Reactions Weekly | 2021

Aflibercept/brolucizumab

 

Abstract


Retinal vasculitis, vascular occlusions and lack of efficacy: 3 case reports In a case series, 3 patients (2 men and 1 woman) aged 52–71 years were described, who developed retinal vasculitis or vascular occlusions during treatment with brolucizumab for polypoidal choroidal vasculopathy OD or typical age-related macular degeneration (AMD) OD. Additionally, a 52-year-old woman exhibited a lack of efficacy during treatment with aflibercept for polypoidal choroidal vasculopathy OD [dosages not stated]. Case 1: A 52-year-old woman developed retinal vasculitis during treatment with brolucizumab and exhibited a lack of efficacy during treatment with aflibercept for polypoidal choroidal vasculopathy OD. The woman with a known medical history of an allergy to tropicamide ophthalmic solution, received intravitreal brolucizumab injection for polypoidal choroidal vasculopathy OD. However, 13 days following initiation of treatment, she developed blurry vision. On the next day, she returned to the hospital. It was reported that she had received intravitreal aflibercept injections (29 injections) since May 2017. Despite treatment, no improvement in accumulations of both sub-retinal and sub-retinal pigment epithelial (sub-RPE) fluid had not resolved (lack of efficacy). Therefore, she was started on brolucizumab therapy. On clinical examination, her visual acuity reduced from 0.6 to 0.1. Slit-lamp examination showed anterior chamber cells (1+), fine keratic precipitates and vitreous cells (1+) without hypopyon. Fundus examination and ultra-widefield color images of the fundus revealed blot retinal haemorrhage, vitreous haze, vascular sheathing on peripheral retinal arteries and veins, which were suggested intraocular inflammation (IOI). Ultra-widefield fluorescein angiography (FA) demonstrated leakage from the optic nerve head, segmental leakage from veins at arcades and the peripheral retina. Spectral-domain optical coherence tomography (OCT) revealed that subretinal hyperreflective material with subretinal and sub-RPE fluid. Based on the clinical history and investigational findings, a diagnosis of brolucizumab-associated retinal vasculitis was made. Therefore, she was treated with betamethasone eye drops, prednisolone and triamcinolone [triamcinolone acetonide]. Eventually, 1 week after diagnosis, an improvement in her condition was noted. Additionally, she received an intravitreal aflibercept injection and no changes in intraocular pressure were noted throughout the follow-up period. Case 2: A 68-year-old man developed retinal vasculitis and vascular occlusion during treatment with brolucizumab typical AMD OD. The man had a history of hypertension, aortic valve replacement, photodynamic therapy, and received 2 intravitreal ranibizumab injections and 54 intravitreal aflibercept injections since 2012 for typical AMD OD. Due to the accumulation of subretinal and sub-RPE fluid, he was started on intravitreal brolucizumab injection. However, 18 days after the initiation of brolucizumab therapy, he developed floaters OD. Three days after the onset of floaters, he returned to the hospital. His slit-lamp examination revealed anterior chamber cells (1+), fine keratic precipitates and vitreous cells (1+) with visual acuity 0.5. Fundus examination and ultra-widefield color images demonstrated blot retinal haemorrhage and vitreous haze, vascular sheathing on peripheral retinal arteries and veins. Ultrawidefield FA revealed segmental leakage in peripheral veins, filling defects in the peripheral retinal arteries and veins, an area of nonperfusion in the peripheral retina. Spectral-domain OCT revealed the disappearance of subretinal and sub-RPE fluid. Based on the clinical history and investigational findings, a diagnosis of brolucizumab-associated retinal vasculitis and vascular occlusion were made. He was treated with betamethasone eye, prednisolone and triamcinolone [triamcinolone acetonide]. Eventually, 1 week after diagnosis, an improvement in his condition was noted. Additionally, he received an intravitreal aflibercept injection and no changes in intraocular pressure were noted throughout the follow-up period. Case 3: A 71-year-old man developed retinal vasculitis and retinal occlusions during treatment with brolucizumab for polypoidal choroidal vasculopathy OD. The man had a history of hypertension, arrhythmia, and treatment-naive polypoidal choroidal vasculopathy OD for which received an intravitreal brolucizumab injection. However, 11 dyas after the initiation of therapy, he developed blurry vision, floaters and redness OD and returned to the hospital 8 days later. Clinical examination showed reduced visual acuity from 15 to 0.6. Slit-lamp examination demonstrated slight conjunctival injection, anterior chamber cells (1+), fine keratic precipitates, and vitreous cells (2+). Fundus examination and ultra-widefield color images demonstrated blot haemorrhage in the peripheral retina, and thick vitreous opacities, which obscured the details of the fundus. Ultra-widefield FA revealed an area of non-perfusion in the peripheral retina, a filling defect in peripheral retinal arteries and veins, and diffused leakage from retinal vessels and the optic nerve head. OCT demonstrated the disappearance of subretinal and sub-RPE fluid. Based on the clinical history and investigational findings, a diagnosis of brolucizumab-associated retinal vasculitis and retinal occlusions were made. He was treated with betamethasone eye, prednisolone and triamcinolone [triamcinolone acetonide]. Eventually, 1 week after diagnosis, an improvement in his condition was noted.

Volume 1855
Pages 24 - 24
DOI 10.1007/s40278-021-95700-9
Language English
Journal Reactions Weekly

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