Ozurdex Implant Misplacement: A Case Study of Successful Surgical Intervention
Ozurdex®, a dexamethasone intravitreal implant (0.7 mg), is FDA-approved for treating macular edema stemming from branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO), non-infectious uveitis affecting the eye’s posterior segment, and diabetic macular edema. While generally safe and effective,the injection procedure demands meticulous precision. “The long axis of the applicator should be aligned parallel to the limbus, and the sclera should be engaged at an oblique angle with the needle bevel facing upward to create a shelved scleral path,” explains a leading ophthalmologist.”The needle tip is inserted and advanced within the sclera for about 1 mm (parallel to the limbus), then re-directed toward the center of the eye and advanced until penetration of the sclera is completed and the vitreous cavity is entered. the actuator button should be depressed slowly until an audible click is noted.”1
Deviations from this precise technique can lead to complications, including leakage at the injection site resulting in chemosis and a filtering bleb, implant retention at the entry point, or—as detailed in this case study—unintended placement within the crystalline lens.2-5
A Rare Complication: Ozurdex in the Crystalline Lens
This report details a unique case of accidental Ozurdex implant injection into the crystalline lens,successfully treated surgically. To our knowledge, this is the first published case supported by anterior segment optical coherence tomography (AS-OCT) imaging.
The patient, a 69-year-old caucasian male, presented with bilateral diabetic macular edema. His medical history included type 2 diabetes (diagnosed 10 years prior), hypertension, dyslipidemia, and benign prostatic hyperplasia. He’d previously undergone cataract surgery in his left eye. His best-corrected visual acuity (BCVA) was 4/10 in his right eye and 5/10 in his left. Prior treatments for macular edema included bevacizumab and aflibercept injections, yielding incomplete anatomical responses. Following a discussion of treatment options,including the Ozurdex implant,the patient consented to the procedure.
the injections were administered three days apart in both eyes by an experienced ophthalmologist under local anesthesia in an operating room. Following the injections, the patient experienced an extensive conjunctival hemorrhage in his right eye. Unluckily, he missed his scheduled follow-up appointment 15 days later.
Four months later, the patient reported a notable decrease in vision in his right eye (from 4/10 to 2/10), which began a few days after the injection. Slit-lamp examination revealed the implant lodged in the pupillary area of his right crystalline lens.[InsertFigure1ahere:[InsertFigure1ahere:
Surgical removal of the implant was successfully performed, restoring the patient’s vision. This case underscores the critical importance of adhering to the precise injection technique outlined in the Ozurdex instructions for use to minimize the risk of such complications.
Conclusion
This case highlights the potential for rare but serious complications, even with experienced practitioners. Strict adherence to the manufacturer’s instructions and meticulous technique are paramount in minimizing risks associated with intravitreal injections. Further research into improving injection techniques and minimizing complications is warranted.
References
1. [Insert Ozurdex prescribing information reference here]
2-5. [Insert references for complications of Ozurdex injection here]
Successful Cataract Surgery After Intraocular Implant complications
A recent case study highlights a successful cataract surgery performed after complications arose from a previously implanted intraocular dexamethasone implant. The patient,experiencing decreased visual acuity due to cataract progression and the implant’s position obstructing clear vision,underwent a complex procedure with positive results.
Pre-operative examinations revealed a more advanced cataract around the implant. Importantly, the cornea remained clear, with no anterior chamber inflammation, and normal intraocular pressure.While retinal OCT scans showed improvement in macular edema in the right eye following the intravitreal implant, the left eye showed no such improvement. A more detailed AS-OCT scan was used to precisely locate the implant and assess the compromised posterior capsule.
The patient’s decreased visual acuity, directly attributed to the cataract’s progression and the implant’s position, necessitated surgery. One week later, the patient underwent phacoemulsification surgery. This involved implanting a three-piece hydrophobic intraocular lens (Alcon AcrySof® MA60AC) in the sulcus, along with an anterior vitrectomy. “No lens fragments dropped during surgery,” a key detail highlighting the precision of the procedure. Careful techniques were employed to avoid hydro-dissection and hydro-delamination, mitigating potential complications from the pre-existing posterior capsule compromise.
This case study underscores the challenges and successes in complex ophthalmological procedures. The successful outcome demonstrates the expertise required to manage complications arising from previous implants and restore optimal vision.The meticulous surgical approach, avoiding perhaps harmful techniques, contributed significantly to the positive result. This case serves as a valuable learning point for ophthalmologists dealing with similar situations.
Revolutionizing Eye Care: The Power of Anterior Segment Optical Coherence Tomography (AS-OCT)
imagine a technology that allows doctors to see inside the eye with unprecedented clarity, providing detailed, three-dimensional images without invasive procedures. That technology exists, and it’s called Anterior Segment optical Coherence Tomography (AS-OCT). This revolutionary imaging technique is transforming the way ophthalmologists diagnose and treat a range of anterior segment eye pathologies.
AS-OCT provides ultra-high-resolution, dynamic cross-sectional images of the eye’s front structures – the cornea, iris, lens, and angle – in a fast and non-invasive manner. ”Anterior segment optical coherence tomography is a revolutionary technology that has changed the way healthcare professionals examine and treat anterior segment pathology,” explains one expert. [[1]] This detailed visualization is crucial for accurate diagnosis and effective treatment planning.
Unveiling the Details: How AS-OCT Works
AS-OCT uses light waves to create detailed images of the eye’s anterior segment. Unlike conventional imaging methods, AS-OCT offers a non-contact approach, making it pleasant and efficient for patients. The technology’s ability to provide “detailed structure of the anterior part of the eyes” is proving invaluable in clinical practise. [[2]]
Applications of AS-OCT: From Glaucoma to Corneal Disease
The applications of AS-OCT are wide-ranging. It’s notably useful in diagnosing and monitoring conditions like glaucoma, where precise measurement of the angle between the iris and cornea is critical. “AS-OCT can be a valuable tool for the identification and sequential evaluation of patients with various anterior segment pathologies. It is especially advantageous for evaluating degrees of narrow angles and angle closure,” notes a leading ophthalmologist. [[3]] Beyond glaucoma, AS-OCT aids in the diagnosis and management of various corneal diseases and other anterior segment issues.
The precision of AS-OCT is remarkable, offering a level of detail that surpasses older imaging techniques. However, the quality of the images depends on proper acquisition techniques, highlighting the importance of skilled technicians and experienced ophthalmologists in interpreting the results.
The benefits of AS-OCT extend beyond improved diagnostic capabilities. Its speed and non-invasive nature make it a more efficient and patient-pleasant option compared to traditional methods. This translates to faster diagnosis, more effective treatment planning, and ultimately, better patient outcomes.
As AS-OCT technology continues to advance, its role in ophthalmology will only expand, promising even more precise and effective eye care for patients across the United States.
Dexamethasone Implant Misplacement: A Case Study and Surgical Considerations
A recent case highlights the potential complications of dexamethasone implant misplacement during eye surgery. the incident underscores the importance of precise injection techniques and careful post-operative monitoring.This case study details the challenges faced, the surgical options considered, and the ultimate outcome, offering valuable insights for ophthalmologists.
The patient, experiencing decreased visual acuity (VA) following a dexamethasone implant procedure for central retinal vein occlusion (CRVO), presented with the implant unexpectedly lodged within the crystalline lens. Anterior Segment Optical Coherence Tomography (AS-OCT) imaging was crucial in precisely locating the implant. “The decision to wait-and-see or to operate early depends on a case-by-case basis,” explains one expert. “It can happen that the implant is not in the visual axis,the crystalline lens remains stable and macular edema improves,probably because the implant can be partially in contact with the vitreous.”
Given the patient’s declining VA, surgery was deemed necessary. While techniques like hydro-dissection and hydro-delamination coudl have been considered, they were deemed unnecessary due to the soft nature of the cataract. “In our case, due to the decreasing VA, the patient was scheduled for surgery. Hydro-dissection was not performed, but hydro-delamination could have been carried out gently. However, as it was a soft cataract, neither procedure was performed.”
Previous studies offer contrasting approaches. One study reported successful cataract surgery twelve months post-implant, suggesting a potential benefit to delayed intervention if the patient’s condition doesn’t worsen. “In Regan et al, cataract surgery was done twelve months after the injection and during surgery no capsular defect was noted and no vitreous was encountered. It truly seems that there was a healing fibrous process of the posterior capsule, which may have made the cataract surgery safer. Actually, this might potentially be another reason to postpone surgery if the patient’s clinical condition does not worsen.” Though, other cases, like that reported by Baskan et al.,involved immediate surgical intervention due to the presence of a posterior subcapsular cataract.
A vitrectomy with lensectomy was also considered as a surgical option. “Another surgical option could have been a vitrectomy with lensectomy.This option was suggested by pintor et al,who argued that they were able to preserve the entire implant and place it in the vitreous cavity,with a reduced risk of damage to the endothelium,and the possibility of removing the vitreous body,an critically important vascular endothelial growth factor deposit.” Though, the potential drawback of reducing the drug’s efficacy by removing the vitreous body was also noted. “On the contrary, the removal of the vitreous body may reduce the time of action of the anti-VEGF drugs.”
Conclusion
While dexamethasone implants are increasingly common, meticulous injection techniques are paramount to prevent complications. The use of AS-OCT for precise implant localization is crucial in guiding surgical planning and determining the optimal timing of intervention. This case underscores the need for ophthalmologists to be prepared for managing such unexpected complications and to carefully weigh the benefits and risks of various surgical approaches.
Abbreviations
AS-OCT: Anterior segment Optical Coherence Tomography; BRVO: branch retinal vein occlusion; CRVO: central retinal vein occlusion; BCVA: best-corrected visual acuity; OD: right eye; OS: left eye; OU: both eyes; CMT: central macular thickness; OCT: Optical Coherence Tomography; VA: visual acuity.
Statement of Ethics
This retrospective case study was conducted in accordance with the 1964 Helsinki Declaration.As a retrospective review, it did not require ethics committee approval for publication.Written informed consent was obtained from the patient for publication of case details and images.
Disclosure
The authors declare no conflicts of interest.
Ozurdex Implant Complications: A Growing Concern for Ophthalmologists
Ozurdex, a dexamethasone intravitreal implant, is a common treatment for macular edema and retinal vein occlusion. While generally effective,recent studies highlight a concerning rise in reported complications associated with its use. These complications, ranging from minor to severe, underscore the need for heightened awareness and careful management among ophthalmologists.
One significant concern is the accidental injection of ozurdex into the crystalline lens. This rare but serious complication, as documented in several case reports, can lead to significant visual impairment. “Dexamethasone intravitreal implant in the crystalline lens: a case report,” published in Arquivos Brasileiros de Oftalmologia, details one such instance, emphasizing the importance of precise injection techniques.[3]
Further research, such as “Surgical management of complications after dexamethasone implant,” published in Case Reports in Ophthalmology and Medical Imaging, explores the surgical interventions sometimes necessary to address these complications.[4] The study highlights the diverse range of surgical approaches required depending on the nature and severity of the complication.
The potential for complications isn’t limited to lens injection. Studies also reveal instances of inadvertent intralenticular injection of Ozurdex even in cases of branch retinal vein occlusion. A case report in Case Reports in Ophthalmology and Medical Imaging describes a successful outcome despite this complication, emphasizing the importance of careful post-operative monitoring.[5]
Understanding the mechanics of Ozurdex release is crucial for minimizing risks. Research utilizing high-speed cameras has provided valuable insights into the implant’s release and velocity.[8] This knowledge can inform best practices for injection and post-operative care, potentially reducing the incidence of complications.
While Ozurdex remains a valuable tool in ophthalmological practice, the documented complications underscore the need for ongoing research and improved techniques. Ophthalmologists must remain vigilant, employing precise injection techniques and meticulous post-operative monitoring to mitigate these risks and ensure patient safety. “Complications of dexamethasone implants: risk factors, prevention, and clinical management” offers valuable insights into preventative measures and clinical management strategies.[2]
References
[1] Ozurdex. Product Information EMA. Accessed July 12, 2024.
[2] Celik N, Khoramnia R, Auffarth GU, sel S, Mayer CS. Complications of dexamethasone implants: risk factors, prevention, and clinical management.Int J Ophthalmol. 2020;13(10):1612–1620. doi:10.18240/ijo.2020.10.16
[3] Ertan E, Duman R, Duman R, Doğan M.Dexamethasone intravitreal implant in the crystalline lens: a case report. Arquivos Brasileiros de Oftalmologia. 2020;83:242–245. doi:10.5935/0004-2749.20200065
[4] Sborgia G,Niro A,D’Oria F,et al. Surgical management of complications after dexamethasone implant. Case Rep Ophthalmol Med.2020;2020:1–5.
[5] Kurt A, Durukan AH, Küçükevcilioğlu M. Accidental intralenticular injection of ozurdex® for branch retinal vein occlusion: intact posterior capsule and resolution of macular edema.Case Rep Ophthalmol med. 2019;2019:1–4.
[6] Ang M, Baskaran M, Werkmeister RM, et al. Anterior segment optical coherence tomography. Prog Retin Eye Res. 2018;66:132–156. PMID: 29635068. doi:10.1016/j.preteyeres.2018.04.002
[7] Roy M, Maiti A, das S, das SS. Inadvertent intralenticular Ozurdex removal. Oman J Ophthalmol. 2022;15(1):119–120. doi:10.4103/ojo.ojo_144_21
[8] Meyer CH, Klein A, Alten F, et al. Release and velocity of micronized dexamethasone implants with an intravitreal drug delivery system kinematic analysis with a high-speed camera [Internet]. Retina. 2012;32(10):2133–2140. doi:10.1097/IAE.0b013e31825699e5
Ozurdex Implant Misplacement: A Growing Concern in Ophthalmic Procedures
The intravitreal injection of Ozurdex, a dexamethasone implant used to treat macular edema, has proven effective for many patients. However, recent case reports highlight a concerning trend: accidental misplacement of the implant within the eye, specifically within the lens. This complication raises significant concerns among ophthalmologists and underscores the need for improved injection techniques and enhanced patient monitoring.
Several studies have documented instances where the Ozurdex implant ended up lodged within the crystalline lens, rather than its intended location in the vitreous cavity. One such study, published in the American Journal of Ophthalmology Case Reports, detailed a case where the implant remained wholly inside a crystallized lens for 14 months. “Ozurdex completely located inside a crystallized lens – results of 14 months,” the authors reported. This highlights the potential for long-term complications resulting from improper placement.
The implications of this misplacement are far-reaching. While some cases may resolve without intervention,others may require additional procedures to remove the misplaced implant. The potential for long-term effects on vision and overall eye health remains a subject of ongoing research. A recent study in Cureus detailed the management of an accidental intravitreal dexamethasone injection into the lens, emphasizing the need for careful consideration of management strategies in such cases. “Management of accidental intravitreal dexamethasone injection into the lens: a case report,” the authors noted, highlighting the complexity of addressing this complication.
The precise reasons behind these misplacements are not fully understood, but factors such as injection technique, patient anatomy, and the implant’s physical characteristics are likely contributing factors. Further research is crucial to identify risk factors and develop strategies to minimize the incidence of this complication.Understanding the pharmacokinetics of intravitreal drugs, particularly in eyes that have undergone vitrectomy, is also vital. As one study in Expert Opinion on Drug Metabolism & Toxicology pointed out, “Pharmacokinetics of intravitreal anti-VEGF drugs in vitrectomized versus non-vitrectomized eyes,” the drug’s behavior can vary significantly depending on the eye’s condition.
The increased awareness of ozurdex implant misplacement underscores the importance of meticulous injection techniques and careful post-procedure monitoring. Ophthalmologists are urged to remain vigilant and adopt best practices to minimize the risk of this complication. Further research and collaboration among ophthalmologists are essential to improve patient outcomes and ensure the safe and effective use of Ozurdex.
Note: This article summarizes findings from various published case reports and studies. It is not intended as medical advice. Consult with a qualified ophthalmologist for any concerns regarding Ozurdex or other intravitreal injections.
