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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 117-118

Fractured blood stained steroid implant


Smt. Kanuri Santhamma Center for Vitreoretinal Diseases, L. V. Prasad Eye Institute, Hyderabad, Telangana, India

Date of Submission28-Apr-2020
Date of Acceptance16-Jul-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Brijesh Takkar
Smt. Kanuri Santhamma Center for Vitreoretinal Diseases, LV Prasad Eye Institute, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1200_20

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  Abstract 


The usual biodegradation of the sustained release steroid implant does not involve fractures. The case presented in this report was noted to have vitreous haemorrhage staining a steroid implant injected for management of diabetic retinopathy. The implant gradually thinned in the areas adjacent to the haemorrhage, to eventually fracture into 2 pieces. Fracture of the implant is an uncommon event and may be a cause of concern as it can potentially alter the pharmacokinetics/dynamics of the drug.

Keywords: Diabetic macular edema, sustained release dexamethasone implant, vitreous haemorrhage


How to cite this article:
Takkar B, Godbole AP. Fractured blood stained steroid implant. Indian J Ophthalmol Case Rep 2021;1:117-8

How to cite this URL:
Takkar B, Godbole AP. Fractured blood stained steroid implant. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Feb 25];1:117-8. Available from: https://www.ijoreports.in/text.asp?2021/1/1/117/305478



Sustained-release-steroid-implant (SRSI) is useful and efficacious for management of macular edema secondary to various diseases.[1],[2],[3] The implant gives advantage of both prolonged delivery of drug, as well as less chances of steroid induced glaucoma.[1] The implantation procedure however is different from other injectable drugs and has a slight learning curve. Apart from faulty injection procedures, the speed and movement of implant inside the eye may also result in complications.[4],[5],[6] Usually, the implant undergoes slow bio-degeneration with complete disappearance over months after the injection.[1],[6]

Fracture of SRSI is very uncommon and is not usually seen in its course of disintegration.[4] We present a case where the SRSI injection was accompanied by vitreous haemorrhage (VH), and it subsequently fractured into 2 pieces. Informed consent was obtained from the patient.


  Case Report Top


A 65-year-old diabetic male presented with low vision in both eyes. His metabolic profile was controlled, and he had received multiple injections of anti-vascular endothelial growth factor (VEGF) agents in left eye (LE), along with one session of focal laser for diabetic macular edema in the past 6 months. Visual acuity was 20/320 in right eye (RE) and 20/250 in LE. RE had a dense senile cataract, while Le had a posterior chamber intraocular lens. The rest of the anterior segment examination and intraocular pressure (IOP) of both eyes were within normal limits. Fundus examination and optical coherence tomography of LE were consistent with diagnosis of chronic diabetic macular edema, while RE optical media was very hazy precluding fundus examination [Figure 1]a. The patient was advised an intravitreal injection of SRSI (Ozurdex, Allergan, Inc., Irvine, CA, USA) in LE, and the procedure was performed uneventfully.
Figure 1: (a-e): (a) Line scan OCT of LE macula showing chronic macular edema with epiretinal membrane. (b) Blood stained sustained-release-steroid-implant (SRSI) can be seen in the inferior and anterior vitreous cavity. (c) Thinning of the SRSI can be seen at the site of the blood staining. (d) The SRSI has fractured into 2 pieces at second month of follow-up. (e) The macular edema is resolved at 4 months of follow-up

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The patient was seen 2 weeks later again for measurement of IOP, when blood was noted to stain the implant surface [Figure 1]b. Two weeks further, the implant had started to thin at the site of the blood [Figure 1]c. The implant got fractured into 2 pieces by the second month of follow-up [Figure 1]d. The intraocular pressure had increased by 15 mm Hg at that visit, though the macular edema had resolved and the vision improved to 20/125. At the last follow-up, 4 months after injection, the visual acuity was maintained, IOP was controlled on topical medication, and macular edema had subsided [Figure 1]e.


  Discussion Top


The sustained release function of the steroid implant is due to the protective matrix covering it, which is biodegradable.[1] This matrix is a polymer filament (PLGA), that undergoes hydrolysis after injection, enabling slow and sustained release of dexamethasone. The polymer then breaks down into smaller compounds (lactic acid and glycolic acid) which are amenable to biodegradation, resulting in its complete disintegration.[1],[2] Any premature dis-integrity in the filament would cause an obvious over exposure of the drug to the vitreous cavity and altered drug release pattern hypothetically. The usual course after the implant injection is an uneventful degradation over months,[1],[2],[3] though the bending of the implant can occur. Fractures into small pellets have been reported only in the setting of faulty injection procedure and are extremely rare.[4]

Vitreous haemorrhage can occur after any intravitreal injection and is generally innocuous or minimal in nature, though it may require surgery in some cases.[7],[8] It may be more common with the steroid implant due to 22 G bore of the injector as compared to the 29 G injection needles usually employed for other drugs.[2] Blood contains many enzymes and they are abundant in the cytoplasm and plasma membranes of the blood cells too. As mentioned earlier, the usual biodegradation of SRSI involves break down of the PLGA polymer filament into biodegradable lactic and glycolic acids over months. It is hypothetically possible that the enzymes released by the blood and its cells right over the implant surface led to a quicker than usual dissolution of the protective coating of the polymer, and quicker metabolism of lactic acid and glycolic acid in this case. The fracture of the implant had occurred in the second month after the injection. This timeline of the fracture is also explained by our theory, as it would take some time for the blood cells to first degenerate and release the enzymes which subsequently resulted in the fracture. In contrast, in the report by Karandikar et al., the fracture had occurred immediately due to faulty procedure.[4] The delayed fracture in our case being an isolated report, proving our hypothesis is beyond the scope of this paper. Fortunately, the fracture occurred late with bifurcation of the implant into 2 pieces only. Greater or earlier exposure of dexamethasone to vitreous cavity could have led to failure of sustained therapy altogether, or even intractable steroid induced glaucoma.


  Conclusion Top


Ooccurrence of VH in patients injected with a SRSI mandates closer follow-up than usual. There may be a risk of implant fractures or their quicker disintegration along with hypothetically associated altered drug pharmacokinetics and dynamics.

Acknowledgment

Hyderabad Eye Research Foundation and Hyderabad Eye Institute, Hyderabad, India.

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

Hyderabad Eye Research Foundation and Hyderabad Eye Institute, Hyderabad, India.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sivaprasad S, McCluskey P, Lightman S. Intravitreal steroids in the management of macular oedema. Acta Ophthalmol Scand 2006;84:722-33.  Back to cited text no. 1
    
2.
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. 2
    
3.
Boyer DS, Yoon YH, Belfort Jr R, Bandello F, Maturi RK, Augustin AJ, et al. Three-year, randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with diabetic macular edema. Ophthalmology 2014;121:1904-14.  Back to cited text no. 3
    
4.
Karandikar SS, Manayath GJ, Saravanan V, Narendran S, Narendran V. Iatrogenic subretinal injection of Ozurdex® implant and its effect on macular edema. Oman J Ophthalmol 2017;10:100-2.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Majumder PD, Palkar AH, Pathare N, Biswas J. Anterior chamber migration of a sustained-release dexamethasone intravitreal implant: A case report and review of literature. Oman J Ophthalmol 2019;12:1337.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Poornachandra B, Kumar VB, Jayadev C, Dorelli SH, Yadav NK, Shetty R. Immortal Ozurdex: A 10-month follow-up of an intralenticular implant. Indian J Ophthalmol 2017;65:2557.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Li MS, Sheu SJ. Persistent vitreous hemorrhage after intravitreal injection of dexamethasone intravitreal implant in patients with diabetic macular edema. Taiwan J Ophthalmol 2019;9:280-3.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Casati S, Bruni E, Marchini G. Retinal and vitreous hemorrhage after traumatic impact of dexamethasone implant in a vitrectomized eye. Eur J Ophthalmol 2016;26:e55-7.  Back to cited text no. 8
    


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