Supratarsal injection of corticosteroids safe, effective against recalcitrant VKC

Study finds recurrence rate lower with triamcinolone compared to dexamethasone.

CHARLESTON, U.S.A. — Supratarsal injection of corticosteroids is a safe and effective modality for treating recalcitrant vernal keratoconjunctivitis (VKC), according to two practitioners who have had experience with the technique.

“This relatively new modality results in less recurrence of VKC and a dramatic and quick relief in symptoms, including itching, redness and watery discharge,” said Suresh K. Pandey, MD, currently a senior research fellow at the Center for Research on Ocular Therapeutics and Biodevices of the Storm Eye Institute here. The technique, studied in India, is useful for ocular allergy disorders. “It encourages healing of shield ulcers and persistent cobblestone papillae,” Dr. Pandey said.

“Both prolonged topical steroids and systemic drugs contribute to and worsen the blinding complications of VKC,” said Jagjit S. Saini, MD, a professor of ophthalmology at the Post Graduate Institute of Medical Education and Research in Chandigarh, India, where the study was performed. “Many of these patients end up in blindness from corneal ulcers, scars, glaucoma, cataract, stem cell limbal deficiencies and inadequate tear film.”

Drs. Pandey and Saini were coauthors of a 1999 published study in Acta Ophthalmologica Scandinavica that concluded both short-acting dexamethasone sodium phosphate and intermediate-acting triamcinolone acetonide were equally effective for managing eyes with recalcitrant VKC.

“Our study demonstrates that there is a simple and inexpensive method to treat nearly all cases of recalcitrant VKC,” Dr. Saini said. “The medication is easily available and the technique to administer can be quickly learned by most ophthalmologists. There is also little risk of medication being misused because the ophthalmologist administers the medication himself.”

Symptoms reduced

The investigators expected that administration of a single injection of triamcinolone would help relieve symptoms of VKC. “But we were surprised that there was almost universal success and induction of remission, with a symptom-free interval of more than a year in most eyes,” Dr. Saini said. “In some eyes, symptoms never came back.”

The study involved 38 eyes of 19 patients with recalcitrant VKC. Except for two initial patients who received supratarsal injection of triamcinolone acetonide in both eyes, one eye of each patient was randomly assigned to receive either 2 mg of dexamethasone sodium phosphate or 20 mg of triamcinolone acetonide.

“We thought triamcinolone acetonide would perform better because it is considered an intermediate-acting drug; however, both drugs were equally effective in the resolution of cobblestone papillae, limbal edema, shield ulcer, diffuse superficial punctate keratitis (SPK) and relief of symptoms,” Dr. Pandey said.

At least a 50% decrease in size of cobblestone papillae was noticed within 3 weeks in both groups. Likewise, complete healing of epithelial defects in patients with shield ulcer was seen over a 2-week period, and superficial punctate keratitis over 3 weeks.

Recurrence rates

During the study’s nearly 1-year follow-up period, the recurrence rate of VKC was lower with triamcinolone acetonide injection. Overall, 4 of 17 patients in the dexamethasone group and 3 of 21 in the triamcinolone group experienced recurrence.

On extended follow-up, the 2 patients on repeat dexamethasone injection showed recurrence while neither of the 2 patients on repeat triamcinolone injection had recurrence.

“Eyes known to demonstrate raised intraocular pressure with topical steroids could potentially demonstrate raised pressure even with a supratarsal injection,” Dr. Saini said. “This has not occurred in any study patients because of careful selection.”

To place medication safely in the supratarsal space, the technique has to be mastered. The conjunctival fornix and supratarsal areas are adequately anaesthetized for injection with repeated applications of local anesthetic (4% lidocaine hydrochloride instilled every minute for 4 minutes). The everted upper lid is further exposed for 1 minute with a swab stick that has been soaked in 4% lidocaine. “The tarsal plate is gently lifted from the globe with the swab stick and a 26-gauge needle is placed in the potential supratarsal space separating conjunctiva and Muller’s muscle, approximately 1 mm above the superior border of tarsal plate,” Dr. Saini said.

Avoiding bleeding

Care is taken to avoid marginal blood vessels and bleeding; “0.25 ml of the lidocaine is infiltrated in the supratarsal space, which balloons the conjunctiva,” Dr. Saini said.

“It is in this ballooned space that another needle is placed and 0.5 ml of either dexamethasone sodium phosphate (2 mg) or triamcinolone (20 mg) is injected,” he said. “It is important to place the needle horizontally and place the complete volume of drug in the supratarsal space.”

Once active inflammation is controlled, “further remission can be maintained on topical mast cell stabilizer and nonsteroidal anti-inflammatory agents,” Dr. Pandey said. “This usually avoids the complication of cataract and glaucoma, which are commonly associated with unsupervised treatment of topical steroids.”

According to Drs. Pandey and Saini, many developing countries such as India do not have tight control on corticosteroids for topical use. “These medications are distributed as free samples to doctors and they are also frequently available over the counter,” Dr. Pandey said. “Therefore, the search for safe and effective treatment modalities continues.”

For Your Information:

• Suresh K. Pandey, MD, can be reached at Center for Research on Ocular Therapeutics and Biodevices, 167 Ashley Ave., P.O. Box 250676, MUSC, Storm Eye Institute, Charleston, SC 29425 U.S.A.; +(1) 843-792-0777; fax: +(1) 843-792-7920; e-mail: pandeys@ musc.edu. Dr. Pandey has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• Jagjit S. Saini, MD, can be reached at Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh-160012, India; +(91) 172 602 421; fax: +(91) 172 663 418; e-mail: jssainichd@yahoo.com. Dr. Saini has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

References:

• Saini JS, Gupta A, Pandey SK, et al. Efficacy of supratarsal dexamethasone versus triamcinolone injection in recalcitrant vernal keratoconjunctivitis. Acta Ophthalmol. Scand. 1999;77:515-518.
• Pandey SK, Saini JS, et al. Mitomycin-C and vernal conjunctivitis. Letter to the editor. Ophthalmology. 2000;107:2125-2126.