Migration of dexamethasone implant (OZURDEX®) into the anterior chamber in a pseudophakic eye with an intact capsular bag

Bristi Majumdar; Ahana Sen; Nikita Goel; Zubin D'Souza; Sanatombi Thounaojam; Surabhi Chattree; Mona Bhargava; Jay Shree; Kumar Saurabh; Rupak Roy

doi:10.4103/IJO.IJO_3127_22

CASE REPORT

Year : 2023 | Volume : 3 | Issue : 2 | Page : 357-359

Migration of dexamethasone implant (OZURDEX®) into the anterior chamber in a pseudophakic eye with an intact capsular bag

Bristi Majumdar¹, Ahana Sen¹, Nikita Goel¹, Zubin D'Souza¹, Sanatombi Thounaojam¹, Surabhi Chattree¹, Mona Bhargava², Jay Shree³, Kumar Saurabh⁴, Rupak Roy¹
¹ Department of Vitreo Retina, Aditya Birla Sankara Nethralaya, Kolkata, West Bengal, India
² Department of Cornea, Aditya Birla Sankara Nethralaya, Kolkata, West Bengal, India
³ Department of Glaucoma, Aditya Birla Sankara Nethralaya, Kolkata, West Bengal, India
⁴ Departement of Vitreo Retina, Nethralayam Superspeciality Eye Hospital, Kolkata, West Bengal, India

Date of Submission	29-Nov-2022
Date of Acceptance	20-Feb-2023
Date of Web Publication	28-Apr-2023

Correspondence Address:
Rupak Roy
Aditya Birla Sankara Nethralaya, 147, Mukundapur, E.M.Bypass, Kolkata . 700 099, West Bengal
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJO.IJO_3127_22

Abstract

Ozurdex^® (Allergan, Inc., Irvine, CA, USA) is an intravitreal sustained-release drug delivery system containing dexamethasone, mainly used for the treatment of macular edema in diabetes, retinal vein occlusions or treatment of non-infectious posterior uveitis, as approved by the US FDA. It can be implanted into the vitreous cavity via the pars plana route. Migration of this implant into the anterior chamber may occur in cases of aphakia, pseudophakia with defective lens capsule, zonular dehiscence, iatrogenic, or as in pseudoexfoliation syndrome. We report a case of a pseudophakic patient with intact posterior capsule and no significant history suggesting a zonular weakness, who presented with diminution of vision due to anterior migration of the dexamethasone implant and its effects on the cornea. Measurements of specular microscopy provide useful information which may aid in management pre- and post-removal of migrated implant.

Keywords: Dexamethasone implant, intact posterior capsule, migration, specular microscopy, zonular weakness

How to cite this article:
Majumdar B, Sen A, Goel N, D'Souza Z, Thounaojam S, Chattree S, Bhargava M, Shree J, Saurabh K, Roy R. Migration of dexamethasone implant (OZURDEX®) into the anterior chamber in a pseudophakic eye with an intact capsular bag. Indian J Ophthalmol Case Rep 2023;3:357-9

How to cite this URL:
Majumdar B, Sen A, Goel N, D'Souza Z, Thounaojam S, Chattree S, Bhargava M, Shree J, Saurabh K, Roy R. Migration of dexamethasone implant (OZURDEX®) into the anterior chamber in a pseudophakic eye with an intact capsular bag. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 2];3:357-9. Available from: https://www.ijoreports.in/text.asp?2023/3/2/357/375023

Ozurdex® (Allergan, Inc., Irvine, CA, USA) is an intravitreal biodegradable sustained-release drug delivery system approved by the U.S. Food and Drug Administration for the treatment of macular edema in diabetes, retinal vein occlusions, or non-infectious posterior uveitis. It can be implanted into the vitreous cavity through the pars plana route using an applicator system.^[1] Migration of this implant into the anterior chamber may occur in cases of aphakia, pseudophakia with defective lens capsule, zonular dehiscence, iatrogenic, or as in pseudoexfoliation syndrome. It may also occur in the presence of a patent peripheral iridectomy, vitrectomized eyes, and any history of trauma that may have caused zonular dehiscence.^[2],[3],[4] We report a case of anterior migration of dexamethasone implant in a pseudophakic patient with an intact posterior capsule and no history of trauma or suggestive of zonular weakness.

Case Report

A 67-year-old man complained of seeing a white spot in his right eye for 4 days. There was a history of Ozurdex® implantation in the same eye 2 months ago for cystoid macular edema. The patient had uneventful cataract surgery in both eyes 3 years ago. He was a known diabetic and hypertensive. He was on topical antiglaucoma medications in both eyes, which he stopped applying in the right eye on his own after noticing the white spot. He had no history of steroid response.

On examination, visual acuity was counting fingers at 3 feet; N36 in the right eye and 6/6; N6 in the left. There was diffuse microcystic epithelial edema and Descemet's membrane folds in the cornea of the right eye along with a dexamethasone implant (Ozurdex®) in the anterior chamber (AC), touching the endothelium [Figure 1]. The left eye anterior segment was within normal limits. Intraocular pressures in both eyes were normal. The fundus of the right eye had poor visibility due to corneal haze, whereas the left eye showed mild non-proliferative diabetic retinopathy changes.

Figure 1: (a). Preoperative slit-lamp image of the right eye showing the implant lying inferiorly in the anterior chamber. (b). Higher magnification under slit-beam showing the presence of the implant inside the anterior chamber and Descemet membrane folds in the cornea. (c, d) Preoperative specular microscopy of the right and the left eyes, respectively, showing no visible cells in the right eye and polymegathism of cells and specular count in the left eye

Click here to view

Specular microscopy of the right eye revealed no visible cells and the central corneal thickness (CCT) did not freeze. The left eye had a specular count of 1736 per sq. mm. with polymegathism and guttae and CCT was 576 microns. The patient has been advised to taper doses of topical steroids and was scheduled for implant removal from the right eye anterior chamber. Antiglaucoma medications were restarted. Implant removal was performed under topical anesthesia via a superior clear corneal incision. It was gently removed in totality from the anterior chamber with the help of a viscoelastic substance and the incision was sutured. The subconjunctival antibiotic–steroid injection was given before patching.

At 1 month follow-up, slit-lamp examination revealed epithelial bullae with diffuse microcystic edema, and pachymetry showed CCT of 676 microns in the right eye. He was started on topical ripasudil (0.4%) along with lubricants and sodium chloride solution (5%). Visual acuity at 3 months follow-up was 6/24; N36. Slit-lamp examination showed reduced corneal edema with microcystic changes inferiorly, and specular microscopy revealed a cell density of 768 cells per sq. mm[Figure 2]. Pachymetry showed a CCT of 640 microns in the right eye and 591 microns in the left.

Figure 2: (a) Postoperative slit-lamp image of the right eye at 3 months showing reduced corneal edema. (b) Specular microscopy in the same visit showing count and cells in superior gaze

Click here to view

Discussion

The biodegradable implant contains 0.7 mg dexamethasone in a polymer drug delivery system. It is 0.46 mm × 6 mm in dimensions, rod-shaped, and injected into the vitreous cavity using a 22-gauge needle.^[1] The polymer matrix of the implant degrades into lactic and glycolic acids, releasing the drug slowly over 6 months or more, hence reducing the need for multiple intravitreal injections.^[2] However, this implant may migrate from the vitreous cavity into the anterior chamber and may cause visual disturbances and corneal decompensation. Migration into the anterior chamber has been described to occur in pseudophakic eyes through a patent peripheral iridectomy, weak zonules, and aphakia.^[3] Most of these cases had vitrectomized eyes. Kocak et al.^[4] presented a case with a history of multiple intravitreal injections where the implant had migrated to the intact capsular bag, just behind the IOL, probably through weak zonules, which may have been caused inadvertently during the intravitreal injection. It has even been reported in post-YAG capsulotomy.^[2] Glidai et al.^[5] reported such a case in iris coloboma. In a retrospective study performed on 640 eyes, migration was reported in four eyes, where three eyes had scleral-fixated intraocular lenses and one eye had a posterior chamber intraocular lens (PCIOL) placed in the capsular bag, with a capsular tension ring (CTR) due to partial zonular dehiscence.^[6]

In our case, the patient had undergone uneventful cataract surgery and had an intact capsular bag with in situ posterior chamber intraocular lens. Other than this and intravitreal implant injection, there was no history of any other intraocular intervention. There was no history of trauma and no evidence of zonular weakness in the form of pseudo-phacodonesis or pseudoexfoliation in any of the visits. Hence, we propose that migration may have occurred through a pre-existing zonular weakness. Implantation in the anterior chamber can cause endothelial toxicity due to mechanical trauma, chemical toxicity, or both. It is known to cause permanent corneal edema, which may require transplantation later on.^[7] Madi et al.^[8] has noted that the presence of an implant in the anterior chamber caused graft failure in a post-descemet stripping automated endothelial keratoplasty (DSAEK) patient.^[8] Literature has revealed several instances where the implant had no contact with the cornea and such cases were managed conservatively.^[9]

In our case, the implant was touching the corneal endothelium and causing corneal edema; hence, it was managed with prompt surgical intervention. Higher rigidity of the implant in the first few weeks causes greater mechanical endothelial trauma; hence, it is essential to remove it on an urgent basis.^[10]

Conclusion

In an uncomplicated cataract surgery and the absence of any tell-tale signs of zonular weakness or pseudoexfoliation, trans zonular migration of Ozurdex® implant can occur as seen in our case. Ozurdex® implant in AC touching endothelium can cause corneal decompensation. Thus, proper preoperative and postoperative evaluation of the cornea, especially with specular microscopy and pachymetry, is important in such cases to determine the need for corneal procedures in the future.

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.

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