Prevent use of Depo-Medrol in eye surgeries, it may lead to vision loss

USA: Methylprednisolone acetate, known by trade name Depo-Medrol should no longer be used in ophthalmological surgeries as its intraocular use can lead to irreversible retinal necrosis and permanent vision loss, according to a recent study in the journal Opthalmology.

The findings are based on a case report of a 68-year-old man who experienced vision loss immediately following cataract surgery. During surgery, Depo-Medrol (methylprednisolone acetate, Pfizer) was used to stain the vitreous after a posterior capsule tear.

Although previous cases of retinal toxicity, including retinal atrophy, detachment, and hemorrhage due to accidental injection of Depo-Medrol into the vitreous have been reported, this is the first known case intentional Depo-Medrol injection to stain vitreous leading to vision loss.

The authors warn that methylprednisolone acetate has similar packaging and appearance to triamcinolone acetonide but toxic to the retina and potentially blinding so should absolutely never be used in the eye.

Upon referral to the retina, the patient’s vision was count fingers in the left eye and 20/30 in the right eye. OCT of the left eye showed loss of all retinal layers in the central macula, and fluorescein angiography confirmed “pruning of the perifoveal vessels with capillary dropout, areas of window defect and blockage of choroidal flow by opacified retina,” both consistent with retinal necrosis, the report said.

The drug’s preservative, myristyl-gamma-picolinium chloride, has been shown to cause toxicity to the retina in rabbit models.

Despite the evidence for retinal toxicity, Depo-Medrol does not carry a warning against intraocular use in its package labeling, according to Michael D. Ober, Retina Consultants of Michigan, Southfield, MI. Kenalog, however, does carry such a warning in its labeling but has been commonly used intraocularly for decades without a single reported case of retinal toxicity of the severity seen from Depo-Medrol.

"Intraocular Depo-Medrol injection is a preventable, devastating cause of retinal necrosis and blindness with very similar packaging and appearance to triamcinolone acetonide. Awareness of its retinal toxicity should be more widely known by both anterior and posterior segment surgeons to avoid iatrogenic vision loss, write the authors.

For the detailed case study log on to doi:10.1016/j.ophtha.2019.03.034.