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Continuing fingolimod after development of macular edema: A case report.

Li V, Kane J, Chan HH, Hall AJ, Butzkueven H - Neurol Neuroimmunol Neuroinflamm (2014)

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology (V.L., H.H.L.C., H.B.), Royal Melbourne Hospital, Melbourne; University of Melbourne (J.K.); Royal Victorian Eye and Ear Hospital (H.H.L.C.), Melbourne; Department of Surgery (A.J.H.), Monash University (H.B.), Melbourne; Department of Medicine (H.B.), Melbourne Brain Centre (Royal Melbourne Hospital), University of Melbourne; and Department of Neurology (H.B.), Eastern Health, Melbourne, Australia.

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Fingolimod is the first effective oral agent in widespread use for relapsing-remitting multiple sclerosis (MS), but it can cause macular edema (ME) as an uncommon complication... The mechanism of fingolimod-associated ME (FAME) is thought to be through sphingosine-1-phosphate receptor antagonism, affecting endothelial integrity and increasing the risk of microvascular leaks... Analysis of phase 2 and 3 fingolimod studies found 19 cases of ME out of 2,615 patients (0.7%)... Treatments include nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, vascular endothelial growth factor antagonists, laser photocoagulation, and vitreoretinal surgery... However, all have side effects, including delayed healing, increased bleeding and infection risk, and elevated intraocular pressure... A 37-year-old woman with an 18-year history of relapsing-remitting MS began fingolimod in May 2011... There are a small number of case reports of FAME in MS, encompassing 11 eyes in 8 patients... In the other 5 eyes, fingolimod was continued with NSAID eye drops in 4 cases and observation only in 1 case... In all 4 treated eyes in which fingolimod was continued, ME and visual acuity improved or resolved... Attempts were made, unsuccessfully, to wean therapy in 2 eyes and fingolimod was ultimately ceased... Increases in macular volume on OCT have been observed more widely in patients on fingolimod over 5–6 months' follow-up... Whether this represents a neuroprotective effect or rather a subclinical form of cystoid ME requires further research... This report provides Class IV evidence that it may be possible to continue fingolimod in patients with FAME with stable vision and macular changes with very close monitoring, potentially allowing highly selected patients with MS to continue an effective treatment.

No MeSH data available.


Serial optical coherence tomographies (OCTs) of left eye (LE) over time with corresponding central foveal thickness (CFT) measurements of both eyesSerial OCTs of LE on (A) October 7, 2011; (B) February 3, 2012; and (C) April 26, 2013. The CFT measurements of both eyes on these dates were (A) 272 μm (LE), 262 μm (right eye [RE]); (B) 308 μm (LE), 258 μm (RE); and (C) 259 μm (LE), 259 μm (RE).
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Figure 1: Serial optical coherence tomographies (OCTs) of left eye (LE) over time with corresponding central foveal thickness (CFT) measurements of both eyesSerial OCTs of LE on (A) October 7, 2011; (B) February 3, 2012; and (C) April 26, 2013. The CFT measurements of both eyes on these dates were (A) 272 μm (LE), 262 μm (right eye [RE]); (B) 308 μm (LE), 258 μm (RE); and (C) 259 μm (LE), 259 μm (RE).

Mentions: When fingolimod was commenced, she was wheelchair-bound with an Expanded Disability Status Scale (EDSS) score of 7.5. Best corrected visual acuity was 6/18 (left eye [LE]) and 6/18−2 (right eye). Baseline ophthalmologic examination was otherwise unremarkable. After 4 months' treatment, she could walk short distances with assistance (EDSS 7). Visual acuity was unchanged. However, OCT (using Stratus OCT [Carl Zeiss Meditec, Inc., Dublin, CA] fast macula thickness protocol) revealed a new left foveal cyst with central foveal thickness of 213 ± 47 µm (LE) (normal: 182 ± 23 μm) (figure). Fundal examination demonstrated altered foveal light reflexes bilaterally, confirming ME.


Continuing fingolimod after development of macular edema: A case report.

Li V, Kane J, Chan HH, Hall AJ, Butzkueven H - Neurol Neuroimmunol Neuroinflamm (2014)

Serial optical coherence tomographies (OCTs) of left eye (LE) over time with corresponding central foveal thickness (CFT) measurements of both eyesSerial OCTs of LE on (A) October 7, 2011; (B) February 3, 2012; and (C) April 26, 2013. The CFT measurements of both eyes on these dates were (A) 272 μm (LE), 262 μm (right eye [RE]); (B) 308 μm (LE), 258 μm (RE); and (C) 259 μm (LE), 259 μm (RE).
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4202669&req=5

Figure 1: Serial optical coherence tomographies (OCTs) of left eye (LE) over time with corresponding central foveal thickness (CFT) measurements of both eyesSerial OCTs of LE on (A) October 7, 2011; (B) February 3, 2012; and (C) April 26, 2013. The CFT measurements of both eyes on these dates were (A) 272 μm (LE), 262 μm (right eye [RE]); (B) 308 μm (LE), 258 μm (RE); and (C) 259 μm (LE), 259 μm (RE).
Mentions: When fingolimod was commenced, she was wheelchair-bound with an Expanded Disability Status Scale (EDSS) score of 7.5. Best corrected visual acuity was 6/18 (left eye [LE]) and 6/18−2 (right eye). Baseline ophthalmologic examination was otherwise unremarkable. After 4 months' treatment, she could walk short distances with assistance (EDSS 7). Visual acuity was unchanged. However, OCT (using Stratus OCT [Carl Zeiss Meditec, Inc., Dublin, CA] fast macula thickness protocol) revealed a new left foveal cyst with central foveal thickness of 213 ± 47 µm (LE) (normal: 182 ± 23 μm) (figure). Fundal examination demonstrated altered foveal light reflexes bilaterally, confirming ME.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology (V.L., H.H.L.C., H.B.), Royal Melbourne Hospital, Melbourne; University of Melbourne (J.K.); Royal Victorian Eye and Ear Hospital (H.H.L.C.), Melbourne; Department of Surgery (A.J.H.), Monash University (H.B.), Melbourne; Department of Medicine (H.B.), Melbourne Brain Centre (Royal Melbourne Hospital), University of Melbourne; and Department of Neurology (H.B.), Eastern Health, Melbourne, Australia.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

Fingolimod is the first effective oral agent in widespread use for relapsing-remitting multiple sclerosis (MS), but it can cause macular edema (ME) as an uncommon complication... The mechanism of fingolimod-associated ME (FAME) is thought to be through sphingosine-1-phosphate receptor antagonism, affecting endothelial integrity and increasing the risk of microvascular leaks... Analysis of phase 2 and 3 fingolimod studies found 19 cases of ME out of 2,615 patients (0.7%)... Treatments include nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, vascular endothelial growth factor antagonists, laser photocoagulation, and vitreoretinal surgery... However, all have side effects, including delayed healing, increased bleeding and infection risk, and elevated intraocular pressure... A 37-year-old woman with an 18-year history of relapsing-remitting MS began fingolimod in May 2011... There are a small number of case reports of FAME in MS, encompassing 11 eyes in 8 patients... In the other 5 eyes, fingolimod was continued with NSAID eye drops in 4 cases and observation only in 1 case... In all 4 treated eyes in which fingolimod was continued, ME and visual acuity improved or resolved... Attempts were made, unsuccessfully, to wean therapy in 2 eyes and fingolimod was ultimately ceased... Increases in macular volume on OCT have been observed more widely in patients on fingolimod over 5–6 months' follow-up... Whether this represents a neuroprotective effect or rather a subclinical form of cystoid ME requires further research... This report provides Class IV evidence that it may be possible to continue fingolimod in patients with FAME with stable vision and macular changes with very close monitoring, potentially allowing highly selected patients with MS to continue an effective treatment.

No MeSH data available.