Clinical impact of diagnostic image-guided injections for musculoskeletal pain work-up in adolescent and adult patients at a children's hospital: initial results.

OBJECTIVE: To assess the clinical impact of diagnostic musculoskeletal (MSK) injections on treatment decision-making in adolescent and adult patients at a children's hospital. MATERIALS AND METHODS: Retrospective study in patients who underwent diagnostic MSK injections by fluoroscopy or ultrasound (US) between 8/2020 and 3/2023 at a children's hospital. Patients received ropivacaine and triamcinolone acetonide at pain site, reporting quantitative FACES pain score prior to, immediately following, and 2-3 days following injection. Impact on patient care was subsequently assessed. RESULTS: A total of 109 diagnostic fluoroscopic or US MSK injection referrals (mean: 17.6 years old) were included, most commonly hip (76.2%), ankle (9.2%), and iliopsoas tendon sheath (8.3%). Pain improvement occurred in 89.0% immediately and 67.9% 2-3 days after MSK injection, with net 84.4% exhibiting improvement based on pain scores and clinical exams. When there was pain improvement at the site of injection, there was a statistically higher incidence of operative intervention or additional therapeutic injections compared with the cohort that did not have symptom improvement (88% versus 35.3%, P < 0.0001). For the 15.6% (N = 17) of referrals that did not have pain improvement, 17.6% (n = 3) ultimately had an operative intervention at a separate site from the diagnostic injection, as an alternative etiology for the pain was found. CONCLUSION: Image-guided MSK injections play an important role in the management of musculoskeletal disorders. 84.4% of referrals experienced symptom relief, improving confidence for treatment decision-making. Importantly, 15.6% of patients were found to have an alternative etiology for symptoms, altering management altogether.

The Effect of 3-Dimensional-Printed Sequential Dual Drug-Releasing Patch on the Capsule Formation Around the Silicone Implant in a Rat Model.

BACKGROUND: Implant-based breast reconstruction is associated with increased risk of early infection and late-stage capsular contracture. OBJECTIVES: We evaluated the feasibility of a dual drug-releasing patch that enabled the controlled delivery of antibiotics and immunosuppressants in a temporally and spatially appropriate manner to the implant site. METHODS: The efficacy of a dual drug-releasing patch, which was 3-dimensional-printed (3D-printed) with tissue-derived biomaterial ink, was evaluated in rats with silicone implants. The groups included implant only (n = 10); implant plus bacterial inoculation (n = 14); implant, bacterial inoculation, and patch loaded with gentamycin placed on the ventral side of the implant (n = 10), and implant, bacterial inoculation, and patch loaded with gentamycin and triamcinolone acetonide (n = 9). Histologic and immunohistochemical analyses were performed 8 weeks after implantation. RESULTS: The 2 drugs were sequentially released from the dual drug-releasing patch and exhibited different release profiles. Compared to the animals with bacterial inoculation, those with the antibiotic-only and the dual drug-releasing patch exhibited thinner capsules and lower myofibroblast activity and inflammation, indicating better tissue integration and less foreign body response. These effects were more pronounced with the dual drug-releasing patch than with the antibiotic-only patch. CONCLUSIONS: The 3D-printed dual drug-releasing patch effectively reduced inflammation and capsule formation in a rat model of silicone breast reconstruction. The beneficial effect of the dual drug-releasing patch was better than that of the antibiotic-only patch, indicating its therapeutic potential as a novel approach to preventing capsular contracture while reducing concerns of systemic side effects.

Evaluation of combined epiretinal membrane removal with intravitreal triamcinolone injection utilizing ectopic inner foveal layer staging scheme.

OBJECTIVE: To investigate the macular morphological and visual outcomes of combined idiopathic epiretinal membrane (iERM) removal with triamcinolone acetonide (TA) injection based on consideration of the ectopic inner foveal layer (EIFL) staging scheme. METHODS: Retrospective case-control study. The clinical data of 84 eyes of 84 patients who underwent vitrectomy for iERM between 2018 and 2022 were reviewed. The enrolled subjects were divided into the TA and non-TA groups. Fifty-one eyes received intravitreal TA injection following vitrectomy and ERM peeling (TA group), and 33 were only treated by standard vitrectomy and ERM peeling (non-TA group). Preoperative and postoperative EIFL stages, central foveal thickness (CFT), and best-corrected visual acuity (BCVA) were compared between both groups. RESULTS: After a mean follow-up of 7.69 ± 3.68 months, both groups exhibited significant improvement in EIFL stages (P < 0.01), with no discernible advantage observed in the TA group. The TA and non-TA groups demonstrated improvement in the EIFL stages in 56.86 and 63.64% of eyes, respectively (P = 0.43). The CFT and BCVA significantly improved in both groups at the final visit (P < 0.01). However, CFT in the non-TA group displayed a more significant reduction during the follow-up (P < 0.03). Subgroup analysis revealed no significant differences in postoperative CFT and BCVA between the two groups in cases with or without continuous EIFL (P > 0.10). CONCLUSION: Our findings indicate that combined intravitreal TA injection following ERM removal conferred no significant benefits in alleviating macular thickening or improving visual acuity in iERM.

Management of highly recurrent bladder neck contractures via transurethral resection combined with intra- and post-operative triamcinolone acetonide injections.

PURPOSE: To present our preliminary experience in managing patients with highly recurrent bladder neck contractures (BNCs) after transurethral resection of the prostate (TURP). METHODS: Between February 2015 and March 2018, 28 patients with highly recurrent BNCs who had failed multiple prior to endoscopic treatments were managed with transurethral resection and intra- and post-operative triamcinolone acetonide injections. The scar tissue was resected to the circular fiber at the bladder neck, and triamcinolone acetonide (2 mL, 40 mg/mL) was injected at the incision sites (8 points) using a cystoscopic injection needle. The cystoscopy-guided injections were repeated every four weeks for total three times after surgery. The patients were followed up at 3, 6, 12 months after surgery, and in July-August 2019. RESULTS: The recurrent interval before the treatments was 2.2 ± 1.2 months, without any BNC recurrence in the first 12 weeks after transurethral resection. The urinary flow rate increased significantly and was maintained during the follow-up period. Adequate voiding function was reported in 25 of 28 patients at a median follow-up of 2.8 (1.7, 3.9) years. One of the three patients with decreased urinary flow rate had underactive detrusor and no BNC recurrence. The complications were mild and tolerable. CONCLUSION: Transurethral resection of the scar tissue combined with intra- and post-operative triamcinolone acetonide injections resulted in a success rate of 92.9% in patients with highly recurrent BNC following TURP. It is a simple, safe, and effective treatment for highly recurrent BNCs.

TRENDS IN INTRAVITREAL CORTICOSTEROID AGENT USE BY US OPHTHALMOLOGISTS IN MEDICARE BENEFICIARIES AND ASSOCIATION WITH PHYSICIAN-INDUSTRY INTERACTIONS.

PURPOSE: To report trends of intravitreal corticosteroid use and explore the relationship between career experience, reported industry payments, and prescribing habits. METHODS: A retrospective review of ophthalmologists who administered intravitreal dexamethasone implants (DEX) and triamcinolone acetonide (TA) injections between August 2013 and December 2017. RESULTS: A total of 1,070 US ophthalmologists were reimbursed by Medicare for 522,804 DEX injections and 2.6 million TA injections. There was a significant positive trend in the number of DEX (P = 0.01), but not TA, injections per year. Mid-career and late-career physicians performed significantly greater total injections on average compared with early-career physicians (both P < 0.001). Early-career physicians performed a greater proportion of DEX injections than late-career physicians (P = 0.006). Industry payments were positively associated with the proportion of DEX used and inversely correlated with the proportion of TA administered (P < 0.001). On multivariate analysis, years in practice, number of payments, and total value of payments were significantly associated with the number of DEX injections administered (all P < 0.001). CONCLUSION: From 2013 to 2017, the use of DEX increased, whereas TA use remained stable. There was a positive association between DEX use and physician-industry interactions, which may be explained by seniority and experience. This study does not define a causal relationship.

CENTRAL RETINAL VEIN OCCLUSION IN YOUNG PATIENTS: Clinical Characteristics and Prognostic Factors.

PURPOSE: To investigate the clinical characteristics and prognostic factors of young patients with central retinal vein occlusion (CRVO). METHODS: This retrospective cohort study involved treatment-naïve patients with CRVO. Medical records regarding basic demographics, predisposing factors, ocular characteristics, and treatments were reviewed and compared according to age at CRVO onset. RESULTS: We enrolled 263 patients, of whom 69 were younger patients. Younger patients had higher prevalence of nontraditional risk factors including physical or psychological stress (P = 0.032), hematologic abnormalities (P = 0.003), and better visual acuity at baseline and last visit (all P < 0.001) and were unlikely to undergo intravitreal injections (47.8 vs. 68.6%, P < 0.001) during follow-up. Younger patients had higher prevalence of paracentral acute middle maculopathy (28.1 vs. 4.7%, P < 0.001). Older age (odds ratio = 1.165, P = 0.028), male sex (odds ratio = 7.074, P = 0.034), coexisting renal disease (odds ratio = 7.845, P = 0.050), and poor baseline visual acuity (odds ratio = 16.069, P = 0.002) were significant risk factors for poor visual outcomes in young CRVO patients. CONCLUSION: Younger CRVO patients had a milder clinical course with fewer treatments and were more likely to have nontraditional risk factors than older patients.

Efficacy and safety of Nd:YAG laser alone compared with combined Nd:YAG laser with intralesional steroid or botulinum toxin A in the treatment of hypertrophic scars.

The aim of this study is to evaluate the efficacy and safety of Nd:YAG laser alone or in combination with intralesional injection of botulinum toxin type A or intralesional injection of steroid in treatment of hypertrophic scars. This study included 45 patients with hypertrophic scars who were randomly divided into three equal groups. All participants received 4 sessions of Nd:YAG laser at 4-week intervals. Immediately after the laser treatment, patients in group II were assigned to intralesional triamcinolone acetonide, and those in group III were assigned to intralesional botulinum toxin type A. All patients were followed up monthly for 3 months after the last session for any recurrence, or side effects. Clinical evaluation of the cases was done by Vancouver Scar Scale. Hypertrophic scars in the three groups showed a significant improvement (p < 0.001) compared with before treatment in all variables (except for pigmentation) and also a significant improvement in pruritus, pain, and patient relief. The highest percentage of improvements was seen in patients treated with Nd:YAG laser combined with intralesional steroid in all variables according to Vancouver Scar Scale. The degree of improvement was negatively correlated with the patients' age. The three treatment modalities were effective, safe with minimal side effects. Nd:YAG laser followed by intralesional injection of Triamcinolone acetonide had the highest percentage of Vancouver Scar Scale reduction. Combination therapy of Nd:YAG laser with intralesional injection of either Triamcinolone acetonide or Botox revealed better results than using Nd:YAG as a single therapeutic modality for HTS.

Triple treatment in ear keloids: Comparison of post-excisional intralesional steroid and platelet-rich plasma treatment.

PURPOSE: Ear keloids lead to psychological problems in the patient by causing complaints, such as itching and swelling. It is highly resistant to treatment, and recurrences are frequent. In the present study, the purpose was to investigate the treatment success of the intralesional steroid and PRP combination in addition to surgical excision in ear keloids. The 5-year recurrence rates and adverse effects of both treatments were also compared in this respect. MATERIALS AND METHODS: In this study, 60 patients between the ages of 16 and 65 who were followed up between 2015 and 2020 due to ear keloids were evaluated retrospectively. Patients were divided into 3 different groups (n = 20) as (A-B-C). There were patients who had only intralesional steroid injections due to ear keloids in Group A, patients who had intraoperative/postoperative steroid injections combined with surgical excision were in Group B, and patients who had intraoperative/postoperative steroid+intraoperative Platelet-Rich Plasma (PRP) injections combined with surgical excision were in Group C. RESULTS: It was found that the 5-year recurrence rate was the lowest in Group C (Surgical Excision+PRP + TAC). The 5-year recurrence rate of Group C was significantly lower when compared with other groups (p < 0.05). When the 5-year recurrence rate of Group A (TAC) and B (Surgical Excision+TAC) was compared, the recurrence rate of Group B was significantly lower (p < 0.05). When the adverse effects were compared, no significant differences were detected between two Groups (A-B) in terms of Skin Atrophy and Telangiectasia. Significant differences were detected between patients in Group C and other groups (p < 0.05). No significant differences were detected between Group B and C (p = 0.832). CONCLUSION: The combination of surgical excision with Intralesional TAC and PRP treatment in patients with ear keloids should be considered as a highly successful multimodal treatment in terms of low recurrence and adverse effects.

Efficacy and Safety of Suprachoroidal CLS-TA for Macular Edema Secondary to Noninfectious Uveitis: Phase 3 Randomized Trial.

PURPOSE: Injection of pharmacotherapy into the suprachoroidal space, between the sclera and choroid, is an alternative delivery technique developed with the rationale of providing higher drug concentrations to posterior ocular structures compared with other intraocular and periocular injection procedures. This study was conducted to evaluate the safety and efficacy of suprachoroidally injected triamcinolone acetonide formulation (CLS-TA), a suspension of triamcinolone acetonide, in improving vision among patients with noninfectious uveitis complicated by macular edema (ME). DESIGN: Phase 3 masked, randomized trial. PARTICIPANTS: One hundred sixty patients with ME secondary to noninfectious uveitis. Patients were required to have a best-corrected visual acuity (BCVA) of 5 or more Early Treatment Diabetic Retinopathy Study (ETDRS) letters (Snellen equivalent, 20/800) and 70 or fewer ETDRS letters read (Snellen equivalent, 20/40) in the study eye. METHODS: Patients were randomized 3:2 to suprachoroidally injected CLS-TA or sham treatment, with administrations at day 0 and week 12. MAIN OUTCOME MEASURES: The primary end point was improvement from baseline of 15 or more ETDRS letters in BCVA at week 24. The secondary end point was reduction from baseline in central subfield thickness (CST) at week 24. RESULTS: In the CLS-TA arm, 47% of patients gained 15 or more ETDRS letters in BCVA versus 16% in the control arm (P < 0.001), meeting the primary end point. Mean reductions in CST from baseline were 153 µm versus 18 µm (P < 0.001). No serious adverse events (AEs) related to treatment were reported. Corticosteroid-associated AEs of elevated intraocular pressure occurred in 11.5% and 15.6% of the CLS-TA and control groups, respectively. Cataract AE rates were comparable (7.3% and 6.3%, respectively). CONCLUSIONS: Patients in the CLS-TA study arm experienced clinically significant improvement in vision relative to the sham procedure, demonstrating the efficacy of suprachoroidal injection of CLS-TA for the treatment of ME in a vision-threatening disorder.

Can a Pretreatment Visual Analog Scale Predict Treatment Outcome in Allergic Rhinitis?

BACKGROUND: The visual analogue scale (VAS) is a simple and useful tool to assess the severity of allergic rhinitis. Whether a pretreatment VAS score can guide appropriate medication is unclear. OBJECTIVE: The aim of this study was to evaluate whether a pretreatment VAS score could be used to predict therapeutic response. METHODS: A prospective 4-week cohort study involving 101 allergic rhinitis patients was carried out. All patients were treated with triamcinolone acetonide aqueous nasal spray 220 µg once daily for 28 days. The treatment outcomes were evaluated using VAS scores (0-10 cm), total nasal symptoms scores (TNSSs), nasal mucociliary clearance times (NMCCTs), and global symptom controls (GSCs). The minimal clinically important differences (MCIDs) method was used to separate the patients into with and without improvement groups. Receiver operating characteristic curve analysis was performed to evaluate the predictive value of pretreatment VAS scores in relation to MCIDs after treatment. RESULTS: Pretreatment VAS scores showed a positive correlation with pretreatment TNSSs and NMCCTs (ρ = 0.66, p < 0.001 and r = 0.44, p < 0.001, respectively), and a negative correlation with GSCs after treatment (r = -0.53, p < 0.001). The MCID values of TNSSs and NMCCTs were 3.19 and 2.78, respectively. The cutoff value of pretreatment VAS ranged between 6.5 and 7.7 points, with an average value of 7.1. CONCLUSION: A pretreatment VAS score of 7 or higher was associated with an unfavorable treatment outcome, which suggests the potential therapeutic predictive value of VAS scoring.

Ocular symptoms improvement from intranasal triamcinolone compared with placebo and intranasal fluticasone propionate: A meta-analysis.

BACKGROUND: Allergic rhinitis is a prevalent disease, which can be classed as seasonal (SAR) or perennial. In addition to nasal symptoms, up to 75% of sufferers experience itching, redness, and tearing of the eyes. Intranasal corticosteroids are effective in controlling the allergic nasal symptoms, and increasing evidence suggests that they also can relieve some of the allergic ocular symptoms. OBJECTIVE: To evaluate the magnitude of efficacy of triamcinolone acetonide (TAA) compared with placebo or fluticasone propionate (FP) on ocular symptom improvement in patients with SAR. METHODS: A meta-analysis of summary data from 8 randomized, double- or single-blind trials, assessing mean change in total or individual (tearing, redness, and itching) eye symptoms was conducted. Trials that administered a daily dose of 220 µg TAA vs placebo or 200 µg FP over at least 2 weeks' duration, in patients aged 12 years or older with SAR, were analyzed. RESULTS: Total eye symptom reduction after 2 weeks was greater with TAA than placebo, with a mean treatment difference of -0.32 (95% CI, -0.444 to -0.203). In addition, significant reductions in tearing, but not itching or redness, were observed after TAA treatment compared with placebo. No significant treatment difference was seen between TAA and FP in total ocular symptoms at any of the time points measured (weeks 1, 2, 3, and overall). All treatments exhibited similar safety profiles and were deemed well tolerated. CONCLUSION: The meta-analysis demonstrated the positive clinical improvements TAA has on total ocular allergy symptoms, especially tearing, in addition to its recognized nasal symptom efficacy in SAR.

Isolated nail lichen planus: An expert consensus on treatment of the classical form.

Lichen planus is a benign inflammatory disorder of unknown etiology that may affect the skin, mucosae, scalp, and nails. When the nails are affected, it may lead to permanent destruction with severe functional and psychosocial consequences. Therefore, prompt diagnosis and early treatment are essential, even in mild cases. There are currently no guidelines for the management of nail lichen planus and the published literature on treatment is limited. The aim of this review is to provide practical management recommendations for the classical form of nail lichen planus, especially when restricted to the nails. Topical treatment has poor short-term efficacy and may cause long-term side effects. Instead, intralesional and intramuscular triamcinolone acetonide should be considered first-line therapies. Oral retinoids are second-line choices, and immunosuppressive agents may also be considered.

Bevacizumab versus triamcinolone for persistent diabetic macular edema: a randomized clinical trial.

PURPOSE: To evaluate 24-week visual acuity and anatomic outcomes of two "pro re nata" (prn) treatment strategies (intravitreal bevacizumab [IVB] prn versus intravitreal triamcinolone acetonide [IVT] prn) in patients with persistent diabetic macular edema (pDME) after 24 weeks of prn-IVB. METHODS: One hundred eyes with center-involving DME were enrolled and treated with prn-IVB for 24 weeks; at week 24, eyes with pDME (central subfield thickness [CST] on spectral domain optical coherence tomography > 300 µm) were randomized to IVB monthly prn (group I; prn-IVB) or IVT every 3 months prn (group II; prn-IVT) and eyes in which the CST was ≤ 300 µm were assigned to continue prn-IVB (group III). RESULTS: Seventy-four eyes completed a 48-week study period. At week 24, 65 (79.3%) eyes still had DME with CST > 300 µm and, therefore, were randomized to prn-IVB (group I, n = 33) or prn-IVT (group II, n = 32); the remaining 17 (20.7%) eyes had CST ≤ 300 µm and were assigned to continued treatment with prn-IVB (group III). At baseline, mean CST (µm) ± standard error of the mean (SEM) was 447.2 ± 24.4, 478.0 ± 19.7, and 386.0 ± 21.0 in groups I, II, and III, respectively (p > 0.05). At week 48, there was no significant difference in mean CST between groups I and II (369.9 ± 23.3 and 426.0 ± 26.1, respectively; p = 0.9995). A significant reduction in mean CST, compared with baseline, was noted at weeks 28 (p = 0.0002) and 44 (p = 0.0002) in group II. Group I did not show a significant reduction in mean CST compared with baseline at any study visit. There were no significant differences in mean CST between groups I and II at any study visit. At baseline, mean ± SEM best-corrected visual acuity (BCVA) (logMAR) was 0.50 ± 0.00, 0.60 ± 0.10, and 0.50 ± 0.10 in groups I, II, and III, respectively (p > 0.05). At week 48, there was no statistically significant difference in mean BCVA between groups I and II (0.50 ± 0.10 and 0.80 ± 0.10, respectively; p = 0.4473). There was no significant improvement in mean BCVA, as compared with baseline, at any study follow-up visit in any of the groups. Group II demonstrated significantly lower BCVA after 24 weeks of IVT (at week 48) compared with baseline (p = 0.0435). There was no significant difference in mean BCVA between groups I and II at any time-point. CONCLUSION: In eyes with pDME after 24 weeks of treatment with prn-IVB, there was no difference between continued treatment with prn-IVB versus a treatment switch to prn-IVT with respect to mean BCVA or mean CST at week 48. However, BCVA was stable in the prn-IVB group, while prn-IVT was associated with BCVA reduction from baseline and a higher risk of IOP elevation.

Comparison of Corticosteroid Injection Dosages in Mild to Moderate Idiopathic Carpal Tunnel Syndrome: A Randomized Controlled Trial.

OBJECTIVES: To evaluate whether the therapeutic effect of ultrasound-guided injections with 10 mg or 40 mg triamcinolone acetonide (TA) was dose-dependent in patients with idiopathic mild to moderate carpal tunnel syndrome (CTS). DESIGN: Prospective, double-blind, randomized controlled study with 12 weeks of follow-up. SETTING: Rehabilitation outpatient clinic of a single medical center. PARTICIPANTS: Patients with CTS (N=56). INTERVENTION: Participants were randomly assigned to 2 treatment groups for injection: (A) 40 mg TA+2% lidocaine hydrochloride or (B) 10 mg TA+2% lidocaine hydrochloride. MAIN OUTCOME MEASURES: Participants were evaluated using visual analog scale (VAS) and Boston Carpal Tunnel Questionnaire (BCTQ, including Symptom Severity Scale [SSS] and Functional Status Scale [FSS]) at baseline and 6 and 12 weeks after injection). Nerve conduction studies, including parameters of distal motor latency, amplitude of compound motor action potential, amplitude of sensory nerve action potential and sensory nerve conduction velocity of median nerve, and the patient's subjective impression of improvement, were recorded before injection and 6 and 12 weeks after injection. RESULTS: No significant differences were observed in baseline demographic characteristics and clinical evaluations. The parameters in group A and B at baseline, 6 weeks, and 12 weeks were (1) SSS: 2.17±0.14, 1.19±0.04, and 1.34±0.09 and 1.87±0.11, 1.21±0.07, and 1.26±0.04; (2) FSS: 1.63±0.07, 1.27±0.06, and 1.33±0.08 and 1.50±0.10, 1.18±0.05, and 1.26±0.05; (3) VAS: 6.4±0.3, 2.2±0.3, and 3.0±0.1 and 6.7±0.3, 2.0±0.3, and 3.1±0.3, respectively, and significantly decreased after 6 and 12 weeks in both treatment groups (P<.05). All parameters of nerve conduction studies improved in both groups after 12 weeks (P<.05). VAS, BCTQ, and nerve conduction studies did not show significant intergroup differences after 6 and 12 weeks. CONCLUSION: In patients with idiopathic mild to moderate CTS, ultrasound-guided injection with 10 and 40 mg TA yield similar improvements in BCTQ, VAS, and nerve conduction studies at the 12-week follow-up.

Perineural Dextrose and Corticosteroid Injections for Ulnar Neuropathy at the Elbow: A Randomized Double-blind Trial.

OBJECTIVE: To assess the effects of perineural corticosteroid and 5% dextrose water (D5W) injections in patients with mild to moderate ulnar neuropathy at the elbow (UNE). DESIGN: Prospective, randomized, double-blind, controlled trial (6-month follow-up). SETTING: Outpatients of local medical center settings. PARTICIPANTS: Patients (N=36) with mild to moderate UNE were randomized, and 33 participants were included in the final data analysis. INTERVENTIONS: Patients were administered a single perineural injection with 5 mL D5W and 3 mL corticosteroid (triamcinolone acetonide, 10mg/mL) mixed with 2 mL normal saline under ultrasound guidance in the dextrose and steroid groups, respectively. MAIN OUTCOME MEASURES: The visual analog scale digital pain or paresthesia/dysesthesia score was the primary outcome. The secondary outcomes were the Disabilities of the Arm, Shoulder, and Hand questionnaire, motor nerve conduction velocity, and cross-sectional area (CSA) of the ulnar nerve. The measurement assessment was conducted before and 1, 3, 4, and 6 months after injection. RESULTS: Thirty-three patients completed the study. Both injections were found to be equally effective at most measurement points, although the dextrose group experienced larger reductions in symptom severity and CSA of the ulnar nerve from the third month onward. CONCLUSIONS: We suggest D5W as a more suitable injectate for perineural injection in patients with UNE.

TOXIC POSTERIOR SEGMENT SYNDROME AFTER DROPLESS CATARACT SURGERY WITH COMPOUNDED TRIAMCINOLONE-MOXIFLOXACIN.

PURPOSE: To report toxic posterior segment syndrome after dropless cataract surgery using locally compounded triamcinolone-moxifloxacin. METHODS: A retrospective case review of 7 patients presenting with a decrease in visual acuity after dropless cataract surgery. RESULTS: All patients experienced significant reductions in best-corrected visual acuity of the postoperative eye ranging from 20/40 to count finger at 4 feet (average best-corrected visual acuity 20/220) immediately after surgery. The presenting symptoms included flashes, floaters, photophobia, glare, halos, visual distortions, and problems assessing colors. In three cases, foveal retinal pigment epithelium changes were noted on dilated fundus exam (DFE). Ellipsoid zone loss was noted on ocular coherence tomography in five of the seven affected eyes. Electrophysiology testing in five of the seven affected eyes demonstrated large decreases in full-field electroretinogram amplitude, oscillatory potentials, multifocal electroretinogram, and visual evoked potential, along with a negative electroretinogram. One patient was treated with a dexamethasone implant, but no improvement in visual acuity was noted. CONCLUSION: This is the first case series of toxic posterior segment syndrome occurring secondary to intracameral compounded triamcinolone-moxifloxacin in dropless cataract surgery. The FDA has attributed the toxicity to abnormally high levels of the binding agent poloxamer 407 in the compounded medication. Clinicians should be aware of this phenomenon and exhibit caution when using compounded medications.

Serum triamcinolone levels during intensive, inpatient wet-dressing therapy.

BACKGROUND: Wet dressings combined with topical corticosteroids are beneficial for patients with generalized and refractory dermatosis; however, to our knowledge, serum levels after topical corticosteroid absorption during intensive therapy have not been reported previously. AIM: To examine serum levels of triamcinolone acetonide (TAC) after topical corticosteroid application during intensive wet-dressing therapy. METHODS: We performed a retrospective study of adult patients admitted for inpatient wet-dressing therapy from 7 November 2015 to 24 June 2016. Data were collected on sex, age, body surface area, TAC serum levels, number of wet-dressing changes after 24 and 48 h, and type of wet dressing. RESULTS: In total, 29 patients (14 men, 15 women) were assessed. Median [interquartile range (IQR)] age was 57 years (51.5-67.0 years) and involved body surface area was 1.98 m2 (1.88-2.15) m2 . Before the 24-hour blood draw, patients had received 1-3 dressing changes. Median (IQR) TAC level at 24 h was 0.33 µg/dL (0.20-0.58 µg/dL), with no significant difference noted between the number of dressing changes and TAC serum level. At 48 h, results of a serum TAC test were available for 22 patients with 2-6 dressing changes. Mean (IQR) serum level was 0.30 µg/dL (0.30-0.87 µg/dL). For each additional dressing change, there was an estimated 0.21 µg/dL increase in TAC serum level (95% CI 0.11-0.31; P < 0.001). TAC serum level was not significantly associated with sex, age, body surface area or dressing type. CONCLUSIONS: Intensive, inpatient wet-dressing therapy is associated with detectable TAC serum levels. However, we suspect that topical TAC has a primarily local therapeutic effect on the skin.

Rebound Phenomenon after Intravitreal Injection of Triamcinolone Acetonide for Macular Edema.

INTRODUCTION: The aim of this article was to report on a rebound phenomenon after intravitreal triamcinolone acetonide (IVTA) injection for macular edema secondary to diabetic retinopathy (DR) and central or branch retinal vein occlusion (CRVO/BRVO). METHODS: The data were analyzed retrospectively. Complete ophthalmic examinations, including spectral domain optical coherence tomography, were performed before and 2 months after IVTA injection. The incidence of a rebound phenomenon was defined as an increase in central retinal thickness of >10% from baseline at 2 months after IVTA injection. RESULTS: This retrospective study included 211 consecutive patients (268 eyes). One hundred ninety (71.2%), 39 (14.6%), and 39 (14.6%) eyes had macular edema (ME) due to DR, CRVO, and BRVO. In total, 9.7% of the eyes showed a rebound phenomenon (DR: 9.5%, CRVO: 5.2%, BRVO: 15.4%). The mean number of prior injections of vascular endothelial growth factor inhibitor or corticosteroid agent was statistically significantly higher in the rebound group (6.8 vs. 5.3) than in the nonrebound group (p = 0.01). CONCLUSION: Our study shows that 9.7% of the eyes with ME secondary to DR and RVO developed a rebound phenomenon following IVTA injection, limiting its therapeutic effect. We found an increased number of prior intravitreal pharmacotherapy to be a risk factor for a rebound phenomenon.

Intralesional Triamcinolone Acetonide in the Treatment of Traction Alopecia

Traction alopecia (TA) is a form of hair loss caused by continuous and prolonged tension to the hair, most commonly seen in Black/African American women and children who wear hairstyles that pull excessively at the frontotemporal hairline. Dermatologists have recommended the use of intralesional triamcinolone acetonide injections (ILK) to decrease the inflammatory process, however, evidence-based proof is lacking in the literature. In this case series, we evaluate the effectiveness and safety of ILK in the TA management of 6 African American women. A retrospective chart review was done of patients with a diagnosis of TA, who were treated with ILK at an academic dermatology clinic, yielding 6 patients. Management of TA was assessed by comparing the photographs for changes in hair density along the frontotemporal hairline. ILK with a concentration of 5 mg/mL, was administered in areas of low hair density along the frontotemporal hairline at 6 to 8-week intervals, for 3 successive visits. All subjects demonstrated visible increase in hair density along the frontotemporal hairline following their first or second treatment, and no severe adverse effects were observed or reported. The use of ILK is currently an effective and safe method of treating TA, particularly in the early to mid-stages. Common adverse effects are pain, and subsequent transient atrophy at the injection site. The transient atrophy is not an indication to stop treatment. Avoidance of treating dented areas is sufficient to allow it to revert. Patient education is pivotal in the prevention and management of TA. It is imperative that dermatologists caution against grooming practices that exert tension on the hairline. J Drugs Dermatol. 2020;19(2)128-130. doi:10.36849/JDD.2020.4635

Surgical excision combined with fully ablative carbon dioxide laser therapy and triamcinolone injections as a potential treatment for keloids in children.

BACKGROUND/OBJECTIVE: Keloids represent a functional and esthetic burden and can be particularly challenging to treat. Various topical, injectable, and ablative therapies exist but are associated with significant recurrence if used alone. We wanted to evaluate the long-term efficacy of multimodal therapy in pediatric patients treated for keloids at the Sainte-Justine University Hospital Center. METHODS: We conducted a retrospective case study of 21 children with 21 keloids treated between April 2006 and April 2016. The following combination of treatments was studied: surgical excision, carbon dioxide (CO2 ) laser therapy on the surgical site, and triamcinolone acetonide (TAC) intralesional injections during surgery and follow-up. Depending on the site treated, pressure garments and/or topical silicone were also used. RESULTS: Of the 21 patients initially treated, four were lost to follow-up. Of the 17 patients who had adequate follow-up (mean duration 18 months, with periodic reassessments and additional TAC injections if needed), 6 (35%) had some recurrence, with remission in three of them following subsequent treatment and three lost to follow-up. In summary, 14 (82.4%) of the patients with adequate follow-up had complete clearance of the keloid. However, this must be interpreted in light of the fact there was a significant loss of follow-up (33.3%) from the initial cohort. CONCLUSION: Our results are in agreement with other recent studies that demonstrate the need for multimodal therapy with combined methods in order to achieve long-term remission. A randomized controlled trial would be necessary to assess the real benefit of this treatment combination in children.