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Bilateral and severe FAME (fingolimod acute macular edema) treated by sub-tenon?s injections of corticosteroids: a case report

Session Details

Session Title: Quick Fire Free Paper Session 04

Session Date/Time: Sunday 29/09/2013 | 11:00-13:00

Paper Time: 11:15

Venue: Hall C (Level 1)

First Author: E.Merce FRANCE

Co Author(s):    S. Allieu              

Abstract Details

Purpose:

To report a severe case of FAME in a 61 years old women with MS (Multiple Sclerosis) treated with Gylenia 0,5 mg (fingolimod 0,5 mg ), to comment macular imaging of this retinal disease and to demonstrate successful use of periocular injections of triamcinolone.

Setting:

Fingolimod 0,5 mg is the first oral drug approved by the FDA for MS. It’s a sphingosine 1-phosphate (S1P) receptor modulator which plays a role in regulating vascular permeability. In studies a cystoid macular edema (CME) was observed in less than 0,5% of patients treated with the fingolimod 0,5 mg.

Methods:

Nine weeks after starting medication, she consulted in our departement because of an acute visual loss ; symptoms started to occur 2 weeks ago with blurred vision and a small shadow in central vision of both eyes . Best-corrected visual acuity was 20/40 OD and 20/40 OS (20/20 both eyes before starting Gylenia). The patient didn’t take any other drug Fundus examination showed CME in both eyes. Fluorescein angiography demonstrated leakage into the extravascular space in both eyes and confirmed bilateral CME without vasculitis. SD-OCT showed in both eyes distorsion of foveal contour with hyporeflective microcysts within the retina which predominantly involved the inner nuclear layer (INL). Central foveal thickness on SD-OCT was 509 μm OD and 451 μm OS. In spite of discontinuing fingolimog, visual acuity (VA) still decreased. 4 weeks after discontinuing medication VA was 20/60 OD and 20/60 OS and foveal thickness increased in both eyes : 523 μm OD and 521 μm OS. A sub tenon’s injection of 1 cc of triamcinolone in each eye was done to try to stop the process.

Results:

One month after sub tenon’s injections of glucosteroids, VA was higher in each eye : 20/30 OD and 20/30 OS. Dilated examination findings were normal in each eye and SD-OCT demonstrated bilateral resolution of macular edema (and of microcysts) and normal retinal profile with normal foveal depression. Central foveal thickness was 294 μm OD and 293 μm OS.

Conclusions:

A majority of cases of FAME occured within 3-4 months of initiation of treatment. Regular screening with Amsler grid, fundus examination and especially SD-OCT studies have to be established. SD-OCT screening is helpful to early detect microcysts in the INL. CME side effect is usually reversible after discontinuing Gylenia only. No additional care is usually required in minor FAME early diagnosed but there is no published data regarding the management of moderate and severe FAME. Topical NSAIDs (nonsteroidal anti-inflammatory drug) and/or corticosteroid eye drops can be used in moderate FAME.

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