Corneal decompensation following anterior migration of Ozurdex: Imaging-based clinical insights

Cystoid macular edema (CME) remains one of the most frequent causes of suboptimal visual recovery following intraocular surgery. Management often requires multiple modalities, including topical, systemic, and intravitreal therapies. The intravitreal dexamethasone implant (Ozurdex, Allergan Inc.) has become a widely accepted treatment option for refractory CME due to its sustained-release profile and favorable efficacy. Although generally safe, rare complications have been reported with Ozurdex use, including implant migration into the anterior chamber. This is most commonly observed in vitrectomized eyes, aphakia, or eyes with a disrupted posterior capsule and surgical iridectomy. Anterior migration can have serious consequences, including corneal edema and irreversible endothelial decompensation, if not recognized and managed promptly. Case A 65-year-old female, previously operated for a right eye dropped nucleus with pars plana vitrectomy and scleral fixated intraocular lens (SFIOL) implantation in the right eye, presented with decreased vision three months postoperatively. Initially, her best-corrected visual acuity (BCVA) had improved to 6/12, N10 at two months. At presentation, her BCVA had declined to 6/36 with no improvement on pinhole testing. Clinical examination revealed an epiretinal membrane with CME [Fig. 1a]. She was managed conservatively with topical and systemic steroids along with topical Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). Over the next three months, her vision improved to 6/18, N12 [Fig. 1b]. Given persistent CME, she was advised an intravitreal dexamethasone implant (Ozurdex), which was administered.Figure 1: (a) OCT macula showing ERM with CME and NSD. (b) OCT macula showing reduction in ERM with CME and resolution of NSD after conservative management. CME: cystoid macular edema; ERM = epiretinal membrane, OCT = optical coherence tomographyHowever, one month later, she presented with sudden vision loss. Examination revealed corneal edema and anterior migration of the Ozurdex implant [Fig. 2], confirmed with AS-OCT [Fig. 3]. Her visual acuity had deteriorated to 2/60. Immediate surgical explantation of the implant was performed, followed by intensive topical steroids, cycloplegics, and hyperosmotic agents. Corneal thickness measured 757 µm at one month and 727 µm at two months’ postconservative management [Fig. 4a and b]. Specular microscopy was performed, and it revealed severe polymegathism, marked pleomorphism, areas of endothelial cell dropout, irregular, enlarged, and distorted endothelial cells. Endothelial cell density could not be calculated due to poor image acquisition from stromal edema.Figure 2: Slit-lamp photo showing Ozurdex in anterior chamber with corneal edemaFigure 3: AS-OCT showing Ozurdex in anterior chamber, AS-OCT = anterior segment optical coherence tomographyFigure 4: (a) Slit-lamp photo and AS-OCT showing corneal edema after removal of Ozurdex. (b) Slit- lamp photo and AS-OCT after two months of conservative management showing persistent corneal edema, AS-OCT = anterior segment optical coherence tomographyDue to persistent corneal edema and no improvement over three months, she underwent Descemet Membrane Endothelial Keratoplasty (DMEK). One month post-DMEK, her BCVA improved to 6/12, N10, and her central corneal thickness reduced to 522 µm [Fig. 5a]. Serial OCT scans showed a stable macular condition without worsening CME [Fig. 5b].Figure 5: (a) Slit-lamp photo and AS-OCT two months after the treatment showing resolution of corneal edema. (b) OCT macula acquired after the resolution of corneal edema showing resolved CME. CME: cystoid macular edema, AS-OCT = anterior segment optical coherence tomography.This case underscores the necessity of thorough anterior segment evaluation before administering Ozurdex, especially in vitrectomized eyes with altered anatomy. While Ozurdex remains an effective option for CME, complications such as anterior migration can be vision-threatening and require timely intervention. Discussion Anterior migration of intraocular pharmacologic agents has been described in varied contexts, ranging from Ozurdex migration in pseudophakic eyes with intact capsules to intralenticular or fractured implants.[1–3] Majumdar et al.[1] demonstrated a similar case of anterior segment migration of Ozurdex. It occurred even with an intact capsular bag. However, prompt explanation of the implant prevented irreversible corneal damage in their case. Takkar and Godbole,[2] Nookala and Gudapati,[4] and Nene AS et al.[3] reported various intraocular iatrogenic injuries occurring at the time of implantation of Ozurdex. Our case represents a more severe and delayed manifestation of this complication spectrum. The patient had multiple high-risk factors—including prior nucleus drop, pars plana vitrectomy, and secondary scleral-fixated IOL with surgical iridectomy—predisposing to anterior migration. Despite these risks, the decision to implant Ozurdex was taken after careful consideration: The patient had shown a good but incomplete response to oral steroids, with recurrence of CME on tapering. Additionally, in a vitrectomized eye, the intravitreal half-life of triamcinolone acetonide is significantly reduced, limiting its therapeutic durability. This migration occurred one month after the implantation, highlighting the necessity of regular follow-ups and the possibility of delayed adverse outcomes. Additionally, the use of serial anterior segment and posterior segment OCT in our case provides objective documentation of corneal failure and macular stability, an aspect not emphasized in previous reports. In our case, serial multimodal imaging helped us tailor the postcomplication treatment protocol and thus achieve a successful visual outcome for the patient. Importantly, despite the anterior segment complication, the macula remained stable with no recurrence of CME six months after explantation—demonstrating the efficacy of Ozurdex in controlling inflammation in challenging cases. Conclusion Complex pseudophakic CME in vitrectomized eyes presents a genuine therapeutic challenge. While Ozurdex can provide effective and sustained macular control, altered anterior segment anatomy significantly increases the risk of migration and corneal toxicity. Careful patient selection, explicit risk counseling, structured follow-up, and readiness for early surgical intervention are essential to achieving favorable outcomes. Authors’ contributions Anushree Naidu did manuscript preparation and literature review. Charu Gupta did manuscript review, editing, and literature review. Mohd Usman did manuscript preparation and data collection. Akashdeep did manuscript preparation and data collection. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.