Sudden vision loss following intralesional injection
Year: 2025
Type: article
Study design: Case Report
Abstract: A 30-year-old male patient presented with acute, painless vision loss in the right eye (RE) for the last 7 days. The patient visited a local hospital 7 days back for treatment of a forehead lesion and received an intralesional preservative-free triamcinolone acetonide injection. During the process of injection, the patient experienced sudden vision loss in the RE and was subsequently referred to a higher center. On presentation, his best-corrected visual acuity in the RE was no perception of light and 20/20 in LE, respectively. Anterior segment examination of the RE showed corneal edema with a mid-dilated non-reactive pupil while LE was unremarkable. Dilated fundus evaluation of the RE showed ischemic retinal whitening along the vessels with retinal hemorrhages, as shown in Fig. 1a, with no significant findings in LE [Fig. 1b].Figure 1: Fundus photography of RE shows multiple whitish emboli along retinal arteries which are suspected to be triamcinolone particles. [Black arrows, Fig 1a]. Fundus photography of LE appears normal (Fig 1b). Fundus fluorescein angiography (FFA) of the early phase shows a delay in arm-retina time [25 seconds, Fig 1c] with non-perfusion of the retinal arteries distal to the emboli seen in the late phase of FFA [Red arrows, Fig 1d]What is the probable cause of vision loss? Ophthalmic artery occlusion due to intense vasospasm Ophthalmic artery occlusion due to embolization of triamcinolone particles Intracranial venous sinus thrombosis due to triamcinolone particles entering the venous system Central retinal venous occlusion due to increased blood viscosity post steroid injection. Findings Fundus photography of RE shows multiple whitish emboli along retinal arteries which are suspected to be triamcinolone particles. [Black arrows, Fig. 1a]. Fundus fluorescein angiography (FFA) of the early phase shows a delay in arm-to-retina time [25 seconds, Fig. 1c] with non-perfusion of the retinal arteries distal to the emboli seen in the late phase of FFA [Red arrow, Fig. 1d]. Diagnosis Retrograde flow of triamcinolone particles causing ophthalmic artery occlusion. Correct answer B) Ophthalmic artery occlusion due to embolization of triamcinolone particles. Discussion The ophthalmic artery branches from the internal carotid artery and provides blood supply to the structures of the orbit, the upper two-thirds of the nose, the frontal area of the scalp, and some parts of the meninges. The artery is prone to occlusion by steroid crystals causing Iatrogenic ophthalmic artery occlusion (IOAO).[1] IOAO is subclassified into three groups based on the movement of the embolic particle- retrograde pathway, anterograde pathway, and through the collateral channels.[2] A forceful injection in the area of the scalp or upper two-thirds of the nose (facial danger area) can cause the steroid crystals to flow retrogradely from the supratrochlear, supraorbital, or dorsal nasal branch of the ophthalmic artery to the main trunk causing IOAO. The forehead lesion in our patient can be traced to the area supplied by the supratrochlear artery [Fig. 2]. IOAO causes irreversible retinal ischemia, leading to poor visual prognosis. Hence, any injection in the facial danger area should be preceded by careful aspiration to avoid injecting into any vessel. Also, the injection should be administered slowly to avoid the retrograde push of the embolus.Figure 2: Distribution of branches of the ophthalmic artery on the forehead. Site of intralesional injection being supplied by the supratrochlear arteryFinancial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.
Source: Indian Journal of Ophthalmology
Authors: Vanaja Jain, Nawazish Shaikh, Pradeep Venkatesh
Language: English
Topic: Retinal and Optic Conditions
Subfield: Ophthalmology
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4410902015