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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 34  |  Issue : 2  |  Page : 145-147

Surgical removal of inadvertent intralenticular sustained-release dexamethasone implant (ozurdex) and implant one-piece posterior capsule intraocular lens


1 Eye and Laser Centre, Bahrain Defence Force Hospital, Royal Medical Services, Military Hospital, Kingdom of Bahrain
2 Department of Ophthalmology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
3 Dhahran Eye Specialist Hospital, Dhahran, Saudi Arabia

Date of Submission12-Mar-2019
Date of Decision23-Dec-2019
Date of Acceptance24-Feb-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Dr. Abdulrahman Albuainain
Eye and Laser Centre, Bahrain Defence Force Hospital, Royal Medical Services, Military Hospital
Kingdom of Bahrain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-4534.305044

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  Abstract 


To report the therapeutic efficacy and results of an accidentally injected intralenticular sustained-release dexamethasone implant (Ozurdex) in a patient with macular edema secondary to diabetic macular edema.Dexamethasone intravitreal implant is an approved formulation in the management of macular edema. The most common adversarial effects are an elevation of intraocular pressure (IOP) and cataract, but the unintentional injection of the dexamethasone implant into the lens is a particularly rare event.We report a case of a 72-year-old man treated for resistant Diabetic macular edema (DME) with dexamethasone intravitreal implant (Ozurdex, Allergan, Inc., Irvine, CA, USA) in which the technique was complicated by accidental implantation into the lens body and review the management. The patient underwent phacoemulsification of the lens, removal of the Ozurdex, intravitreal Avastin injection, and implant of a one-piece lens in the posterior capsule.

Keywords: Cataract, diabetic macular edema, intralenticular Ozurdex


How to cite this article:
Albuainain A, Al Jindan M, Al Bloushi B. Surgical removal of inadvertent intralenticular sustained-release dexamethasone implant (ozurdex) and implant one-piece posterior capsule intraocular lens. Saudi J Ophthalmol 2020;34:145-7

How to cite this URL:
Albuainain A, Al Jindan M, Al Bloushi B. Surgical removal of inadvertent intralenticular sustained-release dexamethasone implant (ozurdex) and implant one-piece posterior capsule intraocular lens. Saudi J Ophthalmol [serial online] 2020 [cited 2021 Jan 17];34:145-7. Available from: http://www.sjo.org/text.asp?2020/34/2/145/305044




  Introduction Top


Intravitreal corticosteroids have shown favorable outcomes with macular edema secondary to diabetes and retinal vein occlusion, idiopathic retinal vasculitis, aneurysms, neuroretinitis,[1] retinitis pigmentosa,[2] radiation macular edema after proton beam therapy for choroidal melanoma[3] and Uveitis.[4] The corticosteroids are delivered via a single intravitreal injection or by implantation of a sustained-release device.[4] Biodegradable, sustained-release dexamethasone implants (Ozurdex) are injected transconjunctivally into the vitreous cavity using preloaded 22-gauge needle delivery systems.[4],[5],[6],[7]

The corticosteroid released from the implant can suppress inflammation in the eye by inhibiting edema, fibrin deposition, capillary leakage, and phagocytic migration. Corticosteroids also inhibit the expression of vascular endothelial growth factor, a cytokine that is expressed at increased concentrations in macular edema and is a potent promoter of vascular permeability, and prevent the release of prostaglandins, some of which are mediators of cystoid macular edema. The most common complications are secondary elevation of IOP[4] and progression of cataract; these complications have been observed in patients receiving dexamethasone intravitreal implants (Ozurdex), although their rates were lower than those in patients treated with triamcinolone acetonide injections and fluocinolone acetonide implants.[4],[5] Additional complications related to intravitreal corticosteroid implants include migration of the implant toward the anterior chamber, frequently in patients with an absent or defective lens capsule.[8] The accidental injection of a dexamethasone implant into the crystalline lens is a rare, unexpected complication also related to the procedure.[9],[10],[11],[12],[13] Several cases have been reported, with most showing the cataract progression and requiring cataract surgery.[9],[11],[14] The inadvertent injection of the dexamethasone implant into the capsular bag is an extremely rare event, with very few cases reported in the literature.[10]


  Case Report Top


A 72-year-old male with a two days history of dexamethasone implant (Ozurdex, Allergan, Inc., Irvine, CA, USA) for treatment of resistant DME came to us for a second opinion. His corrected distance visual acuity was 0.2 in both eyes. The anterior segment examination showed nuclear sclerosis grade 1 in both eyes. IOP 13 and 10mmHg with Goldmann Applanation tonometer. The Ozurdex implant was seen lodged inside the posterior cortex of the lens in the right eye [Figure 1]. Dilated Fundus examination showed moderate non-proliferative Diabetic retinopathy in both eyes with macular edema. Optical coherence tomography (OCT) confirmed DME with central subfield macular thickness of 495μm in the right eye. Anterior segment Optical coherence tomography (AS-OCT), B scan ultrasonography and ultrasound biomicroscopy confirmed the location of the other end of Ozurdex to just anterior to the posterior capsule [Figure 2], the inferonasal capsular entrance at 4o'clock. No improvement of macular edema, and patient developed a cortical cataract subsequently over a period of two months, and was scheduled for a routine cataract surgery in which he underwent a successful phacoemulsification, removal of the dexamethasone implant done by using coaxial irrigation/aspiration handpiece and ophthalmic viscoelastic device to bring the ozurdex to anterior chamber and then retrieved with forceps [Figure 3] and [Video 1], one-piece posterior capsule intraocular lens implantation after confirming a stable bag and intravitreal Avastin injection for his DME.
Figure 1: Anterior segment photograph of right eye showing intralenticular ozurdex

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Figure 2: upper left, Ultrasound biomicroscopy of the right eye showing location of ozurdex (arrow) pellet inside the lens, Upper right, B-scan ultrasonography of the right eye showing intralenticular location of Ozurdex implant (arrow), bottom picture, Anterior segment optical coherence tomography of the right eye showing intralenticular location of ozurdex implant (arrow)

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Figure 3: Intraoperative photograph showing the ozurdex implant after explanation

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  Discussion Top


Ozurdex (Dexamethasone Implant; Allergan, Inc., Irvine, CA, USA) is a water-soluble, biodegradable copolymer of lactic acid and glycolic acid enclosing micronized dexamethasone. It has been official by the US Food and Drug Administration for the treatment of macular edema due to retinal vein occlusion.[15],[16],[17] Several reports have established its efficacy in DME as well.[18] It is a rod-shaped (6mm) implant with 0.7mg of dexamethasone releasing 100–1000μg/ml of the drug per day for the first two months. The concentration of the drug becomes undetectable after 7–8months.[19] Identified complications of the implant include endophthalmitis, glaucoma, and cataract. Lenticular injury of accidental injection of sustained-release intravitreal dexamethasone implant into the crystalline lens is a rare complication but known. The therapeutic effect of intralenticular Ozurdex is controversial. There are a few case reports about this complication.[20–23] Lenticular injuries during intravitreal injections were found to be 0.009% in a multicentric case series study.[24] Ozurdex implantation is unlike regular intravitreal injections because of the larger (22-gauge) needle used and the speed (0.8m/s in vitreous),[25] by which the pellet is introduced into the vitreous cavity. An inappropriate technique, an inexperienced surgeon, and patient head movement can all lead to inadvertent injection of Ozurdex implant into the lens. Trauma to the lens with or without the presence of a foreign body can lead to cataractous changes. There have been reports of intralenticular Ozurdex leading to cataract progression in days or months after injection and rise in IOP requiring intervention.[11],[20],[25] Progression of cataract might take as long as 11months after injection and might require a second. Ozurdex injection for macular edema in the presence of intralenticular Ozurdex.[25] In our case, there was a progression of cataract, with normal IOP. The Ozurdex end inside the lens could have behaved like a sterile foreign body and did not cause any cataract, or the site of Ozurdex entry might be through the equator of lens preserving posterior capsule or vitreous might have plugged the posterior end this could be the reasons for no rapid progression of cataract. Coca-Robinot et al. and Sekeroglu et al. observed the therapeutic effect of intralenticular Ozurdex as long as six months in their case reports. Later, there was a progression of cataract requiring intervention.[12],[21]

In conclusion, accidental intralenticular entry of an Ozurdex implant that entirely located inside the crystallize lens may not have the therapeutic effects. The variable pace of cataract progression underpinning relevant management decisions, clinical management of each case should be individualized and based on concomitant findings, and the development of side effects. The injection of an intravitreal dexamethasone implant (Ozurdex) into the lens body is a rare complication that can be effective and successful managed with the surgical extraction of the implant from the lens body and implant of a one-piece intraocular lens in the posterior capsule.

[Appendix A]: Supplementary material

Supplementary data to this article can be found online at https://doi.org/10.1016/j.sjopt.2020.02.001.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Empeslidis T, Banerjee S, Vardarinos A, Konstas AG. Dexamethasone intravitreal implant for idiopathic retinal vasculi- tis, aneurysms, and neuroretinitis. Eur J Ophthalmol 2013;23:757-60.  Back to cited text no. 1
    
2.
Saatci AO, Selver OB, Seymenoglu G, Yaman A. Bilateral intravitreal dexamethasone implant for retinitis pigmentosa- related macular edema. Case Rep Ophthalmol 2013;4:53-8.  Back to cited text no. 2
    
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Baillif S, Maschi C, Gastaud P, Caujolle JP. Intravitreal dexa- methasone 0.7-mg implant for radiation macular edema after proton beam therapy for choroidal melanoma. Retina 2013;33:1784-90.  Back to cited text no. 3
    
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Kiddee W, Trope GE, Sheng L, et al. Intraocular pressure monitoring post intravitreal steroids: a systematic review. Surv Ophthalmol. 2013;58:291-310.  Back to cited text no. 4
    
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Haller JA, Bandello F, Belfort Jr R, et al. Dexamethasone intravitreal implant in patients with macular edema related to branch or central retinal vein occlusion twelve-month study results. Ophthalmology 2011;118:2453-60.  Back to cited text no. 5
    
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Lowder C, Belfort Jr R, Lightman S, et al. Dexamethasone intravitreal implant for noninfectious intermediate or posterior uveitis. Arch Ophthalmol. 2011;129:545-53.  Back to cited text no. 6
    
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Gillies MC, Lim LL, Campain A, et al. A randomized clinical trial of intravitreal bevacizumab versus intravitreal dexamethasone for diabetic macular edema: the BEVORDEX study. Ophthalmology 2014;121:2473-81.  Back to cited text no. 7
    
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Khurana RN, Appa SN, McCannel CA, et al. Dexamethasone implant anterior chamber migration: risk factors, complications, and management strategies. Ophthalmology 2014;121:67-71.  Back to cited text no. 8
    
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Koller S, Neuhann T, Neuhann I. Conspicuous crystalline lens foreign body after intravitreal injection. Ophthalmologe 2012;109:1119-21.  Back to cited text no. 9
    
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Ram J, Agarwal AK, Gupta A, Gupta A. Phacoemulsification and intraocular lens implantation after inadvertent intracapsular injection of intravitreal dexamethasone implant. (bcr2012007494). BMJ Case Rep 2012;2012.  Back to cited text no. 10
    
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Berarducci A, Sian IS, Ling R. Inadvertent dexamethasone implant injection into the lens body management. Eur J Ophthalmol 2014;24:620-2.  Back to cited text no. 11
    
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Coca-Robinot J, Casco-Silva B, Armada-Maresca F, Garcia-Martinez J. Accidental injections of dexamethasone intravitreal implant (Ozurdex) into the crystalline lens. Eur J Ophthalmol 2014;24:633-6.  Back to cited text no. 12
    
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Kocak N, Ozturk T, Karahan E, Kaynak S. Anterior migration of dexamethasone implant in a pseudophakic patient with intact posterior capsule. Indian J Ophthalmol 2014;62:1086-8.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Kupperman BD, Blumenkranz MS, Haller JA, et al. Dexamethasone DDS Phase II Study Group. Randomized controlled study of an intravitreous dexamethasone drug delivery system in patients with persistent macular edema. Arch Ophthalmol 2007;125(3):309-17.  Back to cited text no. 15
    
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Williams GA, Haller JA, Kupperman BD, et al. Dexamethasone DDS Phase II Study Group. Dexamethasone Posterior-Segment Drug Delivery System in the treatment of macular edema resulting from uveitis or Irvine-Gass syndrome. Am J Ophthalmol 2009;147(6):1048-54.  Back to cited text no. 16
    
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Haller JA, Bandello F, Belfort Jr R, Blumenkranz MS, Gillies M, Heier J, et al. Ozurdex GENEVA Study Group. Randomized, shamcontrolled trial of dexamethasone intravitreal implant in patients with macular edema due to retinal vein occlusion. Ophthalmology 2010;117(6):1134-46.  Back to cited text no. 17
    
18.
Boyer DS, Yoon YH, Belfort Jr R, et al. Three-year, randomized, shamcontrolled trial of dexamethasone intravitreal implant in patients with diabetic macular edema. Ophthalmology 2014;121:1904-14.  Back to cited text no. 18
    
19.
Chang-Lin JE, Attar M, Acheampong AA, et al. Pharmacokinetics and pharmacodynamics of a sustained-release dexamethasone intravitreal implant. Invest Ophthalmol Vis Sci 2011;52:80-6.  Back to cited text no. 19
    
20.
Sekeroglu MA, Anayol MA, Koc F, Tirhis H, Ozkan SS, Yilmazbas P. Intralenticular sustained-release dexamethasone implant: Is it still effective on macular edema? Case Rep Ophthalmol 2016;7:85-9.  Back to cited text no. 20
    
21.
Chhabra R, Kopsidas K, Mahmood S. Accidental insertion of dexamethasone implant into the crystalline lens-”12 months followup. Eye (Lond) 2014;28:624-5.  Back to cited text no. 21
    
22.
Chalioulias K, Muqit MMK. Vitreoretinal surgery for inadvertent intralenticular Ozurdex implant. Eye 2014;28(12):1523-4.  Back to cited text no. 22
    
23.
Meyer CH, Rodrigues EB, Michels S, et al. Incidence of damage to the crystalline lens during intravitreal injections. J Ocul Pharmacol Ther 2010;26:491-5.  Back to cited text no. 23
    
24.
Meyer CH, Klein A, Alten F, et al. Release and velocity of micronized dexamethasone implants with an intravitreal drug delivery system: Kinematic analysis with a high-speed camera. Retina 2012;32:2133-40.  Back to cited text no. 24
    
25.
Chhabra R, Kopsidas K, Mahmood S. Accidental insertion of dexamethasone implant into the crystalline lens-12 months followup.Eye (Lond) 2014;28:624-5.  Back to cited text no. 25
    


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