11.10.2024
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5 Min.

Irvine-Gass Syndrome Management

Cystoid macular edema is a relatively common occurrence following intraocular surgery. In most cases, the course is self-limiting and does not require urgent intervention. Reassurance, patient education, and, where necessary, management are important for the patient and for the prognosis of the procedure.

Dr. Valery Vinzent Wittwer
History
  • 4–12 weeks after intraocular surgery (peak at 6 weeks) (cataract surgery/iris-claw [Artisan] lens implantation/vitrectomy, particularly in cases with complications)
  • Decreased visual acuity, metamorphopsia
Differential diagnosis
  • Side effect of topical prostaglandin analogues (e.g. Monoprost, Xalatan)
  • wAMD, diabetic retinopathy, retinal vein occlusion
  • Uveitis, epiretinal membrane, telangiectasia, vasculitis
Work-up
  • RAPD
  • Amsler grid (metamorphopsia, relative central scotomata)
  • Subjective visual acuity
  • Applanation tonometry and optic disc assessment
  • Anterior segment (cells in the anterior chamber, vitreous incarceration, rubeosis iridis, IOL position)
  • Fundus in mydriasis (vitreous cells, macular edema, flame-/blot-shaped hemorrhages, exudates, dilated/tortuous veins, disc swelling)
  • OCT M P and photographs (macular edema in the INL/OPL, cells in the posterior vitreous, disc swelling)
  • Fluorescein angiography if needed (late-phase leakage in the macular area, often also peripapillary)
Treatment

If findings are mild up to 4 weeks postoperatively with no cells in the anterior chamber > no treatment

If cells are additionally present in the anterior chamber > Pred Forte eye drops 

  • Prednisolone eye drops 4x/day (Pred Forte eye drops)
  • Discontinue prostaglandin eye drops
  • Topical NSAID for up to 6–12 weeks  (Acular 4x/day, Yellox 2x/day, Nevanac 0.1% 3x/day, Nevanac 3mg/ml 1x/day)
  • Follow-up after 2–4 weeks with OCT M P and photographs

If persistent

  • Brinzolamide eye drops 2x/day (Azopt) (caution: contraindicated in severe renal insufficiency)
  • Acetazolamide 250mg 3x/day (Diamox 250mg tablets) and potassium 1x/day (KCl effervescent tablet) (caution: contraindicated in severe renal insufficiency)
  • Follow-up after 2–4 weeks with OCT M P and photographs

If further persistent

  • Thorough examination in mydriasis (vitreous, IOL position, iris/pupil freely mobile, ultrasound if needed)
  • Intravitreal steroids (Ozurdex)
    • Obtain cost approval (insurance authorization)
    • Duration of action 3–4 months
  • Intravitreal anti-VEGF (Lucentis/Eylea) > indication: known steroid response
    • Cost approval required (off-label use)
Prognosis
  • Spontaneous resolution in 3–6 months
  • Chronic course possible

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