Continuing fingolimod after development of macular edema: A case report

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.MEmay be mild and asymptomatic, but it can also produce visual impairment. 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%). Thirteen had onset within 4 months of fingolimod commencement, 4 had onset between 4 and 12months, and 2 had onset after 12 months. Fingolimod was ceased in all cases, with complete resolution of ME in 16 and partial resolution in the remainder. Eleven required treatment with topical anti-inflammatory drugs. Risk factors for FAME include previous uveitis and diabetes. Themost sensitive technique for detectingME is optical coherence tomography (OCT). 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.