|Year : 2023 | Volume
| Issue : 2 | Page : 354-356
Inadvertent intralenticular injection of ozurdex which presented as secondary glaucoma
Anitha Priya Arun Shankar, A Parivadhini
Sankara Nethralaya Medical Research Foundation, Chennai, Tamil Nadu, India
|Date of Submission||01-Oct-2022|
|Date of Acceptance||05-Jan-2023|
|Date of Web Publication||28-Apr-2023|
Anitha Priya Arun Shankar
45, Bhimanna Mudali 1st Street, Alwarpet, Chennai - 600 018, Tamil Nadu
Source of Support: None, Conflict of Interest: None
A 58-year-old male presented with a progressive decrease in vision after he received intravitreal ozurdex injection 6 months ago for diabetic macular edema. Visual acuity in the right eye and left eye was 20/630 and 20/125, respectively. The right eye lens showed intralenticular dexamethasone implant. Intraocular pressure was 40 mmHg in the right eye and 16 mmHg in the left eye. Fundus examination revealed nonproliferative diabetic retinopathy with macular edema in both eyes. As the patient's intraocular pressure was not controlled by maximum medical therapy, he was listed for phacoemulsification with intraocular lens implantation.
Keywords: Cataract, intralenticular ozurdex, secondary glaucoma
|How to cite this article:|
Shankar AP, Parivadhini A. Inadvertent intralenticular injection of ozurdex which presented as secondary glaucoma. Indian J Ophthalmol Case Rep 2023;3:354-6
|How to cite this URL:|
Shankar AP, Parivadhini A. Inadvertent intralenticular injection of ozurdex which presented as secondary glaucoma. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 5];3:354-6. Available from: https://www.ijoreports.in/text.asp?2023/3/2/354/374950
Ozurdex implant is a rod-shaped and water-soluble biodegradable dexamethasone implant, which is injected transconjunctivally into the vitreous cavity using a 22-gauge delivery system. This long-acting dexamethasone-based implant was approved by the United States and Drug Administration (FDA) for macular edema secondary to diabetes and retinal vein occlusion and noninfectious posterior uveitis. The complications documented after ozurdex implant include infection, cataract, raised intraocular pressure, and anterior migration of the implant. Inadvertent intralenticular ozurdex injections have been documented because of faulty technique or patient moving during the procedure. Though there are a handful of case reports documenting ozurdex injection into the lens, our case report shows a patient who presented with refractory glaucoma after accidental intralenticular ozurdex injection.
| Case Report|| |
A 58-year-old male presented to us with complaints of progressive painless decrease in vision in both eyes for the past one-and-a-half years. He was a known diabetic and hypertensive on treatment. He had nonproliferative diabetic retinopathy with diabetic macular edema in both eyes and was treated with intravitreal Avastin injection thrice in the right eye and once in the left eye. On examination, his best-corrected visual acuity in the right eye was 20/100 (0.70) and 20/80 (0.60). Intraocular pressure was 18 and 17 mmHg in the right and left eye, respectively. Dilated fundus examination revealed few hemorrhages, and cystoid macular edema in both eyes. The findings were confirmed by optical coherence tomography and fundus fluorescein angiography. The patient underwent three sittings of pan retinal photocoagulation (PRP) and was advised to take an intravitreal antivascular endothelial growth factor injection after PRP. The patient was lost to follow-up.
Two years later, the patient reported to us complaining of a further decrease in vision in the right eye. This occurred over a 6-month period. The patient had undergone intravitreal ozurdex injection elsewhere after which he noticed a progressive diminution of vision. One month after the intravitreal injection, he was diagnosed to have raised intraocular pressure and was started on three antiglaucoma medications elsewhere in the right eye. On examination, his best-corrected visual acuity in the right eye and left eye was 20/630 and 20/125, respectively. The right eye lens showed a dense nuclear cataract with sustained-release dexamethasone implant inside the lens and the left eye was within normal limits [Figure 1] and [Figure 2]. Intraocular pressure measured by Goldman applanation tonometry was 40 mmHg in the right eye and 16 mmHg in the left eye. Gonioscopy revealed an open angle. Dilated fundus examination of the right eye through the dense lens haze showed a disc with a vertical cup-to-disc ratio of 0.6:1 with a healthy rim, and the left eye had a healthy disc and diabetic macular edema. The patient was investigated further with anterior segment OCT [Figure 3], which confirmed the intralenticular ozurdex implant. The schematic diagram of Ozurdex implant is shown in [Figure 4]. The patient was started on a tablet acetazolamide along with the three antiglaucoma medications. Phacoemulsification with intraocular lens implantation was planned for the right eye. Unfortunately, the patient was lost to follow-up.
| Discussion|| |
In recent times, there has been a widespread use of intravitreal injections for various posterior segment pathologies. To prevent the complications which are induced by faulty technique, it is very important to achieve good training before giving any intravitreal injections. The injection is usually given through the transconjunctival route through the pars plana, 3.5 mm or 4 mm from the limbus in pseudophakia and phakic patients, respectively. Mayer et al. recommended that the correct entry point for the injection should be between the posterior capsule of the lens and the retina, moving a little anterior can damage the lens, and moving posteriorly may damage the retina. The technique of ozurdex injection is bit tricky than other intravitreal injections due to the wide bore needle and the need to point obliquely from the sclera and then point toward the vitreous cavity before injecting. This change of angle requires a better understanding of the anatomy and a learning curve.
Various case reports have shown the development of cataract after intralenticular ozurdex injection.,,, The development of cataract depends on the site of penetration of the implant into the lens, location of implant, and preinjection lens status.
Few studies have shown that, though the implant was present in the lens, it still caused the resolution of macular edema.,,, We still don't have any evidence which explains how the steroids reach the therapeutic concentration into the vitreous despite their position inside the lens. One study has reported no cataract formation but a rise in intraocular pressure 10 months after intralenticular injection with good control of pressure with medical management. Chhabra et al. described a case with intraocular pressure rise as early as 2 weeks post accidental ozurdex injection. To our knowledge, this is the first case of inadvertent lenticular ozurdex injection, which presented with refractory glaucoma. In cases where the patients do not regularly follow-up or in cases where there is a chronic rise in intraocular pressure, there is a chance that it can be missed. Optic nerve damage can happen before it can be recognized. Ram et al. suggested that hypotony induced by uveitis and ocular massage can increase the chance of lenticular touch. Though there are many case reports which suggest that macular edema can resolve despite the intralenticular position of the implant, we conclude that it would be helpful to plan for early cataract surgery to prevent diffusion of the drug resulting in intraocular pressure rise.
| Conclusion|| |
The consequences of administering the procedure without mandatory training can be devastating. A few examples of such instances are explored in the case reports mentioned above. This case report demonstrates the clinical significance of operators getting adequate training prior to intravitreal ozurdex injection. A strong grasp and appreciation of eye anatomy is a prerequisite for safely performing this procedure. Extensive training and constant revalidation are essential to safely administer ozurdex injection intravitreally.
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Poornachandra B, Kumar V. Immortal ozurdex: A 10-month follow-u p o f a n intralenticular implant. Indian J Ophthalmol 2017;65:255-7.
] [Full text]
Regan K, Blake C, Lukowski Z. Intralenticular ozurdex® – One year later. Case Rep Ophthalmol 2017;8:590-4.
Roy M, MaitiA, Das S, Das SS. Inadvertent intralenticular Ozurdex removal. Oman J Ophthalmol 2022;15:119-20. [Full text]
Chalioulias K, Muqit M. Vitreoretinal surgery for inadvertent intralenticular ozurdex implant. Eye 2014;28:1523-4.
Meyer M, Michels S. Incidence of rhegmatogenous retinal detachments after intravitreal antivascular endothelial factor injections. Acta Ophthalmol 2011;89:70-5.
Abdolrahimzadeh S, Plateroti P, Scarinci F, PlaterotiAM. Accidental intralenticular dexamethasone intravitreal implant with the resolution of macular oedema in central retinal vein occlusion. Acta Ophthalmologica 2016;94:e810-1.
Sekeroglu M, Anayol M. Intralenticular sustained release dexamethasone implant: Is it still effective on macular edema. Case Rep Ophthalmol 2016;7:85-9.
Lee K, Park A, Chung S. Elevation of intraocular pressure after inadvertent dexamethasone implant injection into the lens. Can J Ophthalmol 2016;51:e103-5.
Chhabra R, Kopsidas K. Accidental insertion of dexamethasone implant into the crystalline lens—12 months follow-up. Eye 2014;28:624-36.
Ram J, Agarwal AK, Gupta A, Gupta A. Phacoemulsification and intraocular lens implantation after inadvertent intracapsular injection of intravitreal dexamethasone implant. BMJ Case Rep 2012;12:2012.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]