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Journal Français d'Ophtalmologie
Volume 39, n° 8
pages e211-e212 (octobre 2016)
Doi : 10.1016/j.jfo.2015.05.012
Lettres à l'éditeur

Prevention of accidental injection of dexamethasone intravitreal implant into the crystalline lens
Prévention des injections accidentelles d’implant intravitréen de déxaméthasone dans le cristallin
 

N. Taright a, , G. Guedira a, H. Morfeq a, b, A. Drimbea a, S. Milazzo a
a Department of ophthalmology, Amiens university hospital, CHU Amiens-Picardie, avenue René-Laënnec, Salouel, 80054 Amiens cedex 1, France 
b Department of ophthalmology, faculty of medicine, King Abdulaziz university, Jeddah, Rabigh, Saudi Arabia 

Corresponding author.

The dexamethasone implant (Ozurdex®; Allergan, Inc., Irvine, California, USA) can provide beneficial effects in the management of macula edema secondary to retinal vein occlusions, diabetic retinopathy and uveitis. It has a favorable safety profile and acute serious adverse effects including endophtalmitis, retinal detachment and vitreous hemorrage are rare. We present three further cases where dexamethasone implant was accidentally injected into the crystalline lens. Patients were scheduled for Ozurdex® injection to treat macula edema due to vein occlusions. Patients were injected by young residents. Injections were performed in the inferonasal (Figure 1) or inferotemporal quadrant (Figure 2, Figure 3), 4mm posterior to the limbus. Cataract surgery with removal of the implant was performed 43 (case 1), 15 (case 2) and 4 days (case 3) after the injection. In the first patient (case 1) there was an intraocular pressure (IOP) increase, which required treatment with topical hypotensives. For the three patients, surgery was performed through 2.2-mm clear corneal incision. Hydrodelineation with a smooth hydrodissection was performed to prevent extension of posterior capsular tear. The cataract was soft, nucleus and cortex was easily aspirated with using an irrigation-aspiration probe, using low flow parameters. The implant was removed using a forceps with distal command through the 2.2-mm incision. Anterior vitrectomy was performed in all patients. Then the intraocular lens was placed in the sulcus.



Figure 1


Figure 1. 

Patient 1, traumatic cataract in retroillumination, dexamethasone implant into the crystalline lens.

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Figure 2


Figure 2. 

Patient 2, traumatic cataract in retroillumination, dexamethasone implant into the crystalline lens.

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Figure 3


Figure 3. 

Patient 3, traumatic cataract in retroillumination, dexamethasone implant into the crystalline lens.

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Interviewing residents about their injection procedure, they all displaced the conjunctiva with a cotton-tipped swab. They all injected the dexamethasone intravitreal implant at a fairly steep angle between 10 and 20° and bury the bevel into the sclera. However, they directly pushed the needle in and released the implant by pressing the plunger. None of them moved toward the optic nerve with a 90° angle to the sclera before pressing the plunger.

They were not used to small-gauge surgery, and were not comfortable with trocar placement. However, they was used to standard intravitreal injections. One of them did not try to perform injections on wet lab before injecting the first patient.

Several conclusions can be drawn from this case series. The 22-gauge injector is larger than 30-gauge needles used for intravitreal injections. The pressure exerted on the sclera is more important, which can cause pain and inadvertent eye movements [1]. To avoid this complication, subconjunctival anesthesia can be used in selected anxious patients. However, intravitreal injection of Ozurdex® is not associated with increased pain compared with bevacizumab [2]. In our cases, the wrong direction of the needle, 4mm posterior to the limbus, but not toward the posterior pole led to the complication. Furthermore, injection of the dexamethasone implant 3,5mm posterior to the limbus in a phakic patient, although with a good direction can lead to dexamethasone implant into the crystalline lens [3]. The technique of intravitreal injections has a learning curve especially for young residents, or for non-surgical ophthalmologists. The guidelines from various studies suggest that the site of intravitreal injection should be 4mm posterior to the limbus for phakic eyes [4, 5]. Accurate measurements are achieved by the use of sterile calipers [6, 7]. The needle must be directed toward the optic nerve [8] in the inferotemporal quadrant. Chharbra et al. [9], highlights the need to ensure patient education, keep in mind the language barriers and spending extra-time with the patient, with the help of an interpreter if possible, to reassure the patient and avoid this accident. Even if rare, it is important to remember that intravitreal injection of implants can lead to traumatic cataract. This complication can be prevented by a good learning of the technique, 4mm posterior to the limbus, in the inferotemporal quadrant, directed toward the optic nerve, on a reassured patient. We advice for those who are new to injecting the dexamethasone intravitreal implant to approach it much like standard intravitreal injections. If the physician does not have experience with small-gauge surgery, we recommend a wet lab to practice the injection, so that the comfort level is high when injecting the first patient.

Disclosure of interest

The authors declare that they have no competing interest.

References

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