Dexamethasone Intravitreal Implant for Treatment of Patients With Recalcitrant Macular Edema Resulting From Irvine-Gass Syndrome

Current management options for the treatment of refractory postoperative cystoid macular edema: A systematic review

Post-operative cystoid macular edema (PCME) is an important complication following intraocular surgery that often resolves spontaneously without treatment. In some cases, PCME may persist despite initial medical therapy, which can adversely impact visual outcomes. Various topical, intraocular and systemic treatments exist for the prevention and management of cystoid macular edema; however, there is no consensus on treatment of refractory cases in the postoperative setting. In accordance with the PRISMA guidelines, we systematically reviewed 68 articles describing management options and their outcomes for treatment-resistant cases of PCME. The most commonly reported treatments included steroid (39 studies) and biological-based (17 studies) therapies. We provide an overview of the treatment options for refractory PCME.

The efficacy of different anti-vascular endothelial growth factor agents, and dexamethasone implant therapy in patients with serous retinal detachment caused by Irvine-Gass syndrome

PURPOSE

The aim of this study is to compare the efficacy of intravitreal aflibercept (IVA), bevacizumab (IVB), ranibizumab (IVR), and dexamethasone implant (IVDI) in the treatment of serous retinal detachment (SRD) caused by Irvine-Gass syndrome (IGS).

DESIGN

Retrospective cohort, comparative study.

METHODS AND MATERIALS

The medical records of 128 eyes with no previous history of intravitreal agents in 128 IGS patients with SRD that received IVA, IVB, IVR, and IVDI monotherapy were retrospectively reviewed. The patients were divided into 4 groups, according to treatment. Patients with recurrence and/or were unresponsive following a course of topical steroids and non-steroidal anti-inflammatory drugs (NSAIDs) were included in the study. Best corrected visual acuity (BCVA), central macular thickness (CMT), subfoveal choroidal thickness (SFCT), and SRD were compared between the 4 treatment groups at baseline, at follow-up months 1, 3, 6, and 12, and at the final follow-up visit.

RESULTS

Serous retinal detachment completely resolved in 74%, 45.7%, 66.4%, and 40.8% of the eyes at month 1 (P = 0.042), 87%, 50.9%, 75.8%, and 80.9% at month 3 (p = 0.031), 88.9%, 50.4%, 75.7%, 80.2% at month 6 (p = 0.028), 81.7%, 72.8%, 68.7%, 80.1% at month 12 (p = 0.580), and 100%, 66.4%, 87.9%, 93.2% (p = 0.478) at final follow-up visit in the IVA, IVB, IVR, and IVDI groups, respectively. BCVA was significantly better in the IVA group at all follow-up time points (month 1: p < 0.001; month 3: p < 0.001; month 6: p = 0.002; month 12: p = 0.009, final follow-up visit: p < 0.001). CMT was significantly lower in the IVA group at months 3 (p = 0.008), 6 (p = 0.011), and 12 (p = 0.010), and at the final follow-up visit (p < 0.001). Recurrence was observed after a longer period of time and fewer injections were needed in the IVDI and IVA groups (p < 0.05). Resolution of CME was most rapid in the IVA group (p = 0.032).

CONCLUSION

All intravitreal agents were effective in terms of visual results in the SRD patients; however, eyes treated with IVA and IVDI required fewer injections, as compared to the eyes treated with IVB and IVR. Furthermore, SRD entirely resolved in all eyes in the IVA group at the final follow-up visit.

Pseudophakic macular edema in nondiabetic and diabetic patients without diabetic retinopathy treated with intravitreal dexamethasone implant

BACKGROUND

The purpose of this study was to compare the impact of intravitreal dexamethasone (DEX) implant during a 12-month period in nondiabetic and diabetic patients without diabetic retinopathy (DR) as a treatment for refractory pseudophakic cystoid macular edema (PCME) following prior treatment with topical nepafenac 0.1% and prednisolone 1%.

METHODS

Forty-two consecutive medical records of patients diagnosed with PCME after uneventful cataract surgery were included. The outcomes measured included best corrected visual acuity (BCVA) and central foveal thickness (CFT). Linear regression analysis was statistically applied.

RESULTS

Following topical treatment, nondiabetic and diabetic subjects presented a mean ± SD gain of - 0.11 ± 0.11 and - 0.18 ± 0.11 BCVA logMAR and a CFT reduction of - 43.42 ± 53.66 µm and - 58.76 ± 36.28 µm, respectively. The mean BCVA gain at month 12 subsequent to DEX implantation was - 0.35 ± 0.17 in nondiabetic (p < 0.001) and - 0.55 ± 0.26 in diabetic patients (p < 0.001), with CFT reductions of - 195.71 ± 93.23 µm (p < 0.001) and - 260.81 ± 198.69 µm (p < 0.001), respectively. Patients who responded with better VA after topical treatment presented better visual outcomes at month 12 following DEX implantation (r2 = 0.46; rho = - 0.71, p < 0.01).

CONCLUSION

Nondiabetic and diabetic patients without DR demonstrated similar results after DEX implant after combined topical therapy, suggesting that selected diabetic patients may have a response comparable to that of nondiabetic patients with PCME.

Predictive Factors and Management of Macular Edema after Retropupillary Iris-Claw Intraocular Lens Implantation in Aphakia: National Multicenter Audit-Report 2

The aim of this multicenter, national clinical audit is to evaluate the predictive factors and management of postoperative macular edema (ME) after retropupillary iris-claw intraocular lens (RICI) implantation and pars plana vitrectomy (PPV). Preoperative, surgical and postoperative data were collected. Number and type of intravitreal injections (IT) administered (anti-VEGF or dexamethasone implant), visual acuity (VA), intraocular pressure (IOP) and central retinal thickness (CRT) assessed by OCT were collected at 1, 3, 6 and 12 months. From 325 eyes (325 patients), 11.7% (38/325) developed postoperative ME. Previous complicated cataract surgery with no capsular support was the only significant predictive factor for developing postoperative ME (OR 2.27, 95% CI 1.38-4.52, p = 0.02) after RICI implant. Mean time to ME development was 11.4 ± 10.7 weeks, and mean CRT peaked at 3 months follow-up. Different treatment options were non-steroidal anti-inflammatory (NSAIDs) drops (31.6%, 12/38), dexamethasone (DEX) implant (50%, 19/38), anti-VEGF (7.9%, 3/38) or combined IT (10.5%, 4/38). Cumulative probability of ME resolution was higher in the group treated with IT than in the group treated with topical NSAIDs (85.2% vs. 58.3%, p = 0.9). Performing RICI implantation after complicated cataract surgery is a risk factor for the development of postoperative ME. DEX implants may be an effective treatment for postoperative ME in these cases.

PREOPERATIVE VITREORETINAL INTERFACE ABNORMALITIES ON SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY AS RISK FACTOR FOR PSEUDOPHAKIC CYSTOID MACULAR EDEMA AFTER PHACOEMULSIFICATION

PURPOSE

We assessed the role of vitreoretinal interface status in the development of pseudophakic cystoid macular edema (PCME) after cataract surgery.

METHODS

Prospective cohort study in which 112 patients (112 eyes) scheduled for cataract surgery were selected at random to undergo spectral domain optical coherence tomography (OCT) within 1 week preoperatively and at 1 and 3 months postoperatively. Spectral domain OCT macular images included no vitreoretinal contact, focal and diffuse vitreomacular adhesion, focal and diffuse vitreomacular traction, epiretinal membrane, macular hole, and macular edema.

RESULTS

The incidence of PCME was 11.6% (13 eyes), all of them being diagnosed at 1 month, and 7 eyes resolved at 3 months. The only risk factor for PCME was detection of nonsurgical epiretinal membrane by spectral domain OCT before phacoemulsification, being developed in 5 of 16 eyes (χ = 0.08, odds ratio 4.53, 95% confidence interval 1.28-16.13). Other variables such as posterior vitreous detachment, subfoveal choroidal thickness, diabetes, or hypertension were not significantly associated with PCME.

CONCLUSION

In this cohort, preoperative detection of epiretinal membrane by spectral domain OCT was a risk factor for PCME after cataract extraction. It is recommended to perform a spectral domain OCT before cataract surgery because the presence of an epiretinal membrane may be passed unnoticed by fundus examination.

[Modern approaches to treatment of postsurgical macular edema]

Postsurgical macular edema, known as Irvine-Gass syndrome, is one of the possible causes of reduced visual acuity in ophthalmic surgery. The article reviews and summarizes data on the main approaches to the treatment of this pathology, discusses the main groups of drugs used to manage postoperative macular edema.

Current role of intravitreal injections in Irvine Gass syndrome-CRIIG study

OBJECTIVE

To analyze the role of intravitreal anti-vascular endothelial growth factor (anti-VEGF) or steroid injection for the management of Irvine Gass syndrome.

METHODS

It is an interventional, retrospective, multicenter study. One hundred and thirty-two injections were given in 79 eyes of 72 patients with Irvine Gass syndrome. Patients were treated with at least one intravitreal injection of either anti-VEGF or steroid. Outcomes were measured at 12 months (± 1 week). [Ranibizumab (Lucentis; Genentech, South San Francisco, CA) (Razumab; Intas Pharmaceutical Ltd, Ahmedabad, India) Bevacizumab (Avastin; Genentech, South San Francisco, CA) or Aflibercept (Eylea; Regeneron, Tarrytown, NY)] or steroids [Dexamethasone implant (Ozurdex, Allergan Inc, Irvine, CA) or intravitreal triamcinolone)].

RESULTS

Intravitreal injections were initiated in (67.6%) of eyes within 14 weeks of diagnosis. Intravitreal dexamethasone implant was used as the initial intravitreal therapy in (73.4%) of eyes. More than fifty percent (54.5%) of the patients were switched from anti-VEGF to Intravitreal dexamethasone implant. Reduction in the mean CMT was 336.7 ± 191.7 and 160.1 ± 153.1 microns in eyes treated within four weeks and more than 14 weeks from diagnosis (p = 0.005). Mean ETDRS letter gain was 16.7 ± 12.9 and 5.2 ± 9.2 in eyes treated within 4 weeks and more than 14 weeks from diagnosis (p = 0.004). Three eyes injected with intravitreal dexamethasone implant reported an intraocular pressure spike of > 25 mmHg which was controlled with topical medications. No other ocular or systemic adverse events were observed.

CONCLUSION

Study results suggest that physicians tend to introduce intravitreal therapy within 14 weeks of diagnosis. The most common therapy at initiation and for the switch is intravitreal dexamethasone implant. Patients treated early (within 4 weeks) respond better in terms of structure and function.

Curcumin-Based Treatment for Macular Edema from Uncommon Etiologies: Efficacy and Safety Assessment

The aim of this study was to investigate the efficacy and safety of curcumin formulation with a polyvinylpyrrolidone-hydrophilic carrier (CHC*; Diabec^®-AlfaIntes, Italy) for the treatment of macular edema (ME) from uncommon etiologies. We conducted retrospective interventional case series, reviewing the medical records of patients referred to the Eye Center, Humanitas Hospital, Bergamo due to persistent ME related to uncommon causes and treated by oral administration of CHC. The main outcomes assessed were best-corrected visual acuity (BCVA), central macular thickness (CMT), and the presence of intraretinal and/or subretinal fluid (SRF). Only patients with a minimum follow-up (f/u) of 6 months were included. The occurrence of any adverse effect was registered. Thirty-one eyes of 30 patients were included, with a mean f/u of 8.32 ± 1.77 months. Of them, 9 patients (10 eyes) were affected by postoperative ME and 21 by chronic central serous chorioretinopathy. Median BCVA significantly improved after treatment, changing from 0.3 [0.16-0.5] to 0.1 [0-0.3] logarithm of the minimum angle of resolution (P < .001). Also CMT was significantly improved, as it decreased from 400 [364-438] μm before treatment to 280 [242-307] μm at the last f/u visit (P < .001). The complete absorption of intraretinal/SRF was detected in 23 of 31 eyes (74%) at the final f/u. No adverse effects were registered. In conclusion, treatment with CHC was effective and safe for eyes affected by ME of various uncommon etiologies, resulting in significant improvement of both functional and anatomical outcomes, with the complete resolution of the edema in the majority of cases (74%).

Intravitreal Dexamethasone Implantation in Intravitreal Bevacizumab Treatment-resistant Pseudophakic Cystoid Macular Edema

Purpose

To evaluate the changes in visual acuity (VA) and central macular thickness (CMT) after intravitreal dexamethasone (IVD) implantation in intravitreal bevacizumab (IVB) treatment-resistant cases with pseudophakic cystoid macular edema (PCME).

Methods

This study included 10 PCME cases who underwent uneventful phacoemulsification and intraocular lens implantation with similar methods and six PCME cases referred to our hospital for treatment of low VA after cataract surgery. Due to the persistence of PCME, both topical steroid and anti-inflammatory medication were administered first, followed by IVB injection. IVD implantation was performed for all IVB treatment-resistant cases. VA and CMT values were compared before and at three months after the first IVD implantation.

Results

The mean VA values before and at 3 months after the first IVD implantation were 0.69 ± 0.19 logarithm of the minimum angle of resolution (logMAR) (1.50 to 0.10 logMAR) and 0.26 ± 0.07 logMAR (1.00 to 0.00 logMAR), respectively (p < 0.001). The mean CMT was 476.13 ± 135.13 mm (314 to 750 mm) and 294.06 ± 15.26 mm (222 to 480 mm), respectively (p < 0.001). The mean number of implanted IVD was 1.44 ± 0.89 (1 to 4) and the mean follow-up time was 7.4 ± 4.6 months (6 to 24 months). After IVD implantation therapy, the mean VA and CMT values were 0.19 ± 0.05 logMAR (0.70 to 0.00 logMAR) and 268.38 ± 31.35 mm (217 to 351 mm), respectively.

Conclusions

To the best of our knowledge, this is the first report to show the efficacy of IVD implantation even after repeated IVB injections in treatment-resistant PCME. IVD implantation is both a safe and effective method for decreasing PCME after both uneventful and complicated cataract surgery.

Comparison of topical nepafenac 0.1% with intravitreal dexamethasone implant for the treatment of Irvine-Gass syndrome

AIM

To compare safety and efficacy of intravitreal dexamethasone (IVD) implant with topical nepafenac (TN) 0.1% in previously untreated Irvine-Gass syndrome (IGS) in clinical practice.

METHODS

This was a retrospective study of 62 eyes with IGS after phacoemulsification with posterior chamber intraocular lens (IOL) implantation. None of the patients used treatment before IVD or TN. Best-corrected visual acuity (BCVA) with Early Treatment Diabetic Retinopathy Study chart (ETDRS), slit-lamp, intraocular pressure (IOP) measurement, fundus examination, spectral-domain optical coherence tomography (OCT) and fundus florescein angiography were performed to all subjects at baseline, 1, 3 and 6mo.

RESULTS

The mean BCVA of the IVD group was 49.3±6.8, and the mean BCVA of the TN group was 32.9±7.3 ETDRS letters in post-treatment month 6. The mean central macular thickness (CRT) of IVD group was 266.6±53.5 µm and the mean CRT of TN group was 364.9±56.3 µm in post-treatment month 6. Baseline BCVA has correlation with final BCVA in TN group however there was no correlation between baseline BCVA and final BCVA in IVD group.

CONCLUSION

IVD is found to be better than TN in controlling pseudophakic macular edema and improving visual acuity. IVD group also has significantly lower CRT however IOP is not significantly different between two groups in post-treatment month 6.

[Treatment of postoperative macular edema (a clinical case study)]

Pseudophakic cystoid macular edema (CMO) known to appear in 0.1-2.35% of patients after phacoemulsification is one of the common causes of vision decrease during the postoperative period. The authors analyze a case of CMO development in a pseudophakic patient diagnosed 7 months after uncomplicated phacoemulsification. Optical coherence tomography (OCT) was suggested for patients with low vision and a sensation of shroud before the eye for early diagnosis of pathological process. Intravitreal injection of the 0.7 mg dexamethasone micro-implant performed soon after establishing diagnosis was proved to be viable for postoperative CMO arrest in patients without previous treatment. One month after intravitreal implant injection the visual acuity in the patient's eye improved from 0.4 to 0.7, and retinal thickness in the macular area decreased from 705 to 255 μm. The result remained stable for 10 months. Intravitreal micro-implant appeared to have higher efficiency in contrast with traditional treatment methods (according to literature data), which was attributed to direct drug delivery to the area of pathological process. The use of 0.7 mg dexamethasone implant did not increase the intraocular pressure indicating its potential viability for patients with compensated glaucoma.

[Treatment of postoperative macular edema (a clinical case study)]

Pseudophakic cystoid macular edema (CMO) known to appear in 0.1-2.35% of patients after phacoemulsification is one of the common causes of vision decrease during postoperative period. The authors analyzed a case of CMO development in a pseudophakic patient diagnosed 7 months after uncomplicated phacoemulsification. Optical coherence tomography (OCT) was suggested for patients with low vision and a sensation of shroud before the eye for early diagnosis of pathological process. Intravitreal injection of the 0.7 mg dexamethasone micro-implant performed soon after establishing the diagnosis was proved to be viable for postoperative CMO arrest in patients without previous treatment. One month after intravitreal implant injection, the visual acuity in the patient's eye improved from 0.4 to 0.7, and retinal thickness in the macular area decreased from 705 to 255 μm. The result remained stable for 10 months. Intravitreal micro-implant appeared to have higher efficiency in contrast with traditional treatment methods (according to literature data), which was attributed to direct drug delivery to the area of pathological process. The use of 0.7 mg dexamethasone implant did not increase the intraocular pressure indicating its potential viability for patients with compensated glaucoma.

Evaluation of Predictive Factors for Successful Intravitreal Dexamethasone in Pseudophakic Cystoid Macular Edema

Purpose

To determine the efficacy, safety, and predictive outcome factors for intravitreal dexamethasone implant (DEX) in pseudophakic cystoid macular edema (PCME).

Methods

Retrospective, interventional, controlled study. Patients included had to have clinically significant PCME and have been treated with the DEX between 2012 and 2015. Charts and one-year data were selected consecutively, and efficacy and safety were abstracted. Visual acuity (VA) and central foveal thickness (CFT) were analysed.

Results

Nineteen patient data sets were analysed. After treatment with DEX, mean VA increased significantly by 0.2 logMAR (p = 0.034), while the mean CFT was reduced significantly by 162.79 μm (p < 0.001). Five patients receiving a combination of DEX/bevacizumab have not experienced a higher mean VA gain or CFT reduction compared to fourteen patients receiving DEX alone. Decision rules, when to combine DEX with bevacizumab, have not been defined before the study. Only posttreatment VA gains in the nonhypertensive subgroup (n = 11) were significantly better (p = 0.026). Analysis of data from diabetes patients (n = 4) versus nondiabetics yielded no significant differences in efficacy. There have been no adverse events within follow-up time.

Conclusion

The use of DEX in PCME showed significant improvements in VA and CFT. The VA seems to show greater improvements in patients without hypertension.

Clinical Applications of Dexamethasone for Aged Eyes

The risk of severe eye problems has been found to increase significantly with age, particularly between the fifth and sixth decades of life. Cataracts, dry eye, neovascular age-related macular degeneration, diabetic retinopathy and retinal vein occlusion (RVO) are very common and very different age-related ocular diseases that reduce the patient's quality of life. The rationale for using corticosteroids to treat anterior and posterior ocular segment diseases is driven by inflammation. Dexamethasone, one of the most powerful corticosteroids available, is widely used for topical or intravitreal administration. Topical dexamethasone has proven efficacy for the management of postoperative inflammation in the anterior segment after cataract surgery and symptom relief in dry-eye disease. A new sustained-release 700 µg dexamethasone intravitreal implant (DEX) was recently approved for the treatment of macular edema following RVO, diabetic macular edema, or non-infectious uveitis, and its use is increasing, especially when other therapeutic agents have failed. The most common side effects are increased intraocular pressure and cataract formation. The potency of DEX, alone or in combination with other agents, makes DEX a promising option for treating several retinal diseases.

Widening use of dexamethasone implant for the treatment of macular edema

Sustained-release intravitreal 0.7 mg dexamethasone (DEX) implant is approved in Europe for the treatment of macular edema related to diabetic retinopathy, branch retinal vein occlusion, central retinal vein occlusion, and non-infectious uveitis. The implant is formulated in a biodegradable copolymer to release the active ingredient within the vitreous chamber for up to 6 months after an intravitreal injection, allowing a prolonged interval of efficacy between injections with a good safety profile. Various other ocular pathologies with inflammatory etiopathogeneses associated with macular edema have been treated by DEX implant, including neovascular age-related macular degeneration, Irvine-Gass syndrome, vasoproliferative retinal tumors, retinal telangiectasia, Coats' disease, radiation maculopathy, retinitis pigmentosa, and macular edema secondary to scleral buckling and pars plana vitrectomy. We undertook a review to provide a comprehensive collection of all of the diseases that benefit from the use of the sustained-release DEX implant, alone or in combination with concomitant therapies. A MEDLINE search revealed lack of randomized controlled trials related to these indications. Therefore we included and analyzed all available studies (retrospective and prospective, comparative and non-comparative, randomized and nonrandomized, single center and multicenter, and case report). There are reports in the literature of the use of DEX implant across a range of macular edema-related pathologies, with their clinical experience supporting the use of DEX implant on a case-by-case basis with the aim of improving patient outcomes in many macular pathologies. As many of the reported macular pathologies are difficult to treat, a new treatment option that has a beneficial influence on the clinical course of the disease may be useful in clinical practice.

[Treatment of macular edema: Comparison of efficacy and tolerability of subconjunctival triamcinolone injections, sub-tenon's triamcinolone injections and intravitreal dexamethasone implant]

The area of uveitis is related to numerous pathological entities. One of the main causes of decreased visual acuity in these patients is macular edema. One aspect of the treatment includes cortosteroids used peri- and intra-ocularly.

MATERIALS AND METHODS

The goal of our work was to estimate the criteria of efficacy (on improvement in visual acuity and macular edema, as well as time to recurrence) and safety (on intraocular pressure and cataract) of these various routes of administration of corticosteroid after a single injection. We compared patients treated with Ozurdex^® versus subconjonctival triamcinolone versus sub-tenon's triamcinolone. This is a retrospective study conducted in 2 tertiary centers, the university medical center of Nantes and La Pitié-Salpêtrière hospital from November, 2011 to November, 2013.

RESULTS

At presentation, 25 % of the patients displayed VA better than 5/10. During follow-up, this proportion increased to 45 % at M1, 50 % at M3, 49 % at M6 and 48 % at the end of follow-up. There was no significant difference between the groups with respect to VA gain. The reductions in mean CMT compared with D0 were all statistically significant (improvement of one line in log-OCT). We observed an improvement in macular thickness of 88 % at M1, 86 % at M3, 61 % at M6 and 60 % at the end of follow-up, significant at each time, with no significant difference between the three groups. A comparison of time to anatomic vs. functional recurrence was performed, showing no difference. The largest increase in IOP was observed at M1, statistically different from the other time points.

DISCUSSION

Intra- and periocular injections should be considered as an adjuvant therapy, since the majority of the conditions in question require systemic treatment. They allow for increased intravitreal concentrations with fewer systemic effects.

CONCLUSION

We demonstrated neither any true superiority of any of the 3 treatments nor any difference in tolerability between the 3 groups.

Intravitreal dexamethasone implant for recurrent cystoid macular edema due to Irvine-Gass syndrome: a prospective case series

PurposeTo determine the preliminary efficacy and safety of off-label dexamethasone implant for treatment of recurrent cystoid macular edema (CME) secondary to Irvine-Gass syndrome (IGS).Patients and methodsThis study was set in Raghudeep Eye Clinic, Ahmedabad and LV Prasad Eye Institute, Hyderabad (India). It is a Prospective Case Series. Prospective case series comprising of patients with uncomplicated pseudophakia and CME due to IGS who recurred after one course of topical steroids with NSAIDS and a sub-Tenon corticosteroid injection. A complete ocular and systemic exam, fluorescein angiography, and central subfield thickness (CST) on optical coherence tomography scans were performed. Follow-up visits were on days 1, 15, and 30 and then monthly for a year. Appropriate statistical analysis was done. The primary outcome measure was the change in CDVA at months 1, 6, and 12. Secondary outcome measures were recurrence of CME and complications if any as noted at months 1, 2, 6, and 12.ResultsAbout 27 patients (27 eyes) with 16 males were included. Median age: 63.24±5.62 years. At 1 month, the CDVA improved to 0.04±0.02 (20/25) logMAR from 0.52±0.12 logMAR (20/70) (P=0.001) with a reduction in CST from 454.2±45.3 to 218.32±38.15 microns(P=0.013). The CDVA was 0.04±0.03 logMAR(P<0.001) at month 6 and 0.05±0.02 logMAR(P<0.001) at month 12. The CST was 221±35.2 microns (P=0.013) at month 6 and 214±43.34 microns (P=0.0124) at month 12. All improvements were maintained for a year. Only one patient required a second injection. No complications were noted.ConclusionThe implant is safe and effective for the treatment of recurrent CME due to IGS.

USE OF AFLIBERCEPT FOR THE MANAGEMENT OF REFRACTORY PSEUDOPHAKIC MACULAR EDEMA IN IRVINE-GASS SYNDROME AND LITERATURE REVIEW

BACKGROUND/PURPOSE

To present the patient treated for pseudophakic cystoid macular edema with intravitreal aflibercept.

METHODS

Interventional case report.

CASE

An 83-year-old woman presented with decreased vision 1 month after uneventful cataract surgery. After failure to respond to posterior subtenons triamcinolone and three Ranibizumab injections, the patient responded to one intravitreal aflibercept injection. Recurrence occurred two months later, and therefore three monthly injections were then given. Again the patient responded although recurrence occurred two months after treatment. The patient refused further treatment.

CONCLUSION

Intravitreal aflibercept may be effective for the treatment of pseudophakic cystoid macular edema.

Evaluation of best corrected visual acuity and central macular thickness after intravitreal dexamethasone implant injections in patients with Irvine-Gass syndrome: A retrospective study of six cases

PURPOSE

Irvine-Gass syndrome is a macular edema (ME) that specifically occurs after cataract surgery. Its incidence varies from 0.2-2%. The purpose of this study is to evaluate the effectiveness of intravitreal dexamethasone implant injections in patients with Irvine-Gass syndrome.

METHODS

Patients with ME secondary to cataract surgery who underwent intravitreal injections of dexamethasone implant between December 2011 to October 2014 at François-Quesnay hospital (Mantes-la-Jolie, France) were retrospectively reviewed. The patients were followed for at least 10 months. All the patients were handled by intravitreal injection of dexamethasone in the eye of study among which some resisted to a preliminary treatment by non-steroidal anti-inflammatory drug (NSAID) and acetazolamide. The patients were examined each month. The patients were again handled by intravitreal injection of dexamethasone if they presented a recurrence. The primary endpoint of the study was determined on best corrected visual acuity (BCVA) using early diabetic retinopathy study (ETDRS) scale and central macular thickness (CMT) [μm] using optical coherence tomography (OCT) 3 and 6 months after the first injection. Secondary endpoints were the number of recurrences, the number of injections, the duration average before the first recurrence, the BCVA 10 months after the first injection and the tolerance.

RESULTS

Six eyes of six patients were studied. At baseline, the mean (standard deviation [SD]) of the BCVA was 59.8±11. Three months after the first injection, the mean (SD) of the BCVA showed a statistically significant increase to 72.2±8.6 (P=0.03). Six months after the first injection, the mean (SD) of the BCVA showed a statistically significant increase to 72±11.8 (P=0.03). Concerning the CMT, the mean (SD) was 495.6±135.2 before treatment. Three months after the first injection, the mean (SD) of the CMT showed a statistically significant decrease to 268.6±57.8 (P=0.03). Six months after the first injection, the mean (SD) of the CMT showed a significant decrease to 350.1±56.3 (P=0.09).

CONCLUSION

In this study, both mean BCVA and mean CMT had significantly improved from baseline after treatment with dexamethasone implant in patients with Irvine-Gass syndrome.

Effectiveness and safety of dexamethasone implants for postsurgical macular oedema including Irvine-Gass syndrome: the EPISODIC-2 study

AIM

To assess the effectiveness of intravitreal dexamethasone implants for treating postsurgical macular oedema (PSMO) including Irvine-Gass syndrome and determining the predictive factors of treatment response.

METHODS

Descriptive, observational, retrospective, consecutive, uncontrolled, multicentre, national case series. One hundred patients were included between April 2011 and June 2014, with a minimum of 1-year follow-up. Patients received dexamethasone implant 0.7 mg at baseline. Clinical characteristics, best-corrected visual acuity (BCVA), central subfield macular thickness (CSMT) and intraocular pressure were measured at each visit. The main outcome measure was the change in BCVA (Early Treatment of Diabetic Retinopathy Study (ETDRS) letters: L). An analysis of predictive factors of treatment response is also provided.

RESULTS

Mean improvement in BCVA was 9.6 (±10.6) L at month 6 and 10.3 (±10.7) L at month 12 (p<0.001). The proportion of eyes with gains in BCVA of 15 or more letters was 32.5% and 37.5% at months 6 and 12, respectively. The mean reduction in CSMT was 135.2 and 160.9 µm at months 6 and 12, respectively (p<0.001). Thirty-seven per cent of patients did not need a second injection after the first injection during follow-up. The presence of at least one PSMO risk factor decreases the probability of a gain in visual acuity (VA) ≥10 L (p=0.006). Initial VA ≤50 L at baseline and non-naïve status decrease the probability of having only one injection during follow-up (p=0.044).

CONCLUSIONS

The significant gain in BCVA from baseline achieved at month 6 was maintained at month 12 after intravitreal injection of dexamethasone implant. Naïve status seems to be a good predictive factor of treatment response.

INTRAVITREAL DEXAMETHASONE IMPLANT FOR RADIATION MACULOPATHY SECONDARY TO PLAQUE BRACHYTHERAPY IN CHOROIDAL MELANOMA

PURPOSE

To evaluate the efficacy of intravitreal dexamethasone implant 0.7 mg (Ozurdex) in radiation maculopathy secondary to plaque brachytherapy in choroidal melanoma.

METHODS

Twelve eyes diagnosed of radiation maculopathy secondary to plaque brachytherapy and treated with intravitreal dexamethasone implant were included. Visual acuity, foveal thickness using spectral domain optical coherence tomography, and grade of macular edema, using Horgan classification, were evaluated.

RESULTS

Mean age was 65.5 ± 28 years (range, 40-82 years). Mean follow-up was 8.2 ± 7.8 months (range, 2-28 months). Mean visual acuity before treatment was, in logarithm of the minimum angle of resolution scale, 1 ± 0.58 (range, 0.4-2) and mean final visual acuity 0.8 ± 0.58 (range, 0.2-2), showing a nonsignificant trend to improvement (P = 0.091; Wilcoxon's test). Foveal thickness before treatment was 416 ± 263 μm (range, 222-725 μm) and final foveal thickness 254 ± 170 μm (range, 145-750), showing a significant decrease (P = 0.016; Wilcoxon's test). Referring to Horgan classification, a significant reduction in grades before and after treatment was demonstrated (P = 0.007; Wilcoxon's test).

CONCLUSION

Ozurdex is a useful treatment for radiation maculopathy associated to plaque brachytherapy for uveal melanoma, with a significant decrease in foveal thickness and a significant improvement in Horgan classification. This anatomical improvement was correlated with a moderate improvement in visual acuity.

Efficacy and Safety in Retinal Vein Occlusion Treated with at Least Three Consecutive Intravitreal Dexamethasone Implants

Purpose. To evaluate the effects of repeated intravitreal dexamethasone implant (DI) (Ozurdex®) in eyes with macular edema (ME) due to retinal vein occlusion (RVO). Methods. Multicenter observational study including patients who received more than three consecutive DI on an "as-needed" basis for the treatment of ME in RVO. Results. A total of 18 eyes were included for analysis. Mean interval of retreatment with DI was 5.1 months between the first and second DI and 5.4 months following the second DI. Baseline BCVA was 0.74 ± 0.08 log-Mar; it significantly improved to 0.45 ± 0.04 2 months after the 3rd DI. There was no significant difference between the 3 first postinjection BCVA. CMT decreased from 617 μm ± 120 μm (baseline) to 330 ± 109 μm two months after the third DI. Elevated intraocular pressure occurred in 50% and was controlled medically. Cataract progression leading to cataract surgery occurred in 69% of phakic eyes after a mean interval of 17 months. Conclusion. Repeated DI on an "as-needed" basis, with a retreatment interval <6 months, are effective in the long term in the management of ME due to RVO. Rates of increased intraocular pressure and cataract surgery seem to be higher than previously described when eyes were followed during a longer period.

[Treatment of postoperative cystoid macular edema (Irvine-Gass syndrome) with dexamethasone 0.7 mg intravitreal implant]

PURPOSE

To evaluate the efficacy of dexamethasone 0.7 mg intravitreal implant in patients with postoperative cystoid macular edema.

MATERIALS AND METHODS

Fourteen patients' charts with postoperative cystoid macular edema were retrospectively reviewed. The main outcome measures were best-corrected visual acuity (BCVA) and mean central retinal thickness (CRT).

RESULTS

Patients' mean age was 72.1 years old. Five patients were diabetic. All patients had previously been treated with non-steroidal anti-inflammatory drops. Four patients had received a previous treatment with intravitreal ranibizumab. The mean follow-up period was 8.7 months. Mean BCVA before intravitreal dexamethasone was 0.72 logMAR. After injection, it improved to 0.50 at month 1, was 0.47 at month 3, and 0.60 logMAR at month 12. The pre-injection mean CRT was 598 μm. It improved to 286 μm at month 1, 338 μm at month 3, and was 441 μm at month 12. Eight patients received 2 intravitreal injections of dexamethasone. Five patients presented with elevated intraocular pressure during follow-up, which was treated with drops.

CONCLUSIONS

Intravitreal dexamethasone injection improved visual acuity and macular thickness at month 1 and month 3 in patients with postoperative cystoid macular edema. A second injection was necessary after a mean period of 5 months.

Twelve-Month Results of a Single or Multiple Dexamethasone Intravitreal Implant for Macular Edema following Uncomplicated Phacoemulsification

The clinical efficacy of one or two intravitreal injections of a continued deliverance dexamethasone 700 μg implant in ten patients with persistent macular edema following uncomplicated phacoemulsification was evaluated. Complete ophthalmological examination and spectral domain optical coherence tomography were carried out. Follow-up was at day 7 and months 1, 2, 4, 6, 8, and 12. At baseline mean best corrected visual acuity was 62 Early Treatment Diabetic Retinopathy Study Chart letters, which showed statistically significant improvement at each follow-up, except at month 6, to reach 79 letters at month 12 (P = 0.018). Prior to treatment mean central foveal thickness was 622 μm, which showed statistically significant improvement at each follow-up to reach a mean value of 282 μm (P = 0.012) at month 12. Five patients received a second dexamethasone implant at month 7. Two patients were excluded from the study at months 4 and 8. Intraocular pressure remained stable during the study period with the exception of mild increase in two patients requiring topical therapy. In conclusion there was statistically significant improvement of best corrected visual acuity and mean central foveal thickness with one or two intravitreal dexamethasone implants over 12 months.

Sustained-release dexamethasone intravitreal implant for persistent macular edema after vitrectomy for epiretinal membrane

BACKGROUND AND OBJECTIVE

Persistent macular edema (ME) after surgical removal of epiretinal membrane (ERM) may impair postoperative visual recovery. Sustained-release dexamethasone intravitreal implant (DEX) was used to treat recalcitrant ME after vitrectomy for ERM.

PATIENTS AND METHODS

Retrospective chart review of eyes treated with DEX for ME after ERM removal. Visual and anatomic outcomes were evaluated.

RESULTS

Five eyes with refractory ME on optical coherence tomography (OCT) after ERM surgery were treated with DEX. Four of five eyes demonstrated reduction in macular thickness on OCT (mean: 106 μm), with mean percentage reduction in central foveal thickness of 25%. Visual acuity improved by one or more Snellen lines in four of five eyes. DEX effect duration was 3 to 9 months. Two eyes with OCT and visual improvement after initial DEX received multiple DEX implants for maintenance therapy.

CONCLUSION

Inflammatory factors may contribute to persistent ME after vitrectomy for ERM. DEX may be a treatment option in such cases.

[Study of the effect of intravitreal dexamethasone implant in pseudophakic macular edema. Preliminary]

OBJECTIVE

To evaluate the efficacy of intravitreal dexamethasone implant on the treatment of pseudophakic macular edema (PME).

MATERIAL AND METHODS

A retrospective, observational, descriptive study was conducted on 4 patients who received an intravitreal injection of dexamethasone implant due to PME in the period from 1st January 2013 to 31st December 2013 in the Hospital Universitario de La Ribera (Alzira, Valencia, Spain). A complete ophthalmic examination was performed on these patients. Best-corrected visual acuity (BCVA), macular thickness), and duration of the effect of the treatment were studied.

RESULTS

At baseline, the mean MT was 414μm. After dexamethasone implant, mean values of MT decreased to 330.25μm at month one. The mean change from baseline MT was 83.75μm. The baseline mean BCVA was 0.3 and improved to 0.575 at month one and 3. The mean duration of the effect of the treatment was 3.5 months.

CONCLUSIONS

Intravitreal dexamethasone implant is a possible treatment for Irvine-Gass syndrome as it improved visual acuity and reduced the macular thickness of these patients.

Effectiveness and safety of dexamethasone implants for post-surgical macular oedema including Irvine-Gass syndrome: the EPISODIC study

AIM

To assess the effectiveness and safety of intravitreal dexamethasone implants for treating post-surgical macular oedema, including Irvine-Gass syndrome refractory to first-line treatments.

METHODS

Descriptive, observational, retrospective, consecutive, uncontrolled, multicentre, national case series. 50 patients were included in the study between March 2011 and June 2013 with a minimum 6 months follow-up. At baseline, each patient received a dexamethasone implant 0.7 mg (Ozurdex). Best-corrected visual acuity (BCVA), central subfield macular thickness (CSMT), and intraocular pressure (IOP) were measured at baseline and then monthly. The main outcome measure was the mean change in BCVA (in ETDRS letters (Early Treatment Diabetic Retinopathy Study): L) RESULTS: Baseline mean±SD BCVA was 55.7±15.4 L. At month 2, BCVA was 71.8±10.5 L and 61.2% of patients had an increase of more than 15 letters. Baseline mean CSMT was 544±117.2 μm and this decreased to 302 μm at month 2. Anatomic and functional recurrences were both first detected from month 3 and continued throughout follow-up, with values consistently above baseline. The peak in IOP was reached in month 1 with mean IOP of 15.3±4.6 mm Hg. Of the 39/50 patients followed up for 12 months, 49% received a second injection. The anatomic and functional response and safety patterns were similar to that obtained with the first intravitreal injection, demonstrating Ozurdex's reproducibility. However, more than half of the patients followed-up for at least 1 year presented neither functional nor anatomical recurrence.

CONCLUSIONS

Ozurdex would appear to be an interesting alternative therapy for treating post-surgical macular oedema, including Irvine-Gass syndrome refractory to first-line treatments.

Efficacy of intravitreal dexamethasone implant for prostaglandin-induced refractory pseudophakic cystoid macular edema: case report and review of the literature

Background

Macular edema is a known complication even after uneventful cataract surgery. The chronic use of prostaglandin analogs is a risk factor for the development of pseudophakic cystoid macular edema (CME). Nonsteroidal anti-inflammatory drugs (NSAIDs) are considered first-line therapy but refractory postsurgical CME represents a therapeutic challenge, as there is not an evidence-based treatment.

Objective

To report the use of a single implant of intravitreal dexamethasone for tafluprost-associated pseudophakic CME refractory to NSAIDs and to sub-Tenon’s corticosteroid injections.

Case report

A 64-year-old female with ocular hypertension treated with tafluprost experienced decreased vision (visual acuity 20/60) and metamorphopsia 2 months after uneventful cataract extraction. Spectral domain optical coherence tomography (SD-OCT) revealed CME. After 1 month of topical and oral NSAIDs, CME was still evident on SD-OCT (visual acuity 20/50). Two sub-Tenon’s betamethasone injections were performed at a 2-week interval. As CME was still present, 2 months after the diagnosis of CME (visual acuity 20/40), the patient underwent a single dexamethasone intravitreal implant. One month later, macular appearance was normal, and visual acuity increased to 20/30. This result was maintained throughout the 6 months of follow-up.

Conclusion

In this report, a single implant of intravitreal dexamethasone successfully treated pseudophakic CME associated with the use of prostaglandin analogs unresponsive to NSAIDs and sub-Tenon’s betamethasone. The results of this report need to be corroborated by powered, prospective, randomized trials. The need for repeated treatments as well as the retreatment interval in patients requiring more than a single injection are issues still needing further investigations.

Macular oedema related to idiopathic macular telangiectasia type 1 treated with dexamethasone intravitreal implant (ozurdex)

A 65-year-old female presented with visual disturbance in her right eye lasting for over 2 months. Following investigations, she was diagnosed with MacTel type 1 in the right eye. Visual symptoms were refractory to initial treatment with intravitreal bevacizumab and thereafter intravtireal triamicinolone. The patient was then treated with Ozurdex, following which central macular thickness (CMT) decreased (from 397 μm to 286 μm) and visual acuity deteriorated (from logMAR 0.48 to 0.59). At 14 weeks posttreatment with Ozurdex, a recurrence of cystoid macular oedema (CMO) was observed. Following a second Ozurdex, visual acuity improved (from logMAR 0.7 to 0.64) and CMT decreased (from 349 μm to 279 μm). An additional recurrence of CMO was observed at eighteen weeks following the second Ozurdex. Following a third Ozurdex injection visual acuity deteriorated (from logMAR 0.74 to 0.78) and CMT decreased (from 332 μm to 279 μm). Conclusion. Treatment of macular oedema secondary to MacTel with Ozurdex demonstrated promising anatomical outcomes. However, visual outcomes continued to gradually deteriorate.

Evaluation of pain during intravitreal Ozurdex injections vs. intravitreal bevacizumab injections

PURPOSE

The purpose was to evaluate the pain associated with intravitreal Ozurdex injections, and to compare it with that associated with intravitreal bevacizumab injections.

METHODS

The study included 57 eyes of 57 patients who received an intravitreal Ozurdex injection at our institution. Pain was measured by the visual analog scale (VAS). Additional parameters recorded included age, sex, indication for the injection, number of previous Ozurdex injections in the study eye, presence of diabetes mellitus, and lens status. Data were compared with a 2 : 1 sex- and age-matched control group of 114 patients who received intravitreal bevacizumab injections.

RESULTS

Indications for injection included diabetic macular edema (40.4%) and macular edema secondary to central and branch retinal vein occlusion (28% and 31.6%, respectively). Pain scores on the VAS ranged from 0 to 90, with a mean of 20.8±20.3. There was no significant difference in pain between Ozurdex and bevacizumab injections. Pseudophakia was correlated with increased pain in Ozurdex injections.

CONCLUSIONS

This is the first series evaluating the pain associated with intravitreal Ozurdex injections. Despite a larger needle gauge and tunneled injection technique, intravitreal injection of Ozurdex is not associated with increased pain compared with bevacizumab. This finding may be a potential advantage for Ozurdex, and may serve to improve patient compliance with future long-term treatment protocols.

Intravitreal Ranibizumab for the Treatment of Irvine-Gass Syndrome

PURPOSE

The purpose of our study was to evaluate the potential efficacy and safety of intravitreal ranibizumab in patients with pseudophakic cystoid macular edema (CME).

METHODS

This retrospective study comprised 7 eyes with CME treated with intravitreal ranibizumab. Patients were examined at 1 week and 1 month after injection and monthly thereafter. Main outcome measures included changes in best-corrected visual acuity (BCVA) and central retinal thickness (CRT). Safety was assessed by ophthalmic examination and report of systemic adverse effects.

RESULTS

There was a statistically significant difference on BCVA (p < 0.001) and CRT (p < 0.001) before and after the ranibizumab injection. One injection appeared to be sufficient for the resolution of CME, while recurrence was observed in 1 patient, in a long-term follow-up. No observable ocular or systemic side effects were found.

CONCLUSIONS

Intravitreal ranibizumab seems to be effective and safe for the treatment of pseudophakic CME, demonstrating a statistically significant difference in BCVA as well as CRT.

Intravitreal dexamethasone implant for macular edema following uncomplicated phacoemulsification

PURPOSE

To retrospectively study the efficacy of a single 0.7-mg dexamethasone intravitreal implant in eyes with refractory macular edema secondary to uncomplicated phacoemulsification and intraocular lens implant.

METHODS

In 11 eyes of 11 consecutive patients with persistent refractory macular edema, secondary uncomplicated cataract extraction, and intraocular lens implant, the injection of 0.7-mg dexamethasone implant was performed at the Clinica Oculistica, University of Bari, Italy. Best-corrected visual acuity (BCVA), central retinal thickness measured by spectral-domain optical coherence tomography, and intraocular pressure (IOP) was evaluated at baseline, 1 month, and 6 months.

RESULTS

After a mean follow-up of 6.27 ± 0.47 months, BCVA was significantly increased from 20/40 to 20/22 (p<0.0001), mean central retinal thickness decreased significantly from 462 ± 100 to 276 ± 8 µm (p<0.0001), and IOP did not change significantly (p = 0.053). In no case were postoperative complications observed.

CONCLUSIONS

A single injection of 0.7-mg dexamethasone intravitreal implant was effective in the treatment of persistent refractory macular edema secondary to uneventful phacoemulsification and in-bag lens implant.