xRead - September 2022

Wise et al.

Page 96

transient visual loss and diplopia, 1264 blurred vision and temporary blindness, 1265 temporary distorted vision, and decreased visual acuity and paresis of the medial rectus. 1265 Martin et al. 1266 reported the rapid onset of ocular pain, blurred vision, and decreased visual acuity after an intraturbinate injection of triamcinolone acetonide. Choroidal and retinal arterial embolization were confirmed as the cause and they resolved completely within 24 hours. The mechanism of embolization is likely related to retrograde flow from the anterior tip of the inferior turbinate to the ophthalmic artery, followed by anterograde flow with the particles lodging in the end arteries of the choroid and retinal vessels. Steroids with larger particle size (eg, methylprednisolone) are thought to present higher risk than lower-sized particles (eg, triamcinolone). • Aggregate Grade of Evidence: B (Level 1b: 3 studies; Level 2b: 3 studies; Level 4: 7 studies; Table IX.B.2.b). • Benefit: Injectable corticosteroids improve symptoms of AR in clinical studies. • Harm: Injectable corticosteroids have known adverse effects on the hypothalamic-pituitary axis, growth suppression, osteoporosis, hyperglycemia, and other systemic adverse effects. Intraturbinate corticosteroids have a small, but potentially serious, risk of ocular side effects including decline or loss of vision. • Cost: Low. • Benefits-Harm Assessment: In routine management of AR, the risk of serious adverse effects outweighs the demonstrated clinical benefit. • Value Judgments: Injectable corticosteroids are effective for the treatment of AR. However, given the risk of significant systemic adverse effects, the risk of serious ocular side effects, and the availability of effective alternatives (ie, topical INCS therapy), injectable corticosteroids are not recommended for the routine treatment of AR. • Policy Level: Recommendation against. • Intervention: None. IX.B.2.c. Intranasal corticosteroids (INCSs).: INCSs are effective for the treatment of AR. Their potent anti-inflammatory properties directly affect the pathophysiologic mechanisms of nasal inflammation in AR. In both nasal allergen challenge models and seasonal disease, treatment with INCS results in significant reduction in mediator and cytokine release along with a significant inhibition in the recruitment of basophils, eosinophils, neutrophils, and mononuclear cells to the nasal mucosa and secretions. 187,389,1267,1268 INCSs also reduce the antigen-induced hyperresponsiveness of the nasal mucosa to subsequent challenge by antigen 187 and histamine. 1269,1270 Multiple placebo-controlled clinical trials in adults and children have demonstrated the effectiveness of INCS in the reduction of nasal symptoms in AR, including sneezing, itching, rhinorrhea, and congestion. 1271,1272 With the reduction of nasal symptoms, INCS significantly improve the QOL 1272-1274 and sleep 673,706,707,1275,1276 of these patients. No

Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.