Intravitreal methotrexate and fluocinolone acetonide implantation for Vogt-Koyanagi-Harada uveitis

Abstract

Purpose To report a case of intravitreal methotrexate treatment and fluocinolone acetonide (Retisert®) implantation in a patient with Vogt-Koyanagi-Harada syndrome (VKH). Observations A 34-year-old male was referred for worsening vision and bilateral panuveitis consistent with VKH. He was treated with prednisone, mycophenolate mofetil, prednisolone acetate eye drops, and injections of triamcinolone and adalimumab. He failed to improve with these therapies and developed multiple adverse effects, including hepatotoxicity, severe eye pain, cataracts, and cystoid macular edema. We treated him with intravitreal methotrexate injections in both eyes, which rapidly improved his eye pain, inflammation, and vision. He subsequently underwent fluocinolone acetonide (Retisert®) implantation, cataract extraction with intraocular lens insertion, and Ahmed tube placement for long-term intraocular pressure control. His vision improved from hand motions to 20/30, intraocular pressure remained stable at 17, there was complete resolution of his panuveitis and uveitic macular edema, and his systemic medications were able to be discontinued. Conclusions /Importance: This case demonstrates intravitreal methotrexate may successfully treat intraocular inflammation, pain, and macular edema in VKH. Excellent long-term vision and reduction of adverse effects of systemic medications were also achieved with subsequent fluocinolone acetonide implantation. Combining these two targeted therapies may be an effective strategy in treating VKH in patients who have severe pain and cannot tolerate systemic therapy.

Overcoming Treatment Challenges in Posterior Segment Diseases with Biodegradable Nano-Based Drug Delivery Systems

“…Recent studies have shown the effectiveness of intravitreal drug delivery systems such as rapamycinloaded polymeric micelles and nano-liposomes of vancomycin [13,14]. Other intravitreal drug delivery methods include the use of vitamin E/poly-lactic-co-glycolic acid microspheres containing glial cell line derived neurotrophic factor (GDNF) to protect retinal ganglion cells and biodegradable polyester amide implants for diabetic macular edema and neovascular age-related macular degeneration treatment [15][16][17]. An intravitreal injection of flurbiprofen using a novel liposome aggregate platform demonstrated prolonged drug retention and reduced inflammation in ocular tissue compared to conventional liposomes [18].…”

“…Nanoparticles form self-assembling and ordered architectures with different topologies tailored to encapsulate the guest drugs including nanospheres, nanorod assemblies [15,16], and nanocapsules. These polymers usually respond rapidly to micro-environment changes and can release guest molecules in controlled schedules, which makes them good platforms for drug-delivery carriers.…”

A comprehensive review of intravitreal immunosuppressants and biologicals used in ophthalmology

“…There is a single case report which shows the efficacy of a single dose of intravitreal MTX (400 μg/0.1 mL) in a case of Vogt-Koyanagi-Harada disease (VKH) which was previously treated with oral prednisolone and mycophenolate mofetil, subcutaneous triamcinolone, and subcutaneous adalimumab. 58 The patient suffered from bilateral panuveitis and was treated with oral prednisolone, mycophenolate mofetil. Two doses of subtenon triamcinolone and subcutaneous adalimumab were also administered earlier.…”