First Author: M.Parnell UK
Co Author(s): S. Mann
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To present a case of bilateral central retinal vein occlusion in a pregnant female treated successfully with Ozurdex® implants.
Eye emergency clinic and medical retina clinic at St Thomas’ Hospital, part of Guy’s and St Thomas’ NHS Foundation Trust, London.
We present a 23 year old female who visited the eye emergency clinic with blurred vision in the left eye. She had reduced vision at 6/18 (6/12ph) and evidence of a left central retinal vein occlusion. She had no past ocular history of note. Past medical history included type 1 diabetes mellitus with poor control (HbA1C 10.7). There was no history of systemic venous thromboses and no family history of note. She was referred to the medical retina clinic and the diagnosis was confirmed with fluorescein angiography. She was consented for a course of aflibercept intravitreal injections and referred to the diabetes team and the haematology team for further investigation and management. Following the first aflibercept injection to the left eye her macular oedema resolved from central retinal thickness (CRT) of 853microns to 230microns and she therefore continued the course with a second injection. At her third injection appointment she was found to have a right eye central retinal vein occlusion with reduced vision to 6/9.5 and informed us she was 8 weeks pregnant.
The course of aflibercept was discontinued due to pregnancy and the option of Ozurdex® discussed with her diabetologist who advised not to treat during first trimester. At her next follow up her IOP was raised with narrow angle on gonioscopy and peripheral anterior synechiae. She was reviewed by the glaucoma team who performed laser peripheral iridotomy to the right eye and her pressure normalised on g. timolol only which is regarded to be safe in pregnancy. At 13 weeks into pregnancy her right eye had a vision of 6/36 and a CRT of 1030microns and she therefore received a right eye Ozurdex® implant. At 2 month follow up this had completely resolved the oedema and vision improved to 6/9. Her left eye had deteriorated with gross macular oedema (CRT<1000microns) and vision reduced to 6/14. She therefore received an Ozurdex® implant in the left eye which at 1 months follow up had reduced the CRT to 700microns. Her systemic investigations under the haematolgists revealed a mildly positive IgM anticardiolipin and she has been prophylactically anticoagulated on low molecular weight heparin.
This case presented a therapeutic challenge due to bilateral vein occlusions concurrently with pregnancy precluding use of anti-VEGF agents. Anti-VEGF agents would be considered first line in this instance due to phakic status and treated primary angle closure had the patient not been pregnant. Available anti-VEGF agents are not recommended for use in pregnancy due to animal studies demonstrating harm. The USA Food and Drug Administration (FDA) classifies them as category C which they define as ‘Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks’. It is interesting to note that were her visual loss secondary to diabetic macular oedema NICE guidance would not allow use of Ozurdex® due to her phakic status; a restriction not imposed on macular oedema secondary to vein occlusions. In conclusion we report an unusual case of bilateral central retinal vein occlusions occurring in pregnancy successfully treated with bilateral Ozurdex® implants in a multidisciplinary team involving diabetologists, haematologists and ophthalmologists.