Reactions Weekly | 2021
Intraocular inflammation: 3 case reports In a case study, 2 men and 1 woman were described, who developed intraocular inflammation during treatment with brolucizumab [dosage not stated]. Case 1: A 72-year-old man who had polypoidal choroidal vasculopathy in the OD, had been receiving treatment with 20 ranibizumab [Lucentis]. Additionally, he received treatment for systemic hypertension and hyperlipidaemia. His visual acuity found 1.2, despite the treatment, and recurrent subretinal fluid and pigment epithelial detachments also observed. The treatment interval could not extend to more than 8 weeks; hence, he was administered the first dose of intravitreal injection of brolucizumab. However, on the day 3 morning, after the administration of after the first brolucizumab, he reported ocular redness and pain and decreasing vision OD and revisited to the clinic. His intraocular pressure was normal, but the decimal best-corrected visual acuity decreased to 0.3. Thereby, he underwent a biomicroscopic examination, which revealed ciliary hyperaemia, 1+ anterior chamber cells with fine keratic precipitates without fibrin material, and 2+ anterior vitreous cells. Hence, a dilated fundus examination was performed, which revealed no apparent findings that suggested retinal inflammation or vasculitis except for a slight vitreous haze. Eventually, he was diagnosed with intraocular inflammation. After that, he was initiated topical 0.01% betamethasone sodium phosphate. Seven days after the initial administration of brolucizumab, he was re-visited to the clinic, and his ocular redness and pain were resolved. However, hypopyon without fibrin material was present and the best-corrected visual acuity further decreased to hand motions due to advanced vitreous opacities, which caused fundus observation difficult. Hypopyon also noticed the status of the anterior chamber was silent. On the same day, he received triamcinolone [triamcinolone acetonide] injection into the subTenon’s capsule, and his hypopyon was completely resolved, and his vitreous opacities started to improve, and the best-corrected visual acuity was 0.01. Therefore, his vitreous opacities decreased continuously, and his best-corrected visual acuity also improved. His best-corrected visual acuity was reached 0.5, forty days after the onset of intraocular inflammation. Therefore, an optical coherence tomography was performed, which showed no apparent changes in the status of the retinal vessels compared to before the brolucizumab. Case 2: An 82-year-old man who had neovascular age-related macular degeneration, received the first dose of intravitreal brolucizumab injection OD. After 12 days of administration, he complained about painful decreased vision. He also had relevant history of hypertension and myocardial infarction. He also reported that, before receiving brolucizumab injection, he had been receiving 15 ranibizumab, which was switched to was switched to aflibercept [Eylea] and was treated with 17 intravitreal injections. During this, his left eye was progressed to polypoidal vasculopathy, and his and his decimal best-corrected visual acuity found 0.08 due to large scar formation that included the macula. Thereby, his treatment of aflibercept was switched to an anti-VEGF agent, to brolucizumab due to the persistent intraretinal fluid and the tendency of the best-corrected visual acuity to decrease slightly OD. However, he reported to have ocular pain and redness OD, 12 days after brolucizumab administration. Fifteen days after the IVI, he underwent an examination, which showed the right decimal best-corrected visual acuity decreased to 0.06 from 0.3, and the biomicroscopic observation revealed conjunctival hyperaemia, 1+ anterior chamber cells with fine keratic precipitates, and vitreous cells with vitreous opacities. A new intraretinal haemorrhage with sheathed inferior and inferotemporal retinal veins with poor visualization due to vitreous haze was noticed by a fundus examination. Thereby, he was diagnosed with intraocular inflammation. Hence, he was initiated treatment with betamethasone sodium phosphate and triamcinolone [triamcinolone acetonide] into the sub-Tenon’s capsule. After 22 days, he was returned to the clinic, and his ocular redness and pain and the inflammatory signs in the anterior chamber was resolved. Subsequently, his vitreous opacities tended to decrease, and the best-corrected visual acuity remained 0.06 and the retinal vasculature remained sheathed. After 40 days of intravitreal injection, an examination showed that best-corrected visual acuity improved to 0.2 along with a further decrease in the vitreous opacities. The resolution of the intraretinal fluid showed in an optical coherence tomography. In the next examination, about 40 days later, the intravitreal injection showed improvement in the best-corrected visual acuity to 0.3, along with the resolution of the retinal haemorrhage and reduction of the sheathed retinal vessels, which was suggested improvement of the blood flow. Case 3: A 94-year-old woman who had neovascular age-related macular degeneration, received a second dose of intravitreal brolucizumab injection. After 10 days of the administration, she complained about floaters and then gradually progressed blurred vision in OD. She also had a relevant medical history of hyperlipidaemia. It’s reported that she had been receiving 33 ranibizumab intravitreal injection in the OD before receiving brolucizumab. During this, her neovascular age-related macular degeneration was progressed, and her recent best-corrected visual acuity was hand motions because of the large scar formation at the macula. Hence, her therapy was switched to brolucizumab. Two months after the first initiation of her brolucizumab therapy, the decimal bestcorrected visual acuity slightly improved to 0.7 from 0.6, and a resolution of persistent subretinal fluid was noticed; thus, she administered the second dose. However, after 10 days, she developed floaters and increased blurred vision in the OD. She was revisited to the clinic after 17 days, and her right decimal best-corrected visual acuity was decreased to 0.6. No ciliary hyperaemia, rare anterior chamber cells with small fine keratic precipitates, and some vitreous opacities were found by examination. Sheathed retinal vessels including arteries and veins were also noticed and intraretinal and subretinal fluid recurred. Eventually, she was diagnosed with intraocular inflammation, and she started treatment with betamethasone sodium phosphate and triamcinolone into the sub-Tenon’s capsule. After a month, an examination showed resolution of the vitreous opacities and the return of the bestcorrected visual acuity to 0.7 without any complications. The sheathed retinal vessels seemed to improve. An optical coherence tomography showed resolution of intraretinal and subretinal fluid but an extremely thin choroid.