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Efficacité du Tocilizumab dans la stabilisation de l'oedème maculaire réfractaire inflammatoire post-chirurgical: un rapport de deux cas

To determine the efficacy of subcutaneous weekly Tocilizumab in stabilizing post-surgical inflammatory macular edema (riME) refractory to previous immunomodulatory treatment.

Two pseudophakic monocular patients multi operated for glaucoma (2 eyes) were treated for riME. Both patients had demonstrated an anatomical improvement on OCT under oral corticosteroids. Previously used ineffective treatments before oral steroids introduction included: 1) local corticosteroid, 2) intravitreal corticosteroid implant and/or intravitreal anti-vascular endothelial growth factor injections. Tocilizumab, a monoclonal antibody inhibiting the interleukin (IL)-6 receptor, was introduced as steroid-sparing agent and self-administered by patients at a weekly dose of 162mg.   Clinical effectiveness was evaluated after treatment initiation by central foveal thickness (CFT) measured on optical coherence tomography (OCT).

The first patient, age 74 years, presented riME 2 years after combined Baerveldt-XEN surgery. Visual acuity (logarithm of the minimum angle of resolution) and intraocular pressure (IOP) both remained stable throughout Tocilizumab treatment at counting fingers at 3 meters and 8 mmHg, respectively. The second patient, age 58 years, developed riME after cyclophotocoagulation treatment 7 years prior. Visual acuity and IOP remained unchanged during treatment at 0.6 and 11mmHg, respectively. The first patient showed CFT reduction by 18.9%, from 511µm at baseline to 414µm 3 months after treatment. It is worth mentioning that, in this patient CFT increased four months after starting Tocilizumab to subsequently regress back one month later when oral corticosteroids were administered. In the second patient, CFT decreased by 44.4%, from 633µm at baseline to 333µm 3 months after treatment and it remained stable during the two following months.

In both cases of refractory ME, weekly subcutaneous Tocilizumab injections showed a positive anatomical outcome on OCT after 3 months. One patient relapsed at four months of therapy. This could result from: 1) tachyphylaxis to Tocilizumab; 2) presence of cytokines and cellular immune components, other than IL-6, such as IL-1, IL-8, TNF-α, INF- α, CCL2; 3) reduced compliance to self-administered Tocilizumab; 4) induction of neutralizing anti-drug antibodies, all known to potentially reduce its efficacy.

Tocilizumab is an effective option for improving CFT in multi-operated patients with riME. In this type of patients, it can provide anatomical benefits with stabilization of riME fluctuations without corticosteroid-related adverse effects.