Methylprednisolone Acetate (Depo-Medrol) Injection during Cataract Surgery Causing Retinal Necrosis
Authors: Daniel A. Brill, Taylor S. Fields, Steven P. Dunn, Michael D. Ober
Journal: Ophthalmology (2019)

Depo-Medrol (Pfizer, New York, NY) is a formulation of methylprednisolone acetate approved by the Food and Drug Administration for periocular injection for sympathetic ophthalmia, temporal arteritis, uveitis, and ocular inflammatory conditions unresponsive to topical corticosteroids (package insert). Inadvertent injection of Depro-Medrol into the vitreous has been associated with rapid retinal toxicity, including retinal atrophy, detachment, and hemorrhage.1Yonekawa Y. Sun G. D'Amico D.J. Chan R.V. Retinal necrosis secondary to inadvertent intravitreal methylprednisolone acetate (Depo-Medrol) injection during pars plana vitrectomy.Retin Cases Brief Rep. 2009; 3: 336-339Google Scholar The toxicity of Depo-Medrol has been shown in rabbit models to be caused by its preservative myristyl-γ-picolinium chloride.2Jain V.K. Mames R.N. McGorray S. Giles C.L. Inadvertent penetrating injury to the globe with periocular corticosteroid injection.Ophthalmic Surg. 1991; 22: 508-511PubMed Google Scholar Within 1 day of contact with the retina, there is adjacent retinal thickening with disarray of the inner and outer retinal layers.3Hida T. Chandler D. Arena J.E. Machemer R. Experimental and clinical observations of the intraocular toxicity of commercial corticosteroid preparations.Am J Ophthalmol. 1986; 101: 190-195Abstract Full Text PDF PubMed Scopus (207) Google Scholar After 6 weeks, there is almost complete loss of all retinal layers, with corresponding functional damage measured by electroretinography and visual evoked potential.4Zemel E. Loewenstein A. Lazar M. Perlman I. The effects of myristyl gamma-picolinium chloride on the rabbit retina: morphologic observations.Invest Ophthalmol Vis Sci. 1993; 34: 2360-2366Google Scholar Corticosteroids alone have not been demonstrated to cause significant retinal toxicity. Kenalog (Bristol-Myers Squibb, New York, NY) and Triesence (Alcon, Fort Worth, TX) are formulations of triamcinolone acetonide commonly used to improve visualization during vitreoretinal surgery. Triesence, Kenalog, and Depo-Medrol are packed in similar glass bottles and appear as nearly identical white opaque suspensions when placed in syringes1Yonekawa Y. Sun G. D'Amico D.J. Chan R.V. Retinal necrosis secondary to inadvertent intravitreal methylprednisolone acetate (Depo-Medrol) injection during pars plana vitrectomy.Retin Cases Brief Rep. 2009; 3: 336-339Google Scholar (Fig 1C). Additionally, Solu-Medrol (methylprednisolone sodium succinate; Pfizer) is a similar-sounding intravenous corticosteroid that also should not be used as an intraocular injection. Thus, the similar-appearing and -sounding corticosteroid medications easily can be confused. At least 15 published case reports have documented accidental injection of Depo-Medrol into the vitreous causing retinal damage.1Yonekawa Y. Sun G. D'Amico D.J. Chan R.V. Retinal necrosis secondary to inadvertent intravitreal methylprednisolone acetate (Depo-Medrol) injection during pars plana vitrectomy.Retin Cases Brief Rep. 2009; 3: 336-339Google Scholar, 2Jain V.K. Mames R.N. McGorray S. Giles C.L. Inadvertent penetrating injury to the globe with periocular corticosteroid injection.Ophthalmic Surg. 1991; 22: 508-511PubMed Google Scholar None of the previous reports detailed the intentional use of Depo-Medrol injection to stain vitreous during complicated cataract surgery. A 68-year-old man demonstrated central vision loss in the left eye immediately after cataract surgery. He had no other past ocular diagnoses or surgeries. He was not using any ocular or systemic medications and had no significant past medical history. The vision failed to improve after surgery and concern was raised as to corneal edema being the cause. Corneal consultation disclosed minimal edema with vision loss inconsistent with the amount of edema. Abnormal retinal findings resulted in his being referred for retinal consultation 2 months after cataract surgery. On examination, his vision was counting fingers in the left eye and 20/30 in the right eye. Intraocular pressures were 16 mmHg bilaterally. Anterior segment examination showed mild corneal edema with rare anterior segment cell. There was a centered intraocular lens and an open posterior capsule. Posterior segment examination revealed a normal-appearing right macula and a whitened, translucent, atrophic central macula (Fig 1A; Fig S2, available at www.aaojournal.org) in the left eye. Spectral-domain OCT showed central macular thinning with loss of all retinal layers in the central macula (Fig 1B). Fluorescein angiography confirmed pruning of the perifoveal vessels with capillary dropout, areas of window defect, and blockage of choroidal flow by opacified retina (Fig S3, available at www.aaojournal.org). The operative note described cataract surgery complicated by a torn posterior capsule and prolapse of vitreous into the anterior chamber. The surgeon injected 0.5 ml Depo-Medrol into the anterior chamber to aid in visualizing the vitreous for easier removal. An anterior vitrectomy then was performed. Cataract surgery was completed with insertion of a new intraocular lens and placement of a nylon suture to secure the wound. Unfortunately, the surgeon learned about the potential retinal toxicity from intraocular Depo-Medrol during our communication after consultation. This report was conducted in accordance to the tenets of the Declaration of Helsinki. This is a retrospective study using de-identified subject details. Informed consent was not obtained. Although Depo-Medrol is a steroid with similar physical and chemical properties to triamcinolone, it should never be used inside the eye. A variety of corticosteroids are commonly injected for intraocular use, including Triesence and Kenalog. The packaging of these medications is very similar, and after being drawn into a syringe, they are nearly indistinguishable (Fig 1C). Triamcinolone is frequently used to visualize vitreous strands, and Depo-Medrol may perform this function quite well, but it should never be attempted. Great care must be taken to avoid confusing these medications. Although Triesence is approved by the Food and Drug Administration for intraocular use, Kenalog carries a Food and Drug Administration warning against intraocular use (package inserts). Both Triesence and Kenalog are commonly used intraocularly, and there have been no reported cases of toxicity that compare with those when using Depo-Medrol from either medication. A careful reading of the package insert for Depo-Medrol confirmed that there are no written warnings against intraocular use, despite the potentially devastating consequences. The toxicity of Depo-Medrol has been attributed to the preservative myristyl-γ-picolinium.1Yonekawa Y. Sun G. D'Amico D.J. Chan R.V. Retinal necrosis secondary to inadvertent intravitreal methylprednisolone acetate (Depo-Medrol) injection during pars plana vitrectomy.Retin Cases Brief Rep. 2009; 3: 336-339Google Scholar, 3Hida T. Chandler D. Arena J.E. Machemer R. Experimental and clinical observations of the intraocular toxicity of commercial corticosteroid preparations.Am J Ophthalmol. 1986; 101: 190-195Abstract Full Text PDF PubMed Scopus (207) Google Scholar, 4Zemel E. Loewenstein A. Lazar M. Perlman I. The effects of myristyl gamma-picolinium chloride on the rabbit retina: morphologic observations.Invest Ophthalmol Vis Sci. 1993; 34: 2360-2366Google Scholar If Depo-Medrol is injected accidentally, prone positioning of the patient should be initiated immediately to limit contact of myristyl-γ-picolinium with the retina. Emergent pars plana vitrectomy (PPV) has been advocated to remove Depo-Medrol after accidental injection to avoid retinal necrosis but has shown poor visual outcomes.3Hida T. Chandler D. Arena J.E. Machemer R. Experimental and clinical observations of the intraocular toxicity of commercial corticosteroid preparations.Am J Ophthalmol. 1986; 101: 190-195Abstract Full Text PDF PubMed Scopus (207) Google Scholar In the 1950s and 1960s, Phillpotts5Phillpotts J.S. Intra-ocular medication with special reference to depomedrone.Trans Ophthalmol Soc U K. 1969; 88: 729-735Google Scholar advocated for anterior segment injection in eyes at high risk for postoperative inflammation of minute amounts of Depo-Medrone (Pfizer, Kent, United Kingdom), which contains the same active ingredients and preservatives as Depo-Medrol. In addition, there are a few cases of spontaneous visual recovery after intraocular exposure of Depo-Medrol, suggesting retinal necrosis may depend on the dose, concentration, and duration of contact of myristyl-γ-picolinium chloride with the retina. Intraocular Depo-Medrol injection is a preventable cause of blindness, and awareness of its devastating retinal toxicity should be recognized universally by the ophthalmologic community. Given the significant retinal toxicity of Depo-Medrol, we agree with Yonekawa et al1Yonekawa Y. Sun G. D'Amico D.J. Chan R.V. Retinal necrosis secondary to inadvertent intravitreal methylprednisolone acetate (Depo-Medrol) injection during pars plana vitrectomy.Retin Cases Brief Rep. 2009; 3: 336-339Google Scholar that it should be removed from surgical suite shelves. Furthermore, we believe it should carry a warning label and different packaging to distinguish it from triamicinolone. Download .pdf (3.46 MB) Help with pdf files Figure S2 Download .pdf (7.06 MB) Help with pdf files Figure S3