Aditya SudhalkarAbhay Vasavada

Viraj VasavadaVaishali Vasavada

Samaresh Srivastava

Financial Disclosure: None

60 year old male

No systemic complaints

Uncomplicated phacoemulsification with in the bag implantation of hydrophobic IOL(Acrysof IQ, Alcon Laboratories, Fort Worth, TX)

Presented 3 weeks post operatively with sudden, painless DOV-3 days

Patient Profile

Was on topical steroids at the time of presentation

CDVA: RE-20/80, LE-20/40

RE: Anterior Segment-Pseudophakia

LE: Anterior Segment- Nuclear and Posterior Subcapsular Cataract

IOP: RE-15 mm Hg, LE-12 mm Hg

RE Fundus Photograph

Cystoid macular edema

RE PS-OCT scan

ManagementAdvised(and received) a course of topical steroids,

cycloplegics and a NSAID

Asked to review in a month

Vision improved to 20/40(CDVA) after a month

Had a recurrence on tapering topical medication

RE OCT image

Further treatmentGiven posterior subtenon preservative free

triamcinolone acetonide(20mg in o.5ml) and was put on oral acetazolamide therapy(250mg 4 times/day) with potassium supplementation

Asked to review in a month

CME resolved, recurred at the end of month 2

Advised intravitreal dexamethasone implant

RE PS-OCT scan

Intravitreal dexamethasone implantTopical anesthesia

Infero-temporal quadrant

Post-operative topical antibiotics for a week

Asked to review in a week’s time

One week post operativelyVision: RE-20/20

IOP: RE-14 mm Hg

Posterior segment: No CME

RE PS-OCT scan

One year laterVision maintained at 20/20

No recurrences

No IOP spikes noted

IntroductionPseudophakic Cystoid Macular Edema: Clinically

significant in <2% population

Typically presents 4-12 weeks after surgery

Generally self resolving

Responds in most cases to topical ± systemic therapy

Some cases are resistant to therapy

PurposeTo determine the preliminary efficacy and safety of

intravitreal dexamethasone implant(Ozurdex, Allergan Inc) for the treatment of recalcitrant pseudophakic CME

MethodsProspective study

Inclusion Criteria:

Patients with pseudophakic CME

At least one course each of a.)topical steroids+NSAIDS b.)Oral CA inhibitors c.) Intravitreal/periocular steroids

Methods Exclusion Criteria:

Contraindication to ocular steroids

Complicated pseudophakia

Unwilling patient

MethodsInjections were administered using a standardized

technique by a single surgeon(AS).

Postoperative topical antibiotics for a week

Visual acuity testing every month for 6 months

IOP monitoring every month for 6 months

OCT analysis every month for 12 months

Statistical analysisDescriptive statistics, the paired and unpaired t test,

odds ratio were used, as appropriate

Primary outcome measure: Improvement in CDVA

Secondary outcome measure: Change in OCT thicknessRecurrenceComplications, if any

ResultsThirteen patients(13 eyes)

6 males, median age 64.42 ±5.76 years

Mean baseline CDVA: 0.54 ±0.14 logMAR

Median baseline IOP: 12.2 ± 4.3 mm Hg

None of the patients had systemic disease that could confound the results

Average number of topical treatments received: 1.6 ±0.4

Average systemic therapy received: one course of oral CA inhibitors

All patients received at least one subtenon triamcinolone injection

ResultsMedian duration of CME prior to inclusion: 8.6 ±

4.32 months

All patients followed up for a year

CDVA improved to 0.1 ± 0.04 logMAR

OCT thickness improved from 432.24 ±89.32 microns to 254 ± 47.24 microns

One patient developed a recurrence 1 month after injection, he required a second dexamethasone injection

None of the patients developed an IOP spike

DiscussionOur results are similar to a retrospective analysis

published recently

Safe and well tolerated

Only one patient required a second injection

Further trials are warranted

Medeiros et a;’ Dexamethasone Intravitreal Implant for Treatment of Patients With Recalcitrant Macular Edema Resulting From Irvine-Gass Syndrome Invest. Ophthalmol. Vis. Sci. 2013 : 54 (5) 3320-3324

Figure 1(A,B,C) shows the color fundus photograph, fundus fluorescein angiography (FFA) images and spectral-domain optical coherence tomography (SD-OCT) scans of a 27 year old man who presented with dimution of vision in left eye since 3 days. On examination is corrected distance visual acuity (CDVA) was 20/40. At baseline, the colour fundus photograph (A) shows a choroidal neovascular membrane (CNVM) (black arrow) and subretinal fluid. The FFA images show a classic CNVM (black arrow) with early hyperfluoresence (B) and late leakage (C). The SD-OCT scan shows choroidal neovascular complex (black arrow) above the retinal pigment epithelium. He was treated with two intravitreal bevacizumab injections with an interval of one month between injections. At 23-month followup his visual CDVA was 20/20. The color photograph shows scarred CNVM (E, black arrowhead). SD-OCT shows scar (E, black arrowhead) with recovery of foveal contour (F, black arrowhead).

Figure 1

LimitationsSmall number of patients

No comparative arm

ConclusionDexamethasone implant a viable treatment option for

recalcitrant pseudophakic CME

May be considered as primary therapy

Preliminary analysis suggests its safe and effective

References:Brysknov T et al; Longstanding refractory pseudophakic cystoid

macular edema resolved using intravitreal 0.7 mg dexamethasone implants2013 Volume 2013:7 Pages 1171—1174