Steroid-related vision loss is a rare complication following steroid injection for a variety of inflammatory or cicatricial conditions in the facial and periorbital regions. The first systematic review to analyze the literature for incidence, steroid type, injection site, treatment, and outcomes of this devastating complication was recently published in Ophthalmic Plastic & Reconstructive Surgery. Steroid injections in the nasal and periorbital area led to most instances of vision loss, and triamcinolone was the most common offending agent, the study shows.
The investigators conducted a literature search across numerous major literature databases for vision loss following facial and periorbital corticosteroid injections through July 2020. Their study followed Preferred Reporting Items for Systematic and Meta-Analysis guidelines.
They analyzed a total of 35 case reports, series, and reviews that included a total of 49 patients (56 eyes) with steroid-induced vision loss. Cases were reported from the US (67%), Canada (8%), India (6%), France (6%), China (4%), Turkey (4%), Israel (2%), and Japan (2%). Age was mentioned in 35 of 49 cases; the average age was 28.5 years (range, 0.17-77).
The most common injection sites were the nasal turbinate (33%) and the eyelids (10%), followed by intranasal (6%), retrobulbar (6%), scalp (6%), mandible (4%), tonsillar fossae (4%), and subtenons (4%), and various other sites (2%). Injections leading to vision loss were predominantly in the nose area (45%), followed by the periocular area (29%). Reasons for injection were reported as inflammation (50%), lesion (18%), and scarring (6%) or were unspecified (24%). The most frequently used steroid was triamcinolone (54%), followed by methylprednisolone (33%), betamethasone (8%), and hydrocortisone (6%).
Vision loss was unilateral in 86% of cases and bilateral in 14% of cases. Of bilateral cases, 4 of 7 resulted from unilateral steroid injection. Symptoms of ophthalmic and retinal arterial occlusion leading to vision loss were reported during or immediately after injections in 49% of cases. Most occlusions were in the ophthalmic artery (53%), central retinal artery (33%), and branch retinal artery (13%). Vision loss most commonly presented as no light perception (37%). In 90% of cases, vision was 20/200 or worse. Final visual outcomes varied. Some patients remained with vision of 20/200 or worse (56%), while others had improvement to 20/40 or better (30%), to in between (13%).
Limitations of the study were the limitation of the literature review to case reports, series, and reviews, potential underreporting of this rare complication, and an inability to analyze the risks of embolism associated with particular corticosteroid subtypes or brands.
“Triamcinolone was the most common offending agent, likely due to large particle size, low solubility, and extensive particle aggregation,” according to the investigators. “Dexamethasone has the opposite pharmacologic properties and has never been reported in association with vascular occlusion related vision loss. Careful steroid selection, injection techniques, and treatment strategies should be considered to prevent and treat artery occlusion.”
Park SSE, Barmettler A. Vision loss secondary to facial and periorbital steroid injection: a systematic review. Ophthalmic Plast Reconstr Surg. 2021;37(6):511-521. doi:10.1097/IOP.0000000000001910