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| LETTER TO THE EDITOR |
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| Year : 2022 | Volume
: 15
| Issue : 1 | Page : 119-120 |
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Inadvertent intralenticular Ozurdex removal
Madhurima Roy1, Aniruddha Maiti2, Sayan Das1, Sagnik Surya Das1
1 Susrut Eye Foundation and Research Centre, Kolkata, West Bengal, India
2 Department of Retina, Susrut Eye Foundation and Research Centre, Kolkata, West Bengal, India
| Date of Submission | 10-May-2021 |
| Date of Decision | 17-Nov-2021 |
| Date of Acceptance | 20-Nov-2021 |
| Date of Web Publication | 02-Mar-2022 |
Correspondence Address:
Dr. Madhurima Roy
Susrut Eye Foundation and Research Centre, Kolkata, West Bengal
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ojo.ojo_144_21
How to cite this article:
Roy M, Maiti A, Das S, Das SS. Inadvertent intralenticular Ozurdex removal. Oman J Ophthalmol 2022;15:119-20 |
Sir,
With time the number of patients undergoing intravitreal injections has grown exponentially, hence increasing the risk of accidental trauma to the lens. We report a case of accidental injection of Ozurdex into the crystalline lens elsewhere, which was removed successfully. A 45-year-old male who had a history of receiving an intravitreal Ozurdex (dexamethasone) implantation for macular edema due to branched retinal vein occlusion in the left eye elsewhere, came to us 3 months following the injection with the painless, gradual diminution of vision. Visual acuity was 20/120 and examination revealed posterior lenticular opacification with associated nuclear sclerosis, and the Ozurdex implant was visible inside the crystalline lens [Figure 1]. Posterior capsule status was not discernible on the slit lamp. Optical coherence tomography showed resolving macular edema with maintained foveal contour [Figure 2]a. B-scan revealed loss of convexity of the posterior capsule, with a cluster of echoes in the vitreous cavity immediately posterior to the posterior capsule [Figure 2]b. As posterior capsule rupture (PCR) was anticipated, sulcus implantation of three-piece IOL followed by vitrectomy, if required, was planned. The intraoperative view is shown in [Figure 3]a. During phaco-emulsification, the preexistent PCR was noticed [Figure 3]c and some lenticular fragments were seen to dislocate in the vitreous cavity [Figure 3]b. Hydrophobic acrylic three-piece IOL was placed in the sulcus. Pars plana vitrectomy was done in the same sitting and dropped lenticular matter was removed [Figure 3]d. Visual acuity improved to 20/80 at 6-month follow-up. | Figure 1: Slit-lamp photograph of the anterior segment of the left eye showing intralenticular Ozurdex implant (white arrow)
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 | Figure 2: (a) Optical coherence tomography showing resolved macular edema with few intraretinal cysts and maintained foveal contour. (b) B scan showing loss of posterior capsule convexity with a cluster of echoes in the vitreous cavity behind the posterior capsule of the crystalline lens
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 | Figure 3: (a) Intraoperative view of Ozurdex implant inside the crystalline lens (yellow arrow). (b) Dropped lens matter during phacoemulsification. (c) Preexistent posterior capsule rupture margin (yellow arrow) noted during emulsification of nucleus. (d) Intraoperative view of dropped lenticular matter (yellow arrow) removal by vitrectomy cutter
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FDA approved intravitreal dexamethasone implant (Ozurdex®; Allergen) in June 2009 for macular edema due to venous occlusion.[1] Its known side effects are progression of cataracts and secondary elevation of intraocular pressure.[2] The accidental injection of a dexamethasone implant into crystalline lens is an unexpected complication, and several cases among them had shown the progression of cataract, requiring surgery. Despite its intralenticular location, there was an improvement of macular edema in our case, although the therapeutic effect of intralenticular Ozurdex implant is controversial.[3] The implant was presumed to be partially intralenticular and partially intravitreal, later proven by the preexistent PCR discovered intraoperatively. Ozurdex implant had been pushed back into the vitreous cavity through the preexisting posterior capsular dehiscence in a few reports where macular edema was persisting, but there is also risk of drop of lens particles along with the implant.[4] Chhabra et al. reported a similar case where after 3 months of accidental intralenticular injection, removal of the Ozurdex implant was done by phacoemulsification and they also reported resolution of macular edema like in our case.[5] Hence, the therapeutic efficacy of inadvertently injected intralenticular Ozurdex depends on the location. Once inadvertent injection of Ozurdex into the crystalline lens occurs, the clinical management strategy might be based on whether the implant is directly in contact with the vitreous or is mostly inside the crystalline lens. In conclusion, the clinical decision to observe or to operate early a case of intralenticular Ozurdex to be individualized. Chances of preexisting posterior capsular dehiscence should be kept in mind before any intervention.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
 References | |  |
| 1. | Haller JA, Bandello F, Belfort R Jr., Blumenkranz MS, Gillies M, Heier J, et al. Dexamethasone intravitreal implant in patients with macular edema related to branch or central retinal vein occlusion twelve-month study results. Ophthalmology 2011;118:2453-60.  |
| 2. | Schmitz K, Maier M, Clemens CR, Höhn F, Wachtlin J, Lehmann F, et al. Reliability and safety of intravitreal Ozurdex injections. The ZERO study. Ophthalmologe 2014;111:44-52. |
| 3. | Sekeroglu MA, Anayol MA, Koc F, Tirhis H, Ozkan SS, Yilmazbas P. Intralenticular sustained-release dexamethasone implant: Is it still effective on macular edema? Case Rep Ophthalmol 2016;7:85-9. |
| 4. | Babu N, Kohli P, Shekhar M, Ramasamy K. Repositioning of inadvertent intralenticular ozurdex. Kerala J Ophthalmol 2020;32:73. [Full text] |
| 5. | Chhabra R, Kopsidas K, Mahmood S. Accidental insertion of dexamethasone implant into the crystalline lens-12 months follow-up. Eye (Lond) 2014;28:624-5. |
[Figure 1], [Figure 2], [Figure 3]
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