of retinal reattachment after optic nerve sheath fenestration supporting the existence of this connection. A variety of treatment techniques have been proposed for the treatment of retinal detachments associated with morning glory anomaly, including pars plana vitrectomy, careful dissection of peripapillary membranes, endolaser, and tamponade. Optic nerve

Discussion Morning glory disk anomaly is a congenital malformation of the optic disk area first characterized by Kindler1 in 1970 as having a funnel-shaped, excavated optic disk with central glial tissue, resembling the morning glory flower. Retinal detachment is the most common ocular complication with an incidence of

Fig. 2. Pretreatment OCT showing neurosensory retinal elevation adjacent to an area of inner retinoschisis.

Fig. 4. Fundus appearance 20 weeks after treatment showing improved macular appearance.

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Fig. 5. OCT 20 weeks after treatment showing sustained reattachment of macular detachment.

sheath fenestration has been used in cases in which subretinal fluid was suspected to be of cerebrospinal origin. However, no modality has been uniformly successful, and only a small rate of spontaneous retinal reattachment has been reported. Our patient had previously failed multiple vitrectomies with endolaser and gas tamponade but demonstrated complete resolution of his macular detachment and intraretinal fluid after a single intravitreal injection of triamcinolone acetonide. He did not experience similar improvement in visual acuity likely resulting from the chronic nature of the detachment because visual loss has been shown to occur within 6 months.7 Although it is possible that delayed response to his multiple vitrectomy surgeries may have played a role, the disappearance of the subretinal and intraretinal fluid 2 weeks after intravitreal administration of the steroid argues strongly for the efficacy of the intervention in this patient. The mechanism of the triamcinolone acetonide in this case is not clear. The injection may have helped to reduce permeability and facilitate the resorption of the subretinal fluid. Intravitreal triamcinolone acetonide has been used to successfully treat eyes with serous retinal detachments resulting from diabetic macular edema,8 branch retinal vein occlusion,9 and the VogtKoyanagi-Harada syndrome.10 Relief of vitreous traction with the history of vitrectomies may have aided this effect, but it remains unclear whether vitrectomy would be a prerequisite to the success of this intervention. The preoperative OCT appearance of retinal elevation with adjacent inner retinoschisis suggested

an optic pit-type configuration. Physical blockade by the particles of triamcinolone at the anomalous disk may be another possible mechanism of action. The particles may provide more effective and long-lasting mechanical tamponade than the intraocular gas that had been used previously. The brief period of elevated intraocular pressure after injection may also have contributed to the overall tamponade effect. Further investigation into the use of intravitreal triamcinolone in retinal detachment associated with morning glory anomaly is warranted. Key words: intravitreal triamcinolone acetonide, macular retinal detachment, morning glory anomaly. References 1. 2.

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Kindler P. Morning glory syndrome: unusual congenital optic disk anomaly. Am J Ophthalmol 1970;69:376 –384. Steinkuller PG. The morning glory disk anomaly: case report and literature review. J Pediatr Ophthalmol Strabismus 1980; 17:81– 87. Harris MJ, de Bustros S, Michels RG, Joondeph HC. Treatment of combined traction–rhegmatogenous retinal detachment in the morning glory syndrome. Retina 1984;4:249 – 252. Coll GE, Chang S, Flynn TE, Brown GC. Communication between the subretinal space and the vitreous cavity in the morning glory syndrome. Graefes Arch Clin Exp Ophthalmol 1995;233:441– 443. Irvine AR, Crawford JB, Sullivan JH. The pathogenesis of retinal detachment with morning glory disk and optic pit. Retina 1986;6:146 –150. Chang S, Haik BG, Ellsworth RM, St Louis L, Berrocal JA. Treatment of total retinal detachment in morning glory syndrome. Am J Ophthalmol 1984;97:596 – 600. Sobol WM, Blodi CF, Folk JC, Weingeist TA. Long-term visual outcome in patients with optic nerve pit and serous retinal detachment of the macula. Ophthalmology 1990;97: 1539 –1542. Ozdemir H, Karacorlu M, Karacorlu SA. Regression of serous macular detachment after intravitreal triamcinolone acetonide in patients with diabetic macular edema. Am J Ophthalmol 2005;140:251–255. Karacorlu M, Ozdemir H, Karacorlu SA. Resolution of serous macular detachment after intravitreal triamcinolone acetonide treatment of patients with branch retinal vein occlusion. Retina 2005;25:856 – 860. Andrade RE, Muccioli C, Farah ME, Nussenblatt RB, Belfort R Jr. Intravitreal triamcinolone in the treatment of serous retinal detachment in Vogt-Koyanagi-Harada syndrome. Am J Ophthalmol 2004;137:572–574.

Intravitreal triamcinolone acetonide in the treatment of macular retinal detachment associated with morning glory anomaly.

To report the successful treatment of a case of recurrent macular retinal detachment associated with morning glory anomaly using intravitreal triamcin...
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