Altinors, Dilek D.

Ozdemir, Evin Singar

Yesilirmak, Nilufer

International Journal of Ophthalmology

English

Baskent Universtiy

陨灶贼 允 韵责澡贼澡葬造皂燥造熏 灾燥造援 9熏 晕燥援 3熏 Mar.18, 圆园16 www. ijo. cn
栽藻造押8629原愿圆圆源缘员苑圆 8629-82210956 耘皂葬蚤造押ijopress岳员远猿援糟燥皂
Effect of dexamethasone intravitreal implant in a corneal
graft rejection
窑Letter to the Editor窑
1Department of Cornea, Bascom Palmer Eye Institute,
University of Miami Miller School of Medicine, Miami,
Florida 33136, USA
2Ankara Training and Research Hospital, Ankara 06340,
Turkey
3Baskent University Hospital, Ankara 06490, Turkey
Correspondence to: Nilufer Yesilirmak. Bascom Palmer
Eye Institute, University of Miami Miller School of
Medicine, 900 NW 17 St., Miami, Florida 33136, USA.
nxy28@med.miami.edu
Received: 2015-02-10 Accepted: 2015-06-16
DOI:10.18240/ijo.2016.03.28
Yesilirmak N, Ozdemir ES, Altinors DD. Effect of dexamethasone
intravitreal implant in a corneal graft rejection.
2016;9(3):475-477
Dear Sir,
I am Dr. Nilufer Yesilirmak, from the Department ofCornea, Bascom Palmer Eye Institute, Miami, Florida,
USA. We wrote to report a reduction of graft rejection with
dexamethasone intravitreal implant (Ozurdex誖 ) in a case
with aphakia.
Ozurdex誖 (Allergan Inc., Irvine, CA, USA) is an intravitreal
implant containing a biodegradable material combined with
the active drug dexamethasone. It is a small rod-shaped,
0.46 mm in diameter and 6 mm in length. Inside the eye, it
provides sustained delivery of 0.7 mg of preservative-free
dexamethasone to the vitreous cavity and retina for up to
180d[1]. This implant is proved to be effective in the treatment
of macular edema following branch or central retinal vein
occlusions, posterior non-infectious uveitis, diabetic macular
edema, pseudophakic macular edema and neovascular
age-related macular degeneration [2].
Herein we report a different usage of Ozurdex® implant for
51-year-old female diagnosed with corneal graft rejection in
her right eye. The patient had been followed at our clinic
with chronic visual loss in her right eye for 4y and undergone
a penetrating keratoplasty 4y ago due to a fungal keratitis
scar. Simultaneously a cataract extraction had been
performed without implanting an intraocular lens. The
outside surgeon probably decided to implant it on another
occasion after making sure that the cornea survived. Because
of the rejection, the patient had undergone her second
keratoplasty 2y ago. After the second keratoplasty her
best-corrected visual acuity (BCVA) was 0.5, however
during the follow-up period, her vision decreased again due
to an epiretinal membrane and she underwent a pars plana
vitrectomy.
On her last examination, the BCVA was 0.1 and intraocular
pressure (IOP) was 15 mm Hg, in the right eye. The anterior
segment showed 1+ cells, 1+ flare and fine Khodadoust line
which was considered as a rejection (Figure 1A). The
posterior segment was normal. Topical steroids were given 4
times a day and subtenon corticosteroid injections were
applied twice a month for 3mo. She responded well to each
steroid injection, however, because of frequent injections, her
eyelids were bruised and became edematous as well as her
conjunctiva (Figure 1B). In order to reduce the number of
injections, an Ozurdex® implantation was performed through
the superior temporal quadrant of right eye, approximately 3-
to 5-mm posterior to the limbus (through the pars plana).
After first week of implantation, the Ozurdex ® implant
migrated into the anterior chamber (AC) and wandered
between the AC and vitreous cavity with head movements of
the patient without any corneal touch (Figure 2A). Therefore,
patient was advised not to lean forward too much and she
learnt to keep the implant inside the eye by adjusting her
body movements. At 4wk post-implantation, the BCVA was
0.2, IOP was 15 mm Hg and rejection regressed significantly
(Figure 2B). At 8wk post-implantation, the BCVA was still
0.2, IOP was 18 mm Hg, cornea was clearer and the eye
(conjunctiva and eyelids as well) was quiescent with the
implant in the vitreous cavity. On her last visit, at 11wk
post-implantation, the BCVA was 0.1, IOP was 12 mm Hg,
cornea was not clear and the implant was not seen in the
vitreous cavity or AC. At almost 3mo time, the implant was
absorbed and the rejection seemed to be started again.
Penetrating keratoplasty is usually a successful surgical
procedure but some factors may cause graft rejection.
According to literature immunologic rejection is one of the
most common causes for graft failure [3]. Guilbert [4]
observed that lens status influenced the risk of rejection as
well. Besides, severe allograft rejection episodes results in
endothelial cell density decrease that leads to a lower
reversibility rate [5]. Our case had both aphakia and rejection
episodes that might have increased the endothelial failure.
475
Corticosteroids are usually strongest tools to reverse graft
rejection usually. Even though our case received intensive
topical and subtenon corticosteroid therapy, rejection
progressed. Due to the fact that the combination of
subconjunctival and topical corticosteroids was reported [6] as
more effective in reversing rejection than treatment with a
single pulse of methylprednisolone (500 mg) in combination
with the topical corticosteroids, we decided to use Ozurdex誖
due to its long lasting effect. Besides the patient could not
tolerate immunomodulator therapies. One week after the
implantation, the implant dissolved and passed to anterior
chamber easily due to the aphakic and vitrectomized eye. At
the following examination, the rejection was significantly
regressed. In contrast this, according to literature there are
some studies showing the Ozurdex 誖 implant migration to
the anterior chamber in aphakic eyes, which resulted with
corneal decompensation due to the direct contact of the
implant to the endothelium[7-9]. Even, Mar侏n-Lamb侏es [10]
considered that the implant of these devices in aphakic
patients should be contraindicated.
Chang-Lin [11] showed the concentration of
dexamethasone in the vitreous and retina raised to high levels
within 60d of implantation, extending the therapeutic period
to 6mo and Myung [12] showed the duration of its effect
was approximately 3-4mo. It has been mentioned that, in
vitrectomized eyes the half-life of drugs after intravitreal
injection reduces and the drug clearance increases from the
vitreous [13]. Resembling to afore mentioned study, the
Ozurdex® reached its maximum effect within 2mo and instead
of 6mo, it completely dissolved within 3mo, in our case.
In long-term usage of corticosteroids, adverse effects such as
glaucoma and cataract may appear. It is reported that
Ozurdex 誖 can cause lower incidence of IOP elevation
requiring surgery and cataract extraction than the other
intravitreal corticosteroids [14]. In this study, we did not
observe any long-term adverse effect associated with the
implantation. The patient did not complain of eyelid swelling
as seen in the photo before subtenon steroid injections.
Therefore, this swollen eyelid appearance was attributed to
our repeated steroid injections. Due to Ozurdex 誖 could
provide higher and stable corticosteroid levels without
obvious adverse effects we might consider a second
implantation since the rejection started to be occurred again
after the implant dissolution.
In conclusion, dexamethasone intravitreal implantation is a
minimally invasive treatment modality that might be an
effective treatment option in anterior segment inflammations,
especially in aphakic and vitrectomized eyes. Although there
are no cases of dexamethasone intravitreal implantation for
corneal graft rejection in aphakic and vitrectomized eyes in
the literature, this case report provides an insight for future
long-term studies. Future comparative clinical studies with a
large sample size and long-term follow-up will able to
provide better results and guidelines.
ACKNOWLEDGEMENTS
Conflicts of Interest: Yesilirmak N, None; Ozdemir ES,
None; Altinors DD, None.
REFERENCES
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Figure 1 Anterior segment and external eye photography A:
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Figure 2 Anterior segment photography A: The appearance of
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Dexamethasone implant for corneal graft rejection
476
陨灶贼 允 韵责澡贼澡葬造皂燥造熏 灾燥造援 9熏 晕燥援 3熏 Mar.18, 圆园16 www. ijo. cn
栽藻造押8629原愿圆圆源缘员苑圆 8629-82210956 耘皂葬蚤造押ijopress岳员远猿援糟燥皂
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477


Effect of dexamethasone intravitreal implant in a corneal graft rejection

http://acikerisim.baskent.edu.tr/xmlui/bitstream/11727/3942/1/ijo-09-03-475.pdf

Effect of dexamethasone intravitreal implant in a corneal graft rejection

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