Anterior Chamber Migration of Fluocinolone Acetonide Intravitreal Implant

The Treatment of Diabetic Retinal Edema with Intravitreal Steroids: How and When

Diabetic macular edema (DME) is a common complication of diabetes mellitus and a leading cause of visual impairment worldwide. It is defined as the diabetes-related accumulation of fluid, proteins, and lipids, with retinal thickening, within the macular area. DME affects a significant proportion of individuals with diabetes, with the prevalence increasing with disease duration and severity. It is estimated that approximately 25-30% of diabetic patients will develop DME during their lifetime. Poor glycemic control, hypertension, hyperlipidemia, diabetes duration, and genetic predisposition are recognized as risk factors for the development and progression of DME. Although the exact pathophysiology is still not completely understood, it has been demonstrated that chronic hyperglycemia triggers a cascade of biochemical processes, including increased oxidative stress, inflammation, activation of vascular endothelial growth factor (VEGF), cellular dysfunction, and apoptosis, with breakdown of the blood-retinal barriers and fluid accumulation within the macular area. Early diagnosis and appropriate management of DME are crucial for improving visual outcomes. Although the control of systemic risk factors still remains the most important strategy in DME treatment, intravitreal pharmacotherapy with anti-VEGF molecules or steroids is currently considered the first-line approach in DME patients, whereas macular laser photocoagulation and pars plana vitrectomy may be useful in selected cases. Available intravitreal steroids, including triamcinolone acetonide injections and dexamethasone and fluocinolone acetonide implants, exert their therapeutic effect by reducing inflammation, inhibiting VEGF expression, stabilizing the blood-retinal barrier and thus reducing vascular permeability. They have been demonstrated to be effective in reducing macular edema and improving visual outcomes in DME patients but are associated with a high risk of intraocular pressure elevation and cataract development, so their use requires an accurate patient selection. This manuscript aims to provide a comprehensive overview of the pathology, epidemiology, risk factors, physiopathology, clinical features, treatment mechanisms of actions, treatment options, prognosis, and ongoing clinical studies related to the treatment of DME, with particular consideration of intravitreal steroids therapy.

Complications of intravitreal injections: 2022

PURPOSE OF REVIEW

This review highlights the complications of both intravitreal injection procedure as well as different intravitreal medications including antivascular endothelial growth factors, antibiotics, antivirals, antifungals, methotrexate, and steroids. Techniques for reducing rates of endophthalmitis will also be discussed.

RECENT FINDINGS

Intravitreal vancomycin can cause hemorrhagic occlusive retinal vasculitis resulting in severe vision loss. Intravitreal brolucizumab is associated with intraocular inflammation and retinal vasculitis resulting in significant vision loss. Face mask use by both patient and physician is not associated with increased risk of endophthalmitis and may decrease culture positive endophthalmitis.

SUMMARY

Intravitreal injections continue to be one of the most commonly performed procedures by ophthalmologists. Although the injections are generally well tolerated, sight-threatening complications can occur including endophthalmitis, retinal detachment, and/or retinal vasculitis. Adverse events associated with specific medications are outlined below. Several safety measures have been shown to reduce rates of endophthalmitis, the most concerning complication of this procedure.

Non-pharmacological complications associated with Intravitreal dexamethasone implant injection

OBJECTIVE

Intravitreal dexamethasone implant (IID) is an effective and safe treatment for macular oedema as described in the literature. Ocular hypertension and cataracts are the most frequent complications. The indications of IID in the last few years have led to the retrospective reporting of rare complications, with potential visual impact related to the injection procedure.

METHODS

A case series is presented of fifteen patients treated with IID for macular oedema who developed non-pharmacological complications related to the injection procedure or the implant itself, including, among others anterior chamber migration, intracrystalline injection, endophthalmitis, or segmentation. Differentiation was made between true complications and those that did not lead to any ocular damage. Epidemiological and baseline data were collected along with the treatment and outcome in each case. An analysis was made of multimodal imaging available.

RESULTS

The incidence of complications was 0.65% in this series Anterior chamber migration was the most frequent complication (n=4), followed by intracrystalline injection, and endophthalmitis (n=2). The times between the injection and complications were variable. Visual impairment was the most common symptom (n=6). However, despite the complications found, IID was an effective treatment in most of the reported cases.

CONCLUSIONS

Clinicians should be aware of these rare non-pharmacological complications so that they may be prevented and detected early, avoiding irreversible ocular damage.