Ocular Immunology and Inflammation
ISSN: 0927-3948 (Print) 1744-5078 (Online) Journal homepage: http://www.tandfonline.com/loi/ioii20
Spontaneous Dissociation of Fluocinolone Acetonide Sustained Release Implant (Retisert) with Dislocation into the Anterior Chamber Peter Y. Chang MD, Zvi Kresch MD, C. Michael Samson MD, MBA & Ronald C. Gentile MD To cite this article: Peter Y. Chang MD, Zvi Kresch MD, C. Michael Samson MD, MBA & Ronald C. Gentile MD (2015): Spontaneous Dissociation of Fluocinolone Acetonide Sustained Release Implant (Retisert) with Dislocation into the Anterior Chamber, Ocular Immunology and Inflammation, DOI: 10.3109/09273948.2014.902074 To link to this article: http://dx.doi.org/10.3109/09273948.2014.902074
View supplementary material
Published online: 27 Aug 2015.
Submit your article to this journal
Article views: 61
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ioii20 Download by: [186.190.28.215]
Date: 05 November 2015, At: 22:48
Ocular Immunology & Inflammation, Early Online, 1–4, 2014 ! Informa Healthcare USA, Inc. ISSN: 0927-3948 print / 1744-5078 online DOI: 10.3109/09273948.2014.902074
LETTER TO THE EDITOR
Spontaneous Dissociation of Fluocinolone Acetonide Sustained Release Implant (Retisert) with Dislocation into the Anterior Chamber Peter Y. Chang,
MD
1,2
, Zvi Kresch, MD1,2, C. Michael Samson, Ronald C. Gentile, MD1,2,3
MD, MBA
1,2
, and
Downloaded by [186.190.28.215] at 22:48 05 November 2015
1
Department of Ophthalmology, The New York Eye & Ear Infirmary of Mt. Sinai, New York, USA, 2Icahn School of Medicine at Mount Sinai, New York, NY, USA, and 3Department of Ophthalmology, Winthrop University Hospital, Mineola, New York, USA
ABSTRACT Purpose: To report two cases of spontaneous Retisert implant dissociation with dislocation of the medication reservoir into the anterior chamber. Design and methods: Case reports. Results: Two patients with chronic, noninfectious uveitis following Retisert implantation between 6 and 7 years prior presented with a complaint of a ‘‘white spot’’ in their right eyes. Both patients had previous pars plana vitrectomies. Anterior segment examination revealed a dislocated medication reservoir of the Retisert implant in the inferior portion of anterior chamber with associated reservoir-corneal endothelial touch and stromal edema. The reservoirs were subsequently retrieved via a pars plana approach and removed from the anterior chamber through a corneal incision. Conclusions: Spontaneous dissociation of the Retisert implant with dislocation of the medication reservoir into the anterior chamber can be a late complication of Retisert implantation. Eye care professionals and patients should be aware of this complication, particularly with long-term intraocular retention of this device. Keywords: Anterior chamber, dislocation, dissociation, fluocinolone acetonide, implant, Retisert, separation, spontaneous, uveitis
The fluocinolone acetonide implant (Retisert; Bausch & Lomb, Rochester, NY) has proven to be an effective treatment modality for chronic, noninfectious uveitis. The implant is composed of two parts: a sutured anchoring strut and a medication reservoir. The medication reservoir is attached to the distal portion of the anchoring strut with a silicone adhesive. Dissociation of the medication reservoir during surgical implantation, removal, and exchange has been reported.1–4 Most recently, it has also been noted that the components can come apart spontaneously, years after the initial implantation.5,6
Herein we report two cases of spontaneous Retisert implant dissociation with subsequent dislocation of the medication reservoir into the anterior chamber.
CASE 1 A 54-year-old female with chronic bilateral idiopathic panuveitis for over 20 years complained of a painless, atraumatic decrease in vision with a ‘‘white spot’’ in her right eye. She had Retisert implantation with
Received 27 May 2013; revised 28 February 2014; accepted 4 March 2014; published online 10 April 2014 Correspondence: Peter Y. Chang, MD, The New York Eye and Ear Infirmary, 310 East 14th Street, New York, NY 10003, USA. E-mail: [email protected]
1
Downloaded by [186.190.28.215] at 22:48 05 November 2015
2
P. Y. Chang et al.
concurrent pars plana vitrectomy (PPV) to remove vitreous opacities in both eyes. The right eye received a Retisert implant approximately six and a half years prior, after becoming intolerant to systemic immunosuppression with methotrexate and cyclophosphamide for multiple bilateral relapses of intraocular inflammation. Her ophthalmic surgical history also included uncomplicated cataract surgery with posterior chamber intraocular lens (IOL) implantation in both eyes prior to the Retisert implants, and a Baerveldt glaucoma implant with tube in the pars plana a few years after the Retisert implantation in the left eye. Preceding her current presentation, ocular inflammation was controlled with topical 0.05% difluprednate ophthalmic emulsion. Visual acuity was hand motion in the right eye with an intraocular pressure (IOP) of 12 mmHg. Slit-lamp examination of the eye revealed aphakia with dislocation of the medication reservoir of the Retisert implant into the inferior portion of the anterior chamber. There were 2+ anterior chamber (AC) cells and reservoir–corneal endothelial touch with an adjacent area of localized corneal edema with Descemet’s folds (Figure 1). Fundus examination of the right eye revealed a dislocated IOL with intact Soemmering ring and capsule inferiorly with an intact Retisert implant anchoring strut inferonasally (Figure 2). In the office, the patient was dilated and put in the supine position to allow the implant to enter the posterior segment and prevent progressive corneal endothelial cell damage (Figure 3). This allowed time for the corneal edema to improve prior to surgery. Three days later, a pars plana approach was undertaken to bring the IOL and the medication reservoir into the anterior chamber, and they were both removed via a clear corneal incision (Supplementary Video).
FIGURE 1. Case 1: Anterior segment photograph of the right eye with dislocation of the medication reservoir of the Retisert implant into the inferior portion of the anterior chamber with associated reservoir–corneal endothelial touch, corneal edema, and Descemet’s folds.
CASE 2 A 25-year-old female with chronic juvenile idiopathic arthritis-associated uveitis for 20 years complained of a ‘‘white spot’’ in her right eye that was first noted by her co-worker. She had a Retisert implant in this eye 6 years prior. Her ophthalmic surgical history also included aphakic cataract extraction and glaucoma drainage implant with PPV for a pars plana tube placement in the right eye. There was no history of trauma. Preceding her current presentation, ocular inflammation was controlled with 40 mg of subcutaneous adalimumab every 2 weeks and topical 0.05% difluprednate ophthalmic emulsion. Visual acuity was hand motion and IOP was 9 mmHg in the right eye. Slit-lamp examination of the eye revealed aphakia
FIGURE 2. Case 1: Wide-field fundus photograph of the right eye with posteriorly dislocated IOL with intact Soemmering ring and capsule located inferiorly within the posterior segment. The distal end of the Retisert implant anchoring strut can be seen extending into the eye from the inferonasal pars plana.
FIGURE 3. Case 1: Anterior segment photograph of the right eye highlighting the Descemet’s folds after the patient was placed in the supine position and the pupil was dilated to allow the medication reservoir to enter the posterior segment of the eye. Ocular Immunology & Inflammation
Downloaded by [186.190.28.215] at 22:48 05 November 2015
Spontaneous Retisert Dissociation with Dislocation
FIGURE 4. Case 2: External photograph of the right eye taken with a mobile phone by a coworker revealing dislocation of the medication reservoir of the Retisert implant into the inferior portion of the anterior chamber with associated reservoir–corneal endothelial touch, corneal edema, and Descemet’s folds.
with the Retisert medication reservoir located inferiorly in the anterior chamber (Figure 4). There were 1 + AC cells and corneal edema localized to the area of reservoir–endothelial touch. Immediate surgical removal was not possible and the patient was dilated and put in the supine position to allow the medication reservoir to enter the posterior segment. The corneal edema had improved by the time the patient had surgery 2 days after initial presentation. A similar surgical approach as in case 1 was used to remove the reservoir.
DISCUSSION The FDA approved Retisert implants in 2005 for the treatment of chronic, noninfectious uveitis. Spontaneous dissociation of the implant components was initially noted in the phase 3 clinical trials, presumably due to a weakening of the silicone adhesive.1 Although the adhesive was strengthened before the implant became commercially available (please refer to page 52 of the document located at: www.accessdata.fda.gov/drugsatfda_docs/nda/ 2005/021737s000_MedR.pdf), there are numerous reports of separation of the medication reservoir from the anchoring strut during surgical manipulation.2–4 Nicholson et al. found implant dissociation during surgery in 11 eyes, with an average implant residence of 47.4 months and a range of 28.0–66.9 months. Since the patients in this study cohort underwent Retisert implantation between 2001 and 2010, it is possible some of these eyes had an implant with the improved adhesive process by the manufacturer. Others have had similar surgical experiences with implants residing in eyes for over 30 months.2,3 !
2014 Informa Healthcare USA, Inc.
3
Authors have proposed that the longer Retisert has resided in the eye, the more likely it is to become dissociated during surgical manipulation.4 More recently, Rogagha et al. and Akduman et al. reported 5 cases of spontaneous Retisert dissociation in the absence of known trauma, with the initial implantation performed from 3 to 6 years prior.5,6 The authors found the medication reservoir in the vitreous cavity in 4 eyes and within the anterior chamber, similar to our cases, in 1 eye. Our patients, both having Retisert implantation 6–7 years prior, experienced spontaneous implant dissociation not associated with mechanical trauma. Case 1 also had a dislocated PCIOL. Due to the patient’s initial complaint of atraumatic vision loss followed by visibility of the reservoir in the anterior chamber, the authors suspect that the dislocated PCIOL may have occurred first and played a role in mechanically dislodging the reservoir from the suture strut. In both cases, the dislocated medication reservoirs were found in the anterior chamber with associated corneal edema. Since both eyes had a previous vitrectomy, with case 1 having a posteriorly dislocated IOL and case 2 unable to have immediate surgery, the patients were placed in the supine position to allow the implant to enter the posterior segment, avoiding continued corneal endothelial damage. Even though we did not use a miotic (i.e. pilocarpine), it can be used as a mean to prevent the reservoir from reentering the anterior segment, especially in eyes without signs of active inflammation. Although our cases had their ocular inflammation previously controlled on topical and/or systemic immunosuppression, both patients presented with active anterior uveitis that was most likely triggered by the physical irritation of the iris by the dislocated reservoir. Even though the retrieved reservoirs were not sent for analysis, given the original drug content of 590 mg (0.59 mg) and a steady-state release rate of 0.3–0.4 mg/day (lifespan: 4.0–5.4 years), we calculated that they contained no residual fluocinolone acetonide. In our cases, a microincisional 25-gauge pars plana approach was performed to retrieve the medication reservoir that was subsequently removed from the anterior chamber via a corneal incision. During surgery, viscoelastic was used to protect the corneal endothelium. Techniques for removal can vary and surgeons must take into account the best surgical approach for each clinical scenario. In phakic or pseudophakic eyes, removal of the medication reservoir from the anterior chamber is not possible without disturbing the lens. In these cases, as performed by Rogagha et al. [5], removal of the medication reservoir is best performed via a 3.5-mm or greater pars plana scleral incision. This also holds true for aphakic eyes undergoing a larger-gauge and non-conjunctivalsparing pars plana vitrectomy, especially if the
4
P. Y. Chang et al.
anchoring strut will be removed or another Retisert implanted. Spontaneous dissociation can be a late complication of Retisert implantation. This complication has so far been reported 5 years after implantation with our 2 cases occurring 6–7 years after implantation. When this occurs in a one-chambered eye, the medication reservoir can dislocate into the anterior chamber. Patients complain of a ‘‘white spot’’ in the eye. Surgeons and patients should be aware of this potential complication especially in eyes beyond the Retisert’s 30-month lifespan when no exchange of the implant is planned.
Downloaded by [186.190.28.215] at 22:48 05 November 2015
DECLARATION OF INTEREST All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. This study was supported in part by (1) The Einhorn Clinical Research Center, The New York
Eye & Ear Infirmary, Department of Ophthalmology Research Fund and (2) The Norma Lazar Eye Research Grant, New York, USA.
REFERENCES 1. Callanan DG, Jaffe GJ, Martin DF, et al. Treatment of posterior uveitis with a fluocinolone acetonide implant: three-year clinical trial results. Arch Ophthalmol. 2008;126: 1191–1201. 2. Yeh S, Cebulla CM, Witherspoon SR, et al. Management of fluocinolone implant dissociation during implant exchange. Arch Ophthalmol. 2009;127:1218–1221. 3. Wan W, Stewart JM. Use of a high infusion rate to prevent posterior dislocation of fluocinolone acetonide implant during surgical removal. Ocul Immunol Inflamm. 2011;19: 214–215. 4. Nicholson BP, Singh RP, Sears JE, et al. Evaluation of fluocinolone acetonide sustained release implant (Retisert) dissociation during implant removal and exchange surgery. Am J Ophthalmol. 2012;154:969–973. 5. Rofagha S, Prechanond T, Stewart JM. Late spontaneous dissociation of a fluocinolone acetonide implant (Retisert). Ocul Immunol Inflamm. 2013;21:62–63. 6. Akduman L, Cetin EN, Levy J, et al. Spontaneous dissociation and dislocation of Retisert pellet. Ocul Immunol Inflamm. 2013;21:87–89.
Supplementary material available online Supplementary Video
Ocular Immunology & Inflammation
ISSN: 0927-3948 (Print) 1744-5078 (Online) Journal homepage: http://www.tandfonline.com/loi/ioii20
Spontaneous Dissociation of Fluocinolone Acetonide Sustained Release Implant (Retisert) with Dislocation into the Anterior Chamber Peter Y. Chang MD, Zvi Kresch MD, C. Michael Samson MD, MBA & Ronald C. Gentile MD To cite this article: Peter Y. Chang MD, Zvi Kresch MD, C. Michael Samson MD, MBA & Ronald C. Gentile MD (2015): Spontaneous Dissociation of Fluocinolone Acetonide Sustained Release Implant (Retisert) with Dislocation into the Anterior Chamber, Ocular Immunology and Inflammation, DOI: 10.3109/09273948.2014.902074 To link to this article: http://dx.doi.org/10.3109/09273948.2014.902074
View supplementary material
Published online: 27 Aug 2015.
Submit your article to this journal
Article views: 61
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ioii20 Download by: [186.190.28.215]
Date: 05 November 2015, At: 22:48
Ocular Immunology & Inflammation, Early Online, 1–4, 2014 ! Informa Healthcare USA, Inc. ISSN: 0927-3948 print / 1744-5078 online DOI: 10.3109/09273948.2014.902074
LETTER TO THE EDITOR
Spontaneous Dissociation of Fluocinolone Acetonide Sustained Release Implant (Retisert) with Dislocation into the Anterior Chamber Peter Y. Chang,
MD
1,2
, Zvi Kresch, MD1,2, C. Michael Samson, Ronald C. Gentile, MD1,2,3
MD, MBA
1,2
, and
Downloaded by [186.190.28.215] at 22:48 05 November 2015
1
Department of Ophthalmology, The New York Eye & Ear Infirmary of Mt. Sinai, New York, USA, 2Icahn School of Medicine at Mount Sinai, New York, NY, USA, and 3Department of Ophthalmology, Winthrop University Hospital, Mineola, New York, USA
ABSTRACT Purpose: To report two cases of spontaneous Retisert implant dissociation with dislocation of the medication reservoir into the anterior chamber. Design and methods: Case reports. Results: Two patients with chronic, noninfectious uveitis following Retisert implantation between 6 and 7 years prior presented with a complaint of a ‘‘white spot’’ in their right eyes. Both patients had previous pars plana vitrectomies. Anterior segment examination revealed a dislocated medication reservoir of the Retisert implant in the inferior portion of anterior chamber with associated reservoir-corneal endothelial touch and stromal edema. The reservoirs were subsequently retrieved via a pars plana approach and removed from the anterior chamber through a corneal incision. Conclusions: Spontaneous dissociation of the Retisert implant with dislocation of the medication reservoir into the anterior chamber can be a late complication of Retisert implantation. Eye care professionals and patients should be aware of this complication, particularly with long-term intraocular retention of this device. Keywords: Anterior chamber, dislocation, dissociation, fluocinolone acetonide, implant, Retisert, separation, spontaneous, uveitis
The fluocinolone acetonide implant (Retisert; Bausch & Lomb, Rochester, NY) has proven to be an effective treatment modality for chronic, noninfectious uveitis. The implant is composed of two parts: a sutured anchoring strut and a medication reservoir. The medication reservoir is attached to the distal portion of the anchoring strut with a silicone adhesive. Dissociation of the medication reservoir during surgical implantation, removal, and exchange has been reported.1–4 Most recently, it has also been noted that the components can come apart spontaneously, years after the initial implantation.5,6
Herein we report two cases of spontaneous Retisert implant dissociation with subsequent dislocation of the medication reservoir into the anterior chamber.
CASE 1 A 54-year-old female with chronic bilateral idiopathic panuveitis for over 20 years complained of a painless, atraumatic decrease in vision with a ‘‘white spot’’ in her right eye. She had Retisert implantation with
Received 27 May 2013; revised 28 February 2014; accepted 4 March 2014; published online 10 April 2014 Correspondence: Peter Y. Chang, MD, The New York Eye and Ear Infirmary, 310 East 14th Street, New York, NY 10003, USA. E-mail: [email protected]
1
Downloaded by [186.190.28.215] at 22:48 05 November 2015
2
P. Y. Chang et al.
concurrent pars plana vitrectomy (PPV) to remove vitreous opacities in both eyes. The right eye received a Retisert implant approximately six and a half years prior, after becoming intolerant to systemic immunosuppression with methotrexate and cyclophosphamide for multiple bilateral relapses of intraocular inflammation. Her ophthalmic surgical history also included uncomplicated cataract surgery with posterior chamber intraocular lens (IOL) implantation in both eyes prior to the Retisert implants, and a Baerveldt glaucoma implant with tube in the pars plana a few years after the Retisert implantation in the left eye. Preceding her current presentation, ocular inflammation was controlled with topical 0.05% difluprednate ophthalmic emulsion. Visual acuity was hand motion in the right eye with an intraocular pressure (IOP) of 12 mmHg. Slit-lamp examination of the eye revealed aphakia with dislocation of the medication reservoir of the Retisert implant into the inferior portion of the anterior chamber. There were 2+ anterior chamber (AC) cells and reservoir–corneal endothelial touch with an adjacent area of localized corneal edema with Descemet’s folds (Figure 1). Fundus examination of the right eye revealed a dislocated IOL with intact Soemmering ring and capsule inferiorly with an intact Retisert implant anchoring strut inferonasally (Figure 2). In the office, the patient was dilated and put in the supine position to allow the implant to enter the posterior segment and prevent progressive corneal endothelial cell damage (Figure 3). This allowed time for the corneal edema to improve prior to surgery. Three days later, a pars plana approach was undertaken to bring the IOL and the medication reservoir into the anterior chamber, and they were both removed via a clear corneal incision (Supplementary Video).
FIGURE 1. Case 1: Anterior segment photograph of the right eye with dislocation of the medication reservoir of the Retisert implant into the inferior portion of the anterior chamber with associated reservoir–corneal endothelial touch, corneal edema, and Descemet’s folds.
CASE 2 A 25-year-old female with chronic juvenile idiopathic arthritis-associated uveitis for 20 years complained of a ‘‘white spot’’ in her right eye that was first noted by her co-worker. She had a Retisert implant in this eye 6 years prior. Her ophthalmic surgical history also included aphakic cataract extraction and glaucoma drainage implant with PPV for a pars plana tube placement in the right eye. There was no history of trauma. Preceding her current presentation, ocular inflammation was controlled with 40 mg of subcutaneous adalimumab every 2 weeks and topical 0.05% difluprednate ophthalmic emulsion. Visual acuity was hand motion and IOP was 9 mmHg in the right eye. Slit-lamp examination of the eye revealed aphakia
FIGURE 2. Case 1: Wide-field fundus photograph of the right eye with posteriorly dislocated IOL with intact Soemmering ring and capsule located inferiorly within the posterior segment. The distal end of the Retisert implant anchoring strut can be seen extending into the eye from the inferonasal pars plana.
FIGURE 3. Case 1: Anterior segment photograph of the right eye highlighting the Descemet’s folds after the patient was placed in the supine position and the pupil was dilated to allow the medication reservoir to enter the posterior segment of the eye. Ocular Immunology & Inflammation
Downloaded by [186.190.28.215] at 22:48 05 November 2015
Spontaneous Retisert Dissociation with Dislocation
FIGURE 4. Case 2: External photograph of the right eye taken with a mobile phone by a coworker revealing dislocation of the medication reservoir of the Retisert implant into the inferior portion of the anterior chamber with associated reservoir–corneal endothelial touch, corneal edema, and Descemet’s folds.
with the Retisert medication reservoir located inferiorly in the anterior chamber (Figure 4). There were 1 + AC cells and corneal edema localized to the area of reservoir–endothelial touch. Immediate surgical removal was not possible and the patient was dilated and put in the supine position to allow the medication reservoir to enter the posterior segment. The corneal edema had improved by the time the patient had surgery 2 days after initial presentation. A similar surgical approach as in case 1 was used to remove the reservoir.
DISCUSSION The FDA approved Retisert implants in 2005 for the treatment of chronic, noninfectious uveitis. Spontaneous dissociation of the implant components was initially noted in the phase 3 clinical trials, presumably due to a weakening of the silicone adhesive.1 Although the adhesive was strengthened before the implant became commercially available (please refer to page 52 of the document located at: www.accessdata.fda.gov/drugsatfda_docs/nda/ 2005/021737s000_MedR.pdf), there are numerous reports of separation of the medication reservoir from the anchoring strut during surgical manipulation.2–4 Nicholson et al. found implant dissociation during surgery in 11 eyes, with an average implant residence of 47.4 months and a range of 28.0–66.9 months. Since the patients in this study cohort underwent Retisert implantation between 2001 and 2010, it is possible some of these eyes had an implant with the improved adhesive process by the manufacturer. Others have had similar surgical experiences with implants residing in eyes for over 30 months.2,3 !
2014 Informa Healthcare USA, Inc.
3
Authors have proposed that the longer Retisert has resided in the eye, the more likely it is to become dissociated during surgical manipulation.4 More recently, Rogagha et al. and Akduman et al. reported 5 cases of spontaneous Retisert dissociation in the absence of known trauma, with the initial implantation performed from 3 to 6 years prior.5,6 The authors found the medication reservoir in the vitreous cavity in 4 eyes and within the anterior chamber, similar to our cases, in 1 eye. Our patients, both having Retisert implantation 6–7 years prior, experienced spontaneous implant dissociation not associated with mechanical trauma. Case 1 also had a dislocated PCIOL. Due to the patient’s initial complaint of atraumatic vision loss followed by visibility of the reservoir in the anterior chamber, the authors suspect that the dislocated PCIOL may have occurred first and played a role in mechanically dislodging the reservoir from the suture strut. In both cases, the dislocated medication reservoirs were found in the anterior chamber with associated corneal edema. Since both eyes had a previous vitrectomy, with case 1 having a posteriorly dislocated IOL and case 2 unable to have immediate surgery, the patients were placed in the supine position to allow the implant to enter the posterior segment, avoiding continued corneal endothelial damage. Even though we did not use a miotic (i.e. pilocarpine), it can be used as a mean to prevent the reservoir from reentering the anterior segment, especially in eyes without signs of active inflammation. Although our cases had their ocular inflammation previously controlled on topical and/or systemic immunosuppression, both patients presented with active anterior uveitis that was most likely triggered by the physical irritation of the iris by the dislocated reservoir. Even though the retrieved reservoirs were not sent for analysis, given the original drug content of 590 mg (0.59 mg) and a steady-state release rate of 0.3–0.4 mg/day (lifespan: 4.0–5.4 years), we calculated that they contained no residual fluocinolone acetonide. In our cases, a microincisional 25-gauge pars plana approach was performed to retrieve the medication reservoir that was subsequently removed from the anterior chamber via a corneal incision. During surgery, viscoelastic was used to protect the corneal endothelium. Techniques for removal can vary and surgeons must take into account the best surgical approach for each clinical scenario. In phakic or pseudophakic eyes, removal of the medication reservoir from the anterior chamber is not possible without disturbing the lens. In these cases, as performed by Rogagha et al. [5], removal of the medication reservoir is best performed via a 3.5-mm or greater pars plana scleral incision. This also holds true for aphakic eyes undergoing a larger-gauge and non-conjunctivalsparing pars plana vitrectomy, especially if the
4
P. Y. Chang et al.
anchoring strut will be removed or another Retisert implanted. Spontaneous dissociation can be a late complication of Retisert implantation. This complication has so far been reported 5 years after implantation with our 2 cases occurring 6–7 years after implantation. When this occurs in a one-chambered eye, the medication reservoir can dislocate into the anterior chamber. Patients complain of a ‘‘white spot’’ in the eye. Surgeons and patients should be aware of this potential complication especially in eyes beyond the Retisert’s 30-month lifespan when no exchange of the implant is planned.
Downloaded by [186.190.28.215] at 22:48 05 November 2015
DECLARATION OF INTEREST All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. This study was supported in part by (1) The Einhorn Clinical Research Center, The New York
Eye & Ear Infirmary, Department of Ophthalmology Research Fund and (2) The Norma Lazar Eye Research Grant, New York, USA.
REFERENCES 1. Callanan DG, Jaffe GJ, Martin DF, et al. Treatment of posterior uveitis with a fluocinolone acetonide implant: three-year clinical trial results. Arch Ophthalmol. 2008;126: 1191–1201. 2. Yeh S, Cebulla CM, Witherspoon SR, et al. Management of fluocinolone implant dissociation during implant exchange. Arch Ophthalmol. 2009;127:1218–1221. 3. Wan W, Stewart JM. Use of a high infusion rate to prevent posterior dislocation of fluocinolone acetonide implant during surgical removal. Ocul Immunol Inflamm. 2011;19: 214–215. 4. Nicholson BP, Singh RP, Sears JE, et al. Evaluation of fluocinolone acetonide sustained release implant (Retisert) dissociation during implant removal and exchange surgery. Am J Ophthalmol. 2012;154:969–973. 5. Rofagha S, Prechanond T, Stewart JM. Late spontaneous dissociation of a fluocinolone acetonide implant (Retisert). Ocul Immunol Inflamm. 2013;21:62–63. 6. Akduman L, Cetin EN, Levy J, et al. Spontaneous dissociation and dislocation of Retisert pellet. Ocul Immunol Inflamm. 2013;21:87–89.
Supplementary material available online Supplementary Video
Ocular Immunology & Inflammation
