|Year : 2018 | Volume
| Issue : 4 | Page : 211-215
Supratarsal injections versus topical steroids in resistant vernal keratoconjunctivitis
Nermeen M Badawi
Departement of Ophthalmology, Menoufia University, Shebin Elkom, Menoufia, Egypt
|Date of Submission||11-Aug-2018|
|Date of Acceptance||26-Sep-2018|
|Date of Web Publication||20-Dec-2018|
Nermeen M Badawi
Compound Lake View, 90th Street, Villa 3/1, New Cairo, Cairo 11835
Source of Support: None, Conflict of Interest: None
Purpose The aim of this study was to compare the safety and efficacy of supratarsal triamcinolone acetonide injection versus supratarsal dexamethasone sodium phosphate injection versus topical prednisolone acetate 1% eye drops in the treatment of resistant cases of vernal keratoconjunctivitis (VKC).
Patients and methods This is a comparative, prospective randomized study that was done on 120 eyes (60 patients) having resistant VKC. The eyes included in the study were divided into three groups. Group 1 included 40 eyes (20 patients) that received supratarsal injection of 20 mg of triamcinolone acetonide; group 2 included 40 eyes (20 patients) that received supratarsal injection of 2 mg of dexamethasone sodium phosphate; and group 3 included 40 eyes (20 patients) that received topical prednisolone acetate 1% eye drops.
Results Supratarsal steroid injections provided more effective resolution of symptoms and signs in comparison to topical steroid eye drops. No statistically significant difference was found between triamcinolone acetonide and dexamethasone sodium phosphate supratarsal injections (P>0.05). However, the supratarsal injections showed a statistically significant higher resolution of symptoms and signs than those of topical steroids. Eyes in groups 1 and 2 (supratarsal injections) had a lower recurrence rate and a delayed recurrence in comparison to group 3 (topical steroid eye drops) (P<0.05). No complications related to the drugs or to the technique of injection were reported in all groups.
Conclusion Supratarsal injection of steroids is an effective, easy, well-tolerated, and safe technique in the treatment of resistant VKC, which provides an effective and longer relief of symptoms and signs with a delayed and lower rate of recurrence.
Keywords: steroids, supratarsal, topical, vernal keratoconjunctivitis
|How to cite this article:|
Badawi NM. Supratarsal injections versus topical steroids in resistant vernal keratoconjunctivitis. Delta J Ophthalmol 2018;19:211-5
|How to cite this URL:|
Badawi NM. Supratarsal injections versus topical steroids in resistant vernal keratoconjunctivitis. Delta J Ophthalmol [serial online] 2018 [cited 2019 Mar 23];19:211-5. Available from: http://www.djo.eg.net/text.asp?2018/19/4/211/248089
| Introduction|| |
Vernal keratoconjunctivitis (VKC) is a chronic, severe, recurrent, and bilateral seasonal allergic conjunctivitis characterized by itching, photophobia, lacrimation, redness, and ropy discharge ,. It can take one of the three forms: palpebral, bulbar, and mixed . It may be associated with other atopic manifestations like eczema, hay fever, allergic rhinitis, and food allergy . Severe resistant forms can develop blinding sequels .
New treatment modalities such as topical mast cell stabilizers ,, topical forms of NSAIDs , immunotherapeutic drugs like cyclosporine-A  and ganglioside derivatives , were found to be ineffective. Recently, with supratarsal injection of steroids, introduced as an alternative, good results could be obtained .
| Patients and methods|| |
A written, informed consent was obtained from every patient before participating in the study. The procedures followed the ethical standards of the Helsinki Declaration and were approved by the Ethics Committee of Menoufia University.
This was a prospective study performed on 120 eyes (60 patients) from March 2015 to May 2017. They were divided into three groups. Group 1 included 40 eyes of 20 patients, who received supratarsal injection of triamcinolone acetonide; group 2 included 40 eyes of 20 patients, who received supratarsal injection of dexamethasone sodium phosphate; and group 3 included 40 eyes of 20 patients, who received topical prednisolone acetate 1% eye drops.
All eyes included in this study were subjected to a detailed preoperative assessment of both anterior and posterior segments.
- Severe, recurrent, and resistant VKC with corneal manifestations (superficial punctate keratitis, shield ulcer, vascularization, or pannus).
- Free ocular examination other than VKC, and its related manifestations.
Resistance was defined as cases that received a continuous treatment for 2 weeks with the following regimen: artificial tears (carboxymethylcellulose 0.5%) eye drops four times per day for 2 weeks (Lacritears; Talent Pharma, Cairo Egypt) and sodium cromoglycate 4% eye drops two times per day for 2 weeks (Epicrom; EIPICO, Cairo, Egypt), NSAID (bromfenac 0.09%) eye drops two times per day for 2 weeks (Bromoflam; Orchidia, Cairo, Egypt), Olopatadine 0.1% eye drops two times per day for 2 weeks (Olopatanol; Alcon, Forthworth, Texas, United States), naphazoline hydrochloride 0.025%, and pheniramine maleate 0.3% eye drops four times per day for 2 weeks (Nostanine; EIPICO), cold compresses and avoiding exposure to the sun and wearing dark glasses when needed, with the presence of one or more of the following manifestations by the end of the 2 weeks: persistent symptoms (redness, itching, photophobia, lacrimation, and whitish ropy discharge), persistent papillae, persistent gelatinous limbal nodules with or without Tranta’s spots, persistent superficial punctate keratitis, persistent shield corneal ulcer, and/or progressive corneal pannus.
Patients and their parents were well informed about the aim of the study and the full details about injection in groups 1 and 2 and the full details about corticosteroid regimen in group 3.
- Poor patient compliance.
- Active local infection.
- Systemic contraindication to steroid therapy like diabetes mellitus and tuberculosis.
- Concurrent treatment for other allergic disorders.
Technique of supratarsal injection in groups 1 and 2
Supratarsal injections were given under topical anesthesia using benoxinate 0.4% (Benox; EIPICO) eye drops. One drop was instilled into the conjunctival sac every minute for 5 min before injection. Then the upper eyelid was everted, injecting the supratarsal space about 1 mm above the superior border of the tarsus in the potential space between the conjunctiva and Muller’s muscle, using a 26-G needle injecting 0.5 ml (20 mg) of triamcinolone acetonide (Kenacort Glaxo Smith Kline, Cairo, Egypt), in group 1 and 0.5 ml (2 mg) of dexamethasone sodium phosphate (dexamethasone; Amriya, Cairo, Egypt) in group 2. The landmark of a successful injection was ballooning of the potential space between the conjunctiva and Muller’s muscle. Then the lid was returned to its original position.
In group 3, steroids were administered in the form of prednisolone acetate 1% eye drops 5 times/day for 2 weeks (Econopred Plus; Alcon).
Treatment regimen after supratarsal injection in groups 1 and 2, or after the 2 weeks of topical steroid therapy in group 3 was the same as that of the preprocedure period.
Eyes were followed up at 1 day, 1 week, 1 month, 3 months, 6 months, and 12 months. Follow-up period started from the day of injection in groups 1 and 2, and from the last day of topical steroid therapy in group 3. Resolution of symptoms and signs, recurrence rates, and complications were evaluated and documented.
Data were collected, tabulated, and analyzed using the paired t test.
| Results|| |
The 60 patients included in the study were men. The age of the patients ranged from 6 to 13 years (mean, 9.5±3.1 years).
The condition was bilateral in all patients who complained of the following symptoms: itching, photophobia, lacrimation, redness, and whitish ropy discharge.
[Table 1] illustrates the distribution of the clinical signs of VKC in each group prior to any procedure, which had no statistically significant difference between groups (P>0.05).
|Table 1 Distribution of clinical signs of vernal keratoconjunctivitis in each group|
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The presence of clinical symptoms and signs with their resolutions or recurrences on the first day, first week, first month, third month, sixth month, and 12th month are listed in [Table 2] and [Table 3]. Resolution of symptoms in all groups started from the first day with no clinically significant differences between the three groups (P>0.05) till the end of the first month, in spite of the fact that group 3 had a slightly increased number of eyes showing resolution of papillae, limbal nodules, superficial punctate keratitis, and corneal pannus. After the first month, groups 1 and 2 showed a better resolution of symptoms in comparison to group 3. There was no statistically significant difference between groups 1 and 2 (P>0.05). A statistically significant difference was found between groups 1 and 3 (P<0.05). A statistically significant difference was also found between groups 2 and 3 (P<0.05).
|Table 2 Follow-up data at 1 day,1 week, and 1 month (after injection in groups 1 and 2 and starting after 2 weeks of topical intensive steroid regimen in group 3)|
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|Table 3 Follow-up data at 3, 6, and12 months (after appearance of recurrences)|
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There were no statistically significant differences between groups regarding superficial punctate keratitis, shield corneal ulcer and corneal pannus (P>0.05) till the end of the first month. However, this continued afterwards just in case of shield ulcer, while regarding other signs it was noticed that groups 1 and 2 had a better resolution of papillae, limbal nodules, superficial punctate keratitis, and corneal pannus in comparison to group 3. There was no statistically significant difference between groups 1 and 2 (P>0.05). A statistically significant difference was present between groups 1 and 3 (P<0.05). A statistically significant difference was also detected between groups 2 and 3 (P<0.05).
Regarding recurrence of symptoms and signs ([Table 3]): in group 3, recurrence started earlier (at 3 months) and it was significantly higher in comparison with the other two groups (P<0.05). In groups 1 and 2, recurrence started later (at 6 months) and it was significantly lower in comparison with group 3. There was no statistically significant difference in recurrence rate between groups 1 and 2 (P>0.05).
| Discussion|| |
VKC is a common disease in hot climates. Some of the patients have resistant symptoms and signs which do not respond to the usual treatment. Such resistant cases can develop complications which may be severe up to the level of blindness ,.
In spite of maximum treatment, some patients especially debilitated ones can be rendered unable to perform their daily activities with these cases considered as very challenging cases . A symptomatic relief could be noticed in such cases with the use of topical cyclosporin but with a very weak effect on papillae and shield corneal ulcers . Surgical removal and cryo-application on resistant papillae became prohibited due to the high risk of severe conjunctival scarring, which may lead to many cicatricial complications . This necessitates the development of a safe and effective treatment for resistant cases of VKC. The initial experience by Holsclaw et al.  with supratarsal steroid injection showed marked symptomatic relief with improvement of clinical signs.
In the current study, a prompt symptomatic relief was noticed within the first week after injection with improvement of signs. The improvement continued over the first 3 months after injection. Such improvement was nearly equal in both triamcinolone acetonide (with similar results noticed by Aghadoost and Zare , as well as Costa et al. ), and dexamethasone sodium phoshphate (with similar results noticed by Singh et al. , who encountered no statistically significant difference between both drugs as stated by the current study). Similarly, in the study of Sahu et al. , topical steroids resulted in less statistically significant results regarding symptom improvement, as well as resolution of signs in comparison to supratarsal injection of triamcinolone acetonide which supports the current study’s results.
The superiority of supratarsal injection over local steroids was attributed to its ability to decrease local inflammation, which when controlled, remission could be maintained by topical mast cell stabilizers and NSAIDs .
In the current study, recurrence started to occur with supratarsal injection after 6 months which means a longer period of relief with a better quality of life after a single easily tolerated safe injection. This is in comparison to the earlier recurrence that occurred in cases of topical steroids after 3 months. Other studies such as the Sahu et al.  study found a longer relief period with delay of recurrence of up to 24 months.
The intralesional triamcinolone acetonide injection has not been found to produce therapeutic blood levels, and so it has not been found to produce systemic anti-inflammatory effects or systemic side effects . Also, the plasma half life time of parenteral dexamethasone is about 4 h only and therefore it is unlikely to produce long-term systemic side effects after a single injection . In the current study, no systemic side effects were encountered from triamcinolone acetonide or from dexamethasone sodium phoshphate.Intralesional steroid injection in the eyelid in cases of chalazion or hemangioma can produce skin depigmentation, subcutaneous tissue atrophy, and retinal vascular occlusion . However, no complications were reported in relation to the injection itself or to the injected drugs in the present study.
| Conclusion|| |
Supratarsal steroid injection (triamcinolone or dexamethasone) in resistant cases of VKC is a safe, easy, and effective technique which can produce a more effective and longer period of improvement of symptoms and signs, with a lower rate and a delayed recurrence in comparison to topical steroid eye drops. The high clinical improvement with a safe, easy, and well-tolerated method can improve the quality of life in resistant cases of VKC.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]