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To the best of our knowledge this is the first published report describing ultrasonographic pictures of intravitreal triamcinolone acetonide. Given the widespread use of this medication in various ocular diseases, triamcinolone acetonide particles should be added to the list of differential diagnoses of vitreous opacities.

Endndophthalmitis is an important complication after IVTA injection. Infectious endophthalmitis and sterile pseudoendophthalmitis may be seen following intravitreal triamcinolone acetonide.^{2, 13-15} It is crucial to differentiate the two in order to treat cases of an infectious nature effectively and to avoid the complications of unnecessary treatment in sterile cases.² The potential for decreased local immunity induced by the corticosteroid that may increase infection risk and the anti-inflammatory action of the steroid are two important factors that could mask the symptoms of endophthalmitis after IVTA injection.²  Echography is very usful for determining the severity and extent of infection in the eye with endophthalmitis. The first step in the evaluation is to assess the vitreous cavity for the presence of inflammatory opacities and membranes.¹⁶ Therefore the ophthalmologist and also sonologist need to be familiar with Ultrasonographic pictures of IVTA. In post injection endophthalmitis the opacities possibly start near the injection site but as the infection spreads the opacities become more evenly distributed throughout the vitreous cavity. In our series opacities of IVTA settled down inferiorly during subsequent exams and density of opacity decreased around the injection site. Therefore we propose this echographic finding as a useful diagnostic point in clinically challenging cases.

Another new finding in our patients was ultrasonic enhancement of some vitreoretinal pathologies by triamcinolone acetonide. In 5 patients the PVD picture was enhanced and in one patient the PVD was not detected before IVTA injection. Triamcinolone was used about 12 years ago for visualizing the vitreous during vitrectomy.  Deposition of TA over acoustic interfaces may enhance sound reflectivity at these levels and highlight them. This phenomenon could potentially increase the reflectivity of a membrane and lead to misinterpretation of the picture.

In our study we used 4mg/0.1cc dosage (most popular dose), however higher doses may cause different sonographic pictures. Also we excluded patients who had previous total or subtotal vitrectomy from our study. We believe in such patients the pictures are possibly different. In patients with incomplete vitrectomy intravitreal triamcinolone may precipitate in retained vitreous and highlight it. Vitreous consistency and the degree of its syneresis is another potential factor for different sonographic pictures of intravitreal triamcinolone. Performing a baseline ultrasound examination after IVTA injection can aid the examiner in interpretation of subsequent pictures.

In summary our findings indicate that IVTA has a bright hyper-reflective ultrasonic image and should be considered as a differential diagnosis for vitreous opacity. IVTA changes the reflectivity of acoustic interfaces in the vitreous cavity and may cause misinterpretation of the images. Baseline US examination after IVTA injection may help the examiner in interpreting US pictures during early post-injection period, especially in patients with opaque media.