USE OF AFLIBERCEPT FOR THE MANAGEMENT OF REFRACTORY PSEUDOPHAKIC MACULAR EDEMA IN IRVINE-GASS SYNDROME AND LITERATURE REVIEW

Current management options for the treatment of refractory postoperative cystoid macular edema: A systematic review

Post-operative cystoid macular edema (PCME) is an important complication following intraocular surgery that often resolves spontaneously without treatment. In some cases, PCME may persist despite initial medical therapy, which can adversely impact visual outcomes. Various topical, intraocular and systemic treatments exist for the prevention and management of cystoid macular edema; however, there is no consensus on treatment of refractory cases in the postoperative setting. In accordance with the PRISMA guidelines, we systematically reviewed 68 articles describing management options and their outcomes for treatment-resistant cases of PCME. The most commonly reported treatments included steroid (39 studies) and biological-based (17 studies) therapies. We provide an overview of the treatment options for refractory PCME.

Bilateral effect following off label unilateral intravitreal brolucizumab injection in patient with pseudophakic cystoid macular edema

PURPOSE

To report a bilateral reduction in pseudophakic cystoid macular edema (PCME) after unilateral intravitreal injection (IVI) of brolucizumab.

OBSERVATIONS

A 64-year-old female with bilateral recalcitrant PCME was treated with one dose of intravitreal ozurdex implant and triamcinolone acetonide each in both the eyes, with an equivocal response. On switching to IVI brolucizumab in the right eye (OD), the patient showed significant improvement in the best-corrected visual acuity (BCVA) with a notable reduction in the intraretinal fluid (IRF) and central subfield thickness (CST) in both the eyes at one month.

CONCLUSIONS AND IMPORTANCE

In conclusion, IVI brolucizumab is effective for the management of recalcitrant PCME with good visual and anatomical outcomes at one month. However, this molecule can also have therapeutic efficacy in the uninjected eye possibly due to systemic escape. More research into the pharmacokinetic properties of this novel molecule is needed to validate our findings.

Current Management Options in Irvine-Gass Syndrome: A Systemized Review

Irvine-Gass syndrome (IGS) remains one of the most common complications following uneventful cataract surgery. In most cases, macular edema (ME) in IGS is benign, self-limiting, and resolves spontaneously without visual impairment; however, persistent edema and refractory cases may occur and potentially deteriorate visual function. Despite the relatively high prevalence of IGS, no solid management guidelines exist. We searched the PUBMED database for randomized clinical trials (RCT) or case series of at least 10 cases published since 2000 evaluating different treatment strategies in patients with cystoid macular edema (CME). The search revealed 28 papers that fulfilled the inclusion criteria with only seven RCTs. The scarceness of material makes it impossible to formulate strong recommendations for the treatment of IGS. Clinical practice and theoretical background support topical non-steroidal anti-inflammatory drugs (NSAIDs) as the first-line therapy. Invasive procedures, such as periocular steroids, intravitreal corticosteroids, and anti-vascular endothelial growth factor (anti-VEGF), are usually applied in prolonged or refractory cases. Results of novel applications of subthreshold micropulse laser (SML) are also promising and should be studied carefully in terms of the safety profile and cost effectiveness. Early initiation of invasive treatment for providing better functional results must be examined in further research.

Case Report: Subconjunctival Bevacizumab for the Treatment of Refractory Pseudophakic Cystoid Macular Edema

SIGNIFICANCE

In this report, the authors present a case of a 63-year-old man with recurrent pseudophakic cystoid macular edema. Macular edema was refractory to the treatments with periocular corticosteroid injection and topical anti-inflammatory medications. It was treated with subconjunctival bevacizumab (2.5 mg) injections.

PURPOSE

The purpose of this report was to demonstrate the efficacy and safety of repeated injections of subconjunctival bevacizumab in pseudophakic cystoid macular edema.

CASE REPORT

A 63-year-old White man presented with ongoing blurred vision in his left eye 4 months after a complicated cataract surgery. Despite the administration of sub-Tenon triamcinolone in the first-month visit because of cystoid macular edema and the use of topical steroid and nonsteroidal anti-inflammatory medications during the 4 months, there was no change in his vision. The first subconjunctival bevacizumab injection was performed 16 weeks after cataract surgery. The best-corrected visual acuity was significantly improved, and central retinal thickness dramatically decreased after the first injection. Macular edema reoccurred 26 and 46 weeks after cataract surgery. At these relapses, repeated subconjunctival injections of bevacizumab were influential in resolving macular edema and restoration of vision, even in the chronic phase. After 6 months, visual acuity (20/20) and central retinal thickness (274 μm) were stable after four total injections. No drug-related adverse events were observed during the follow-up period.

CONCLUSIONS

The repeated subconjunctival injections of bevacizumab were effective and well tolerated in pseudophakic cystoid macular edema. Subconjunctival bevacizumab may be a safe alternative to intravitreal applications in patients with pseudophakic cystoid macular edema.

Comparison of intravitreal anti-vascular endothelial growth factor agents and treatment results in Irvine-Gass syndrome

AIM

To compare the efficacy of bevacizumab, ranibizumab, and aflibercept in pseudophakic cystoid macular edema (CME) patients with Irvine-Gass syndrome (IGS).

METHODS

This study is designed as retrospective consecutive case series. Those who developed postoperative pseudophakic CME that refractory to topical treatment and were treated with anti-vascular endothelial growth factor (VEGF) agents included in the study. Optical coherence tomography (OCT) examination including central macular thickness (CMT), total macular volume (TMV), retinal nerve fiber layer (RNFL), ganglion cell layer (GCL) and choroidal thickness (ChT) measurements at the baseline, 1^st, 3^rd and 6^th month controls were performed.

RESULTS

Fifty-nine eyes of 59 patients with CME and other healthy eyes of the patients (Control group) were evaluated. There were 22 eyes of 22 patients in the bevacizumab group (group 1), 19 eyes of 19 patients in the ranibizumab group (group 2), and 18 eyes of 18 patients in the aflibercept group (group 3). There was no difference in terms of age, gender, axial length, IOP, and spherical equivalent values. The baseline subfoveal and mean ChT were higher in the IGS group. The difference between the baseline and sixth month values of subfoveal and mean ChT were compared in the CME groups, thinning was observed in all three groups. GCL was thinner in the patient group at the 6th month of treatment. The resolution time of CME was observed faster in group 1.

CONCLUSION

All three anti-VEGF agents seem to be effective in CME but bevacizumab appears to be slightly more cost-effective than the other two alternatives.

Subthreshold micropulse yellow laser for the management of refractory cystoid macular edema consequent to complicated cataract surgery

PURPOSE

To report the safety and efficacy of subthreshold micropulse yellow laser of 577 nm for a complex case of refractory pseudophakic cystoid macular edema.

METHODS

A retrospective chart review of an interventional case report of three subthreshold micropulse yellow laser interventions for refractory pseudophakic cystoid macular edema.

PATIENT

A 77-year-old healthy female underwent pseudoexfoliative cataract surgery complicated by posterior capsule rupture and sulcus intraocular lens implantation. After 3 months, she required a scleral fixation of the same lens, due to a lack of capsular support and decentration of the intraocular lens. One month later, she experienced a severe pseudophakic cystoid macular edema (foveal thickness of 399 µm and best-corrected visual acuity of 20/80 Snellen). The condition was refractory to conventional treatments prior to subthreshold micropulse yellow laser interventions, including non-steroidal anti-inflammatory eye drops, topical steroids, oral indomethacin and three sub-Tenon's triamcinolone injections, attempted over a 14-month period.

RESULTS

Subthreshold micropulse yellow laser treatment was performed and immediate resolution was achieved and maintained for 2 months. Two cases of edema relapse were observed at 3 months from initial laser treatment and again at 4 months from the second laser treatment. Final patient's follow-up at 6 months from the third laser treatment evidenced the absence of edema, improved visual acuity (foveal thickness of 265 µm/best-corrected visual acuity of 20/30 Snellen) and the absence of complications.

CONCLUSIONS

Subthreshold micropulse yellow laser seems to be a safe and effective treatment for short-term resolution of refractory pseudophakic cystoid macular edema after complicated cataract surgery and represents a useful alternative to expensive and invasive therapies. A trend towards a longer duration of edema resolution with every subthreshold micropulse yellow laser repetition was observed.

Intravitreal Dexamethasone Implantation in Intravitreal Bevacizumab Treatment-resistant Pseudophakic Cystoid Macular Edema

Purpose

To evaluate the changes in visual acuity (VA) and central macular thickness (CMT) after intravitreal dexamethasone (IVD) implantation in intravitreal bevacizumab (IVB) treatment-resistant cases with pseudophakic cystoid macular edema (PCME).

Methods

This study included 10 PCME cases who underwent uneventful phacoemulsification and intraocular lens implantation with similar methods and six PCME cases referred to our hospital for treatment of low VA after cataract surgery. Due to the persistence of PCME, both topical steroid and anti-inflammatory medication were administered first, followed by IVB injection. IVD implantation was performed for all IVB treatment-resistant cases. VA and CMT values were compared before and at three months after the first IVD implantation.

Results

The mean VA values before and at 3 months after the first IVD implantation were 0.69 ± 0.19 logarithm of the minimum angle of resolution (logMAR) (1.50 to 0.10 logMAR) and 0.26 ± 0.07 logMAR (1.00 to 0.00 logMAR), respectively (p < 0.001). The mean CMT was 476.13 ± 135.13 mm (314 to 750 mm) and 294.06 ± 15.26 mm (222 to 480 mm), respectively (p < 0.001). The mean number of implanted IVD was 1.44 ± 0.89 (1 to 4) and the mean follow-up time was 7.4 ± 4.6 months (6 to 24 months). After IVD implantation therapy, the mean VA and CMT values were 0.19 ± 0.05 logMAR (0.70 to 0.00 logMAR) and 268.38 ± 31.35 mm (217 to 351 mm), respectively.

Conclusions

To the best of our knowledge, this is the first report to show the efficacy of IVD implantation even after repeated IVB injections in treatment-resistant PCME. IVD implantation is both a safe and effective method for decreasing PCME after both uneventful and complicated cataract surgery.

Comparison of topical nepafenac 0.1% with intravitreal dexamethasone implant for the treatment of Irvine-Gass syndrome

AIM

To compare safety and efficacy of intravitreal dexamethasone (IVD) implant with topical nepafenac (TN) 0.1% in previously untreated Irvine-Gass syndrome (IGS) in clinical practice.

METHODS

This was a retrospective study of 62 eyes with IGS after phacoemulsification with posterior chamber intraocular lens (IOL) implantation. None of the patients used treatment before IVD or TN. Best-corrected visual acuity (BCVA) with Early Treatment Diabetic Retinopathy Study chart (ETDRS), slit-lamp, intraocular pressure (IOP) measurement, fundus examination, spectral-domain optical coherence tomography (OCT) and fundus florescein angiography were performed to all subjects at baseline, 1, 3 and 6mo.

RESULTS

The mean BCVA of the IVD group was 49.3±6.8, and the mean BCVA of the TN group was 32.9±7.3 ETDRS letters in post-treatment month 6. The mean central macular thickness (CRT) of IVD group was 266.6±53.5 µm and the mean CRT of TN group was 364.9±56.3 µm in post-treatment month 6. Baseline BCVA has correlation with final BCVA in TN group however there was no correlation between baseline BCVA and final BCVA in IVD group.

CONCLUSION

IVD is found to be better than TN in controlling pseudophakic macular edema and improving visual acuity. IVD group also has significantly lower CRT however IOP is not significantly different between two groups in post-treatment month 6.