despite the lack of randomized , controlled trials proving its long - term safety and efficacy , intravitreal corticosteroid injections have emerged in the past decade as an increasingly used treatment for patients with macular edema secondary to diabetes mellitus , retinal vein occlusion , exudative macular degeneration , chronic uveitis and pseudophakic cystoid macular edema.1 potential complications of intravitreal corticosteroid treatment are divided into steroid - related and injection - related adverse effects .
steroid - related side effects most commonly include cataract formation and an elevation in intraocular pressure ( iop ) .
injection - related side effects include retinal tear , choroidal and retinal detachment , vitreous hemorrhage , bacterial endophthalmitis , non - infectious endophthalmitis , pseudo - endophthalmitis , and activation of latent infections ( such as acute syphilitic posterior placoid chorioretinitis or cytomegalovirus retinitis).211 we describe a rare case of triamcinolone acetonide entrapment in the berger 's space between the posterior lens capsule and the anterior hyaloid face after intravitreal triamcinolone acetonide ( ivta ) injection .
the patient underwent neodymium : yttrium - aluminum - garnet ( nd : yag ) laser anterior hyaloidotomy , allowing the trapped fluid to flow into the vitreous cavity .
a 65-year - old male with a 15-year history of type 2 diabetes mellitus presented with a complaint of blurred vision in the left eye over a 2-month period .
best corrected visual acuity was 20/30 and 20/80 in the right and left eyes , respectively .
fundus examination showed a bilateral moderate non - proliferative background diabetic retinopathy and a clinically significant macular edema ( csme ) in the left eye .
time - domain optical coherence tomography ( stratus oct3 , carl zeiss meditec inc . , dublin , ca , usa ) showed a diffuse thickening in the macula with a foveal thickness of 630 m . there was no evidence of significant vitreomacular traction .
the left eye underwent injection into the vitreous cavity of 0.1 ml ( 4.0 mg ) of a commercially available suspension of triamcinolone acetonide ( trigon depot ; 40 mg / ml , bristol - myers squibb sl , new york , ny , usa ) under aseptic conditions in the operating room .
the 26-g needle was inserted perpendicular through sclera in the inferotemporal quadrant , 4 mm from the limbus , with the tip aimed toward the center of the globe ( to avoid any contact with the posterior lens ) . as a part of the routine protocol ,
the next day , the patient returned to our emergency department complaining of sudden decrease of vision in the left eye . visual acuity in this eye dropped to hand movements .
slit - lamp examination showed the drug between the posterior capsule of the lens and the displaced anterior hyaloid membrane , within the berger 's space [ figure 1 ] .
there was no view of the fundus , but an ultrasound b scan exam revealed a clear vitreous . during 2 weeks of follow - up , there was no change in the appearance of the milky fluid , and the blurred vision persisted unchanged . with the patient 's consent , an nd :
the anterior face of the hyaloids was nicely outlined by the triamcinolone , allowing easily its identification .
it was approximately 1 mm far from the posterior capsule . a peyman contact lens ( opyg-12/12 , ocular instruments , inc . ,
bellevue , wa , usa ) was applied to the eye . after a single pulse application at 2.0 mj for 1.0 ms duration aiming at the displaced anterior face of the hyaloid , the trapped triamcinolone acetonide leaked into the vitreous cavity .
one week later , slit - lamp examination revealed the complete disappearance of the milky fluid [ figure 2 ] .
the patient did not receive other treatments , macular thickness decreased significantly to 302 m , and no posterior subcapsular cataract was observed .
slit - lamp examination showing the triamcinolone acetonide between the posterior capsule of the lens and the anterior hyaloid membrane ( berger 's space ) following intravitreal triamcinolone acetonide injection one week after performing neodymium : yttrium - aluminum - garnet laser anterior hyaloidotomy , slit - lamp examination revealed the complete disappearance of the milky fluid
anterior segment problems after ivta injection are rare and include vitreous prolapse into anterior chamber with or without intraocular lens ( iol ) and decentration and opaque coating over the iol.1213 salman et al.14 reported the only case of entrapment of intravitreal triamcinolone behind the crystalline lens . in that case
, the head movement at the time of injection caused the drug to be delivered into the berger 's space between the posterior lens capsule and the anterior hyaloid face .
the pathogenesis of this complication is unclear . probably , the injected triamcinolone was misdirected alongside the anterior vitreous surface
. a closed chamber might have formed behind the posterior lens capsule by a central detachment of the anterior hyaloid membrane still adherent to the posterior lens capsule by a fibrosed ring .
the lens is usually attached to the anterior vitreous surface along a circular zone called the hyaloideocapsular ligament or ligamentum pectinatum , of approximately 12 mm in width and 89 mm in diameter.15 this circular attachment is firm in youth and weakens with age .
the potential space of berger lies within the hyaloideocapsular ligament , where the vitreous is attached to the posterior aspect of the lens .
this case highlights the importance of proper technique of intravitreal injections because triamcinolone acetonide may become entrapped behind the crystalline lens if the needle is not properly positioned .
although both conservative approach to avoid damage to the lens and surgical removal via the pars plana were valid options , we preferred nd : yag laser anterior hyaloidotomy .
it was successfully performed resulting in a dramatic increase in visual acuity and the lens remaining clear . in conclusion ,
nd : yag laser anterior hyaloidotomy is an effective , simple , useful and minimally invasive outpatient procedure in cases with persistent entrapment of triamcinolone acetonide behind the crystalline lens .
this technique offers patient rapid recovery of visual acuity and the avoidance of more invasive surgical procedures , allowing the drug to clear without trauma to the crystalline lens .
nd : yag laser posterior hyaloidotomy has been indicated for subhyaloid hemorrhages16 and premacular vitreous floaters.17 likewise , nd : yag laser anterior hyaloidotomy has been indicated for malignant glaucoma following cataract surgery.18 to the best of our knowledge , this is the first case report to document the use of nd : yag laser anterior hyaloidotomy for allowing the persistent depot of triamcinolone acetonide to flow into the vitreous cavity .
a limitation of this paper is the short follow - up period of only 7 days .
although no complications were observed during this time , late complications such as the progression of diabetic macular edema due to rupture of the anterior hyaloid membrane or the development of a posterior subcapsular cataract might be expected .
 a 65-year - old male underwent intravitreal triamcinolone acetonide ( ivta ) injection for treating a clinically significant macular edema ( csme ) due to background diabetic retinopathy in his left eye . on the first postoperative day , 
 visual acuity dropped from 20/80 to hand movements . 
 slit - lamp examination showed the drug between the posterior capsule of the lens and the anterior hyaloid face . 
 two weeks later , visual acuity and the milky fluid seemed unchanged . 
 neodymium : yttrium - aluminum - garnet ( nd : yag ) laser anterior hyaloidotomy was performed . 
 one week later , slit - lamp examination of the retrolental space revealed the complete disappearance of triamcinolone and intraocular pressure remained stable . after a follow - up period of 2 months , 
 visual acuity increased to 20/50 with the lens remaining clear . 
 nd : yag laser anterior hyaloidotomy is an effective , simple , useful and minimally invasive outpatient procedure in patients with persistent entrapment of triamcinolone behind the crystalline lens , allowing the drug to clear without trauma to the lens . 
INTRODUCTION
CASE REPORT
DISCUSSION