Unintentional intraocular injection of corticosteroids

L E T T E R S TO T H E E D I T O R

Clinicopathology of a case with retinopathy of pancreatitis

the possibility that retinopathy of pancreatitis may develop without vascular occlusion cannot be denied.

I read with particular interest the paper of Hollo and Bobek in the June issue of Acta Ophthalmologica (1) and congratulate the authors on giving us the opportunity to study histopathologically a case of retinopathy associated with pancreatitis. The lack of aggregates in the retinal vessel of their patient does not mean that there was no prior intravascular aggregation of blood particles. As we have pointed out, there may developdesaggregation after microinfarcation, establishing cotton wool spots (2). In our experimental study we were able to produce Purtscher’s retinopathy by fibrin clots (3),which may develop in acute pancreatitis, too. So, the pathogenesis of the retinopathy can still only be explained by occlusion of small retinal capillaries.

R+-l??lCl?S:

1. Behrens-Baumann W, Scheurer G & Schroer (1992): Pathogenesis of Purtscher’s retinopathy. An Experimental Model. Graefe’s Arch Clin Exp 230: 286-291. 2. Holl6G&PopikE(1992):Isretinopathyinpancreatitis caused by leukocyte emboli? Acta Ophthalmol (Copenh) 70: 820-823. Gabor Hollo. M.D., 1st Department of Ophthalmology, Semmelweis University Medical School, Budapest.

Reference.. 1. Ho116 G & Bobek I (1993): Clinicopathology of a case with retinopathy ofpancreatitis Acta Ophthalmol (Copenh) 71: 422-425. 2. Behrens-Baumann W & Scheurer, G (1991): Morbus Purtscher. Variationsbreite der klinischen Manifestation bei 11Patienten und Oberlegungen zur Pathogenese. Klin Monatsbl Augenheilkd 198: 99-107. 3. Behrens-BaumannW & Scheurer G (1992):Pathogenesis of Purtscher’s Retinopathy. An Experimental Model. Graefe’s Arch Clin Exp 230 286-291.

Prof. W. Behrens-Baumann, Department of Ophthalmology, University of Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany.

Reply: It is true that Dr. Behrens-Baumann’s animal experiments (1) establish that occlusions in retinal microcirculation caused by fibrin clots lead to cotton wool spots of ischemic origin. However, in contrast with this model there is no evidence of a similar process in the retinal circulationduring acute pancreatitis. Retinopathy of pancreatitis develops without DIC and ARDS in most cases. In our animal experients with fluoresceinangiographyand electron microscopy (2)we observed no vascular occlusionsor granulocyte aggregationin the retina and choroid during acute necrotizing pancreatitis. Dr. Behrens-Baumann’s results seem to characterize a special situation, and on t h i s basis

Unintentional intraocular injection of corticosteroids We read with interest the article ‘Unintentionalintraocular injection of corticosteroids’by Dr. Gomez-Ulla and his colleagues (Acta Ophthalmologica (Copenh) 71 (1993) 419-421). Unfortunately, the authors did not specify all the ingredients of the paramethasone injected. Hida and his colleagues have reported that vehicles of commercially availablecorticosteroidsare toxic to the retina.We recently demonstrated that the preservative of Depo-Medrol, myristyl-gamma-picoliniumchloride, is toxic to the rabbit retina, as assessed by ERG and VEP responses and by histochemical studies (2,3). These studies demonstrated that ‘pure’ corticosteroids injectedintravitreallydonot damagetheretina.However, when a commercial preparation is inadvertentlyinjected into the vitreous, the toxicity of the vehicle should be considered when making a decision how to approach the problem. R+.t??lCl?S:

1. Hida T, Chandler D, Arena R & Machemer R (1986): Experimentaland clinical observation of the intraocrular toxicity of commercialcorticosteroid preparations. Am J Ophthalmol 101: 190-195. 2. bewenstein A, Zemel A, Lazar M & Perlman I(l991): The effects of Depo-Medrol preservative on the rabbit visual system. Invest Ophthalmol Vis Sci 32: 30533060.

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3. %emelE, Loewenstein A, Lazar M & Perlman I The effect of myristil gamma picolinium chloride (Depo-Medrol preservative)on the rabbit visual retina: histological and immunocytochemical observations). Invest Ophthalmol Vis Sci, in press.

Sinrmly youn Anat Loewenstein, MD and Moshe Lazar, MD, Department of Ophthalmology, Ichilov Hospital, Tel-Aviv. Israel.

Reply: We appreciate the interest of Drs. Anat 1,oewenstein and Moshe Lazar in our article "Unintentional intraocular injection of corticosteroids". We agree with their remarks on the toxic effect to the retina of the vehicles ofcommercially available corticosteroids. References in the literature prove it. The vehicle ingredients and concentrations of the corticosteroid we reported (Triniol, Syntex Latino, SA, Barcelona)were: benzyl alcohol 9 mg/ml, sodium chloride 1.5 mg/ml, potassium phosphate 2.7 mg/ml, polyvinylpirrolidone 100 mg/ml, Tween-60 0.05 mg/ml, sodium metabisulphite 0.25 mg/ml, and edetate disodium 0.1 mg/ml. Hida and colleagues (1) reported the results of an experimental study on the toxic effects of the vehicles of sixcommercially available corticosteroid preparations. They tested the vehicle of Decadron L.A., which is quite similar to the vehicle of our preparation. These authors found that 0.1 ml injectionofthe vehicle of Decadron L A . into the vitreous of pigmented rabbits did not cause clinically detec-

able abnormalities.However, they found that the same vehicle produced retinal changes in two of four eyes when the concentration was doubled. It was also shown by Dr. Loewenstein and his colleagues (2) that the preservative myristyl-gamma picolinium was toxic to the retina. However, this substance was not present in the vehicle of our preparation. As Drs. Loewenstein and Lazar point out, the question of vehicle toxicity was considered when the problem was approached, although it was not reflected in the report. We believe that in our patient the vehicle did not produce any detectable toxic effect for two reasons. First, we injected a vehicle concentration that seems not to produce toxic effects in the retina, at least in rabbits (1).And second, the visual acuity of the patient finally returned to its initial level. Additionally, the ERG made when the vitreous became clear did not show abnormalities.

Rejkences: 1. Hida T, Chandler D, Arena J E & Machemer R (1986): Experimentaland clinicalobservationsof the intraocular toxicity of commercial corticosteroid preparations. Am J Ophthalmol 101: 190-195. 2. Loewenstein A, Zemel E,Lazar M & Perlman I(1991): The effects of Depo-Medrol preservative on the rabbit visual system. Invest Ophthalmol vis sci 32: 3053-3060.

Sincerely yours, Dr. Fancisco Gomez-Ulla and Dr. Francisco Gonzalez, Departamento de Oftalmologia, Facultad de Medicina, 15705 Santiago de Compostela, Spain.

BOOK REVIEWS f4e.v.s1.ronard.l.& Moore Brut? D.: Clinical pediatric optometry. Butterworth-Heinemann, ISBN: 0-7506-9080-1, Pgs. 403. Price: 254.

Seegmschmiedl M.H. and S a w R (Ed$): Interstitial and Intracavitary Thermoradiotherapy. Springer Verlag 1993, ISBN: 3-540-55670-2. XVI, 379 pp, 153 figs, 108 tab. Price: DM 420.

The goal of this book is to present a comprehensive guide for optometric care of the infant and child. It is not meant to bc read or used by ophthalmologists who are familiar with most of the topics described in this book. However, many of the chapters describe strictly ophthalmological topics. Rarer ophthalmologic or systemic syndromes and diseases are described in such detail that the book seems to far too comprehensive for Scandinavian optometrists. Therefore the book can only be recommended as a handbook for the optometrist with special interest for ophthalmological disorders. %rbm Sfirmen

The use of hyperthermia to enhance the effect of radiotherapy is far from new and was in fact proposed and used very early in this decennium. Over the last two decades, there has been an increasing interest for this principle because very substantial improvement of the radiation effect is seen at temperatures above 42-43'C. The caveat, however, has been the technical application ofhyperthermia, and for this reasoninterstitial and intracavitary techniques have become more interesting due to their better ability to heat tumours. The book by Seegenschmiedt and Sauer contains chapters from experienced people working in the field, and goes into detail

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