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PHOTO ESSAY
Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 986-987

Steroids: Double-edged sword in graft rejection


Cornea, Cataract and Refractive Surgery Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

Date of Submission20-Mar-2022
Date of Acceptance13-Jun-2022
Date of Web Publication11-Oct-2022

Correspondence Address:
Dr. Manpreet Kaur
Cornea, Cataract and Refractive Surgery Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_699_22

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  Abstract 


Keywords: Graft, occlusion, rejection, steroid, vein


How to cite this article:
Bari A, Kaur M, Nair S, Titiyal JS. Steroids: Double-edged sword in graft rejection. Indian J Ophthalmol Case Rep 2022;2:986-7

How to cite this URL:
Bari A, Kaur M, Nair S, Titiyal JS. Steroids: Double-edged sword in graft rejection. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Nov 30];2:986-7. Available from: https://www.ijoreports.in/text.asp?2022/2/4/986/358182



A 60-year-old hypertensive male presented with chief complaints of diminution of vision, redness, and photophobia in his left eye since a week. His uncorrected distance visual acuity (UDVA) was counting fingers close to the face. He had undergone a simultaneous optical penetrating keratoplasty and cataract surgery 2 years back with a corrected distance visual acuity (CDVA) of 20/200.

On examination, the graft clarity was 1+ with graft edema and Descemet membrane (DM) folds [Figure 1]a. A diagnosis of acute graft rejection was made, and intravenous methylprednisolone in 5% dextrose for 3 days was given owing to the one-eyed status of the patient. In addition, topical moxifloxacin 0.5% TDS, homatropine 2% QID, timolol 0.5% BD, and prednisolone phosphate 1% 1 hourly were given. There was worsening of hypertensive control which was eventually medically managed.
Figure 1: Anterior segment optical coherence tomography of the left eye: (a) Acute graft rejection with a central corneal thickness of 621 μm; (b) Resolved graft rejection with a central corneal thickness of 493 μm

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At 1 month, the UDVA improved to 2/60; however, the fundus details were hazy. At 3 months, the CDVA did not improve, but the graft was clear [Figure 1]b. Fundus examination revealed superotemporal branch retinal vein occlusion (BRVO). On fundus fluorescein angiography, partial sclerosis and tortuosity of the third-order vein with dye extravasation was observed [Figure 2]. Sectoral laser photo-coagulation of the superotemporal quadrant was performed.
Figure 2: Ultra-wide field fundus angiographic image (Optos, California, Optos, PLC, Scotland, UK) of the arteriovenous phase shows leakage from areas of retinal neovascularisation (arrow)

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  Discussion Top


Graft rejection is a potentially devastating complication with 30% incidence following penetrating keratoplasty.[1] Topical and systemic steroids form the mainstay of treatment; however, they may have associated adverse effects. They are known to accentuate mineralocorticoid action causing fluid retention and worsening of hypertensive control. Thus, steroids with lower mineralocorticoid and glucocorticoid activity may be preferred in hypertensives and diabetics, respectively.[2] Local steroid therapy is a viable alternative in cases at high risk of developing systemic adverse side effects.[3]

The ocular adverse effects of steroids include cataract, a rise in intra-ocular pressure, secondary infection, and aggravation of hypertensive retinopathy.

To conclude, steroids are a double-edged sword in graft rejection. Their potent anti-inflammatory action is invaluable in the management of cases of acute graft rejection; however, the associated side effects may in itself adversely impact the eventual visual and anatomical outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Liu D, Ahmet A, Ward L, Krishnamoorthy P, Mandelcorn ED, Leigh R, et al. A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy Asthma Clin Immunol 2013;9:30. doi: 10.1186/1710-1492-9-30.  Back to cited text no. 1
    
2.
Panda A, Vanathi M, Kumar A, Dash Y, Priya S. Corneal graft rejection. Surv Ophthalmol 2007;52:375-96.  Back to cited text no. 2
    
3.
Yesilirmak N, Ozdemir ES, Altinors DD. Effect of dexamethasone intravitreal implant in a corneal graft rejection. Int J Ophthalmol 2016;9:475-7. doi: 10.18240/ijo.2016.03.28.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2]



 

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