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A surprising intravitreal injection attempt

Ozurdex™ implantation for Behçet's disease

Furundaoturan, Onur; Barış, Mine E; Yılmaz, Suzan Güven

Author Information
doi: 10.4103/ijo.IJO_2241_20
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Dear Editor,

Behçet's disease (BD) is a multisystem disorder characterized by oral and genital ulcerations, skin lesions, ocular inflammation, and vascular involvement.[1] The underlying pathology is occlusive vasculitis effecting mostly veins. The most common ocular manifestation is acute, recurrent, often bilateral, and nongranulomatous panuveitis. The disease has a higher prevalence in the Mediterranean region.[2] Macular edema is one of the most common causes of vision decrease in BD.[3] Corticosteroids, immunosuppressants, and biologic agents are used for the treatment of macular edema in Behçet uveitis.[45]

A 42-year-old man with history of BD for 24 years developed cystoid macular edema, 1 year after the ocular symptoms started as posterior uveitis. The patient was consulted with rheumatology, and ocular inflammation was stabilized with oral corticosteroids and interferon alfa treatment. After 4 months without recurrence of the uveitis, he applied to our clinic with decreased vision in the right eye. His best-corrected visual acuity was 0.30 logMar in the right eye and 0.00 logMar in the left eye. Anterior segment examination was within normal limits and fundus examination revealed perivascular sheathing with a swelling optic disk. Optical coherence tomography and fluorescein angiography images were obtained. The imaging revealed cystoid macular edema with no neovascularization and ischemia [Fig. 1]. In the light of examination and imaging findings, the decision of intravitreal Ozurdex™ injection was made. The injection of the drug was performed in the operation room under sterile operation conditions. During the injection, we encountered a resistance and observed that both the sclera and the conjunctiva were still intact. By evaluating the injector under the operating microscope, we detected a microscopic curvature at the tip of the injector [Fig. 2]. The injection of the drug was cancelled, and we contacted the company. After replacement of the faulty product with a new one, injection was performed without any issues or complications.

Figure 1
Figure 1:
Optical coherence tomography and fluorescein angiography images revealed cystoid macular edema
Figure 2
Figure 2:
Image of the curved injector tip

Although using the appropriate technique recommended for intravitreal injection, we encountered an unexpected event. Possible causes are manufacturing or packaging faults.

In conclusion, an improbable event which made a delay for the treatment was happened, and to the best of our knowledge, it has not been reported before. Controlling the injector before the procedure might prevent possible damages that could be caused by the forced injection of a faulty needle to the eye.

2.1 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.

2.2 Financial support and sponsorship

Nil.

2.3 Conflicts of interest

There are no conflicts of interest.

References

Ksiaa I, Abroug N, Kechida M, Zina S, Jelliti B, Khochtali S, et al Eye and Behçet's disease J Fr Ophtalmol. 2019;42:e133–46
Cunningham ET Jr, Tugal-Tutkun I, Khairallah M, Okada AA, Bodaghi B, Zierhut M. Behçet Uveitis Ocul Immunol Inflamm. 2017;25:2–6
Kahloun R, Ben Yahia S, Mbarek S, Attia S, Zaouali S, Khairallah M. Macular involvement in patients with Behçet's uveitis J Ophthalmic Inflamm Infect. 2012;2:121–4
Cantini F, Niccoli L, Nannini C, Kaloudi O, Cassarà E, Susini M, et al Efficacy of infliximab in refractory Behçet's disease-associated and idiopathic posterior segment uveitis: A prospective, follow-up study of 50 patients Biologics. 2012;6:5–12
Sota J, Rigante D, Lopalco G, Frediani B, Franceschini R, Galeazzi M, et al Biological therapies for the treatment of Behçet's disease-related uveitis beyond TNF-alpha blockade: A narrative review Rheumatol Int. 2018;38:25–35
© 2020 Indian Journal of Ophthalmology | Published by Wolters Kluwer – Medknow