Refractory post-surgical cystoid macular edema managed following suprachoroidal microcatheterization and delivery of triamcinolone

Abstract

Background: Post-surgical macular edema (ME) is a common cause of prolonged visual impairment. Here we report on the feasibility and clinical outcomes from the use of a novel suprachoroidal microcatheter to treat post-surgical chronic ME by the posterior suprachoroidal placement of a triamcinolone acetonide (TA) suspension.

Methods: Two patients were catheterized with the Oxulumis suprachoroidal delivery system on two separate occasions starting 5 and 10 mm posterior to the limbus. The catheter only remains in the suprachoroidal space for the time of the drug administration. Visual acuity and spectral domain optical coherence tomography (SD-OCT) changes were followed over several weeks to months to determine the duration of ME resolution.

Results: Suprachoroidal microcatheterization for posterior delivery of triamcinolone was possible in all attempts using the illuminated Oxulumis catheter. No reflux, scleral or choroidal trauma was observed. There was no intraocular pressure rise during the follow-up period. The triamcinolone deposit was visible on infrared imaging and on SD-OCT a choroidal elevation was visible. Both progressively disappeared over time. A rapid resolution of ME associated with improved vision was observed following each injection for 3 to 7 months with a TA dose of 2.4 mg or 4 mg.

Conclusions: In these patients with poorly responsive ME, posterior suprachoroidal TA led to a visible suprachoroidal drug deposit and prolonged visual improvement. The Oxulumis microcatheterization device performed as expected and was not associated with any complications.

Keywords: CME; Drug visualization; Infrared; Macular edema; Microcatheterization; OCT; Posterior; Steroid; Suprachoroidal.

Fig. 1

(A) Schematic of the Oxulumis device for suprachoroidal catheterization and drug delivery. Depression of the lever allows deployment of an illuminated flexible catheter. (B) Schematic of the site of insertion and deployment of the Oxulumis device. The insertion site is at or beyond the pars plana, posterior to the limbus (left). The needle is inserted initially with an angle between 40 and 45 degrees until the bevel is fully engaged. The angle is then reduced to 15–20 degrees relative to the surface of the sclera (1). Even with the microcatheter triggered (2), deployment into the suprachoroidal space only happens once the needle tip has advanced past the scleral wall (3)

Fig. 2

Image of the clinical deployment of the Oxulumis device in the suprachoroidal space. The red light from the illuminated microcatheter is visible through the sclera and confirms correct suprachoroidal placement

Fig. 3

Evolution of visual acuity and OCT central macular thickness over time in Patient 1 and Patient 2. The time points of suprachoroidal injection are indicated by black triangles (days 0 and 183 for Patient 1, and days 0 and 107 for Patient 2). In Patient 1, two subtenon injections at days − 43 and − 29 are indicated by an orange arrow

Fig. 4

Heidelberg multispectral view of Patient 1: (A) at the time of the second injection, and (B) 118 days later. (C) shows the Optos image following the second injection. A temporal indentation is visible and delineated by the white arrows

Fig. 5

Heidelberg Spectralis imaging of the injection site in Patient 1: (A) at the time of the second injection and (B) 118 days later. The image on the left corresponds to the infrared imaging, while the image on the right is the corresponding enhanced depth imaging OCT image of the deposit. Both images show regression of the deposit over time