Pham Brandon Huy, Hien Doan Luong, Matsumiya Wataru, Tuong Ngoc Than Trong, Doan Huy Luong, Akhavanrezayat Amir, Yaşar Çigdem, Nguyen Huy Vu, Halim Muhammad Sohail, Nguyen Quan Dong
Byers Eye Institute, Stanford University, Palo Alto, CA, USA.
Pham Ngoc Thach University of Medicine, Saigon, Viet Nam.
Am J Ophthalmol Case Rep. 2020 Aug 20;20:100881. doi: 10.1016/j.ajoc.2020.100881. eCollection 2020 Dec.
To describe the clinical course of a patient with refractory pseudophakic cystoid macular edema treated with interleukin-6 receptor antagonist tocilizumab.
An 80-year-old Caucasian man with past ocular history significant for glaucoma (right eye) and iritis presented with cystoid macular edema (CME) in the right eye (OD). His ocular surgery history was significant for cataract extraction with posterior chamber intraocular lenses in 1999 and YAG laser capsulotomy in 2014 in both eyes (OU). His medications at time of presentation included latanoprost and dorzolamide-timolol in OD for glaucoma, as well as prednisolone in OD for iritis. Upon examination, his visual acuity was 20/250 in OD and 20/20 in the left eye (OS). Intraocular pressure was 20 mmHg in OD and 10 mmHg in OS. Slit-lamp examination revealed no cells or flare in OU. Dilated fundus exam showed CME and a cup-to-disk ratio of 0.9 in OD and normal findings in OS. Initial spectral domain optical coherence tomography (SD-OCT) demonstrated intraretinal fluid in both outer and inner layers as well as mild subretinal fluid with an intact ellipsoid zone in OD. Fluorescein angiography revealed perifoveal leakage in OD. Laboratory evaluations, including infectious work-up, were unremarkable. While the patient's CME initially improved after initiation of therapy with topical prednisolone and oral acetazolamide, the CME later recurred after systemic acetazolamide was stopped due to intolerable side effects. Despite multiple therapeutic approaches, including topical and systemic corticosteroids (both oral and intravenous) and topical interferon α2b over the course of more than one year, the patient's visual acuity continued to worsen with increasing intra- and subretinal fluid in the macula. Due to the refractory CME, the patient was started on monthly infusions of anti-interleukin (IL)-6 receptor tocilizumab (8 mg/kg) with three days of methylprednisolone infusions (500 mg/day). After nine cycles of treatment, SD-OCT demonstrated restoration of normal foveal contour with complete resolution of CME.
IL-6 inhibition with tocilizumab may be a safe and effective treatment for refractory CME. Further studies are needed to elucidate the nature and extent of therapeutic IL-6 inhibition in CME.
描述一名难治性人工晶状体性黄斑囊样水肿患者接受白细胞介素-6受体拮抗剂托珠单抗治疗的临床过程。
一名80岁的白人男性，既往有青光眼（右眼）和虹膜炎病史，右眼出现黄斑囊样水肿（CME）。他的眼科手术史包括1999年右眼白内障摘除联合后房型人工晶状体植入术以及2014年双眼YAG激光晶状体后囊切开术。就诊时他使用的药物包括右眼用于治疗青光眼的拉坦前列素和多佐胺-噻吗洛尔，以及右眼用于治疗虹膜炎的泼尼松龙。检查时，他的右眼视力为20/250，左眼视力为20/20。右眼眼压为20 mmHg，左眼眼压为10 mmHg。裂隙灯检查显示双眼均无细胞或前房闪辉。散瞳眼底检查显示右眼有CME且杯盘比为0.9，左眼检查结果正常。最初的频域光学相干断层扫描（SD-OCT）显示右眼外层和内层均有视网膜内液以及轻度视网膜下液，椭圆体带完整。荧光素血管造影显示右眼黄斑周围渗漏。包括感染相关检查在内的实验室评估均无异常。虽然患者在开始使用局部泼尼松龙和口服乙酰唑胺治疗后CME最初有所改善，但由于出现无法耐受的副作用而停用全身用乙酰唑胺后CME后来复发。尽管在一年多的时间里采取了多种治疗方法，包括局部和全身使用皮质类固醇（口服和静脉注射）以及局部使用干扰素α2b，但患者的视力随着黄斑区视网膜内和视网膜下液的增加而持续恶化。由于CME难治，患者开始每月输注抗白细胞介素（IL）-6受体托珠单抗（8 mg/kg），并连续三天输注甲泼尼龙（500 mg/天）。经过九个周期的治疗，SD-OCT显示黄斑中心凹轮廓恢复正常，CME完全消退。
托珠单抗抑制IL-6可能是治疗难治性CME的一种安全有效的方法。需要进一步研究以阐明在CME中治疗性抑制IL-6的性质和程度。
