Inadvertent intralenticular dexamethasone implant: 1-year follow-up and management.

We report the case of a 72-year-old female who developed macular edema (ME) due to hemicentral retinal vein occlusion in her right eye. A dexamethasone implant was inadvertently injected into the crystalline lens. The patient was followed without repositioning of the dexamethasone implant during the 12 months. Besides, the posterior subcapsular cataract and ME had progressed significantly; hence, cataract extraction and intravitreal ranibizumab injection were performed in the same session. A three-piece intraocular lens was implanted in the sulcus with optic captured, and then intravitreal ranibizumab injection was performed. The patient had an uncomplicated postoperative recovery. At 2 months, best-corrected visual acuity was 0.7, and the macula was dry.

Introduction

Ozurdex® (Allergan Inc., Irvine, CA, USA), a sustained-release dexamethasone implant, can provide useful effects in the treatment of macular edema (ME) secondary to retinal vein occlusions (RVOs).[1] The implant dissolves in the vitreous while slowly releasing the dexamethasone for up to 6 months.

We describe a case presenting lens damage after dexamethasone implantation for the treatment of ME secondary to hemicentral RVO. We also present the management of traumatic cataract related to inadvertent injection.

Case Report

A 72-year-old female was presented with a 3-week history of blurred vision in her right eye. The baseline best-corrected visual acuity (BCVA) was counting fingers at a distance of 2 m. The intraocular pressure (IOP) was 17 mmHg. A fundus examination, an optical coherence tomography (OCT), and a fundus fluorescein angiography revealed hemiretinal vein occlusion with diffuse ME [Figure 1]. The injection of a dexamethasone implant was planned, and the inferotemporal quadrant of the right eye was injected. The steroid implant must be the first option in patient with RVO according to Social Security Institution in Turkey. Therefore, we performed dexamethasone implant as the first treatment approach. The needle was introduced 4.0 mm posterior to the limbus. This was the first Ozurdex® injection for the surgeon. After 1 week of routine follow-up visit and during a slit-lamp examination, it was observed that the dexamethasone rod was impeded into the inferonasal quadrant of the lens. The rare event of an Ozurdex® being inadvertently placed in the lens was diagnosed. No inflammatory reaction was seen, and IOP remained normal. The patient was followed without repositioning the implant and was monitored closely for complications related to Ozurdex® such as progression of a cataract, steroid-induced glaucoma, and retinal detachment. After 4 weeks, the IOP rose to 26 mmHg, which was managed well with topical antiglaucoma medications. In addition, ranibizumab (Lucentis®, Genentech, Inc., USA) injection was performed for ME after 1 month. The macular edema had already started to subside, and conservative management was continued. After 3 months, the implant did not show any notable signs of degeneration [Figure 2a]. The IOP was 8 mmHg, and antiglaucomatous treatment was stopped. During the 9-month follow-up, the anterior segment of the right eye remained uneventful with no progression of cataract; the implant was still seen in the crystalline lens. The IOP remained within normal limits. The cataract had progressed; phacoemulsification was planned 12 months later for mild posterior subcapsular cataract formation and dexamethasone implant in the crystalline lens [Figure 2b]. The implant did not show any notable signs of degeneration [Figure 2b]. There was a remarkable improvement in ME in OCT. The BCVA was 0.1 before the surgery.

Figure 1

Hemicentral retinal vein occlusion. (a) Preoperative fundus image, (b) preoperative red free image, (c) preoperative fluorescein angiography, (d) The fundus image in 14 months after the first presentation

Figure 2

(a) The dexamethasone rod into the inferonasal quadrant of the lens in dilated pupilla after 3 months. (b) The mild posterior subcapsular cataract formation in 1 year. (c) The appearance of intraocular lens in 2 months after surgery. (d) The appearance of posterior capsular rupture

A cataract extraction was performed through a 2.8 mm clear temporal corneal incision. The anterior chamber was filled with dispersive viscoelastic. Standard capsulorhexis, hydrodissection, and phacoemulsification were performed gently. At the end of the nucleus removal, a small defect in the inferior site of posterior capsule was identified – there was no vitreous on the capsule surface. The Ozurdex® implant was aspirated using a phacoemulsification probe, and a three-piece intraocular lens (AcrySof SA60, Alcon Laboratories, Inc., Fort Worth, TX, USA) was implanted in the sulcus with optic captured within the intact anterior capsule. Ranibizumab was injected after cataract surgery into the vitreous for persisted ME related to RVO in the same session. Regular follow-up visits were performed, and no further complications were registered. The intraocular lens position was normal [Figure 2c] despite the posterior capsular rupture [Figure 2d]. At 2 months, BCVA was 0.7 and the macula was dry [Figure 1d].

Discussion

The lens damage related to Ozurdex® injection may happen with inexperienced hands. There are six case reports in the literature related to this topic.[234567] There are several reasons for injecting into the lens. Regarding the intravitreal procedure: The 22-gauge injector has a relatively large diameter compared to 28- or 30-gauge needles used for antivascular endothelial growth factor (VEGF) treatment, and the injection technique requires excess pressure on the globe.[2] The pain experienced by the patient may trigger inadvertent eye or head movements. In addition, if the applicator needle is not perpendicular to the vitreous cavity, the needle may be advanced into the lens, and the dexamethasone implant may be injected into the crystalline lens.[3]

A cautious preoperative evaluation to identify the site and the extension of posterior capsular defect is essential in considering cataract extraction. Hydrodelineation procedures with the purpose of separating the nucleus from the epinucleus need to be done. If hydrodissection is planned, it must be performed carefully. During phacoemulsification, device parameters should be reduced, and anterior vitrectomy must always be taken into consideration. If the surgeon realizes the posterior capsule has ruptured, a three-piece intraocular IOL must be implanted in the sulcus to avoid stress on the already damaged capsular bag. This IOL is considered to provide the best stability in these cases.

An anti-VEGF injection can be performed after cataract surgery for ME. This treatment was effective in our case. Visual acuity improved with cataract extraction and ranibizumab injection in this case.

Lens damage can be a complication of dexamethasone implant. In cases of inadvertent injection into the crystalline lens, patients can be observed prudently and followed for the development of cataract or elevation in IOP. Ophthalmologists should be aware of this rare complication. During the intravitreal Ozurdex® injection, the direction of the needle should always be perpendicular to the scleral surface to avoid this complication. A careful cataract surgery can resolve anatomical and functional damages. If there is a coexisting ME in such cases, anti-VEGF injection can be performed after cataract surgery in the same session. This is the first report of a patient who had performed cataract extraction together with intravitreal anti-VEGF injection in such cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.