BILATERAL EFFECT OF UNILATERAL DEXAMETHASONE INTRAVITREAL IMPLANT IN A CASE OF NONINFECTIOUS UVEITIC MACULAR EDEMA AND VITRITIS Zohar Habot-Wilner, MD, Nir Sorkin, MD, Dafna Goldenberg, MD, Michaella Goldstein, MD

Purpose: To describe a bilateral therapeutic effect of the 0.7-mg dexamethasone drug delivery system injected in 1 eye of a patient with bilateral, noninfectious uveitic macular edema and vitritis. Methods: Interventional case report. Results: A 26-year-old woman had vitritis and macular edema in both eyes and received a dexamethasone drug delivery system injection to the right eye. Best-corrected visual acuity, clinical examination, and Heidelberg Spectralis spectral domain optical coherence tomography were performed at baseline and during follow-up visits. Follow-up time was 24 months. Vitritis and macular edema completely resolved in both eyes with bilateral improvement in visual acuity. Treatment effect enabled systemic immunosuppressive treatment to be lowered, and the effect lasted for 24 months. Conclusion: Unilateral dexamethasone drug delivery system injection might have a bilateral therapeutic effect in uveitic eyes. This observation may be related to the compromised blood– retina barrier in eyes with uveitis. Further studies are warranted to assess this effect. RETINAL CASES & BRIEF REPORTS 9:151–153, 2015

bilateral anterior uveitis and vitritis, treated with topical and systemic corticosteroids and mycophenolate mofetil (Cellcept; Roche). In addition, macular edema in the right eye had been treated successfully with 2 subtenon methylprednisolone acetate (Depo-Medrol; Pfizer) injections, 1.5 years apart from each other (last injection, 1.2 years before current presentation). At presentation, systemic treatment included mycophenolate mofetil 2 g/day (a fixed dose for last 10 months). Best-corrected visual acuity was 20/70 in the right eye and 20/30 in the left eye. Both eyes had remnants of anterior uveitis attacks; flare +1 and posterior synechiae. The right eye had posterior chamber intraocular lens and significant vitritis with vitreous haze Grade +3. The fundus was blurred; however, there were no signs of retinitis, choroiditis, or vasculitis. The left eye had posterior chamber intraocular lens coated with old inflammatory cells and very mild vitritis with moderate amount of cells, but no impairment in the fundus view. Heidelberg Spectralis spectral domain optical coherence tomography revealed normal macular appearance in both eyes (Figure 1A). Fluorescein angiography was not done as the fundus view of the right eye was severely impaired. Because of significant vitritis in the right eye, the patient was offered the 0.7-mg DEX-DDS implant intravitreal injection. The patient arrived for treatment 1 month

From the Division of Ophthalmology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

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he 0.7-mg dexamethasone drug delivery system (DEX-DDS) (Ozurdex; Allergan Inc, Irvine, CA) was approved by the U.S. Food and Drug Administration for treating posterior noninfectious uveitis. Few reports showed favorable visual outcomes in nonvitrectomized and vitrectomized eyes with uveitis and macular edema.1–3 We report the first case of a bilateral simultaneous effect of a unilateral intravitreal dexamethasone implant injection in a patient with idiopathic bilateral vitritis and macular edema. Case Report A 26-year-old woman presented with vision deterioration in the right eye. Ocular history revealed recurrent attacks of idiopathic

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Fig. 1. Infrared and optical coherence tomography images (a vertical scan) of both eyes. A. One month before dexamethasone intravitreal implant injection, normal macular appearance was revealed in both eyes. B. On dexamethasone intravitreal implant injection, both eyes developed cystoid macular edema and subretinal fluid. C. One week after dexamethasone intravitreal implant injection, the right eye shows significant improvement with nearly complete resolution of cystoid macular edema and minimal subretinal fluid remnants. The left eye shows improvement in macular edema. D. One month after dexamethasone intravitreal implant injection, the right eye macula regained its normal architecture with complete resolution of subretinal fluid. The left eye shows improvement of intraretinal cysts remnants. E. Twenty-four months after dexamethasone intravitreal implant injection, there is normal macular appearance in both eyes. LE, left eye; RE, right eye.

later. She complained of further vision deterioration in both eyes; visual acuity was 20/100 in the right eye and 20/40 in the left eye, and both eyes developed macular edema, including cystoid macular edema, and subretinal fluid (Figure 1B). Systemic corticosteroids were offered because macular edema involved both eyes; however, the patient refused and asked for local treatment because of previous side effects of insomnia and mood changes under systemic corticosteroids’ treatment, and an intravitreal injection of DEXDDS was administered to the right eye after an informed consent was obtained from the patient. One week later, visual acuity improved to 20/40 in the right eye and 20/30 in the left eye, vitreous haze significantly improved to +1 in the right eye and macular edema significantly improved with nearly complete resolution of cystoid macular edema and minimal subretinal fluid remnants. Moreover, interestingly, macular edema in the left eye improved as well (Figure 1C). One month after injection, visual acuity further improved to 20/27 in the right eye and 20/25 in the left eye. The right eye macula regained its normal appearance, and a further significant improvement was demonstrated in macular edema in the left eye (Figure 1D). Vitritis completely resolved in both eyes 2 months after injection. The patient was followed, and at Paper presented as a poster at the 12th IOIS congress, Valencia, Spain, March 2014. M. Goldstein is a medical consultant for Allergan, Novartis, and Bayer. The other authors do not have any financial/conflicting interests to disclose. The study was approved by the Tel Aviv Medical Center Review Board and adhered to the tenets of the Declaration of Helsinki for research involving human subjects. Reprint requests: Zohar Habot-Wilner, MD, Division of Ophthalmology, Tel Aviv Medical Center, 6 Weizmann Street, Tel Aviv 64239, Israel; e-mail: [email protected]

the last examination 24 months after single DEX-DDS injection to the right eye, visual acuity of 20/27 in the right eye and 20/25 in the left eye and vitritis or macular edema were not noticed in both eyes (Figure 1E). The systemic treatment with mycophenolate mofetil could be further reduced to 1 g/day.

Discussion This case demonstrates a bilateral therapeutic effect on vitritis and macular edema resolution after administration of intravitreal DEX‐DDS injection to one eye. Bilateral resolution of macular edema and vitritis was accompanied by visual acuity improvement in both eyes. In addition, the effect might last for a long period, and in our patient, this enabled reduction of the systemic immunosuppressive treatment. ChangLin et al4 determined the pharmacokinetics and pharmacodynamics of dexamethasone implant injection in normal eyes in a monkey model and showed that dexamethasone was present at low concentrations in plasma until Day 90 after injection. In our case, the increased ocular permeability because of compromised blood–retina barrier in the setting of uveitis may have allowed dexamethasone to enter the contralateral eye in sufficient quantity to have a clinical effect. Two other reports show a bilateral effect after a unilateral intravitreal anti-vascular

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endothelial growth factor treatment in uveitic eyes. The first is a case report5 of an 8-year-old girl with a 6-year history of insulin-dependent diabetes and a 2-year history of idiopathic, bilateral intermediate uveitis. The girl presented with bilateral anterior uveitis, optic nerve head edema, and cystoid macular edema without evidence of diabetic retinopathy. She received a unilateral intravitreal bevacizumab injection to her right eye, and macular edema significantly improved in both eyes. In addition, further bilateral reduction in macular edema was documented after injection of the contralateral eye. The second report is a small case series6 describing bilateral effect of a unilateral intravitreal ranibizumab injection in three eyes with uveitic cystoid macular edema. Furthermore, one patient had neovascularization regression in both eyes, after injection to one eye. These cases show that in some uveitic eyes, the active inflammatory state may be a predisposing factor for a bilateral response after a unilateral treatment. Further studies are needed to investigate this finding in uveitic eyes.

Key words: dexamethasone drug delivery system, dexamethasone intravitreal implant, uveitis, uveitic macular edema, vitritis. References 1. Myung JS, Aaker GD, Kiss S. Treatment of noninfectious posterior uveitis with dexamethasone intravitreal implant. Clin Ophthalmol 2010;4:1423–1426. 2. Miserocchi E, Modorati G, Pastore MR, Bandello F. Dexamethasone intravitreal implant: an effective adjunctive treatment for recalcitrant noninfectious uveitis. Ophthalmologica 2012; 228:229–233. 3. Adán A, Pelegrín L, Rey A, et al. Dexamethasone intravitreal implant for treatment of uveitic persistent cystoid macular edema in vitrectomized patients. Retina 2013;33:1435–1440. 4. Chang-Lin JE, Attar M, Acheampong AA, et al. Pharmacokinetics and pharmacodynamics of a sustained-release dexamethasone intravitreal implant. Invest Ophthalmol Vis Sci 2011;52:80–86. 5. Al-Dhibi H, Khan AO. Bilateral response following unilateral intravitreal bevacizumab injection in a child with uveitic cystoid macular edema. J AAPOS 2009;13:400–402. 6. Acharya NR, Sittivarakul W, Qian Y, et al. Bilateral effect of unilateral ranibizumab in patients with uveitis-related macular edema. Retina 2011;31:1871–1876.

Copyright ª by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.

Bilateral effect of unilateral dexamethasone intravitreal implant in a case of noninfectious uveitic macular edema and vitritis.

To describe a bilateral therapeutic effect of the 0.7-mg dexamethasone drug delivery system injected in 1 eye of a patient with bilateral, noninfectio...
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