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Brief Report
March 21, 2019

Outcomes Associated With Sustained-Release Intraocular Fluocinolone Implants in a Case of Melanoma-Associated Retinopathy Treated Without Systemic Immunosuppression

Author Affiliations
  • 1Royal Surrey County Hospital, Guildford, United Kingdom
  • 2Moorfields Eye Hospital, London, United Kingdom
  • 3University College London Institute of Ophthalmology, London, United Kingdom
  • 4University of Surrey, Guildford, United Kingdom
JAMA Ophthalmol. 2019;137(5):564-567. doi:10.1001/jamaophthalmol.2019.0284
Key Points

Question  What is the outcome of a fluocinolone implant on melanoma-associated retinopathy without systemic immunosuppression?

Findings  In 1 patient with melanoma-associated retinopathy, marked improvement in symptoms and retinal function as measured by automated perimetry and electroretinography were noted after treatment with an intravitreal fluocinolone acetonide implant.

Meaning  While results from 1 case should be generalized with caution, this outcome suggests that sustained-release steroid intraocular implants may offer an alternative to systemic immunosuppression in the treatment of melanoma-associated retinopathy, although the precise safety and effectiveness over time cannot be determined from a single case.

Abstract

Importance  Melanoma-associated retinopathy (MAR) is a paraneoplastic syndrome in which antiretinal antibodies crossreact with retinal ON-bipolar cells, resulting in night blindness and progressive visual field loss. Current therapeutic options include cytoreductive surgery in combination with immunoglobulin, corticosteroids, or plasmapheresis, but their effectiveness is limited and may be contraindicated, given the possible protective role of circulating autoantibodies against metastatic spread. We report 3-year follow-up of the first case (to our knowledge) of MAR treated with intravitreal long-acting steroid implants.

Objective  To report on a patient with MAR who was treated with intravitreal fluocinolone acetonide implants in the absence of systemic immunosuppression.

Design, Setting, and Participants  This is a 3-year follow-up of a 73-year-old woman with a history of surgical excision of a malignant melanoma of the left pinna who presented with visual symptoms of shimmering and nyctalopia. Fundus examination, fundus autofluorescence, and optical coherence tomography were normal, with no evidence of cystoid macular edema. Automated perimetry showed a reduction in visual field and full-field electroretinography (ERG) demonstrated findings consistent with generalized ON-bipolar cell dysfunction, typical of MAR. The patient was treated with bilateral fluocinolone acetonide intravitreal implants.

Main Outcomes and Measures  Visual acuity, visual field, and electroretinography testing for 3 years after treatment.

Results  Visual fields improved in this 73-year-old patient from 20/30 (Snellen measured as 6/9) OD and 20/16 (6/5) OS at baseline to 20/20 OU within 1 week of treatment. Detailed electroretinography monitoring indicated characteristic abnormalities that partly resolved after treatment, consistent with improved inner retinal ON-bipolar cell function. Bilateral cataracts developed approximately 2 years after injection; cataract surgery was performed uneventfully. At 3 years posttreatment, the patient remained visually stable and in systemic disease remission, with best-corrected visual acuity remaining at 20/20 OU.

Conclusions and Relevance  We report what is, to our knowledge, the first case of MAR treated with intravitreal slow-release corticosteroid implants, which shows improvements in visual symptoms, visual fields, and retinal function. Sustained-release intraocular steroid implants may offer an effective and safe alternative to systemic immunosuppression in MAR, although results from 1 case should be generalized with abundant caution.

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