Intralenticular Ozurdex implant: A rare clinical scenario and timely management
Click Here to Manage Email Alerts
Intravitreal steroids have been widely used in the treatment of various ocular pathologies including macular edema and noninfectious uveitis.
Ozurdex (dexamethasone intravitreal implant 0.7 mg, Allergan) is delivered by a 22-gauge needle as an intravitreal implant. The FDA has authorized it as a first-line treatment for noninfectious uveitis affecting the posterior segment, diabetic macular edema and macular edema due to retinal vein blockage. There are case reports of complications such as migration of the implant, complicated cataract, glaucoma and accidental injection in the crystalline lens. In this column, we would like to present a case complicated by an intralenticular Ozurdex implant and subsequent management.
Source: Shaina Saroya, MS, Dhivya Ashok Kumar, MD, FRCS, FICO, FAICO, Arnav Saroya, MS, Priya Narang, MS, and Amar Agarwal, MS, FRCS, FRCOphth
Case summary
A 52-year-old man with hypertension presented to our outpatient department with a complaint of painless vision decrease in the right eye for the past 4 months. He received an Ozurdex implant for retinal vein occlusion in the right eye 4 months prior at another clinic. Best corrected visual acuity was 1/60 in the right eye, and IOP with applanation tonometry was 23 mm Hg; BCVA was 6/6 in the left eye, and IOP was 17 mm Hg. Pupillary reaction was normal.
Dilated slit lamp examination revealed an intralenticular Ozurdex implant in the pupillary area in the central lens standing vertical and posterior subcapsular cataract in the right eye with quiet anterior chamber and a clear lens in the left eye. Anterior segment OCT confirmed the location of the implant inside the crystalline lens near the posterior surface. On fundus examination, the view was hazy due to the posterior subcapsular cataract and Ozurdex implant; few hemorrhages were noted around the foveal region. OCT of the macula showed resolved macular edema with maintained foveal contour and central foveal thickness of 231 µm.
The clinical scenario confirmed that the decreased vision was due to the presence of the pupillary location of intralenticular Ozurdex implant obscuring the visual axis with secondary complicated cataract. Right eye phacoemulsification was planned, keeping in mind the possibility of a preexisting posterior capsular rupture, with sulcus implantation of three-piece IOL or glued IOL, if required. During surgery, slow hydrodissection was followed by hydrodelineation. The Ozurdex implant with the cataractous nucleus was emulsified and aspirated with the phaco probe. A preexisting posterior capsular rupture was noticed intraoperatively, and a three-piece foldable IOL was placed in the sulcus with optic capture after anterior vitrectomy. Postoperative day 1 unaided vision in the right eye was 6/9, and the fellow eye was normal.
Ozurdex implant
Ozurdex is a biodegradable preservative-free dexamethasone implant that is rod shaped, 6mm in length and 0.46mm in diameter. It is injected through a 22-gauge needle into the vitreous cavity 3.5mm to 4mm posterior to the limbus. The muzzle velocity has been calculated as 0.8m/s in the Novadur solid polymer drug delivery system. It has been used as a first-line treatment for noninfectious uveitis affecting the posterior segment, diabetic macular edema and macular edema due to retinal vein blockage.
Adverse effects
Side effects of the implant include conjunctival hemorrhage, glaucoma, cataract formation, retinal detachment and endophthalmitis. There are case reports of accidental Ozurdex injection in the crystalline lens; possible factors are thought to be lack of experience or inappropriate technique on the surgeon’s part and uncontrolled head movement during the procedure by the patient. Accelerated cataract development has been reported in some intralenticular Ozurdex implant cases, while other cases had increased IOP or both these complications. Resolution of macular edema with intralenticular Ozurdex is controversial. Many case reports have shown a gradual resolution of macular edema with an intralenticular implant, but few found decreasing vision and no edema improvement.
Managing complications
An intralenticular implant can be managed depending on the presenting signs and symptoms. In the presence of macular edema and absence of anterior chamber inflammation with normal IOP, wait and watch can be done with later cataract surgery. Some surgeons prefer early phacoemulsification with repositioning of the implant in the vitreous, but an increase in the size of the posterior capsule tear and vitreous resistance can cause a problem in pushing the implant in the vitreous. Sometimes, the implant can become fragmented with too much manipulation, thus increasing the risk for glaucoma, and there is the possibility of the implant migrating to the anterior chamber through the capsule defect, thus causing corneal decompensation.
We described an intralenticular Ozurdex implantation case in which the macular edema had subsided, and 4 months later, a cataract had formed without raising the IOP, thus requiring phacoemulsification. A proactive approach will be more appropriate for people with an elevated IOP and if the anterior segment is abnormal and the resulting cataract obscures the retina. However, this cautious approach may not be applicable in all circumstances.
Conclusion
To summarize, the inadvertent intralenticular injection of Ozurdex is an exceedingly uncommon consequence. When faced with a situation like this, the surgeon must choose whether to act right away or to wait and watch. Reduced visual acuity (from the progression of cataract or from the implant blocking the visual axis), elevated IOP and the condition of the macula must be considered. When a cataract develops and the macular edema has subsided, cataract surgery is required. It can avoid needless reinjections by delaying lens extraction and implant removal until after its effect has fully taken hold.
- References:
- Kumar DA, et al. Indian J Ophthalmol. 2019;doi:10.4103/ijo.IJO_841_18.
- Kurt A, et al. Case Rep Ophthalmol Med. 2019;doi:10.1155/2019/8630504.
- Roy M, et al. Oman J Ophthalmol. 2022;doi:10.4103/ojo.ojo_144_21.
- Sekeroglu MA, et al. Case Rep Ophthalmol. 2016;doi:10.1159/000444163.
- For more information:
- Amar Agarwal, MS, FRCS, FRCOphth, director of Dr. Agarwal’s Eye Hospital and Eye Research Centre, is the author of several books published by SLACK Books, sister company of Healio publisher Ocular Surgery News, including Phaco Nightmares: Conquering Cataract Catastrophes, Bimanual Phaco: Mastering the Phakonit/MICS Technique, Dry Eye: A Practical Guide to Ocular Surface Disorders and Stem Cell Surgery and Presbyopia: A Surgical Textbook. He can be reached at aehl19c@gmail.com; website: www.dragarwal.com.
Collapse
Read more about
Click Here to Manage Email Alerts