Author: Margarida Ribeiro (Portugal)
Co-authors: Ana Faria Pereira, Susana Penas, Fernando Falcão-Reis, João Nuno Beato
Retinal vein occlusion is an important cause of vision loss, being the second most common cause of retinal vascular disease in the world. Despite the differences in frequency and natural history, branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO) can both often complicate with macular edema. Corticosteroids represent one of the possible therapeutic approaches due to their anti-angiogenic and anti-inflammatory effect. Although widely studied in diabetic macular edema, little information is available on the effectiveness of intravitreal fluocinolone acetonide (FAc, 190 µg) implant ILUVIEN® (Alimera Sciences Inc., Georgia, USA) in macular edema after BRVO and CRVO. The purpose of this study was to evaluate the anatomical and functional response in patients with macular edema following BRVO and ischemic CRVO, 12 months after the placement of the FAc implant.
Department of Ophthalmology of Centro Hospitalar e Universitário São João, Portugal.
Prospective interventional review of two clinical cases (two eyes) of chronic persistent macular edema after BRVO and ischemic CRVO treated with ILUVIEN® implant. Description of demographic and clinical data in addition to anatomical (central retinal thickness [CRT]) and functional (best corrected visual acuity [BCVA[ in ETDRS scale) outcomes during a 12-month period of follow-up after a single administration of the FAc implant. Both patients were female with 73 and 71 years. One patient had a diagnosis of BRVO of the superior temporal branch of the right eye after cataract surgery and the other developed an ischemic CRVO of the left eye (also pseudophakic). No systemic steroids were given at the time ILUVIEN® was administered or during the 12 months of follow-up.
The patient with BRVO presented a baseline BCVA of counting fingers at two meters and a CRT of 616 µm. She was initially treated with 6 intravitreal injections of 1,25mg bevacizumab followed by 7 injections of 2 mg triamcinolone, with good anatomic response but minimal functional improvement (BCVA of 23 letters). Subsequently, a dexamethasone intravitreal implant (OZURDEX®) was administered, with better functional response (BCVA of 36 letters); however, not sustained beyond 3 months, requiring the use of 3 OZURDEX implants. After this an FAc implant was injected, resulting in a complete and sustained resolution of the macular edema at 12months (CRT of 198 µm and BCVA of 38 letters). The patient with the ischemic CRVO presented a baseline BCVA of 29 letters and a CRT of 664 µm. In the absence of response to anti-VEGF (bevacizumab and aflibercept) and triamcinolone intravitreal injections, she was proposed to a dexamethasone implant (OZURDEX). She showed an anatomical improvement (CRT of 364 µm), although not sustained, despite a total of 5 implants. An FAc implant was then administered, with a significant and sustained functional (BCVA of 38 letters) and anatomical (CRT of 271 µm) improvement at 12 months.
Retinal vein occlusion is presumed to be a potentially chronic disease. The existence of several therapeutic modalities for macular edema highlights that there is no perfect solution. However, the most adequate approach will be the one that best fits the patient's needs, given its side effects and the least interference with patient´s quality of life. ILUVIEN® was effective in treating the macular edema secondary to BRVO and CRVO with a favorable and sustained clinical and anatomical response throughout a 12-month period, reducing the burden of numerous intravitreal procedures and visits to the hospital.