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 Table of Contents    
CASE REPORT
Year : 2020  |  Volume : 13  |  Issue : 2  |  Page : 92-94  

Secondary ocular hypertension post intravitreal dexamethasone implant (OZURDEX) managed by pars plana implant removal along with trabeculectomy in a young patient


1 Department of Glaucoma, Jadhavbhai Nathamal Singhvi, Sankara Nethralaya, Chennai, Tamil Nadu, India
2 Department of Vitreoretina, Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India

Date of Submission12-Jun-2018
Date of Decision09-Dec-2018
Date of Acceptance25-Nov-2019
Date of Web Publication28-May-2020

Correspondence Address:
Rathini Lilian David
Department of Glaucoma, Jadhavbhai Nathamal Singhvi, Sankara Nethralaya, No. 18, College Road, Nungambakkam, Chennai - 600 006, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ojo.OJO_40_2018

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   Abstract 


We report a case of refractory secondary ocular hypertension after insertion of dexamethasone implant (OZURDEX) for posterior uveitis in a young patient, which necessitated removal of the implant through pars plana vitrectomy along with a trabeculectomy. A young male developed secondary ocular hypertension following dexamethasone implant (OZURDEX) injection for control of posterior uveitis. As the implant was still present in the vitreous cavity, we successfully performed a pars plana removal of the implant along with trabeculectomy with mitomycin C. Early intervention is essential to prevent glaucomatous optic neuropathy in young uveitic patients receiving OZURDEX implant.

Keywords: Dexamethasone, secondary ocular hypertension, trabeculectomy


How to cite this article:
David RL, Sen P. Secondary ocular hypertension post intravitreal dexamethasone implant (OZURDEX) managed by pars plana implant removal along with trabeculectomy in a young patient. Oman J Ophthalmol 2020;13:92-4

How to cite this URL:
David RL, Sen P. Secondary ocular hypertension post intravitreal dexamethasone implant (OZURDEX) managed by pars plana implant removal along with trabeculectomy in a young patient. Oman J Ophthalmol [serial online] 2020 [cited 2020 Oct 22];13:92-4. Available from: https://www.ojoonline.org/text.asp?2020/13/2/92/285301




   Introduction Top


The dexamethasone implant (OZURDEX; Allergan Inc., Irvine, CA, USA) is a biodegradable, sustained-release device injected transconjunctivally into the vitreous cavity, containing 0.35 or 0.7 mg of dexamethasone. The implant has been approved by the Food and Drug Administration for use in noninfectious intermediate and posterior uveitis.[1] The occurrence of raised intraocular pressure (IOP) as a side effect of the drug is around 27% and is usually transient and can most often be controlled medically.[2] We report a case of uncontrolled ocular hypertension after OZURDEX implant insertion for posterior uveitis in a young patient which necessitated implant removal along with trabeculectomy.


   Case Report Top


A 32-year-old gentleman, diagnosed with chorioretinitis in the left eye probably due to tuberculosis, was treated elsewhere with intravitreal OZURDEX for control of inflammation 72 days prior. Thereafter, he presented to our hospital with secondary rise in IOP. On examination, his unaided visual acuity for distance was 6/6, N6 for near vision in both eyes. His anterior chamber in both eyes was quiet with a clear lens. His IOP was 14 and 42 mmHg in the right and left eye, respectively. Gonioscopy revealed open angles up to scleral spur in all quadrants in both eyes. Fundus examination of his right eye was within normal limits; in his left eye, anterior vitreous face was quiet, optic disc (vertical cup: disc ratio 0.3) and macula were normal, an isolated chorioretinal patch was seen in the inferotemporal quadrant, and the OZURDEX implant cylinder was seen floating freely in the vitreous cavity [Figure 1]. On Optical coherence tomogramphy (OCT) macula, his foveal contour in both eyes was normal. The patient was on maximal medical therapy including oral carbonic anhydrase inhibitors, despite which his IOP was uncontrolled. Therefore, we decided to perform a 25-gauge pars plana removal of the implant along with trabeculectomy with mitomycin C [Figure 2]. The postoperative period was uneventful with a minimal manipulation of the bleb by the removal of releasable suture on day 5 when the IOP was 18 mmHg, and the IOP then stabilized at 14 mmHg. When the patient came back for a follow-up after 6 weeks, he had a quiet anterior chamber and vitreous cavity and his IOP of 6 mmHg [Figure 3].
Figure 1: OZURDEX implant floating in the vitreous cavity

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Figure 2: Pars plana removal of the OZURDEX implant

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Figure 3: Postoperatively, a diffuse avascular bleb

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   Discussion Top


Ocular hypertension following the use of dexamethasone implant (OZURDEX) is reported to be relatively less frequent when compared to other forms of intraocular steroids.[3] The IOP usually reaches its peak at around 60 days after the implant insertion.[4]

Uveitic eyes are more prone to have a steroid response due to the already compromised trabecular meshwork.[5] Although OZURDEX is considered to have a better safety profile, the SAFEODEX study identified six independent risk factors for secondary ocular hypertension after OZURDEX injection, including younger age <60 years (odds ratio [OR] = 2.94, P < 0.001), eyes with uveitis (OR = 3.26, P = 0.017), and preexisting glaucoma (OR = 3.7, P = 0.017).[6]

Lowder et al.[1] reported that using 0.35 mg DEX implant, 0.7 mg DEX implant, and sham in patients with noninfectious intermediate or posterior uveitis only <5% had IOP >35 mmHg and <10% had IOP >25 mmHg in all treatment arms. The majority of the study patients needed only a single IOP-lowering medication for IOP control and none required surgical intervention throughout the follow-up period of 26 weeks. However, our patient required a trabeculectomy and a pars plana vitrectomy was also done simultaneously to remove the residual OZURDEX, for a more effective control of IOP.

OZURDEX implant removal for anterior migration in aphakic eyes has been reported in the past, especially in eyes with absent capsular support and prior vitrectomy, but there are not many instances of performing pars plana OZURDEX implant removal for uncontrolled glaucoma.[7] One similar case report from India describes the removal of OZURDEX implant in a child with uveitis after developing intractable glaucoma. Although later, the child still needed trabeculectomy for control of glaucoma despite the removal of the implant.[8] This can probably be explained by the resultant damage to the trabecular meshwork by the steroid.

The effect of the OZURDEX implant usually lasts for as long as 6 months, and a sizable portion of the implant was still present in the vitreous cavity 2½ months after the insertion; hence, we decided to go ahead and remove the implant.[9] Trabeculectomy was combined owing to the persistently high IOP for a duration >2 months, the possible permanent damage to the trabecular meshwork, the need for maximum IOP-lowering medications, and the chances of recurrence of inflammation.

There are few studies done on the effects of OZURDEX in the younger age group in which population uveitis often occurs. Young people, especially in the age group of <6 years, respond more dramatically to steroids.[10] Further studies are required to evaluate the safety of OZURDEX on young eyes with uveitis and to set guidelines for follow-up. This case report throws light on the possible vision-threatening complication of OZURDEX in a young patient that was managed efficiently by removal of implant along with trabeculectomy.


   Conclusions Top


Steroids must be used with caution especially in young patients, patients with uveitic eyes, steroid responders, and patients with preexisting glaucoma. Young patients with uveitis receiving implant must be evaluated periodically, and prompt treatment must be initiated for raised IOP to prevent permanent optic nerve damage.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Lowder C, Belfort R Jr., Lightman S, Foster CS, Robinson MR, Schiffman RM, et al. Dexamethasone intravitreal implant for noninfectious intermediate or posterior uveitis. Arch Ophthalmol 2011;129:545-53.  Back to cited text no. 1
    
2.
Chin EK, Almeida DR, Velez G, Xu K, Peraire M, Corbella M, et al. Ocular hypertension after intravitreal dexamethasone (OZURDEX) sustained-release implant. Retina 2017;37:1345-51.  Back to cited text no. 2
    
3.
Saraiya NV, Goldstein DA. Dexamethasone for ocular inflammation. Expert Opin Pharmacother 2011;12:1127-31.  Back to cited text no. 3
    
4.
Haller JA, Bandello F, Belfort R Jr., Blumenkranz MS, Gillies M, Heier J, et al. Randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with macular edema due to retinal vein occlusion. Ophthalmology 2010;117:1134-46000.  Back to cited text no. 4
    
5.
Siddique SS, Suelves AM, Baheti U, Foster CS. Glaucoma and uveitis. Surv Ophthalmol 2013;58:1-10.  Back to cited text no. 5
    
6.
Malclès A, Dot C, Voirin N, Vié AL, Agard É, Bellocq D, et al. Safety of intravitreal dexamethasone implant (OZURDEX): The SAFODEX study. Incidence and risk factors of ocular hypertension. Retina 2017;37:1352-9.  Back to cited text no. 6
    
7.
Khurana RN, Appa SN, McCannel CA, Elman MJ, Wittenberg SE, Parks DJ, et al. Dexamethasone implant anterior chamber migration: Risk factors, complications, and management strategies. Ophthalmology 2014;121:67-71.  Back to cited text no. 7
    
8.
Kumari N, Parchand S, Kaushik S, Singh R. Intractable glaucoma necessitating dexamethasone implant (OZURDEX) removal and glaucoma surgery in a child with uveitis. BMJ Case Rep 2013;2013. doi:10.1136/bcr2013-201293.  Back to cited text no. 8
    
9.
Chang-Lin JE, Attar M, Acheampong AA, Robinson MR, Whitcup SM, Kuppermann BD, 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. 9
    
10.
Jones R 3rd, Rhee DJ. Corticosteroid-induced ocular hypertension and glaucoma: A brief review and update of the literature. Curr Opin Ophthalmol 2006;17:163-7.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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