Wandering Ozurdex® implant
© The Author(s) 2011
Received: 4 August 2011
Accepted: 13 September 2011
Published: 30 September 2011
To report the behavior of intravitreal Ozurdex® implant in eyes with post-lensectomy–vitrectomy (PLV) aphakia.
Retrospective chart review of three eyes with PLV aphakia (three patients with uveitis) who received intravitreal injection of Ozurdex® for cystoid macular edema (one eye), persistent inflammation (one eye), and ocular hypotony (one eye). Final outcome was assessed in terms of effectiveness, stability, and tolerance of the implant.
Following the implant, an initial improvement was seen in all the three eyes. However, the implant migrated into the anterior chamber (AC) at 1 week in two eyes and at 5 weeks in one eye, and wandered between the AC and vitreous cavity with changing postures of the patient. Two eyes developed corneal edema, of which one eye underwent implant removal from the AC.
Ozurdex® implant should be contraindicated in eyes with PLV aphakia to avoid its deleterious effect on the corneal endothelium.
Corticosteroids have been the mainstay for treatment of noninfectious uveitis. They can be administered systemically or locally by topical, periocular, or intravitreal routes. Persistent inflammation and cystoid macular edema (CME) secondary to ocular inflammation are often vision-threatening and pose a significant therapeutic challenge.
The Ozurdex® (Ozurdex®; Allergan, Inc, Irvine, CA, USA) dexamethasone drug delivery system (DDS) is a biodegradable intravitreal implant that delivers sustained release of 700 μg of preservative-free dexamethasone to the retina and vitreous. It is approved by the United States Food and Drug Administration as a first-line therapy for the treatment of macular edema following branch or central retinal vein occlusion, as well as for noninfectious posterior uveitis [1–3].
The results of its use in uveitis in clinical practice and animal models for controlling inflammation and improving CME and visual acuity have been encouraging [4, 5]. However, it has not been studied in aphakic eyes with uveitis so far. We report our experience with the intravitreal use of Ozurdex® implant in three eyes (three patients) with post-lensectomy–vitrectomy (PLV) aphakia.
We did a retrospective chart review of three patients with uveitis who received intravitreal Ozurdex® in eyes with PLV aphakia. Demographic features, location and etiology of uveitis, systemic therapy and surgical intervention prior to Ozurdex® injection, indications for the injection, best corrected visual acuity (BCVA) and intraocular pressure (IOP) before and after injection, and final outcome in terms of effect, stability, and tolerance of the implant were noted. Ozurdex® was injected into the vitreous cavity under sterile conditions in accordance with the manufacturer’s instructions.
Baseline characteristics and behavior of intravitreal Ozurdex implant in post-lensectomy–vitrectomy aphakic eyes
Pre-implant IOP (mmHg)
Indication for Ozurdex implant
Interval between implantation and migration into AC
Chronic anterior uveitis
Cystoid macular edema
Oral CS + azathioprine
Persistent intraocular inflammation
Oral CS + azathioprine/infliximab/cyclosporine
Chronic anterior uveitis
Topical anti-inflammatory/cycloplegic therapy
Outcome of intravitreal Ozurdex implant in post-lensectomy–vitrectomy aphakic eyes
Adverse effects of migrated implant
Surgical removal of Ozurdex implant
Post-implant IOP (mmHg)
Follow-up after implant migration, months
Final location of the implant
Resolution of cystoid macular edema; resolution of corneal edema
Corneal edema, elevation of IOP
Yes, 40 days after implantation
Regression of inflammation, control of IOP, corneal edema persisted
Removed from the eye
Improvement of hypotony
Ozurdex® has been reported to be well tolerated in uveitis as well as in retinal disorders. So far, the ocular adverse effects reported after intravitreal injection include cataract formation, IOP elevation, subconjunctival hemorrhage, hyperemia, and conjunctival edema. These are often temporary and can be medically managed.
In all our patients described above, there was an initial improvement following intravitreal Ozurdex® injection, in terms of CME (one eye), control of inflammation (one eye), and hypotony (one eye). However, the retention of Ozurdex® implant in the vitreous cavity became a major challenge as it wandered between the AC and the vitreous cavity.
The IOP elevation was temporary and was medically managed. Corneal edema could be medically managed in one eye but necessitated a repeat surgical intervention in the other eye for removal of the Ozurdex® implant.
The encouraging role of Ozurdex® is due to its potency, dose consistency, extended duration of action, and minimal adverse effects [4–8]. Additional advantages of the biodegradable DDS are that they do not need to be retrieved and can be administered repeatedly. Myung et al. reported successful control of inflammation and CME in their patients with uveitis . No serious ocular or systemic adverse effects were noted during the mean follow-up (post-injection) time of 5.25 months. The only concern in their experience with the implant was a shorter durability of its effect (about 3 to 4 months) than the typical 6-month period reported in retinal vein occlusion .
While the efficacy of Ozurdex® in uveitis has been proved in clinical trials [2, 3], clinical case series , and experimental animal studies , none of the studies have reported its use and outcome in aphakic eyes of patients with uveitis after PPL and PPV.
The use of Ozurdex® implant in vitrectomized eyes with diabetic macular edema has been reported recently by Boyer et al . Their patients were phakic/pseudophakic, and the implant was well tolerated with an acceptable safety profile. Moreover, the authors believed that vitrectomized eyes responded well to sustained drug delivery with an implant.
To the best of our knowledge, our series is the first to report the behavior of Ozurdex® implant and its outcome in eyes with PLV aphakia. In aphakic–vitrectomized eyes, the implant is placed within the vitreous cavity actually filled with aqueous fluid and therefore has the potential to migrate back and forth with changing postures and minimal resistance leading to complications as seen in our patients. Such behavior of the implant in these eyes is not unexpected. Moreover, the anterior migration of the implant at 5 weeks in case 3 after absorption of the gas may reflect the buoyancy of the implant in aqueous fluid and tendency to shift. We believe that Ozurdex® injection should be contraindicated in eyes with PLV aphakia, even in the presence of recalcitrant macular edema due to any cause, to avoid its deleterious effect on the corneal endothelium.
Conflict of interest
None of the authors have any proprietary interest.
This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution and reproduction in any medium, provided the original author(s) and source are credited.
- Haller JA, Bandello F, Belfort R Jr et al Ozurdex® GENEVA Study Group (2010) Randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with macular edema due to retinal vein occlusion. Ophthalmology 117:1134–1146View ArticleGoogle Scholar
- Kuppermann BD, Blumenkranz MS, Haller JA et al (2007) Randomized controlled study of an intravitreous dexamethasone drug delivery system in patients with persistent macular edema. Arch Ophthalmol 125:309–317PubMedView ArticleGoogle Scholar
- Williams GA, Haller JA, Kuppermann BD et al (2009) Dexamethasone posterior-segment drug delivery system in the treatment of macular edema resulting from uveitis or Irvine-Gass syndrome. Am J Ophthalmol 147:1048–1054PubMedView ArticleGoogle Scholar
- Myung JS, Aaker GD, Kiss S (2010) Treatment of noninfectious posterior uveitis with dexamethasone intravitreal implant. Clin Ophthalmol 4:1423–1426PubMedPubMed CentralGoogle Scholar
- Ghosn CR, Li Y, Orilla WC, Lin T, Wheeler L, Burke JA et al. (2011) Treatment of experimental anterior and intermediate uveitis by a dexamethasone intravitreal implant. Invest Ophthalmol Vis Sci [in press].Google Scholar
- Herrero-Vanrell R, Cardillo JA, Kuppermann BD (2011) Clinical applications of the sustained-release dexamethasone implant for treatment of macular edema. Clin Ophthalmol 5:139–146PubMedPubMed CentralGoogle Scholar
- Saraiya NV, Goldstein DA (2011) Dexamethasone for ocular inflammation. Expert Opin Pharmacother 12:1127–1131PubMedView ArticleGoogle Scholar
- London NJ, Chiang A, Haller JA (2011) The dexamethasone drug delivery system: indications and evidence. Adv Ther [in press].Google Scholar
- Boyer DS, Faber D, Gupta S, Patel SS, Tabandeh H, Li XY et al (2011) Dexamethasone intravitreal implant for treatment of diabetic macular edema in vitrectomized patients. Retina 31:915–923PubMedView ArticleGoogle Scholar
This article is published under license to BioMed Central Ltd. Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.