Dexamethasone implant anterior chamber migration: risk factors, complications, and management strategies.

OBJECTIVE: To describe the risk factors, clinical course, and complications of migration of a dexamethasone (DEX) intravitreal implant (OZURDEX; Allergan, Inc., Irvine, CA) into the anterior chamber and subsequent management strategies. DESIGN: Retrospective, observational case series. PARTICIPANTS: Fifteen patients had 18 episodes of migration of the DEX implant into the anterior chamber. METHODS: The medical records of 15 patients with spontaneous migration of a DEX implant were retrospectively reviewed. MAIN OUTCOME MEASURES: Migration of the DEX implant into the anterior chamber. RESULTS: Migration of a DEX intravitreal implant into the anterior chamber occurred in 6 patients who were aphakic, 4 patients with an anterior chamber intraocular lens, 2 patients with a scleral-fixated posterior chamber intraocular lens (PCIOL), 2 patients with a PCIOL, and 1 patient with an iris-fixated PCIOL. All 15 patients had prior pars plana vitrectomy, and 14 patients (93%) had no lens capsule. The average interval from DEX implant injection to detection of the implant migration into the anterior chamber was 13 days (range, 5-44 days). In 14 patients, corneal edema developed. Among those eyes undergoing surgical removal of the implant, earlier intervention reduced the likelihood of permanent corneal edema (0.5 days [from diagnosis of migration to surgical removal of the implant] vs. 5.5 days; P = 0.04). Aspiration was necessary to remove the implant in 6 patients. Among the 14 patients with corneal edema, the corneal edema did not resolve in 10 patients (71%), 6 (43%) of whom required corneal transplantation. CONCLUSIONS: Absence of lens capsule and prior vitrectomy are risk factors for migration of the DEX implant into the anterior chamber. Early removal of the implant may be necessary to minimize the risk of chronic corneal edema.

SEGMENTAL PATTERN OF INFILTRATES OVER RETINAL VESSELS IN FUNGAL ENDOPHTHALMITIS.

PURPOSE: To describe the case of a patient with Candida tropicalis endophthalmitis who presented with a pattern of segmentally distributed preretinal infiltrates overlying the retinal blood vessels. METHODS: A retrospective chart review was performed. A 72-year-old East Indian male presented with redness, pain, photosensitivity, and loss of vision in the right eye for 1 month. He had been recently hospitalized for necrotizing pancreatitis and had been receiving intravenous medications as well as parenteral nutrition through a peripherally inserted central catheter. RESULTS: Fundus examination revealed moderate vitreous cells and infiltrates, including a segmental pattern of preretinal bead-like opacities along several blood vessels. The patient underwent emergent vitrectomy with injection of antibiotics and antifungal medications. Vitreous cultures grew C. tropicalis. The patient was treated with oral antifungal medication for 6 weeks. By 7 weeks after surgery, all infiltrates and inflammatory cells had completely resolved. The imaging and intraoperative observations suggest that the opacities behaved like infiltrates and were associated with vitreous rather than vascular inflammation. CONCLUSION: A segmental pattern of preretinal infiltrates over retinal vessels can be a presenting feature in endogenous fungal endophthalmitis. The observations in this case may contribute to understanding the pathophysiology of the findings.

Subclinical hypercortisolism in central serous chorioretinopathy.

PURPOSE: To describe a case of a patient with chronic central serous chorioretinopathy who was found to have an adrenocorticotropin-secreting pituitary microadenoma despite the absence of many clinical signs of Cushing syndrome. METHODS: A retrospective chart review was performed. This study included a 42-year-old white woman with a history of chronic central serous chorioretinopathy. RESULTS: The patient was found to have severe osteoporosis; although many of the classic signs of Cushing syndrome were absent, laboratory studies and neuroimaging suggested the presence of a pituitary microadenoma. Ophthalmic evaluation revealed the presence of bilateral submacular fluid because of chronic multifocal central serous chorioretinopathy. The patient underwent bilateral photodynamic therapy and surgical excision of the pituitary lesion. Pathologic evaluation confirmed that the pituitary lesion was a pituitary microadenoma. CONCLUSION: Careful attention to the signs of hypercortisolism in patients with central serous chorioretinopathy may aid in detecting underlying systemic pathology. Endocrinology evaluations in patients presenting with any manifestations of Cushing syndrome may be warranted, even if many classic physical findings are absent.