Dexamethasone intravitreal implant for diabetic macular edema in a pregnant patient

Dear Editor, W e present a case of dexamethasone (DEX) intravitreal implantation (Ozurdex 誖 ; Allergan, Irvine, CA, USA) to treat diabetic macular edema (DME) during pregnancy. According to Pescosolido [1], pregnancy may promote the onset of diabetic retinopathy in about 10% of cases and may contribute to its worsening when already present, causing macular edema . Although one report has indicated that DME during pregnancy spontaneously regresses after delivery, others have reported that DME can persist and be associated with severe and persistent visual dysfunction [2]. Treatment of diabetic retinopathy during pregnancy is limited. The National Institute for Clinical Excellence guidelines state that evidence supports the use of laser treatment for DME [3]. Intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) such as bevacizumab to women early in a pregnancy can result in miscarriage, although the exact cause-and-effect relationship is not demonstrated [4-5]. Cases of patients who were suffering from preeclampsia and caesarean section with preterm delivery have been reported. The infant also has respiratory distress syndrome, pulmonary hemorrhage, pulmonary stenosis, and intraventricular cerebral hemorrhage . There has been a case report of a single intravitreal injection of triamcinolone acetonomide to treat DME in a woman who was 6mo pregnant. The resolution of DME and the improved vision persisted throughout the pregnancy without further intervention[7]. The Ozurdex 誖 , DEX intravitreal implant is a sustainedrelease biodegradable implant approved for treating macular edema due to retinal vein occlusion or diabetic retinopathy. The safety and the effectiveness of this implant have been demonstrated in several studies, including a report of a mean of four to five injections over 3y with robust long-term improvement in vision and resolution of macular edema in patients with DME . Here, we present a case of a pregnant patient treated with intravitreal DEX implantation at Konkuk University Medical Center. The patient was examined by slit-lamp biomicroscopy, dilated ophthalmoscopy, and spectral-domain optical coherence tomography (SD-OCT). A 30-year-old pregnant female with a 14y history of type 1 diabetes under combined long and rapid acting insulin presented to a tertiary care ophthalmology department with a complaint of decreased vision in both eyes beginning 1wk ago. Her diabetes was well-controlled before pregnancy (hemoglobin A1c, 5.8%) without diabetes-related complications other than non-proliferative diabetic retinopathy with non-perfusion area on fluorescein angiography (FA). During the entire pregnancy period, her diabetes was controlled by long and rapid-acting insulin as before pregnancy. Her hemoglobin A1c during pregnancy was maintained from 5.4% to 5.8%. Her fasting blood sugar was from 90 to 100 mg/dL. She had undergone full pan retinal photocoagulation (PRP) in both eyes for bilateral non-high risk proliferative diabetic retinopathy (PDR) 1mo previously. She was in week 10 of another wise healthy intrauterine pregnancy (IUP). An ophthalmologic examination revealed 20/66 best corrected visual acuity (BCVA) in both eyes. The anterior segment examination was unremarkable without neovasulcarization of iris or angle. Adilated funduscopic examination showed significant intraretinal hemorrhages with cotton wool spots, diffuse macular edema, and scars from previous PRP in both eyes. No prominent retinal neovascularization was observed in both eyes. SD-OCT revealed central retinal thickness (CRT) of 733 滋m in the right eye and 694 滋m in the left eye with intraretinal cysts and subretinal fluid in both eyes (Figure 1A, 1B). After full discussion with the patient and her obstetrician, we decided to closely observe the DME until the third trimester of pregnancy. We did not consider an intravitreal injection of bevacizumab or ranibizumab to treat the DME because of possible risk of miscarriage or teratogenic effect on the fetus. The DME was persistent. DEX intravitreal implant in a pregnant patient