DISCUSSION
Bilateral conjunctival and scleral necrosis after sub-Tenon triamcinolone injection is a rare but severe complication, especially in children. This 3-year-old boy’s case underscores the danger of local steroid-induced tissue necrosis, an experience well described in adult cases but infrequently in children. The mechanisms likely include direct cytotoxicity of triamcinolone and its preservatives, especially benzyl alcohol, which has been associated with ocular surface toxicity and delayed wound healing (1, 9).
Moreover, steroid-induced vasoconstriction could have potentiated ischemic necrosis in the supronasal quadrants areas with relatively poor vascular density (6,10).The patient in this instance had localized conjunctival ischemia and thinning of the sclera at the site of injection, which indicates a local toxic effect of the drug on ocular tissue. Experimental studies have indicated that benzyl alcohol initiates disruption of the epithelial cell membrane and apoptosis, which results in delayed healing and inflammation of the wound (9).
A similar case has been reported in a child with conjunctival necrosis after subconjunctival injection of triamcinolone acetonide for chronic severe anterior uveitis (8). In a similar case, another case had been reported where there was chronic retention of steroid resulting in progressive thinning of the sclera(6).
In contrast to these cases, our patient had neither systemic risk factors nor previous surgery, pointing towards drug toxicity as the etiology. In addition, though most of the adult cases need grafting, early treatment with drug withdrawal, surgical debridement, and support therapy permitted spontaneous healing without grafting, highlighting the possible conservative management in children with minor necrosis.
This case reminds us that one must remain vigilant while using periocular steroids in children because of the tremendous susceptibility of their tissues and prolonged drug retention in the developing eye. Practitioners must be alert for any early signs of conjunctival ischemia following the injection, which could be instrumental in preventing dangerous scleral thinning and structural complications. Lack of pediatric data for steroid-induced ocular necrosis, further research is needed to determine risk factors, better delineate steroid injection techniques, and investigate alternatives to safer control of postoperative inflammation.