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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 32  |  Issue : 1  |  Page : 73-75

Repositioning of inadvertent intralenticular ozurdex


1 Department of Vitreo-Retinal Services, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
2 Department of Cataract Services, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India

Date of Submission09-Jun-2019
Date of Acceptance21-Dec-2019
Date of Web Publication17-Apr-2020

Correspondence Address:
Dr. Piyush Kohli
Department of Vitreo-Retinal Services, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_46_19

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  Abstract 


With increasing availability and acceptability of intravitreal injections for various pathologies, the number of patients undergoing intravitreal injections has grown exponentially, hence increasing the risk of accidental trauma to the crystalline lens. One of the gravest and rarest complications is the inadvertent intralenticular implantation of ozurdex implant, causing immediate cataract formation. As available resources in the developing countries are limited, aim of the cataract surgery should be to reposition the same implant in the vitreous cavity, through the preexisting posterior capsular dehiscence, and placing an intraocular lens to prevent anterior migration of the implant. Due to the presence of posterior capsular dehiscence, some amount of lens matter may drop into the vitreous and can invoke postoperative uveitis and raised intraocular pressures. We report such a rare case of accidental intralenticular injection of ozurdex implant, our unconventional surgical approach and the long-term follow-up.

Keywords: Intralenticular, ozurdex, posterior vitreous detachment, reposition, vitrectomy


How to cite this article:
Babu N, Kohli P, Shekhar M, Ramasamy K. Repositioning of inadvertent intralenticular ozurdex. Kerala J Ophthalmol 2020;32:73-5

How to cite this URL:
Babu N, Kohli P, Shekhar M, Ramasamy K. Repositioning of inadvertent intralenticular ozurdex. Kerala J Ophthalmol [serial online] 2020 [cited 2020 May 28];32:73-5. Available from: http://www.kjophthal.com/text.asp?2020/32/1/73/282657




  Introduction Top


Ozurdex (Allergan, Inc., Irvine, CA) is a sustained-release, biodegradable dexamethasone intravitreal implant developed to increase the duration of action of the drug. It is a 6-mm long pellet, measuring 0.46 mm in diameter and is delivered with a 22G needle delivery system.[1] The larger bore of the needle increases the chances of a surgical accident.[2],[3],[4] In inexperienced hands, the implant can get accidently injected into the crystalline lens either because of improper positioning of the needle or due to sudden movement of the patient's head caused by the pain while penetrating the wide-bore needle.

Due to the high cost of the implant, the surgery should be performed with the aim of repositioning the implant into the vitreous cavity. However, performing phacoemulsification surgery and placing an intraocular lens (IOL) in the presence of posterior capsular dehiscence, while preventing damage to the intraocular implant is challenging.

We report our unconventional surgical approach and the long-term follow-up of a patient with cystoid macular edema (CME) due to Branch retinal vein occlusion (BRVO) who received an inadvertent intralenticular ozurdex implant.


  Case Report Top


A 60-year-old hypertensive male presented with a sudden-onset painless decrease of vision in his left eye. His best-corrected visual acuity (BCVA) was 20/20 in the right eye 20/60 in the left eye. His anterior segment examination was normal in both the eyes. Posterior segment examination was normal in the right eye, whereas the left eye showed macular BRVO with CME in the left eye. He was given multiple intravitreal anti-vascular endothelial growth factor injections. As the CME was recurrent, he was advised to undergo an injection of ozurdex.

At the time of injecting, the patient moved his head vigorously. After the injection, the implant was seen to be stuck in the pupillary axis. On slit-lamp examination, the implant was found to be lodged in the crystalline lens. Ten days postinjection, the patient complained of a drop in his vision. His BCVA reduced to 20/300, but there was no increase in the intraocular pressure (IOP). Anterior segment examination showed a shallow chamber, intumescent cataract, and the presence of the implant inside the crystalline lens [Figure 1].
Figure 1: Slit lamp photo showing the presence of the ozurdex implant in the crystalline lens

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He was planned for cataract surgery with the aim of repositioning the implant. Following the construction of a 2.2-mm clear corneal tunnel and paracentesis, the anterior capsule was stained with the help of trypan blue solution (0.06%, Auroblue, Aurolab, India). The anterior chamber was filled with cohesive viscoelastics (sodium hyaluronate), and a careful capsulorhexis was initiated with a capsulotome and completed with Kraff-Utrata capsulorhexis forceps. As the cataract was soft with preexisting posterior capsule rupture, the hydroprocedure was avoided. Phacoemulsification was performed with the help of Centurion® Vision system (Alcon Laboratories, Forth Worth, Texas, USA). As the cataract was soft, it was easily aspirated with low machine parameters. The machine parameters used during the surgery to ensure a stable anterior chamber included a fixed IOP of 48 mmHg, a liner vacuum of 400 mmHg, a fixed aspiration flow rate of 30 mL/min and a torsional power of 0%–40%. During the surgery, special attention was paid to prevent accidental aspiration of the implant. After the emulsification of the lens, the implant was pushed down into the vitreous cavity through the preexisting posterior capsular dehiscence. Along with the implant, some amount of lens matter also got dropped into the vitreous. Then, automated anterior vitrectomy was done and the cortex in the bag was aspirated using bimanual irrigation-aspiration method. Finally, a three-piece hydrophobic acrylic IOL was placed in the sulcus with posterior optic capture.

As lens matter dropped in the vitreous, the patient immediately underwent a 25G pars plana vitrectomy. Core vitrectomy was done, and the lens matter in vitreous cavity was carefully removed while taking care to prevent accidental aspiration of the implant. The periphery was examined for any retinal breaks before removing the trochar cannula system.

The postoperative examination at 1-month showed that the IOL was stable; the implant was intact in the vitreous cavity [Figure 2]. There was neither a reaction in the anterior chamber nor a rise in the IOP of the eye. Ocular coherence tomography showed total resolution of macular edema. The edema did not recur for the next 3 months.
Figure 2: Posterior segment photo showing the ozurdex implant in vitreous cavity

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  Discussion Top


Most prior case reports of intralenticular ozurdex reveal the minimal or slow progression of cataract.[5],[6],[7] Such cases can be managed conservative. However, in the case of early cataract formation, immediate surgical intervention has to be done for visual rehabilitation of the patient.[3],[8]

The patient in our study developed a visually significant cataract within 10 days of the injection. Hence, we decided to proceed with phacoemulsification with the placement of a three-piece IOL in the sulcus. Due to the high cost of ozurdex, we decided to reposition the implant instead of removing it and injecting another one. However, separating the implant from the lens matter can lead to its accidental aspiration and even zonular dialysis. Zonular dialysis alleviates the chances of a primary IOL placement, which further increase the chances of anterior migration of the implant. Hence, in our case, we pushed the implant in the vitreous through the preexisting posterior capsular dehiscence. The lens matter that drop in the vitreous through the posterior capsular dehiscence is expected to invoke postoperative uveitis and raised IOPs. Hence, we performed an additional vitrectomy to remove the lens matter from the vitreous.

One of the major concerns regarding this approach is the faster absorption of drugs in a vitrectomized eye. However, ozurdex is a sustained-drug release implant and has been found to have similar pharmacokinetics and noninferior clinical effect in a vitrectomized compared to a a nonvitrectomized eye.[9]

With an increase in the use of ozurdex implant, such complications are set to increase. All the potential complications should be borne in mind while managing such a cataract. We suggest that the cataract surgery should be done at low machine parameters and the implant can be pushed into the vitreous cavity through the posterior capsular dehiscence. In case lens matter also gets dropped in the vitreous, it is advisable to perform immediate vitrectomy as well.

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.



 
  References Top

1.
Haller JA, Bandello F, Belfort R Jr., Blumenkranz MS, Gillies M, Heier J, et al. Dexamethasone intravitreal implant in patients with macular edema related to branch or central retinal vein occlusion twelve-month study results. Ophthalmology 2011;118:2453-60.  Back to cited text no. 1
    
2.
Fasce F, Battaglia Parodi M, Knutsson KA, Spinelli A, Mauceri P, Bolognesi G, et al. Accidental injection of dexamethasone intravitreal implant in the crystalline lens. Acta Ophthalmol 2014;92:e330-1.  Back to cited text no. 2
    
3.
Munteanu M, Rosca C. Repositioning and follow-up of intralenticular dexamethasone implant. J Cataract Refract Surg 2013;39:1271-4.  Back to cited text no. 3
    
4.
Ram J, Agarwal AK, Gupta A, Gupta A. Phacoemulsification and intraocular lens implantation after inadvertent intracapsular injection of intravitreal dexamethasone implant. BMJ Case Rep 2012;2012. pii: bcr2012007494.  Back to cited text no. 4
    
5.
Baskan B, Cıcek A, Gulhan A, Gundogan M, Goktas S. Ozurdex completely located inside a crystallized lens – Results of 14 months. Am J Ophthalmol Case Rep 2016;4:38-40.  Back to cited text no. 5
    
6.
Sekeroglu MA, Anayol MA, Koc F, Tirhis H, Ozkan SS, Yilmazbas P. Intralenticular sustained-release dexamethasone implant: Is it still effective on macular edema? Case Rep Ophthalmol 2016;7:85-9.  Back to cited text no. 6
    
7.
Regan KA, Blake CR, Lukowski ZL, Iyer SSR. Intralenticular ozurdex® – One year later. Case Rep Ophthalmol 2017;8:590-4.  Back to cited text no. 7
    
8.
Chalioulias K, Muqit MM. Vitreoretinal surgery for inadvertent intralenticular Ozurdex implant. Eye (Lond) 2014;28:1523-4.  Back to cited text no. 8
    
9.
Medeiros MD, Alkabes M, Navarro R, Garcia-Arumí J, Mateo C, Corcóstegui B. Dexamethasone intravitreal implant in vitrectomized versus nonvitrectomized eyes for treatment of patients with persistent diabetic macular edema. J Ocul Pharmacol Ther 2014;30:709-16.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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