Hadi Zambarakji¹* and Amany Abelaziz²

¹Eye Treatment Centre, Whipps Cross University Hospital NHS Trust, Barts Health, London, UK ²Health Radiation Research Department, National Centre for Radiation Research an Technology NCRRT, Egyptian Atomic Energy Authority, Cairo, Egypt

*Corresponding Author: HadiZambarakji,Eye Treatment Centre, Whipps Cross University Hospital NHS Trust, Barts Health, London, UK.

Received: February 11, 2021; Published: March 06, 2021;

Introduction

  Cystoid macular edema (CME) is a well-defined cause of poor visual outcome after intraocular surgery including pars plana vitrectomy (PPV).

   We report a 65-year-old male who presented to his local retina specialist ten years ago with reduced visual acuities measured at 0.7 Log Mar in the right eye and 0.6 Log Mar in the left eye. Intraocular pressures (IOPs) were measured at 14mmHg in each eye. Bilateral PPV and epiretinal membrane (ERM) peel surgery and subsequent phacoemulsification cataract surgery and intraocular lens implantation were performed with a good outcome. CME was first noted in the right eye 4 weeks following cataract surgery with little response to a combination of Dexamethasone and Ketorolac. The left eye had a post-operative fibrinous uveitis following phacoemulsification cataract surgery with a partial recovery of vision to 0.5 Log Mar at 3 months and was further complicated by recurrent CME.

   Subsequent repeated intravitreal treatment with Triamcinolone (Kenalog Bristol-Myers Squibb pharmaceuticals limited, UK) was administered (IVTA) with complete resolution of CME and improved visual acuity in each eye with a total of 24 IVTA injections over a period of 6 years. Secondary IOP rise in the right eye was managed with a combination of Travoprost/Timoptol from a maximum of 30 mmHg and 21 mmHg in the right and left eyes respectively and further treatment with Brinzolamide was administered to the right eye. The patient sustained marked redness and crusting of the eyelids as well as periocular discomfort as a result of chronic topical medication use.

   A trial of the Dexamethasone implant (Ozurdex) showed successful resolution of CME. Subsequent treatment with bilateral intravitreal Fluocinolone implants (190 micrograms; Iluvien) resulted in successful resolution of CME and improved IOP control on a single topical IOP lowering agent. Visual acuity recordings were 0.1 Log Mar and 0.2 Log Mar in the right and left eyes respectively at 2 years after Iluvien implantation and IOP measurements were 13 and 14 mmHg in the right and left eyes respectively. Visual acuities remained fairly stable at 3 years at 0.12 Log Mar and 0.3 Log Mar and IOP measurements were 12 and 11 mmHg in the right and left eyes respectively. Optical coherence tomography (OCT) and central retinal thickness (CRT) measurements were consistent with a good response to treatment (Figure) and there was significant resolution of all peri-ocular side-effects of topical anti-glaucoma medications. Final review at 46 months following implantation shows minor cystic change noted on OCT and measured visual acuities at right 0.24 Log Mar and left 0.2 Log Mar.

Discussion and Conclusion

   CME post PPV and ERM peel are not well documented in the literature with reported rates of 12% in one study[1]. The pathogenesis of CME has been hypothesized to be secondary to structural changes or inflammation. Some propose that iatrogenic damage of the Muller cells after membrane peeling leads to the formation of intraretinal cysts that can disrupt the photoreceptor layer and inner segment–outer segment junctions. Others propose that inflammatory processes drive a breakdown in the blood–retinal barrier, leading to the accumulation of fluid[2,3]. Most treatment options aim to quell the inflammatory drive, but the use of intravitreal steroids are probably the most potent agents[4].

   The Fluocinolone Iluvien implant however has been approved for the treatment of chronic diabetic macular edema (DME) and is thought to have a long-term efficacy of 36 months[5]. In the present report, we document a patient with a successful response to bilateral Fluocinolone implant administration for chronic CME complicating PPV and ERM peel surgery followed by phacoemulsification cataract surgery.

Statement of Ethics

   The authors have no ethical conflicts to disclose.

Disclosures

   The authors have no conflicts of interest to declare.

Funding Sources

   The authors received no financial support for the research, authorship, and/or publication of this article.

Patient Consent

   Consent to publish was obtained from the patients in this case series.