To examine the efficacy of the dexamethasone (DEX) intravitreal implant (Ozurdex; Allergan, Inc, Irvine, California, USA) in the control of uveitic macular edema in the perioperative setting of cataract surgery.
Retrospective observational case series.
setting : Clinical practice. participants : A total of 17 eyes of 14 patients that received a DEX implant for cystoids macular edema (CME) associated with noninfectious uveitis who underwent subsequent phacoemulsification within 4 months. intervention : Each patient was treated with a DEX 0.7 mg intravitreal implant and underwent phacoemulsification with intraocular lens placement. main outcome measures : Primary outcome measure was the change in central macular thickness (CMT) measured by optical coherence tomography (OCT), measured preoperatively and postoperatively.
Seventeen eyes (14 patients) were included for analysis. There was no statistically significant change from preoperative CMT (mean 302 μm) to postoperative CMT (307 μm) on OCT. In the subset of eyes that underwent phacoemulsification within 4 weeks of the DEX implant (8 eyes), the mean change in CMT was −47.0 μm, compared to +51.1 μm in those that received the DEX implant greater than 4 weeks prior to phacoemulsification ( P = .005).
Intravitreal dexamethasone implant was shown to prevent the recurrence or worsening of macular edema in uveitic patients with a history of CME who underwent phacoemulsification. The mean CMT decreased in the subset of eyes that received the DEX implant within 4 weeks prior to cataract surgery.
Cystoid macular edema (CME) is an important cause of decreased vision after cataract surgery and can prove especially challenging in patients with uveitis. The incidence of CME after uveitic cataract surgery ranges between 21% and 50%, a much higher rate than in nonuveitic patients undergoing cataract surgery. The mainstay of treatment for post–cataract surgery CME includes topical steroids and nonsteroidal anti-inflammatory drops. Macular edema in the uveitic patient can be difficult to treat, especially in the perioperative setting.
The dexamethasone (DEX) implant (Ozurdex; Allergan, Inc, Irvine, California, USA) is a biodegradable intravitreal implant designed to deliver 700 μg of preservative-free dexamethasone in a sustained-release manner. The implant has been approved by the US Food and Drug Administration (FDA) for the treatment of diabetic macular edema (DME), macular edema secondary to retinal vein occlusion, and noninfectious intermediate and posterior uveitis. A study by Cao and associates demonstrated the effectiveness of the DEX implant in treating persistent uveitic macular edema. The purpose of this study is to examine the effect of the DEX implant on uveitic macular edema, as measured by change in central macular thickness (CMT) on optical coherence tomography (OCT) in the perioperative setting of phacoemulsification.
The study was conducted in accordance with the Declaration of Helsinki and institutional review board approval was obtained by Porter, Littleton and Parker Adventist Hospitals. A retrospective chart review was performed on patients >18 years of age with a diagnosis of noninfectious uveitis with associated macular edema who had received a DEX implant between February 2012 and August 2015. Patients were included that subsequently underwent phacoemulsification with posterior chamber intraocular lens implantation within 4 months of their last DEX implant.
All patients who received the DEX implantation prior to cataract surgery met FDA-approved indications for Ozurdex for treatment of noninfectious intermediate or posterior uveitis and had no active inflammation at the time of surgery. Each patient had a history of previously treated uveitic CME prior to surgery. All patients receiving systemic immunomodulatory therapies were receiving stable therapeutic doses at the time of DEX implant and cataract surgery. The use of systemic perioperative steroids (oral prednisone) was left to the discretion of the cataract surgeon in conjunction with the uveitis specialist. All patients received the typical post–cataract surgery anti-inflammatory eye drop regimen preferred by the cataract surgeon.
Patients underwent a complete ophthalmologic assessment including visual acuity, slit-lamp biomicroscopy, intraocular pressure, and indirect ophthalmoscopy. OCT was performed at each visit.
The DEX implant was administered to uveitic patients with current CME or to those with known history of recurrent uveitic CME who have been receiving DEX at regular intervals to treat recurrent macular edema. All patients had no active uveitis, defined as <0.5 anterior chamber cells and zero vitreous haze, at the time of DEX implant. The implant was administered using the standard technique recommended by the manufacturer using the 22 gauge applicator device provided.
The main outcome assessed was CMT measured by OCT in the preoperative and postoperative period. Macular edema was defined as CMT >300 μm with the presence of typical cystic lesions on OCT. The OCTs were obtained after pupil dilation by a certified operator using the Spectralis (Heidelberg Engineering, Heidelberg, Germany) or the Cirrus 4000 (Carl Zeiss Meditec, Dublin, California, USA) device. Visual acuity was not measured as an outcome, as cataract surgery would be expected to improve vision, thus making it an unreliable indicator of the degree of macular edema.
Statistical analysis was conducted using the Student t test for comparison between means (GraphPad, La Jolla, California, USA).
Seventeen eyes of 14 patients (6 men, 8 women) were included in this study ( Table ). The mean age was 54.5 years (range, 32–70 years). Causes of uveitis included pars planitis or intermediate uveitis (n = 3, 21.4%), rheumatoid arthritis and human leukocyte antigen B27–associated uveitis (n = 1, 7.1%; 1 individual with dual diagnosis), birdshot retinochoroidopathy (n = 1, 7.1%), sarcoidosis (n = 1, 7.1%), multiple sclerosis (n = 1, 7.1%), idiopathic recurrent anterior uveitis (n = 1, 7.1%), idiopathic posterior or panuveitis (n = 5, 35.7%), and idiopathic isolated CME (n = 1, 7.1%). Nine patients (64.3%) were receiving systemic immunomodulatory therapy (at stable therapeutic doses) at the time of DEX implantation and phacoemulsification. Four of the 17 eyes (23.5%) received perioperative systemic steroids consisting of 20 mg of oral prednisone starting 3 days prior to surgery and continued for 2 weeks postoperatively. None of the eyes had previously undergone pars plana vitrectomy. One patient underwent combined phacoemulsification with glaucoma drainage device to facilitate additional DEX implants in a patient with significant glaucoma. All postoperative OCTs were taken within 4 weeks of cataract surgery (range, 1–4 weeks).
|Parameter||Number of Patients (%)|
|Mean age (y)||54.5 (range, 32–70)|
|Intermediate uveitis||3 (21.4)|
|RA and HLA-B27||1 (7.1)|
|Birdshot retinochoroidopathy||1 (7.1)|
|Multiple sclerosis||1 (7.1)|
|Idiopathic recurrent anterior uveitis||1 (7.1)|
|Idiopathic posterior or panuveitis||5 (35.7)|
|Idiopathic isolated cystoid macular edema||1 (7.1)|
|Methotrexate alone||3 (21.4)|
|Adalimumab and methotrexate||1 (7.1)|
|Mycophenolate mofetil||3 (21.4)|
|Perioperative oral steroids|
|Yes (eyes)||4 (23.5)|
|No (eyes)||13 (76.4)|
The mean preoperative central macular thickness was 302 μm (range, 194–456 μm). The mean interval between DEX implant and phacoemulsification was 6.8 weeks (range, 2 days to 16 weeks). The mean postoperative CMT was 307 μm (range, 231–448 μm), which was not statistically significantly different from the preoperative CMT. In the subset of eyes that underwent phacoemulsification within 4 weeks of the DEX implant (8 eyes), the mean change in CMT was −47.0 μm, compared with +51.1 μm in those that received the DEX implant greater than 4 weeks prior to phacoemulsification ( P = .005).
One patient developed a small vitreous hemorrhage after the DEX implant, which resolved without treatment. Two eyes developed ocular hypertension within the 4-month period after injection. One patient was treated with topical antihypertensive medication. The other patient was noted to have 360 degrees of posterior synechiae and was treated with topical antihypertensive medication and required laser peripheral iridotomy.