Ocular Immunology & Inflammation, 2013; 21(4): 257–263

! Informa Healthcare USA, Inc.

ISSN: 0927-3948 print / 1744-5078 online
DOI: 10.3109/09273948.2013.767353

ORIGINAL ARTICLE

Periocular Triamcinolone Acetonide Injections for

Control of Intraocular Inflammation Associated
with Uveitis
Sherveen S. Salek, MD1, Henry A. Leder, MD1, Nicholas J. Butler, MD1,
Theresa J. Gan, MD1, James P. Dunn, MD1, and Jennifer E. Thorne, MD, PhD1,2

1
Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland,
Ocul Immunol Inflamm Downloaded from informahealthcare.com by HINARI on 08/27/14

USA and 2Department of Epidemiology, Center for Clinical Trials, The Johns Hopkins University Bloomberg
School of Public Health, Baltimore, Maryland, USA

ABSTRACT
Purpose: To describe the effectiveness of periocular corticosteroid injections for the control of intraocular
inflammation associated with noninfectious uveitis.
Methods: A total of 81 patients (109 eyes) who received a periocular injection were evaluated for active
For personal use only.

inflammation, visual acuity, intraocular pressure, degree of intraocular inflammation, and the presence of
ocular complications, including macular edema.
Results: Of all eyes, 36% (95%CI: 25%, 45%) demonstrated clinical resolution of inflammation at the 1-month
visit after first injection, and 48% (95%CI: 37%, 59%) at 3 months. For multiple injections, 50% (95%CI: 28%,
72%) demonstrated resolution of inflammation at 1 month after the last injection, and 41% (95%CI: 20%, 63%)
resolution of inflammation at 3 months after the last injection. Of the 49 eyes that initially responded, the
estimated median time to recurrence was 7.6 months.
Conclusions: Approximately half of the treated eyes had resolution of intraocular inflammation at 3 months after
corticosteroid injection.
Keywords: Control of inflammation, effectiveness, periocular corticosteroids, side effects, uveitis

Uveitis can be classified anatomically into anterior,
intermediate, posterior, or panuveitis, and may be
associated with long-term ocular morbidity.1,2
Periocular corticosteroid injections for uveitis are a
well-established practice of clinical care, and their
effectiveness in noninfectious uveitis complicated by
cystoid macular edema has been well demon-
strated.3–7 Sub-Tenon’s triamcinolone acetonide injec-
tions have been reported to be effective in the
treatment of uveitis, with relatively few side effects
that typically include elevated intraocular pressure
and cataract.7–11 As the anti-inflammatory effect of
corticosteroid injections is transient, control of inflam-
mation often requires multiple injections over time,
and close follow-up to assess whether additional
therapy is required.12,13 Further, data regarding
recurrence of inflammation are limited. The aim of
our study is to describe the effectiveness and side
effects of periocular injection of corticosteroids for
control of intraocular inflammation associated with
anterior, intermediate, posterior, and panuveitis.
13
20
MATERIALS AND METHODS
Study Population
The charts of 197 patients with uveitis (4102 patient
visits) seen at the Division of Ocular Immunology at
the Wilmer Eye Institute from January 1993 to August
2006 and treated with periocular corticosteroid injec-
tions were reviewed. Exclusion criteria were a past

Received 13 August 2012; revised 11 January 2013; accepted 14 January 2013; published online 25 March 2013
Correspondence: Jennifer E. Thorne, MD, PhD, Wilmer Eye Institute, 600 N. Wolfe Street, Woods 476, Baltimore, MD 21287, USA. E-mail:
jthorne@jhmi.edu

257
 258 S. S. Salek et al.
ocular history of scleritis, keratitis, or HIV infection.
Patients for which the indication for treatment with
PST injection was cystoid macular edema (e.g., min-
imal or absent intraocular inflammation) were also
excluded as this subset of patients was reported in a
previous publication.4 There were 81 patients with
uveitis in at least one eye at the time of first injection
as the primary reason for injection, although cystoid
macular edema may have been present alongside
intraocular inflammation at the time of initial injec-
tion. All periocular corticosteroid injections for uveitis
were conducted in adherence with previously pub-
lished techniques.3,5
Data Collection
Patients in the database had been previously identi-
Ocul Immunol Inflamm Downloaded from informahealthcare.com by HINARI on 08/27/14
fied through billing records for the Johns Hopkins
Hospital, and information on identified patients was
collected retrospectively from clinical charts that
utilized flow sheets. Information on the flow sheets
included the date of the clinical visit, demographic
characteristics, medications for treatment of uveitis,
visual acuity as determined by Snellen or logarithmic
ETDRS charts, intraocular pressure, slit-lamp exam-
ination, grading of anterior chamber and vitreous
For personal use only.
inflammation, fundus examination, and presence of
uveitic complications such as cystoid macular edema
(CME).14 The diagnoses of uveitis and CME were
made with slit-lamp examination and (in the case of
CME) confirmed with fluorescein angiography or
ocular coherence tomography when possible, in
accordance with the recommendations of the
Standardization of Uveitis Nomenclature (SUN)
Working Group.1
Data from each clinical visit also included systemic
and topical corticosteroid medications, ocular anti-
hypertensive medications, and immunosuppressive
drug information. The overwhelming majority of
corticosteroid injections were delivered using a pos-
terior sub-Tenon’s approach (98%), while remaining
injections were delivered through the orbital floor, as
described in the literature.3–5 Triamcinolone acetonide
was used for all injections, most commonly at a
dose of 40 mg per injection (495% of injections).
All patients not treated with 40 mg of triamcinolone
per injection received 20 mg per injection.
It has been our practice to see patients with uveitis
treated with periocular injection within 1 month
(range: 2–6 weeks) after injection to assess for inflam-
matory activity, ocular complications, and injection-
related side effects, and then at 1-month intervals
thereafter until the resolution of inflammation, as
typically repeated injections are given until a treat-
ment failure is determined (defined below).
The decision to perform additional periocular cortico-
steroid injections was based on the treating
physician’s assessment. After resolution of the
inflammation was achieved, patients would be fol-
lowed every 1–3 months, depending on disease
severity, use of immunosuppressive agents, and
physician’s assessment. Data were collected for 12
months after the last periocular corticosteroid injec-
tion to assess for recurrence of uveitis and to provide
additional data regarding injection-related side
effects.
Main Outcome Measures
The main outcome measures included resolution of
inflammation, improvement in visual acuity (defined
as a halving of the visual angle or gain of 3 or more
lines of vision), development of periocular injection-
related side effects, and recurrence of inflammation in
eyes free of inflammation after injection. The primary
time points for assessing resolution of inflammation
and improvement in visual acuity were at the clinical
visits approximately 1 and 3 months after periocular
corticosteroid injection. If 41 injection was provided
as the initial periocular corticosteroid course, then
outcomes were measured at 1 and 3 months after the
last injection.
The criteria for resolution of inflammation con-
sisted of (1) 50.5þ cells in the anterior chamber,
(2) 50.5þ active inflammatory cells in the vitreous
chamber, and (3) absence of active chorioretinal
lesions in the fundus if applicable. So, for example,
in a patient with anterior uveitis, the first criterion
would need to be achieved to be considered reso-
lution, whereas a patient with active panuveitis
would have to meet all 3 criteria to achieve resolution.
The ophthalmologist’s assessment of resolution of
inflammation was used in a small number of visits
(approximately 5% of visits) when it was not clear if
the vitreous cells were old or represented active
inflammation. Treatment failure was defined as the
persistence of intraocular inflammation after 3 perio-
cular corticosteroid injections given consecutively
over 3 months.
Side effects of periocular corticosteroid therapy
were also assessed at every clinical visit after the
periocular injections as defined and included two
thresholds of ocular hypertension (IOP422 mmHg
and IOP  30 mmHg), retinal detachment, cataract
development (defined as 1þ nuclear or cortical
changes or trace or greater PSC), need for cataract or
glaucoma surgery, and scleral perforation (with or
without subretinal deposition of corticosteroid).
Recurrence was defined as any return of active
inflammation in an eye in which the inflammation
previously had been resolved.
Statistical Analysis
The demographic and clinical characteristics of study
patients at the time of initial periocular triamcinolone
Ocular Immunology & Inflammation
 Periocular Triamcinolone Acetonide Injections 259

acetonide injection were tabulated. Cumulative inci- TABLE 1. Continued

dences of and estimated median times to outcomes
were calculated with Kaplan-Meier methods using Patient-specific characteristics Median Range
‘‘by-eye’’ analyses. Rates of events were calculated as
Oral corticosteroids
number of events divided by number of eyes at risk None 64.2 52/81
(eye-time) and 95% confidence intervals (CI) were Any oral corticosteroid 35.8 29/81
calculated for rates using Poisson estimates. Because 10 mg prednisone daily 8.6 7/81
the correlation between eyes was less than 0.4, we 10–20 mg prednisone daily 9.9 8/81
did not adjust the analyses for between-eye 20–40 mg prednisone daily 7.4 6/81
440 mg prednisone daily 11.1 9/81
correlations. Statistical analyses were performed
Eye-specific characteristics
with Stata 9.0 statistical software (Stata, College
Anterior uveitis 29.4 32/109
Station, Texas, USA). Intermediate uveitis 0.9 1/109
Posterior uveitis 8.3 9/109
Panuveitis 61.5 67/109
RESULTS Visual acuity at time of first injection
20/40 or better 26.6 29/109
Demographic and clinical characteristics of the study 20/50 to 20/200 52.3 57/109
Ocul Immunol Inflamm Downloaded from informahealthcare.com by HINARI on 08/27/14

Worse than 20/200 21.1 23/109

population at the time of first injection are provided in
Activity of inflammation at injection
Table 1. A total of 109 eyes in 81 patients received
Anterior chamber cells (grade)
periocular injections. The median age at first injection 0 22.0 24/109
was 42 years (range: 6–71 years), and the median 0.5þ 10.1 11/109
duration of uveitis from the time of its initial diagno- 1þ 23.9 26/109
sis until the time of first injection was 3.7 years (range: 2þ 27.5 30/109
3þ or greater 14.7 16/109
0–66 years). Most patients were white (59.3%) and
Not avail 1.8 2/109
female (69.1%). Approximately 29.4% of eyes had Any anterior chamber inflammation 76.1 83/109
anterior uveitis, 0.9% had intermediate uveitis, 8.3% (40.5þ cells)
For personal use only.

had posterior uveitis, and 61.5% had panuveitis. Vitreous inflammation

About 35% of patients received periocular injections None 30.6 33/109
for uveitis in both eyes. Smoking history at the time Any (0.5þ cells) 64.8 70/109
of first injection was available in 90% of patients. No view 5.6 6/109
Cystoids Macular Edema
CME 19.3 21/109
TABLE 1. Demographic and clinical characteristics of patients No CME present 45.0 49/109
with uveitis at time of first periocular corticosteroid injection. No view 35.8 39/109

Patient-specific characteristics Median Range Ocular hypertension

IOP422 mmHg 5.5 6/109
Age at time of first injection, years 42 6–71 IOP430 mmHg 0.9 1/109
Age at diagnosis of uveitis, years 34 4–70 Lens status
Duration of uveitis from time of diagnosis to 3.7 0–66 Phakic, no cataract 30.3 33/109
time of first injection, years Any cataract 38.5 42/109
% n/N Pseudophakic 23.9 26/109
Gender Aphakic 5.5 6/109
Male 30.9 25/81 Unavailable 1.8 2/109
Female 69.1 56/81 Topical corticosteroids
Race None 22.9 25/109
Caucasian 59.3 48/81 4 times daily 22.9 25/109
African-American 35.8 29/81 44 times daily (up to every 2 h) 20.2 22/109
Other 4.9 4/81 hourly while awake 33.9 37/109
Smoking history Treatment for ocular hypertension or
Never smoked 43.2 35/81 glaucoma
Current smoker 30.9 25/81 None 86.2 94/109
Former smoker 16.0 13/81 Any topical IOP-lowering medication 13.8 15/109
Not available 9.9 8/81 1 medication 8.3 9/109
Bilateral 34.6 28/81 2 medications 2.8 3/109
3 or more medications 2.8 3/109
Immunosuppressant therapy
Mycophenolate 9.9 8/81 Number of injections
Cytoxan 1.2 1/81 1 injection 81.7 89/109
Methotrexate 7.4 6/81 2 injection 9.2 10/109
Cyclosporine 6.2 5/81 3 injection 9.2 10/109
Infliximab 1.2 1/81
CME, cystoid macular edema; IOP, intraocular pressure; n/N,
(continued ) number of eyes with complication/number of eyes at risk.

! 2013 Informa Healthcare USA, Inc.

 260 S. S. Salek et al.

Forty-three percent of patients reported never smok- TABLE 2. Outcome of corticosteroid injections for treatment of
ing, 31% were current smokers, and 16% reported uveitis.
previous use. Cumulative
Medical therapy at the time of the first periocular incidence 95%
corticosteroid injection was evaluated. At the time of Outcome (%) CI (%)
first injection, 36% of eyes were receiving treatment
First periocular corticosteroid injection
with oral corticosteroids, and 26% were receiving (all eyes)
systemic immunosuppressive therapy (Table 1). Resolution of inflammation at 1-month 36 25, 45
Ten percent of patients were taking mycophenolate visit
mofetil, 7% were on methotrexate, 6% were on Resolution of inflammation at 3-month 48 37, 59
cyclosporine, 1% were on cyclophosphamide, and visit
First periocular corticosteroid injection
1% were on infliximab at initial injection. Fourteen (single injection only)
percent of patients were receiving topical therapy for Resolution of inflammation at 1-month 40 30, 52
glaucoma. Topical corticosteroid therapy was used in visit
34% of eyes on an hourly basis with patients awake at Resolution of inflammation at 3-month 48 36, 58
the time of initial injection, while 40% of eyes used visit
Overall 41 periocular corticosteroid
topical corticosteroids greater than 4 times per day, up
Ocul Immunol Inflamm Downloaded from informahealthcare.com by HINARI on 08/27/14

injection
to every 2 h, while patients were awake. An equal Resolution of inflammation at 1-month 15 0, 30
proportion of eyes (23%) utilized either no or 4 or visit (after 1st injection)
fewer drops per day. Twenty-seven percent of patients Resolution of inflammation at 3-month 47 23, 68
had visual acuity of 20/40 or better, 52% of patients visit (after 1st injection)
Resolution of inflammation at 1 month 50 28, 72
had visual acuity of 20/50 to 20/200, and 21% of after last injection
patients had visual acuity of 20/200 or worse at time Resolution of inflammation at 3 41 20, 63
of first injection. months after last injection
Table 2 summarizes outcomes after periocular Halving of the visual angle
corticosteroid injections. For all eyes, the cumulative At 1-month visit (for all eyes) 29 21, 39
At 3-month visit (for all eyes) 37 28, 46
For personal use only.

incidence of resolution of inflammation was 36% (95%
CI: 25–45%) at the 1-month visit after first injection,
and 48% (95% CI: 37–59%) at the 3-month visit. For
those eyes that received a single periocular injection
only, 40% (95% CI: 30–52%) of eyes had resolution of
inflammation at the 1-month follow-up visit and 48%
(95% CI: 36–58%) of eyes had resolution by 3 months
after single periocular injection. Eyes of patients who
reported smoking at initial injection were less likely to
have resolution of inflammation after a single injec-
tion, with this difference being statistically significant
for the 3-month visit (cumulative incidences = 26%
[95% CI: 14–42%] and 34% [95% CI: 33–37%]
resolution at the 1- and 3-month visits, respectively).
Twenty patients received two or more periocular
corticosteroid injections for control of inflammation.
For the 20 eyes that received more than one injection,
15% (95% CI: 0–30%) had resolution of inflammation
at the 1-month visit after the first injection. However,
at 1 month after the last injection, 50% (10/20 eyes,
95% CI: 28–72%) had resolution of inflammation, and
41% (7/17 eyes, 95% CI: 20–63%) maintained reso-
lution at 3 months after the last injection. Thirty-six
eyes, or 73%, experienced a recurrence of uveitis after
successful control of intraocular inflammation, with
an estimated median time to recurrence of 7.6 months.
Of the 36 eyes with recurrence of intraocular inflam-
mation, 39% were on immunosuppressive therapy at
the time of initial injection, and an equal proportion of
eyes were on oral corticosteroid therapy.
Twenty eyes (18%) had CME in addition to active
uveitis at the time of initial injection. Of these 20 eyes,
At 1-month visit (for eyes with single 33 23, 43
injection)
At 3-month visit (for eyes with single 37 27, 48
injection)
At 1-month visit after last injection (41 35 18, 57
injection)
At 3-month visit after last injection (41 32 15, 54
injection)
95% CI, 95% confidence interval.
9 (45%) experienced resolution of intraocular inflam-
mation at 3 months after initial injections. For the
51 eyes documented without CME at initial injection,
27 (52%) had resolution of inflammation at 3 months
after initial injection. The macula was not well
visualized in 38 eyes (35%) primarily due to extensive
posterior synechiae, of which 13 (34%) experienced
resolution of intraocular inflammation (described as
no cells in the anterior chamber and no evidence of
active vitreous cells, and the assessment of resolved
inflammation in the ophthalmologist’s note). We
compared our results for resolution of intraocular
inflammation and improvement in visual acuity with
patients in our previous cohort who had CME as the
primary reason for injection,4 alongside intraocular
inflammation. The rates of resolution, recurrence, and
improvement in visual acuity were similar between
the two subgroups.
Visual acuity was recorded in subsequent injections
and follow-up visits. For all eyes, the cumulative
incidence of halving of the visual angle was 29% (95%
CI: 21–39%) at 1 month after initial injection, and 37%
Ocular Immunology & Inflammation
 Periocular Triamcinolone Acetonide Injections 261

TABLE 3. Incidence rates of corticosteroid injection-related side is possible that more severe cases of uveitis
effects for treatment of uveitis. were referred to our center than those treated in
Side effect n/N Rate (/EY) 95% CI the community setting. Indeed, approximately 60%
of eyes had panuveitis, one-third of patients
Elevated IOP had bilateral disease; one-half were receiving oral
IOP  22 mmHg 39/103 0.29 0.20, 0.38 corticosteroids, and greater than one-quarter of
IOP  30 mmHg 24/108 0.18 0.10, 0.25
Requiring glaucoma 2/109 0.01 0, 0.03* patients were receiving immunosuppressive drug
surgery therapy at the time of the first periocular injection.
Cataract, newly 18/63 0.11 0.05, 0.17 In contrast with our previous study,4 patients
diagnosed in this cohort did not receive the injections primar-
Cataract surgery 38/77 0.22 0.14, 0.31 ily for CME, but instead the injection was
Ptosis 22/107 0.10 0.04, 0.16
Vitreous hemorrhagea 1/109 0.01 0, 0.02* given primarily for active uveitis according to the
Scleral perforationa 1/109 0.01 0, 0.02* medical records. Because this is a retrospective study,
Retinal detachmenta 1/109 0.01 0, 0.02* we had to rely on the documented assessment and
Subretinal corticosteroid 1/109 0.01 0, 0.02* plan to understand the primary reason for the
deposition periocular injection; therefore, the possibility of
Endophthalmitis 0/109 0 0, 0.02*
misclassification of the reason for injection is
Ocul Immunol Inflamm Downloaded from informahealthcare.com by HINARI on 08/27/14

95% CI, 95% confidence interval; EY, eye-year; IOP, intraocular
pressure; n/N, number of eyes with complication/number of
eyes at risk.
a
These adverse events were all reported from a single injection
in a single eye.
*Upper 97.5% confidence interval (1-tailed confidence interval).
(95% CI: 28–46%) at 3 months after initial injection.
For eyes with single injection, 33% (95% CI: 23–43%)
achieved a halving of the visual angle at 1 month, and
For personal use only.
possible. Further, an eye may have both active
uveitis and CME. For example, 19% of eyes in this
analysis had concurrent CME. A subanalysis of
outcomes that included only eyes with both active
uveitis and CME demonstrated no significant differ-
ences in the cumulative incidences of resolution of
intraocular inflammation at the 1- and 3-month visits.
This is perhaps not surprising since the degree and
location of uveitis was similar between the eyes with

37% (95% CI: 27–48%) at 3 months after initial
injection. For eyes with more than one injection, the
proportions were 35% (95% CI: 18–57%) and 32%
(95% CI: 15–54%) at 1 and 3 months, respectively.
Table 3 summarizes the rates of periocular corti-
costeroid-related complications during the follow-up
period. The rate of IOP to 22 mm Hg was 0.29 per
eye-year (EY) (95% CI: 0.20/EY, 0.38/EY) and to
30 mmHg was 0.18/EY (95% CI: 0.10/EY, 0.25/EY).
Only 2 eyes required glaucoma filtration surgery
(rate = 0.01/EY). Cataract formation was observed in
18 of 63 eyes at risk (rate = 0.11/EY). Cataract surgery
was required in 38 of 77 eyes, for a rate of 0.22/EY
(95% CI: 0.14/EY, 0.31/EY). Vitreous hemorrhage,
retinal detachment, and subretinal corticosteroid
deposition with scleral perforation were all observed
in just 1 eye. There were no observed cases of
endophthalmitis.
DISCUSSION
Periocular corticosteroid injections are a common
regimen in the armament of therapies for uveitis
and uveitic CME.2–5,15 We provide a summary of our
institution’s experience with periocular corticoster-
oids injections for management of noninfectious
uveitis over a 14-year period, with follow-up
extended for a total of 18 years. Our study is
retrospective and therefore results need to be
interpreted with caution. Likely there is a referral
bias given our role as a tertiary care hospital, and it
! 2013 Informa Healthcare USA, Inc.
concomitant CME and those without CME. All types
of noninfectious uveitis were represented in the series
but the number of cases of intermediate uveitis was
extremely small (n = 1). Further investigation revealed
that the overwhelming majority of cases of intermedi-
ate uveitis had concomitant CME and the docu-
mented reason for the periocular injection was for
treatment of CME (n = 19).4 Evaluation of these eyes
for resolution of intraocular inflammation (rather than
CME) revealed similar but slightly higher resolution
rates when compared to this study.
Despite the retrospective design, our follow-up
schedule for periocular injections at 1 and 3 months
following injection allowed for a more rigorous
assessment of the effectiveness of periocular cortico-
steroid injections. We had relatively consistent
monthly follow-ups, with a minimum of 3 months
of follow-up after the last corticosteroid injection
for all patients and a median follow-up of
1 year (range = 4 months to 13 years). The extended
follow-up allowed us to better assess for recurrence
of uveitis after successful control of intraocular
inflammation and for side effects associated with
periocular corticosteroid injections. Further, we col-
lected data on all consecutive patients who presented
to our clinic for evaluation and treatment of uveitis
with periocular injections during the study period.
Activity and grade of uveitis was assessed according
to the published SUN recommendations for retro-
spective studies.1
Our study consists of a relatively large cohort
of patients with noninfectious uveitis, which
 262 S. S. Salek et al.
allows for assessment of outcomes of inflammation,
improvement of visual acuity, as well as incidence of
side effects of periocular corticosteroid injections. In
our study, 36% of eyes had a resolution of inflamma-
tion at the 1-month visit after initial injection and 48%
of eyes at the 3-month visit, which is less than the
proportion that was observed with the previously
published cohort of patients that received periocular
corticosteroid injections for uveitic CME from our
clinic.4 It appeared that patients who were currently
smoking at the time of the first injection were less
likely to have resolution of inflammation at the 1- and
3-month follow-up visits, although the result was only
statistically significant for the 3-month visit and the
sample size limited our ability to control for con-
founding variables. Nonetheless, these data sup-
ported previously published work suggesting that
Ocul Immunol Inflamm Downloaded from informahealthcare.com by HINARI on 08/27/14
smoking may be associated with poorer outcomes in
uveitis and its treatment.7,16–18
Eighteen percent of eyes required more than one
periocular corticosteroid injection in order to bring the
intraocular inflammation under control. A similar
percentage has been reported by us in the treatment of
uveitic CME with periocular corticosteroid injections.4
The proportion of eyes with halving of the visual
angle was similar between eyes with single or mul-
For personal use only.
tiple injections, and most of the improvement was
noted in the first month after initial injection.
Approximately one-third of eyes experienced a halv-
ing of the visual angle, which may be lower than that
reported in other retrospective series describing clin-
ical outcomes of periocular corticosteroid injections.
In these series, improvement in visual acuity ranges
from 56 to 67% but follow-up was variable (6 months
to 2 years) and rates or cumulative incidences were
not reported.7,19 Ferrante and colleagues described a
prospective study of 60 patients with active posterior
uveitis comparing two methods of periocular cortico-
steroid injection that failed to show any difference in
the proportion of eyes with improvement of visual
acuity of 2 lines after a single periocular injection.10
About 33–41% of eyes had an improvement of 2
lines in visual acuity at the 12-week visit,10 which is
similar to what we have reported herein (37% of eyes
had a 3-line improvement in vision 12 weeks after the
first periocular injection).
The rates of cataract formation and elevation of IOP
occurred with relative frequency in our study popu-
lation. The rate of newly diagnosed cataract (0.11/EY)
was similar to our previous study (0.13/EY)4 and to
previously published incidences for panuveitides and
posterior uveitidies (0.08–0.10/EY).20–22 The rate of
ptosis is comparable with our previous cohort, as well
as previous studies.4,7,9,10 The reported rate in this
paper may be an underestimation of ptosis incidence
since this finding may not be consistently recorded by
clinicians. The low rates of serious complications such
as endophthalmitis, retinal detachment, and scleral
perforation are consistent with the published
literature.4,9,10
Given the concern of corticosteroid-responsive rises
in IOP, it has been our practice to minimize the use of
periocular corticosteroid injections for patients with a
history of glaucoma or uncontrolled ocular hyperten-
sion. Therefore, the rates of IOP elevation and glau-
coma surgery may be lower than what one would
have observed had more patients with a history of
uveitic glaucoma or ocular hypertension been given
periocular injections and, thus, been included in this
study. Nonetheless, the rate was high, confirming
other reports that have demonstrated that patients
treated with periocular corticosteroid injections may
develop an elevated IOP in the face of not having a
previous history of steroid response to topical cor-
ticosteroid therapy.4,7
In summary, 48% of eyes treated with a single
periocular corticosteroid injection for noninfectious
uveitis had resolution of inflammation at 3 months.
For eyes with more than one injection, 41% experi-
enced resolution at 3 months after the last injection.
Recurrence of uveitis was common, occurring at an
estimated median time of 7.6 months after periocular
injection.
DECLARATION OF INTEREST
The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of
the paper.
Dr. Thorne is the recipient of a RPB Sybil B.
Harrington Special Scholars Award. Dr. Leder is
supported by unrestricted funds from Research to
Prevent Blindness. Dr. Thorne serves on a scientific
advisory board for Allergan, Inc.
Contributions of authors: Design and conduct of
study (SSS, HAL, JET), collection of data (SSS, HAL,
TJG), management of study (SSS, HAL, JET), analysis
and interpretation of data (SSS, HAL, NJB, TJG, JPD,
JET), preparation and review of manuscripts (SSS,
HAL, NJB, TJG, JPD, JET).
IRB approval: Retrospective, approved by Johns
Hopkins Medical Institutions in compliance with the
Declaration of Helsinki. This study is compliant with
HIPAA regulations.
REFERENCES
1. Jabs DA, Nussenblatt RB, Rosenbaum JT; Standardization
of Uveitis Nomenclature (SUN) Working Group.
Standardization of uveitis nomenclature for reporting
clinical data: results of the First International Workshop.
Am J Ophthalmol. 2005;140:509–516.
2. McCluskey PJ, Towler HM, Lightman S. Management of
chronic uveitis. BMJ. 2000;320:555–558.
3. Nozik RA. Periocular injection of steroids. Trans Am Acad
Ophthalmol Otolaryngol. 1972;76:695–705.
Ocular Immunology & Inflammation

4. Leder HA, Jabs DA, Galor A, et al. Periocular triamcino-
lone acetonide injections for cystoid macular edema
complicating noninfectious uveitis. Am J Ophthalmol.
2011;152:441–448 e2.
5. Riordan-Eva P, Lightman S. Orbital floor steroid injections
in the treatment of uveitis. Eye (Lond). 1994;8:66–69.
6. Kok H, Lau C, Maycock N, et al. Outcome of intravitreal
triamcinolone in uveitis. Ophthalmology. 2005;112:1916
e1–e7.
7. Helm CJ, Holland GN. The effects of posterior subtenon
injection of triamcinolone acetonide in patients with
intermediate uveitis. Am J Ophthalmol. 1995;120:55–64.
8. Mueller AJ, Jian G, Banker AS, et al. The effect of deep
posterior subtenon injection of corticosteroids on intrao-
cular pressure. Am J Ophthalmol. 1998;125:158–163.
9. Byun YS, Park YH. Complications and safety profile of
posterior subtenon injection of triamcinolone acetonide.
J Ocul Pharmacol Ther. 2009;25:159–162.
10. Ferrante P, Ramsey A, Bunce C, et al. Clinical trial to
compare efficacy and side-effects of injection of posterior
Ocul Immunol Inflamm Downloaded from informahealthcare.com by HINARI on 08/27/14
sub-Tenon triamcinolone versus orbital floor methylpred-
nisolone in the management of posterior uveitis. Clin Exp
Ophthalmol. 2004;32:563–568.
11. Galor A, Margolis R, Brasil OM, et al. Adverse events after
intravitreal triamcinolone in patients with and without
uveitis. Ophthalmology. 2007;114:1912–1918.
12. Whitcup SM. 2010. Intermediate uveitis. In: Nussenblatt RB,
Whitcup SM (eds.), Uveitis: Fundamentals and Clinical
Practice, 4th ed. (pp. 269–276). St. Louis: CV Mosby.
13. Taylor SR, Isa H, Joshi L, et al. New developments in
corticosteroid therapy for uveitis. Ophthalmologica. 2010;
For personal use only.
224:46–53.
! 2013 Informa Healthcare USA, Inc.
Periocular Triamcinolone Acetonide Injections 263
14. Beck RW, Maguire MG, Bressler NM, et al. Visual acuity as
an outcome measure in clinical trials of retinal diseases.
Ophthalmology. 2007;114:1804–1809.
15. Jermak CM, Dellacroce JT, Heffez J, et al. Triamcinolone
acetonide in ocular therapeutics. Surv Ophthalmol. 2007;52:
503–522.
16. Thorne JE, Daniel E, Jabs DA, et al. Smoking as
a risk factor for cystoid macular edema com-
plicating intermediate uveitis. Am J Ophthalmol. 2008;145:
841–846.
17. Galor A, Feuer W, Kempen JH, et al; and the Systemic
Immunosuppressive Therapy for Eye Diseases Cohort
Study Group. Adverse effects of smoking on patients
with ocular inflammation. Br J Ophthalmol. 2010;94:
848–853.
18. Lin P, Loh AR, Margolis TP, Acharya NR. Cigarette
smoking as a risk factor for uveitis. Ophthalmology. 2010;
117:585–590.
19. Yoshikawa K, Kotake S, Ichiishi A, et al. Posterior sub-
Tenon injections of repository corticosteroids in uveitis
patients with cystoid macular edema. Jpn J Ophthalmol.
1995;39:71–76.
20. Thorne JE, Jabs DA, Peters GB, et al. Birdshot retinochor-
oidopathy: ocular complications and visual impairment.
Am J Ophthalmol. 2005;140:45–51.
21. Thorne JE, Wittenberg SE, Jabs DA, et al. Multifocal
choroiditis with panuveitis: incidence of ocular complica-
tions and loss of visual acuity. Ophthalmology. 2006;113:
2310–2316.
22. Bykhovskaya I, Thorne JE, Kempen JH, et al. Vogt-
Koyanagi-Harada disease: clinical outcomes. Am J
Ophthalmol. 2005;140:674–678.