Efficacy and safety of tocilizumab for refractory postsurgical cystoid macular edema

Abstract Purpose Postsurgical CME is a common cause of suboptimal vision following both unremarkable cataract and vitreoretinal surgery. While there is no widely accepted treatment algorithm, therapeutic options include topical nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, carbonic anhydrase inhibitors (CAI), anti-VEGF agents, and less commonly, immunomodulatory therapy. In a small subset of patients, CME can assume a chronic course and become refractory to usual therapy, leading to vision loss. In this retrospective study, we analyzed the efficacy and safety of intravenous tocilizumab (TCZ) in the treatment of postsurgical CME that has been nonresponsive to conventional therapies. Objective To determine the outcomes of TCZ infusions in the management of patients with refractory postsurgical cystoid macular edema (CME). Methods Medical records of patients with refractory postsurgical CME treated with TCZ for up to 12 months duration at a tertiary eye center were reviewed. All patients were previously treated with other therapies with poor response. Outcome measures included central macular thickness (CMT) and best-corrected visual acuity (BCVA), measured at baseline and 3, 6, and 12 months following TCZ therapy. Adverse events (AEs) related to TCZ therapy were also assessed. Results A total of 9 eyes from 7 patients (4 females) were included. Mean age was 69.1 years (range, 59–84). Prior surgery included phacoemulsification ( n = 7), combined phacoemulsification with pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling ( n = 1), and scleral buckling, PPV, epiretinal membrane peeling, silicone oil followed by phacoemulsification ( n = 1). Previous therapies used prior to TCZ included topical NSAIDs, corticosteroids (including topical, oral, periocular, intravitreal routes), oral acetazolamide, intravitreal anti-VEGF, and immunomodulatory therapy. Mean duration of CME was 25.2 months (range, 23–34). The patients received TCZ at a dose of 4–8 mg/kg monthly with a median of 11 (range, 7–12) infusions over the follow-up period. Mean CMT (in µm) was 500.0 ± 169.5 at baseline, 354.4 ± 81.2 at month 3 ( p = 0.002), 351.8 ± 81.9 at month 6 ( p = 0.002), and 327.8 ± 60.8 at month 12 ( p = 0.002). Mean BCVA (in LogMAR) improved from 1.06 ± 0.91 at baseline to 0.97 ± 0.96 at month 3 ( p = 0.172), 0.91 ± 0.96 at month 6 ( p = 0.118), and 0.63 ± 0.61 at month 12 ( p = 0.011). While significant reduction in CMT was observed in all follow-up points, statistically significant improvement in BCVA was observed only at the 12-month follow-up point. The drug was well-tolerated in all patients with minor adverse events reported including hyperlipidemia ( n = 1) and insomnia ( n = 1). Conclusion TCZ may be a safe and effective option for the treatment of postsurgical CME that is refractory to other therapies.