eMedicine Specialties > Ophthalmology > Retina

Macular Edema, Irvine-Gass: Treatment & Medication

Author: David G Telander, MD, PhD, Assistant Professor, Department of Ophthalmology and Vision Science, Division of Vitreo-Retinal Diseases and Surgery, University of California Davis School of Medicine
Coauthor(s): Christopher T Cessna, DO, Vitreo-Retinal Fellow, University of California, Davis Medical Center
Contributor Information and Disclosures

Updated: Feb 25, 2008

Treatment

Medical Care

Treatment is aimed at the underlying etiology; however, several of the common treatments may help different causes of CME.

Medical treatment modalities include the following:

  • Corticosteroids directly inhibit the enzyme phospholipase, blocking the formation of prostaglandins. They are considered the primary treatment of CME in many instances, specifically in the treatment of CME secondary to uveitis. Corticosteroids can be administered topically or orally; they can also be injected intravitreally (off-label use) or injected into the sub-Tenon space (off-label use). However, corticosteroids have many systemic and ocular adverse effects, and some patients become intolerant to them as a result.
  • NSAIDs inhibit the enzyme cyclooxygenase and can be used in the prevention and treatment of CME.
    • NSAIDs are usually administered topically for approximately 3-4 months and on an as-needed basis.
    • In a large, multicenter, prospective, double-masked, study of ketorolac versus placebo in the treatment of 120 patients with chronic aphakic or pseudophakic CME, statistically significant improvement in visual acuity occurred in patients that received ketorolac versus placebo.
  • The RPE is important in the maintenance of the blood-retinal barrier and in the prevention of a surplus of extracellular and intracellular fluid within the retina. The enzyme carbonic anhydrase is present on the apical and basal surfaces of the RPE cell membrane. Carbonic anhydrase inhibitors (CAIs), such as acetazolamide, enhance the pumping action of RPE cells, facilitating the transport of fluid across the RPE.
  • When vitreous is captured in the corneal wound following complicated cataract surgery, YAG laser lysis of the vitreous strands has been used with some success.

Surgical Care

Surgical therapy includes pars plana vitrectomy (PPV).

  • PPV is useful in the treatment of CME in several instances, as follows:
    • Remove vitreous strands tracking to the surgical wound or pupil status after complicated ocular surgery or trauma.
    • Peeling of the posterior hyaloid face from the surface of the macula in vitreomacular traction syndrome or chronic CME cases unresponsive to medical treatment.
    • Peeling of epiretinal membranes from the surface of the macula when associated with CME.
    • Removal of inflammatory mediators from the vitreous cavity.
    • Removal of retained nuclear lens fragments.
    • Repositioning of a dislocated or subluxed IOL.
  • Multiple studies have reported improvement of CME after PPV in cases of aphakic, pseudophakic, or uveitis-related CME.

Medication

Medical therapy of Irvine-Gass syndrome includes NSAIDs, corticosteroids, and carbonic anhydrase inhibitors.

Nonsteroidal anti-inflammatory drugs

NSAIDs inhibit enzyme cyclooxygenase and also can be used in the prevention of CME. NSAIDs are administered topically usually for 3-4 months.


Diclofenac (Voltaren)

Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclooxygenase, which in turn decreases formation of prostaglandin precursors. Commonly used in the treatment of CME and for postoperative inflammation in patients who have undergone cataract extraction.

Adult

1 gtt qid

Pediatric

Not established

Documented hypersensitivity to diclofenac, ketorolac, or related products

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Recently, cases of corneal stromal thinning or melting have been reported in patients receiving diclofenac drops for extended period of time


Ketorolac (Acular)

For treatment of CME and postoperative inflammation in patients who have undergone cataract extraction. Inhibits prostaglandin synthesis by decreasing activity of the enzyme, cyclooxygenase, which results in decreased formation of prostaglandin precursors, which in turn results in reduced inflammation.

Adult

1 gtt qid

Pediatric

Not established

Documented hypersensitivity to ketorolac, diclofenac, or related products

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Long-term use may delay wound healing; perform ophthalmologic studies in patients who develop eye complaints during therapy; discontinue therapy if changes are noted; changes may include blurred or diminished vision, corneal deposits, retinal disturbances, scotomata, changes in color vision, and macula degeneration


Nepafenac (Nevanac)

Newer agent used for treatment of CME and postoperative inflammation. Inhibits prostaglandin formation by decreasing activity of the enzyme, cyclooxygenase.

Adult

1 gtt tid

Pediatric

Not established

Documented hypersensitivity to diclofenac, ketorolac, or related products

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Long-term use may cause impaired wound healing, corneal thinning

Carbonic anhydrase inhibitors

Carbonic anhydrase is present on both the apical and basal surfaces of the RPE cell membrane. CAIs enhance the pumping action of RPE cells and change ion flux, which affects the cellular environment in the retina.


Acetazolamide (Diamox)

Effective in the treatment of CME. Commonly used in lowering IOP in the therapy of glaucoma.

Adult

250 mg PO bid/qid

Pediatric

Not established

Can decrease therapeutic levels of lithium and alter excretion of drugs (amphetamines, quinidine, phenobarbital, salicylates) by alkalinizing urine

Documented hypersensitivity; depressed potassium and/or sodium levels in blood serum; liver and/or kidney dysfunction; hyperchloremic acidosis; suprarenal gland failure

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Adverse reactions common to all sulfonamide derivatives may occur; patients with impaired hepatic function may go into coma; may cause substantial increase in blood glucose in some diabetic patients

Corticosteroids

Inhibit the enzyme phospholipase and have a primary role in treatment of CME secondary to uveitis. Can be administered topically, orally, or injected in the sub-Tenon space.


Prednisolone acetate (AK-Pred, Pred Forte)

Indicated in several conditions of steroid-responsive intraocular inflammation including CME.

Adult

1% solution: 1 gtt qid

Pediatric

Not established

Documented hypersensitivity; active eye infection, including fungal, viral, or mycobacterial

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Prolonged use of corticosteroids may result in glaucoma, optic nerve damage, posterior subcapsular cataract, increased risk of secondary ocular infections, and corneal thinning (monitor ocular pressure regularly)


Triamcinolone acetonide (Kenalog)

Indicated in several conditions of steroid-responsive intraocular inflammation and CME.

Adult

Intravitreal injection dose: 4 mg (typical); off-label use
Sub-Tenon injection dose: 40 mg (typical); off-label use

Pediatric

Not established

Documented hypersensitivity; active eye infection, including fungal, viral, or mycobacterial

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Prolonged use of corticosteroids may result in glaucoma, optic nerve damage, posterior subcapsular cataract, increased risk of secondary ocular infections, and corneal thinning

More on Macular Edema, Irvine-Gass

Overview: Macular Edema, Irvine-Gass
Differential Diagnoses & Workup: Macular Edema, Irvine-Gass
Treatment & Medication: Macular Edema, Irvine-Gass
Follow-up: Macular Edema, Irvine-Gass
Multimedia: Macular Edema, Irvine-Gass
References
[ CLOSE WINDOW ]

References

  1. Altintas O, Yüksel N, Karabas VL, Demirci G. Cystoid macular edema associated with latanoprost after uncomplicated cataract surgery. Eur J Ophthalmol. Jan-Feb 2005;15(1):158-61. [Medline].

  2. Flach AJ, Jampol LM, Weinberg D, Kraff MC, Yannuzzi LA, Campo RV, et al. Improvement in visual acuity in chronic aphakic and pseudophakic cystoid macular edema after treatment with topical 0.5% ketorolac tromethamine. Am J Ophthalmol. Nov 15 1991;112(5):514-9. [Medline].

  3. Flach AJ, Stegman RC, Graham J, Kruger LP. Prophylaxis of aphakic cystoid macular edema without corticosteroids. A paired-comparison, placebo-controlled double-masked study. Ophthalmology. Oct 1990;97(10):1253-8. [Medline].

  4. Fung WE. Vitrectomy for chronic aphakic cystoid macular edema. Results of a national, collaborative, prospective, randomized investigation. Ophthalmology. Aug 1985;92(8):1102-11. [Medline].

  5. Gamache DA, Graff G, Brady MT, Spellman JM, Yanni JM. Nepafenac, a unique nonsteroidal prodrug with potential utility in the treatment of trauma-induced ocular inflammation: I. Assessment of anti-inflammatory efficacy. Inflammation. Aug 2000;24(4):357-70. [Medline].

  6. Gass JD, Norton EW. Cystoid macular edema and papilledema following cataract extraction. A fluorescein fundoscopic and angiographic study. Arch Ophthalmol. Nov 1966;76(5):646-61. [Medline].

  7. Gass JD, Norton EW. Fluorescein studies of patients with macular edema and papilledema following cataract extraction. Trans Am Ophthalmol Soc. 1966;64:232-49. [Medline].

  8. Gass JD, Norton EW. Follow-up study of cystoid macular edema following cataract extraction. Trans Am Acad Ophthalmol Otolaryngol. Jul-Aug 1969;73(4):665-82. [Medline].

  9. Harbour JW, Smiddy WE, Rubsamen PE, Murray TG, Davis JL, Flynn HW Jr. Pars plana vitrectomy for chronic pseudophakic cystoid macular edema. Am J Ophthalmol. Sep 1995;120(3):302-7. [Medline].

  10. Holekamp NM. Treatment of pseudophakic CME. Ocul Immunol Inflamm. Jun 1998;6(2):121-3. [Medline].

  11. Irvine SR. A newly defined vitreous syndrome following cataract surgery. Am J Ophthalmol. May 1953;36(5):499-619. [Medline].

  12. Italian Diclofenac Study Group. Efficacy of diclofenac eyedrops in preventing postoperative inflammation and long-term cystoid macular edema. Italian Diclofenac Study Group. J Cataract Refract Surg. Oct 1997;23(8):1183-9. [Medline].

  13. Jampol LM. Pharmacologic therapy of aphakic cystoid macular edema. A review. Ophthalmology. Aug 1982;89(8):891-7. [Medline].

  14. Ke TL, Graff G, Spellman JM, Yanni JM. Nepafenac, a unique nonsteroidal prodrug with potential utility in the treatment of trauma-induced ocular inflammation: II. In vitro bioactivation and permeation of external ocular barriers. Inflammation. Aug 2000;24(4):371-84. [Medline].

  15. Lane SS, Modi SS, Lehmann RP, Holland EJ. Nepafenac ophthalmic suspension 0.1% for the prevention and treatment of ocular inflammation associated with cataract surgery. J Cataract Refract Surg. Jan 2007;33(1):53-8. [Medline].

  16. McColgin AZ, Raizman MB. Efficacy of topical Voltaren in reducing the incidence of postoperative cystoid macular edema. Invest Ophthalmol Vis Sci. 1999;40:S289.

  17. Ray S, D'Amico DJ. Pseudophakic cystoid macular edema. Semin Ophthalmol. Sep-Dec 2002;17(3-4):167-80. [Medline].

  18. Rho DS. Treatment of acute pseudophakic cystoid macular edema: Diclofenac versus ketorolac. J Cataract Refract Surg. Dec 2003;29(12):2378-84. [Medline].

  19. Rossetti L, Autelitano A. Cystoid macular edema following cataract surgery. Curr Opin Ophthalmol. Feb 2000;11(1):65-72. [Medline].

  20. Ruiz RS, Saatci OA. Visual outcome in pseudophakic eyes with clinical cystoid macular edema. Ophthalmic Surg. Apr 1991;22(4):190-3. [Medline].

  21. Solomon LD. Efficacy of topical flurbiprofen and indomethacin in preventing pseudophakic cystoid macular edema. Flurbiprofen-CME Study Group I. J Cataract Refract Surg. Jan 1995;21(1):73-81. [Medline].

  22. Stark WJ Jr, Maumenee AE, Fagadau W, Datiles M, Baker CC, Worthen D, et al. Cystoid macular edema in pseudophakia. Surv Ophthalmol. May 1984;28 Suppl:442-51. [Medline].

  23. Telander DG, Sarraf D. Cystoid macular edema with docetaxel chemotherapy and the fluid retention syndrome. Semin Ophthalmol. Jul-Sep 2007;22(3):151-3. [Medline].

  24. Ursell PG, Spalton DJ, Whitcup SM, Nussenblatt RB. Cystoid macular edema after phacoemulsification: relationship to blood-aqueous barrier damage and visual acuity. J Cataract Refract Surg. Nov 1999;25(11):1492-7. [Medline].

  25. Wright PL, Wilkinson CP, Balyeat HD, Popham J, Reinke M. Angiographic cystoid macular edema after posterior chamber lens implantation. Arch Ophthalmol. Jun 1988;106(6):740-4. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

Irvine-Gass syndrome, cystoid macular edema, CME, macular fluid accumulation, cataract surgery, ocular surgery

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

David G Telander, MD, PhD, Assistant Professor, Department of Ophthalmology and Vision Science, Division of Vitreo-Retinal Diseases and Surgery, University of California Davis School of Medicine
David G Telander, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, and Association for Research in Vision and Ophthalmology
Disclosure: OSI/Eyetech Consulting fee Consulting

Coauthor(s)

Christopher T Cessna, DO, Vitreo-Retinal Fellow, University of California, Davis Medical Center
Christopher T Cessna, DO is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Medical Editor

Brian A Phillpotts, MD, Former Vitreo-Retinal Service Director, Former Program Director, Clinical Assistant Professor, Department of Ophthalmology, Howard University College of Medicine
Brian A Phillpotts, MD is a member of the following medical societies: American Academy of Ophthalmology, American Diabetes Association, American Medical Association, and National Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Steve Charles, MD, Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine
Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Club Jules Gonin, Macula Society, and Retina Society
Disclosure: Alcon Laboratories Consulting fee Consulting; OptiMedica Ownership interest Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.