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Aflibercept/dexamethasone/triamcinolone Increased intra-ocular pressure in the right-eye and unresponsiveness to therapy: case report

An approximately 54-year-old woman exhibited unresponsiveness to aflibercept and desamethasone, indicated for diabetic macular edema (DME). She additionally developed increased intra-ocular pressure in the right-eye (RE) during treatment with dexamethasone for DME and off-label use of triamcinolone for DME [dosages and time to reaction onset not stated]. The woman, who had type 2 diabetes and DME, presented in 2011 with severe non-proliferative non-proliferative diabetic retinopathy (DR) in the right eye (RE). Macular laser and pan-retinal photocoagulation were performed in both the eyes in 2011 and in 2012. Her comorbidities included hypertension and dyslipidaemia. In 2013 (i.e. at the age of approximately 54 years), several intravitreal therapies were performed into the RE in a serial manner as follows: four intravitreal injection of off-label bevacizumab, one intravitreal injection of off-label triamcinolone [triamcinolone acetonide], three intravitreal injection of off-label bevacizumab, seven intravitreal injection of ranibizumab, two intravitreal injection of aflibercept and one intravitreal implant of dexamethasone injected into the RE. However, her DME was unresponsive. Of note, triamcinolone led to increased IOP in the right-eye. The IOP changes were being managed with timolol, brinzolamide and brimonidine. However, within one week of dexamethasone therapy, a further increase in IOP was noted. As a result, surgery (cyclophotocoagulation guided with transillumination) was performed. At that point, IOP was ~16mm Hg and was managed without any medication. In June 2016, she received fluocinolone acetonide [Iluvien] implant. One week later, her IOP decreased [aetiology not stated]. Timolol and brimonidine eye drops were required to manage her IOP. On day 40, cataract surgery was performed without worsening of DME. Due to persistence of DME, ranibizumab was added at months 4, 7, 9 and monthly thereafter up to month 20, with two more injections given at months 23 and 24. A total of six and ten administrations of ranibizumab were given in year 1 (2016) and year 2 (2017), respectively. From month 24, the macula was dry, and no supplemental therapies were required. A reduction in oedema was accompanied by an improvement in DR status. Her central macular thickness and best corrected visual acuity improved at month 39 post fluocinolone acetonide injection (i.e. in 2019 at the age of 60 years). At baseline she had poor glycemic control, which progressively improved at the end of follow-up period. Pessoa B, et al. Challenging clinical cases - a walk through supplemental therapy with intravitreal ranibizumab therapy following treatment of diabetic macular edema with the 0.19 mg fluocinolone acetonide implant (iluvien). International Medical Case Reports Journal 13: 437-448, 2020. Available from: URL: http://doi.org/10.2147/ 803515388 IMCRJ.S262587

0114-9954/20/1830-0001/$14.95 Adis