Original Article

Comparison of topical steroids versus adjunctive intracameral triamcinolone

versus posterior subtenon triamcinolone in pediatric cataract surgery

Usha K Raina, Kumar Ravinesh, Shruti Bhattacharya, Banu Pavitra, Meenakshi Thakar

Purpose: Prolonged postoperative topical corticosteroids are commonly given after pediatric cataract Access this article online
surgery to control inflammation. This study was undertaken to compare the efficacy, safety, and compliance Website:
of postoperative topical steroids and adjunctive intracameral (I/C) triamcinolone acetonide (tricort) www.ijo.in
and posterior subtenon (PST) triamcinolone in modulating postoperative inflammation after surgery. DOI:
Methods: Forty‑eight eyes of children with pediatric cataract between the ages of 5 and 10 years were 10.4103/ijo.IJO_1659_22
randomized into three equal groups (T, I, S) before surgery. Group T received postoperative topical 1%
prednisolone tapered over 4 weeks; Group I received adjunctive intraoperative I/C 1.2 mg/0.03 ml tricort
and topical 1% prednisolone for 2 weeks postoperatively, and Group S received a single 0.5 ml (40 mg/ Quick Response Code:
ml) PST tricort without topical steroids. Signs of inflammation, intraocular pressure (IOP), and central
corneal thickness were assessed at day 1, week 1, week 3, week 6, and week 12 postoperatively with
optical coherence tomography (OCT) macula to rule out cystoid macular edema at the sixth and 12th weeks
postoperatively. Results: Posterior synechiae were present in two eyes out of 16 in groups T and I, which
resolved. Severe anterior chamber cells were present in four eyes out of 16 in group T, in two eyes in
group I, and in one eye in group S, which resolved. All groups had comparable pre‑ and postoperative
IOP. Conclusion: In pediatric cataracts, outcomes were better with PST tricort and the adjunctive I/C tricort
compared to postoperative topical prednisolone, for modulating postoperative inflammation.

Key words: Intracameral triamcinolone, pediatric cataract surgery, posterior subtenon triamcinolone

Congenital cataract is one of the most common causes of To overcome these drawbacks, other modes of steroid delivery
reversible blindness worldwide,[1,2] being responsible for systems have been tried, such as subconjunctival, intracameral,
7.4%–15% of childhood blindness in India, and its incidence subtenon, intravitreal injections, or oral preparations. It has
has been estimated to be up to six per 10,000 births.[3] Cataracts been postulated that the use of intracameral corticosteroid
in adults cause diminution in vision, while in children it can at the end of the surgery confers a comparable control of
also lead to stimulus deprivation amblyopia, which can cause postoperative intraocular inflammation.[7,11] Intraoperative
lifelong deprivation of vision. Therefore, early diagnosis and posterior subtenon steroid is another route of drug delivery. The
intervention with good postoperative optical rehabilitation is advantage of using this method intraoperatively is that it is easy
a must to prevent amblyopia in such children. to administer for the operating surgeon.[12] The drug used here
is triamcinolone acetonide, which was used earlier to visualize
Compared to cataract surgery in adults, there are many
the vitreous and to ensure thorough and complete vitrectomy in
peculiarities of pediatric cataract surgery. For instance, in the
pediatric cataract surgery. Triamcinolone acetonide is a depot
postoperative period, there is heightened inflammatory reaction
corticosteroid with low water solubility, which contributes to
due to irritation of iris and a greater risk of intense posterior
its prolonged action.[13] In a few studies,[7,8,10,11,12,14,15] both these
capsule opacification.[4‑6] There is also a poorer adherence
routes have shown a good therapeutic response and have been
with topical medications. Traditionally, intensive topical
reported to be a safe and effective alternative to topical steroids
corticosteroids have been used to control this postoperative
by eliminating the need for frequent postoperative eye drops.
inflammation, with a good response, as this inflammation is
steroid sensitive in most of the cases.[7,8] But frequent dosing of In this study, our aim is to comparatively evaluate the
steroids is needed as the intraocular levels of topically applied safety, efficacy, and compliance of intracameral triamcinolone
preparations are low and unreliable, with concentrations acetonide versus a single posterior subtenon triamcinolone
fluctuating between instillations and peak concentrations,[9] acetonide injection versus conventional topical steroids in
which increases the risk of adverse events. Moreover, many
caregivers do not adhere to these dosing instructions, which
This is an open access journal, and articles are distributed under the terms of
may compromise visual prognosis.[7,10] the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are licensed under
the identical terms.
Department of Ophthalmology, Guru Nanak Eye Centre, Maulana
Azad Medical College, New Delhi, India
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
Correspondence to: Dr. Shruti Bhattacharya, Guru Nanak Eye Centre,
Maulana Azad Medical College, New Delhi ‑ 110 002, India. E‑mail: Cite this article as: Raina UK, Ravinesh K, Bhattacharya S, Pavitra B,
shrutibhattacharya1993@gmail.com Thakar M. Comparison of topical steroids versus adjunctive intracameral
Received: 05-Jul-2022 Revision: 27-Sep-2022 triamcinolone versus posterior subtenon triamcinolone in pediatric cataract
surgery. Indian J Ophthalmol 2023;71:119-23.
Accepted: 07-Oct-2022 Published: 30-Dec-2022

© 2022 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

120 Indian Journal of Ophthalmology Volume 71 Issue 1

controlling postoperative inflammation after pediatric cataract In Group S, patients underwent surgery with the above
surgery. technique and received a single 0.5 ml (40 mg/ml) posterior
subtenon injection of triamcinolone acetonide at the end
Methods of surgery in the inferotemporal quadrant. Five millimeter
from the limbus, the conjunctiva and tenon were incised
A randomized interventional study was conducted on patients
to enter the subtenon space and a 0.5 ml (40 mg/ml) bolus
with congenital and developmental cataract between 5 and
of triamcinolone acetonide was injected in the posterior
10 years of age presenting to the outpatient department and
subtenon space using a blunt cannula mounted on a 1‑ml
Pediatric Ophthalmology Clinic at a tertiary care hospital in
syringe as shown in Fig. 2. The conjunctival opening was
India. Patients with active or chronic inflammation, uveitis
closed with 10‑0 Vicryl suture.
and secondary glaucoma, family history of glaucoma, high
myopes, and presence of any gross ocular pathology like Postoperative treatment
microphthalmos, aniridia, coloboma, Persistent hyperplastic All children received systemic antibiotic syrup amoxicillin
primary vitreous (PHPV), retinal detachment, or any for 5 days along with topical tobramycin 0.3% four times
subluxation of lens were excluded. daily and homatropine 2% thrice daily in the postoperative
Written informed consent was obtained from the patients’ period. In Group T and Group I, the children received topical
parents, and this study was conducted after obtaining the steroid prednisolone acetate 1%, and this was gradually
tapered and stopped as per the schedule mentioned earlier.
approval of the institutional ethics committee.
In Group S, no topical steroids were given postoperatively.
A total of 48 eyes were divided into three groups of 16 eyes Follow‑up was conducted at day 1, week 1, week 3, week
each. All patients underwent comprehensive ophthalmological 6, and week 12. Postoperatively, the eye was examined for
examination. The grouping was as follows: an inflammatory response such as synechiae formation,
• Group T – Patients received only postoperative topical AC cells, AC flare; pupillary membranes; pigment deposits
steroids on IOL; posterior capsule opacification; and intraocular
• Group I – Patients received single intracameral triamcinolone pressure (IOP), with > 21 mmHg being considered as high. IOP
acetonide intraoperatively and postoperative topical was measured using Goldmann applanation tonometry (GAT)
steroids on the first post operative day and in weeks 1, 3, 6, and 12.
• Group S – Patients received single posterior subtenon Additionally, optic disk cupping and retinal nerve fiber layer
triamcinolone acetonide intraoperatively without defects were closely monitored at each visit. Along with this,
postoperative topical steroids. central corneal thickness (CCT) was measured and optical
coherence tomography (OCT) of the macula was performed
A detailed history including ocular complaints, previous to rule out cystoid macular edema at the sixth and 12th weeks
treatment, and systemic complaints was taken and complete postoperatively.
ophthalmological examination was done.
Grading of AC cells15
Surgical technique
Standardization of Uveitis Nomenclature (SUN)[16] was used
All surgeries were performed by the same surgeon under for grading AC cells, as presented in Table 1. AC cells were
general anesthesia. Preoperatively, the pupil was dilated with divided into two groups: severe and nonsevere. We considered
mydriatic eye drop and in all three groups, the surgical steps AC cells with a grading of >2 as the severe group and ≤2 as the
were the same. Two paracenteses, 1 mm in size, were created in nonsevere group.
the clear cornea. This was followed by an anterior continuous
curvilinear capsulorhexis with soft lens matter aspiration, Statistical analysis
in‑the‑bag intraocular lens (IOL) implantation (Supraphob The quantitative variables in all three groups were expressed
preloaded system, Appasamy), removal of residual sodium as mean ± standard deviation (SD), and a P value <0.05 was
hyaluronate, and suturing of the incisions with 10‑0 Vicryl. considered to be statistically significant.
At the end of surgery, all patients received subconjunctival
gentamycin and dexamethasone. Results
In Group T, patients received postoperative topical 1% A total of 48 eyes were included in the present study, with
prednisolone according to the following schedule: one drop 16 eyes in each group. The mean age of patients in Group T
four times daily (week 1), three times daily (week 2), two times was 7.22 ± 1.61 years, in Group I was 7.75 ± 1.61 years, and
daily (week 3), and once daily (week 4). in Group S was 7.56 ± 1.68 years. There were no statistically
differences among the three groups (P = 0.716 and 0.65) with
In Group I, patients received an intracameral injection respect to age. The mean axial length of eyes in Group T was
of preservative‑free triamcinolone acetonide and topical 1% 22.75 ± 1.64 mm, in Group I was 22.61 ± 1.34 mm, and in Group S
prednisolone postoperatively according to the following was 22.72 ± 1.27 mm.
schedule: one drop two times daily (week 1), once daily
Posterior synechiae were present in two eyes out of
(week 2), and then stopped. The anterior chamber (AC)
16 (12.50%) in both groups T and I on the first postoperative
was reformed using single air bubble, and 1.2 mg/0.03 ml
day, as shown in Table 2.
preservative‑free triamcinolone acetonide was injected in
the angle of AC as shown in Fig. 1. Triamcinolone occupied These patients were given ointment atropine to dilate the
360° circumference of the space between the angle of AC pupil and break the synechiae. None of the eyes in Group S
and the air bubble. had posterior synechiae on postoperative day 1. However, on
January 2023 Raina, et al.: Comparision of topical vs intracam vs PST tricort in ped cat surgery 121

subsequent visits in postoperative week 1, week 3, week 6, and The mean CCT on postoperative day 1 was 600.5 ± 16.58 µm
week 12, posterior synechiae were absent in all three groups. in Group T, 581.06 ± 31.64 µm in Group I, and 571.31 ± 38.12 µm
in Group S. The mean CCT at postoperative week 12 was
AC cells were calculated using SUN classification. Severe
564.75 ± 9.59 µm in Group T, 563.25 ± 19.31 µm in Group I,
AC cells were present in four eyes out of 16 (25%) in group T,
and 563.88 ± 26.83 µm in Group S. No statistically significant
two eyes out of 16 (12.50%) in group I, and in one eye out of
difference was present among the above groups.
16 (6.25%) in group S on the first postoperative day, as seen
in Table 3. Nonsevere AC cells were present in 12 eyes out of None of the eyes had posterior capsular opacification in all
16 (75%) in group T, 14 eyes out of 16 (87.50%) in group I, and in three groups (T, I, and S) in postoperative week 6 and week 12.
15 eyes out of 16 (93.75%) in group S on the first postoperative
None of the eyes had cystoid macular edema, as seen on
day. None of the eyes had severe AC cells on the subsequent
OCT macula, in all three groups (T, I, and S) in postoperative
visits at postoperative week 1, week 3, week 6, and week
week 6 and week 12.
12 in all three groups.
Pigments over IOL were present in two eyes out of Discussion
16 (12.50%) in both groups T and I on the first postoperative One of the major challenges of pediatric cataract surgery is to
day. These pigments gradually disappeared with no special control the intense postoperative inflammatory reaction and
treatment. None of the eyes had pigments over IOL in Group S reduce the dependence on frequent instillations of topical
on postoperative day 1. steroids.
Pupillary membranes were present in two eyes out of Conventionally, intensive topical corticosteroids have been
16 (12.50%) in both groups T and I on the first postoperative used to control this postoperative inflammation, with a good
day and in one eye in Group S. These resolved on their own response, as this inflammation is steroid sensitive in most of
with no additional treatment. However, on subsequent visits at the cases.[7,8] But frequent dosing of steroids is needed as the
postoperative week 1, week 3, week 6, and week 12, pupillary intraocular levels of topically applied preparations are low and
membrane was absent in all three groups. unreliable, with concentrations fluctuating between instillations
An additional fact noted in the current study was that in and peak concentrations,[9] which increases the risk of adverse
Group I, the intracameral crystals of tricot persisted for up to events. Moreover, many caregivers do not adhere to these frequent
5 days in the AC, as seen on slit‑lamp microscopy [Fig. 1b]. dosing instructions, which may compromise visual prognosis.[7,10]

T h e m e a n p r e o p e r a t i v e I O P i n G r o u p T wa s To overcome these disadvantages, newer routes have been

16.01 ± 2.77 mmHg, in Group I was 16.85 ± 2.51 mmHg, and researched. Use of intracameral triamcinolone or posterior
in Group S was 16.98 ± 2.29 mmHg. There was no statistically subtenon triamcinolone at the end of the surgery confers
significant difference among the three groups (P = 0.51). The
mean IOP on postoperative day 1 was 17.62 ± 2.73 mmHg in
Group T, 18.75 ± 3 mmHg in Group I, and 19.38 ± 2.33 mmHg
in Group S. The mean IOP at postoperative week 1 was
18.56 ± 2.38 mmHg in Group T, 17.81 ± 2.32 mmHg in
Group I, and 17.75 ± 3.61 mmHg in Group S. The mean IOP
at postoperative week 3 was 18.32 ± 1.52 mmHg in Group T,
19.48 ± 2.46 mmHg in Group I, and 18.62 ± 2.78 mmHg
in Group S. The mean IOP at postoperative week 6 was
17.31 ± 1.7 mmHg in Group T, 19.1 ± 2.9 mmHg in Group I, and
18 ± 3.25 mmHg in Group S. The mean IOP at postoperative
a b
week 12 was 16.82 ± 1.84 mmHg in Group T, 17.19 ± 2.43 mmHg
in Group I, and 17.21 ± 2.06 mmHg in Group S. None of the eyes Figure 1: (a) Intracameral injection of triamcinolone acetonide in
had mean IOP > 21 mmHg at any follow‑up visit in our study. the space between a single air bubble and the angle of the anterior
chamber. (b) Crystals of triamcinolone acetonide in the anterior
chamber on postoperative day 1

Table 1: SUN classification of AC cells

Grade AC cells (field size used is AC flare
1 mm by 1 mm slit beam)
0+ None None
0.5+ One to five cells in the field ‑‑
1+ Six to 15 cells Faint
2+ 16-25 cells Moderate (iris and
lens details are clear)
3+ 26-50 cells Marked (iris and lens a b
details are hazy) Figure 2: (a) Marking the site of injection, 5 mm from the limbus in the
4+ >50 cells Intense (fibrin and inferotemporal quadrant. (b) A 0.5 ml (40 mg/ml) bolus of triamcinolone
plasmoid aqueous) acetonide being injected in the posterior subtenon space using a blunt
AC=anterior chamber, SUN=Standardization of Uveitis Nomenclature cannula mounted on a 1‑ml syringe
122 Indian Journal of Ophthalmology Volume 71 Issue 1

Table 2: Posterior synechiae seen on Day 1

Posterior synechiae Group T (n=16) Group I (n=16) Group S (n=16) P
Day 1
Absent 14 (87.50%) 14 (87.50%) 16 (100%) 0.526
Present 2 (12.50%) 2 (12.50%) 0 (0%) T versus I: 1
T versus S: 0.484
I versus S: 0.484

Table 3: Postoperative AC cells in all three groups

AC cells Group T (n=16) Group I (n=16) Group S (n=16) P
Day 1
Nonsevere 12 (75%) 14 (87.50%) 15 (93.75%) 0.467
Severe 4 (25%) 2 (12.50%) 1 (6.25%) T versus I: 0.654
T versus S: 0.333
I versus S: 1
Mean±SD 1.62±1.31 1.38±1.26 0.84±0.96 0.175
T versus I: 1
Median (25th-75th percentile) 1 (1-2.25) 1 (0.75-2) 0.75 (0-1.25)
T versus S: 0.207
Range 0-4 0-4 0-3
I versus S: 0.636
AC=anterior chamber, SD=standard deviation

a good control of postoperative inflammation.[7,8,10,11,12,14,15] clinically comparable response compared to topical steroid
The advantage of using triamcinolone is that it is a depot drops in controlling postoperative inflammation. Philip
corticosteroid with low water solubility, which contributes et al.[15] compared the clinical efficacy of a single intraoperative
to its prolonged action,[13] and it is easy to administer. An posterior subtenon triamcinolone versus postoperative topical
additional advantage that was observed in our current study is steroids in controlling inflammation after pediatric cataract
that the intracameral crystals of tricot persisted for up to 5 days surgery in children less than 13 years of age and concluded
in the AC, as seen on slit‑lamp microscopy, which probably that post subtenon injection is an effective and safe route of
contributed to its efficacy, as inflammation is maximum steroid delivery.
immediately following cataract surgery in children. This is
similar to the results of a study by Cleary et al.[7] A potential side effect of corticosteroid administration by
any route is increased IOP. Neither groups in our study had
In our study, posterior synechiae were present in two eyes mean IOP >21 mmHg at the end of follow‑up period. A possible
out of 16 (12.50%) in both topical group and intracameral reason for this could be that posterior subtenon steroid injection
group on the first postoperative day. None of the eyes had caused less of an IOP spike compared to the anterior subtenon
posterior synechiae in the subtenon group on postoperative approach, and that the current study used a lower dose (20 mg)
day 1, and severe AC cells were present in four eyes out of of triamcinolone, instead of the conventional 40 mg.
16 (25%) in the topical group and in two eyes out of 16 (12.50%)
in the intracameral group. Severe AC cells were present in The potential serious complications reported with posterior
one eye out of 16 (6.25%) in the subtenon group on the first subtenon injection of corticosteroids include spikes in IOP and
postoperative day. Severe AC flare was present in three eyes the resultant secondary glaucoma; perforation of the globe
out of 16 (18.75%) in the topical group and in two eyes out of with or without intravitreal injections, central artery occlusion,
16 (12.50%) in the intracameral group. Severe AC flare was and inadvertent injection into the choroidal or retinal artery
present in one eye out of 16 (6.25%) in the subtenon group on circulations.[12,17] Other complications reported infrequently are
the first postoperative day. Hence, the efficacy of intraoperative subconjunctival infections and ulceration, lower eyelid orbital
posterior subtenon triamcinolone alone and adjunctive fat herniation, and proptosis.[12] None of these complications
intracameral triamcinolone was found to be comparable to that occurred in our study.
of postoperative high‑frequency topical steroids.
Conclusion
Ventura et al.[11] have also reported intracameral triamcinolone
Intraoperative posterior subtenon triamcinolone acetonide is
to be as effective as oral prednisolone in modulation of
both a safe and effective alternative to control postoperative
inflammation after cataract surgery. In fact, according to Dixit
inflammation compared to topical steroids, and it has a good
et al.,[8] patients who received intracameral triamcinolone
therapeutic response and ocular tolerance. It provides a new
had fewer cell deposits and posterior synechiae than those
way of preventing patients from self‑medicating with topical
who did not. Cleary et al.[7] also concluded that intracameral
steroids, and also reduces problems with postoperative
triamcinolone promotes rapid resolution of inflammation in a
compliance and instructions. Our study also found that the
setting where effective topical therapy is not possible.
use of intraoperative intracameral triamcinolone acetonide,
Paganelli et al.[12] concluded that a single intraoperative as an adjunct to topical steroids, confers good control of
40‑mg triamcinolone acetonide subtenon injection showed a postoperative intraocular inflammation. Triamcinolone
January 2023 Raina, et al.: Comparision of topical vs intracam vs PST tricort in ped cat surgery 123

crystals persisted for several days in AC, providing prolonged Vasavada AR, et al. Outcomes of cataract surgery and intraocular
anti‑inflammatory action. lens implantation with and without intracameral triamcinolone in
pediatric eyes. J Cataract Refract Surg 2010;36:1494‑8.
The limitations of the study were its smaller sample size 9. Krupin T, Waltman SR, Becker B. Ocular penetration in
and a restricted age group of 5–10 years. Larger multicentric rabbits of topically applied dexamethasone. Arch Ophthalmol
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Financial support and sponsorship
11. Ventura MC, Ventura BV, Ventura CV, Ventura LO, Arantes TE,
Nil. Nosé W. Outcomes of congenital cataract surgery: Intraoperative
intracameral triamcinolone injection versus postoperative oral
Conflicts of interest
prednisolone. J Cataract Refract Surg 2014;40:601‑8.
There are no conflicts of interest.
12. Paganelli F, Cardillo JA, Melo LA Jr, Oliveira AG, Skaf M, Costa RA,
et al. A single intraoperative sub‑Tenon’s capsule triamcinolone
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