Late Onset Macular Oedema in a Patient with Multiple Sclerosis Treated with Fingolimod

Uveitis

This review offers comprehensive insights into the presenting features, terminology, imaging techniques and management strategies associated with uveitis, specifically designed to help neurologists understand this complex condition. We have created a glossary of terms used in uveitis care and ocular imaging to help clarify terminology. We have ordered uveitis subtypes in an intuitive manner, focusing on those that neurologists are more likely to encounter. We have written the article from the perspective of uveitis specialists practising in the UK, while emphasising the global variability in clinical presentations and causes. By offering practical guidance on recognising uveitis features as well as treatment options, we aim for this to be a neurologists' aide mémoire to help manage intraocular inflammation.

Diagnosis and Management of Fingolimod-Associated Macular Edema

Objective

To investigate the clinical features, treatment, and prognosis of fingolimod-associated macular edema (FAME) and to provide a reference for its rational management.

Methods

FAME-related case reports were included in a pooled analysis by searching Chinese and English databases from 2010 to November 31, 2021.

Results

The median age of 41 patients was 50 years (range, 21, 67 years), of whom 32 were women. The median time to onset of FAME was 3 m (range.03, 120), and blurred vision (17 cases) and decreased vision (13 cases) were the most common complaints. A total of 55 eyes were involved in FAME, including the left eye (14 cases), right eye (10 cases), and both eyes (15 cases), of which 46 eyes had best-corrected visual acuity close to normal (20/12-20/60) and 8 eyes had moderate to severe visual impairment (20/80-20/500). Fundus examination in 23 patients showed macular edema (11 cases). Optical coherence tomography (OCT) in 39 patients mainly showed perifoveal cysts (24 cases), ME (23 cases), and foveal thickening (19 cases). Fundus fluorescein angiography (FFA) in 18 patients showed vascular leakage (11 cases). Complete resolution of ME occurred in 50 eyes and recovery of visual acuity occurred in 45 eyes at a median time of 2 m (range 0.25, 24) after discontinuation of fingolimod or administration of topical therapy.

Conclusions

Macular edema is a known complication of fingolimod. All patients using fingolimod require regular eye exams, especially those with a history of diabetes and uveitis and those undergoing cataract surgery.

Fingolimod increases parvalbumin-positive neurons in adult mice

In recent years, it has been shown that central nervous system agents, such as antidepressants and antiepileptic drugs, reopen a critical period in mature animals. Fingolimod, which is used for the treatment of multiple sclerosis, also restores neuroplasticity. In this study, we investigated the effects of parvalbumin (PV)-positive neurons and perineuronal nets (PNN) on fingolimod administration with respect to neuroplasticity. Fingolimod was chronically administered intraperitoneally to mature mice. PV-positive neurons and PNN in the hippocampus, prefrontal cortex, and somatosensory cortex were analyzed. An increase in PV-positive neurons was observed in the hippocampus, prefrontal cortex, and somatosensory cortex of the fingolimod-treated mice. An increase in Wisteria floribunda agglutinin-positive PNN was confirmed in mice treated with fingolimod in the somatosensory cortex only. Fingolimod increased the density of PV-positive neurons in the brains of mature mice. The results indicate that fingolimod may change the critical period in mature animals.

Long-term safety and efficacy of ozanimod in relapsing multiple sclerosis: Up to 5 years of follow-up in the DAYBREAK open-label extension trial

Background:

Ozanimod, an oral sphingosine 1-phosphate receptor 1 and 5 modulator, is approved in multiple countries for treatment of relapsing forms of MS.

Objective:

To characterize long-term safety and efficacy of ozanimod.

Methods:

Patients with relapsing MS who completed a phase 1‒3 ozanimod trial were eligible for an open-label extension study (DAYBREAK) of ozanimod 0.92 mg/d. DAYBREAK began 16 October 2015; cutoff for this interim analysis was 2 February 2021.

Results:

This analysis included 2494 participants with mean 46.8 (SD 11.9; range 0.033‒62.7) months of ozanimod exposure in DAYBREAK. During DAYBREAK, 2143 patients (85.9%) had treatment-emergent adverse events (TEAEs; similar in nature to those in the parent trials), 298 (11.9%) had a serious TEAE, and 75 (3.0%) discontinued treatment due to TEAEs. Serious infections (2.8%), herpes zoster infections (1.7%), confirmed macular edema cases (0.2%), and cardiac TEAEs (2.8%) were infrequent. Adjusted annualized relapse rate was 0.103 (95% confidence interval, 0.086‒0.123). Over 48 months, 71% of patients remained relapse free. Adjusted mean numbers of new/enlarging T2 lesions/scan and gadolinium-enhancing lesions were low and similar across parent trial treatment subgroups.

Conclusions:

This long-term extension of ozanimod trials confirmed a favorable safety/tolerability profile and sustained benefit on clinical and magnetic resonance imaging measures of disease activity.

Fingolimod-associated severe bilateral cystoid macular edema

Purpose

To report a rare case in which a patient undergoing long-term oral fingolimod treatment for multiple sclerosis (MS) developed late-onset severe bilateral cystoid macular edema (ME) at 3-weeks post cataract surgery.

Observations

This study involved a 61-year-old female undergoing long-term oral fingolimod treatment for MS in whom at 4-years post initiation of treatment and the treatment being tapered to a 0.5 mg twice-weekly dose severe bilateral cystoid ME occurred at 3-weeks post cataract surgery. Although the patient was administered the proper treatments for pseudophakic ME, including a 20-mg sub-Tenon's-capsule triamcinolone acetonide injection, it took 13 months for the ME to ultimately resolve with continued oral fingolimod treatment.

Conclusions and importance

The findings in this study show that severe bilateral cystoid ME can occur even several years after initiating fingolimod treatment, thus indicating that detailed follow-up is necessary post cataract surgery.

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Severe cystoid ME can occur even several years after initiating fingolimod treatment.

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Fingolimod-associated ME post cataract surgery did not resolve with STTA in this case.

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It took 13 months for the ME to ultimately resolve with continued oral fingolimod treatment.