Role of optical coherence tomography in evaluation of pseudophakic cystoid macular edema (on the basis of clinical cases)

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Ophthalmology Azerbaijan Medical University

Clinic of Surgery of the Azerbaijan Medical University

Role of optical coherence tomography in evaluation of pseudophakic cystoid macular edema (on the basis of clinical cases)

Gahramanov Hafiz Musalim oglu, MD, PhD, Docent of the Department

Zulfiyev Gabil Gadulla oglu, MD, PhD, Docent of the Department

Rizayeva Malahat Karam kizi, Ophthalmologist Ophthalmology Department

Summary

Pseudophakic cystoid macular edema (PCME) is one of the reasons that reduces the vision significantly after the cataract surgery. One of the modern non-invasive imaging detections and response in treatment for pseudophakic cystoid macular edema is OCT. In this study, 2 clinical cases of PCME were described after the cataract surgery, the efficacy of OCT examination was evaluated before the treatment and the follow up examination after the treatment. Although the first clinical case did not have any risk factors, it was recorded that the second clinical case had a risk factor of diabetic retinopathy. In both of the cases OCT detected that the central retinal thickness was increased (in accordance with 400 gm and 800 gm). In the first case only medical treatment, but in the second case medical treatment with i/v bevacizumab was injected. In both cases, in response to treatment, restoration of vision and the normalization of macular thickness was detected by OCT.

As a result, we believe that OCT plays a big role in evaluating the response treatment with local, oral and invasive benefit when is appropriate for PCME.

Key words: Pseudophakic cystoid macular edema, local, oral and intravitreal (invasive) treatment, OCT.

Abstrakt

Ismayilov Gurban Meyfali oglu. MD, PhD, Assistant of the Department of Ophthalmology Azerbaijan Medical University

Ztilfiyev Q.Q. Oftalmologiya §Obssi Azsrbaycan Tibb Universiteti

Qshrsmanov H.M., Oftalmologiya gObssi Azsrbaycan Tibb Universiteti

Ismayilov G. M., Oftalmologiya Obssi Azsrbaycan Tibb Universiteti

Rizayeva M.K., Oftalmologiya §Obssi Azsrbaycan Tibb Universiteti

PSEVDOFAKIK KISTOID MAKULA ЦDEMI KLINIKASININ D0Y0RL0NDIRILM0SIND0 OKULYAR KOHERENT TOMOQRAMANIN ROLU (KLINIK HALLAR 0SASINDA)

Psevdofakik kistoid macula Odemi (PKMO) katarakta carrahiyyasi sonrasi rast galinan va gOrmani ciddi azal- da bilan sabablardan biridir. PKMO-nin a§kar olunmasinda va mualicaya cavabin dayarlandirilmasinda muasir qeyri-invaziv gOruntulama usullarindan biri olan OKT olduqca yararlidir.

Bu tadqiqat i§inda katarakta amaliyyati sonrasi PKMO inki§af etmi§ 2 klinik hal tasvir olunmu§ va mualicaya cavabi va mualicanin taqib olunmasi sirasinda OKT muayinasinin taqib olunmasi sirasinda OKT muayinasinin effektliliyi dayarlandirilmi§dir. I klinik halda har hansi bir risk amili olmadigi halda II klinik halda yana§i diabet retinopatiyasi oldugu risk amili kimi qeyda alinmi§dir.

Har iki halda markazi retina qalinliginin artmi§ olmasi (mu- vafiq olaraq 460 щ va 800 щ) OKT ila muayyan olundu. I halda yalnizyerli medikal mualica, II halda isa yerli medikal mualica ila yana§i i/v bevacizumab inyeksiya olundu. Har iki halda mualicaya cavab naticasi olaraq gOrmanin barpasi ila barabar makula qalinliginin normalla§masi OKT ila a§kar olundu.

Natica olaraq PKMO mualicasinda yerli, oral va lazim galdikda invaziv mualicanin yararli olmasi va mualicaya cavabin dayarlandirilmasinda OKT-nin rolunun bOyuk olmasini du§unuruk.

Agar sOzbri: Psevdofakik kistoid makula Odemi, yerli, oral va intravitreal (invasiv) mualica, OKT.

Аннотация

РОЛЬ ОКУЛЯРНОЙ КОГЕРЕНТНОЙ ТОМОГРАММЫ (ОКТ) ПРИ ОЦЕНКЕ КЛИНИКИ ПСЕВДОДАКИЧНОГО КИСТОИДНОГО МОКУЛЯРНОГО ОТЁКА (КЛИНИЧЕСКИЕ СЛУЧАИ)

Гахраманов Хафиз Мусалим оглы, доктор медицинских наук, доцент кафедры офтальмологии Азербайджанский медицинский университет

Исмайлов Гурбан Мейфали оглы, доктор медицинских наук, ассистент кафедры офтальмологии Азербайджанский медицинский университет

Зульфиев Габиль Гадулла оглы, доктор медицинских наук, доцент кафедры офтальмологии Азербайджанский медицинский университет

Ризаева Малахат Карам кызы офтальмолог, Офтальмологическое отделение, Клиника хирургии Азербайджанского медицинского университета

Псевдофакичный кистоидный макулярный отёк (ПКМО) один из серьёзных осложнений встречаемых после хирургии катаракты который приводит значительному ухудшению зрения. ОКТ не инвазивный метод обследования-очень ценный для раннего выявления РКМО и оценки эффективности лечения.

В это исследование включены 2 клинических случая с РКМО развившиеся после хирургии катаракты. Течение патологических изменений и эффективность лечения были контралированы ОКТ. В 1-м клиническом случае факторы риска не были обнаружены, во 2-ом случае была отмечена диабетическая ретинопатия. В обоих случаях ОКТ обнаружила значительное повышение центральной макулярной толщины (ЦМТ), соответственно 460 мкм и 800 мкм.

В 1-ом случае была применена местная медикаментозная терапия, а во 2-ом случае наряду с медикаментозным лечением введён и/в бевачизумаб. В обоих случаях наряду с повышением зрения ОКТ выявила снижение ЦМТ до нормальных величин. Как результат можно отменить ценную роль ОКТ для раннего выявления и динамического наблюдения ПКМО, а также для оценки ответа на применяемое локальное и и/в лечение.

Ключевые слова: псевдофакичный кистоидный макулярный отёк, локальное и интравитреальное лечение, ОКТ.

Introducion

pseudophakic macular edema tomography

Cystoid macular edema is the result of the collection of retinal fluid in the perifoveal zone (inner and outer nuclear layers) and the formation of fluid-filled cystic changes Fig.1, 2 [1; 2].

One of the complications of the cystoid macular edema that is seen mostly after the cataract surgery is called pseudophakic cystoid macular edema (PCME). For the first time this complication after the cataract surgery was described by Irvine in 1953 and later by Gass [3] due to description of cystoid macular edema by fluorescein angiography [4], so the pseudophakic cystoid macular edema was called the Irvine-Gass syndrome.

Fig. 1 (J. J. Kanski, 2007)

Fig. 2 (J. J. Kanski 2007)

In literature the frequency of pseudophakic cystoid macular edema is between 1-30% [5]. This indicator can be affected by many factors such as the experience of the surgeon, characteristics of each clinical condition, type of surgery, accompanying systemic diseases and eye diseases, and complications occurring during the surgery.

The incidence of PCME is more seen after the in- tracapsular extraction of the lens [6] and less likely to be followed by phacoemulsification (Phaco) and extracapsular extraction of the lens (ECCE) [7], but angiographic PCME after ECCE compared to after Phaco surgery has been reported to be less common [8].

Without risk factors and complications after the cataract surgery, the clinical significance of PCME is seen between 1-2% [5].

Modern imaging techniques such as ocular coherent tomography (OCT) and fluorescein fundus angiography (FFA) play a big role in finding the PCME. Thus, the incidence of PCME in OCT studies have been reported to be 41% and 20-30% in FFA studies [9].

Purpose. To investigate the role of OCT in the diagnosis of pseudophakic cystoid macular edema after the cataract surgery and treatment response based on the findings we encountered in our clinic.

Clinical Case 1

A 68-year-old patient (woman) was admitted to our clinic with a complaint of poor vision in the right eye and upon evaluation of ophthalmic examination, Vis

OD was 0.09 in the right eye and Vis OS was 0.6 in the left eye. Patient was diagnosed with immature age-related cataract in the right eye and phacoemulsification of the cataract was performed with no complications and intraocular artificial lens (IOL) was implanted. There was no somatic or ocular risk factor that could have detected a cystoid macular edema in the patient previously. First day after the surgery: Vis OD was

9. Patient was prescribed topical prednisolone acetate drop: 1 drop 6 times a day, Moxifloxacin 1 drop 6 times a day, Diclofenac sodium 1 drop 3 times a day and after 4 weeks the drops were lowered in dosage and were no longer used. 6 weeks after the surgery the patient was admitted back to our clinic with a complaint of decreased vision and the vision in the right eye decreased to 0.1. Upon examination, cornea was transparent, anterior chamber and anterior vitreous were stable and artificial IOL was in capsular bag, but some less noticeable opacities in posterior vitreous (USE), loss of macular reflex on ophthalmoscopy of the retina, not very noticeable intraretinal cysts and subretinal fluid was found on OCT. Thickness of macula was found to be 356 pm (Figure 3, 4, 5), taking into account available signs and clinical picture, it was diagnosed with pseudophakic cystoid macular edema. Again, prednisolone acetate 1 drop 4 times a day, Nevanac 1 drop 4 times a day for the right eye, and oral carbonicanhydrase inhibitor (Diacarb 0.5mg) (and/or systemic acetazolamide 2 x 125) was prescribed.

Fig. 3

Fig. 4

Fig. 5

Fig. 6

Fig. 7

Fig. 8

Fig. 9

The patient was called back after a 2-week break. During this visit, the visual acuity in the right eye was slightly up (Vis OD=0.2) and due to the fact that on fundus examination there was a lack of macular reflex a subtenon kenalog injection was done. The next time during the control period, there was a marked increase in vision: 4 weeks after the injection, the visual acuity in the right eye increased to 0.6. The reflex of macula was seen clearly, and most importantly OCT examination revealed correct foveal contours and decreased in macular thickness (Figure 6, 7, 8, 9).

Clinical Case 2.

A 62-year-old male was admitted to our clinic with a complaint of poor vision in both of his eyes. When he was admitted: Vis OD = 0.2 with no correction, and Vis OS = 0.04 with no correction, and and he was diagnosed with cataract for both eyes. Patient is diabetic for a long time now.

Considering that the pupil of the right eye was not dilating very well before the surgery, Diclofenac sodium was prescribed 1 drop 3 times a day; phacoemulsification surgery with no complication was performed and IOL was implanted in the right eye together. First day after the surgery, visual acuity for the left eye was 0.8. Patient was prescribed topical prednisolone acetate drop: 1 drop 6 times a day, Moxifloxacin: 1 drop 6 times a day, Diclofenac sodium: 1 drop 3 times a day. 3 weeks after the surgery, the visual functions remained stable and the prescribed eye drops were reduced. However, the 4th week after the surgery, patient noticed that his vision in the left eye was decreased, so he came back to our clinic once again. This time, patient's left eye's visual acuity was 0.08, transparent cornea, intraocular fluid and vitreous stable, pupillary reaction to the light was alive, IOL was in capsular bag. Fundus examination revealed significant macular edema and loss of foveal reflex. OCT examination showed intraretinal cysts, collection of subretinal fluid and increased macular thickness (811pm) (Figure 10, 11, 12).

Local prednisolone acetate 1 drop 6 times a day, Diclofenac sodium 1 drop 4 times a day, Diacarb 0.5mg 3 times, was prescribed and subtenon triamcinolon (kenaloq) was injected. After 2 weeks: although vision improved to 0.2 in the left eye, there was no significant change in macular thickness and it was decided to continue for control. 8 weeks' postop examination, vision in the left eye the same and little bit reduction in the central macular thickness on OCT examination (Figure 13, 14).

Fig. 10

Fig. 11

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Fig. 13

Fig. 14

Fig. 15

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Fig. 17

Fig. 18

Inravitreal bevacizumab was injected into the patient's left eye and 2 weeks after the i/v injection on examination, the visual acuity increased to 0.7 and there was a decrease in macular thickness (Figure 15, 16, 17, 18).

As of right now, Diclofenac sodium is continued to the left eye 1 drop 3 times a day and the patient is kept under the supervision.

Discussion

PCME is thought to be one of the significant complications that may result in a decrease of vision 4-6 months after the surgery [10]. Even without systemic and ocular risk factors, this complication can occur after a cataract surgery [5]. Decrease in vision is a result of the development of edema in fovea. It is believed that CME develops in the fovea as a result of high metabolic activity of fovea, and that the foveal avascular zone and internal limiting membrane (ILM) of retina are thin [11].

The inflammatory mediators especially the prostaglandins are important in the ethiopathogenesis of PCME [12].

It is believed that, due to increased inflammatory mediators, the breakdown of blood-anterior chamber fluid and blood-retinal barrier, and increased vascular permeability stimulates the mechanism of CME pathogenesis [9].

There are literature informations about a role of diabetes, uveitis, retinal vein occlusion and epiretinal membrane, the use of prostaglandin analogues, choroidal tumors, systemic and ocular risk factors such as aging, in the development of PCME [13]. Vitreous liquification, pre-displacement, vitreous loss during the surgery [14], posterior capsular tear [15], the inflammation due to intraocular lens (IOL) always touching the iris [16], can also play a role in development of PCME.

The diagnostics of PCME is associated with decreased vision along with fundus examination (loss of foveal reflex). FFA and OCT examinations also play a big role. On the FFA there is a perifoveal leakage in the early phases and characteristic of petaloid-flower- image in late phases [17] (Figure 19).

Fig. 19

OCT is a special method [9] to detect thickening in macula and cysts in the outer strand, but also a very valuable method that allows you to monitor and control the correction of macular edema. One of the patients that we observed had only OCT examination and treatment dynamics was monitored with OCT image and clinical picture. The other patient had an OCT examination and FFA was used for the diagnosis. It should be noted that, the development of PCME in the first patient corresponds to the 6th week of postop period and 4th week for the second patient. In both patients, there was a macular thickening on OCT examination (respectively 356 and 811pm) with typical cystic gaps, and in the second patient typical angiographic image was detected on FFA. PCME in the second patient was seen earlier and thickness of the macula on the OCT examination can be correlated with the relevant risk factor that the patient had diabetes mellitus for a long term.

There is extensive information in the literature about the use of non-steroidal anti-inflammatory drugs in the treatment of PCME, local periocular oral steroids, intravitreal administration, the use of oral carbohydrase ingibitors, and the use VEGF drugs in recent years [18; 19; 20; 21].

After the surgery, both of the patients received steroid and non-steroidal anti-inflammatory drugs locally. Because there was a good visual acuity and no risk factors in the first patient, both of the drugs were discontinued after 4 weeks.

In the second patient, CME has developed continuing the use of these drugs. For both patients, oral carboantihydrase inhibitor was added in addition to continuation of NSAID and steroids.

The first patient received a subtenon kenalog injection 2 weeks after the treatment (8 weeks after surgery) and 4 weeks after injection OCT revealed redusing of macular thickness. The second patient received subtenon kenalog injection 4 weeks after the surgery. Although the vision increased in the second patient 8 weeks postoperatively, there was still no reduction of thickness of the macula on the OCT examination so, intravitreal injection of bevacizumab was done.

After 2 weeks, the vision in the right eye increased to the level it was the first day after the surgery and a significant decrease in macular thickness (280pm, Fig.16) was seen on the OCT examination.

Thus, PCME both risky and risk-free can also occur after non-traumatic cataract surgery. To overcome this complication, the use of long-term local steroids, NSAIDs and oral carboanhydrases inhibitors were very effective, which was also reflected in literature. A particular aspect is that, to assess the treatment dynamics particularly in measuring macular thickness and evaluating the reverse rate of PCME, the OCT examination as noninvasive method plays a big role.

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