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Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 213-214

Retinal pigment epithelial tear following intravitreal injection of brolucizumab

1 Department of Ophthalmology, Bascom Palmer Eye Institute, Retina Service, University of Miami Miller School of Medicine, Miami, Florida, USA
2 Department of Ophthalmology, New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA

Date of Submission16-Aug-2020
Date of Acceptance22-Dec-2020
Date of Web Publication01-Apr-2021

Correspondence Address:
Dr. Audina M Berrocal
Bascom Palmer Eye Institute, 900 N. W. 17th Street, Miami - 33136, Florida
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2665_20

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Keywords: Aflibercept, age-related macular degeneration, anti-vascular endothelial growth factor (anti-VEGF), brolucizumab, pigment epithelial detachment, retinal pigment epithelial tear

How to cite this article:
Ashkenazy N, Baumal CR, Berrocal AM. Retinal pigment epithelial tear following intravitreal injection of brolucizumab. Indian J Ophthalmol Case Rep 2021;1:213-4

How to cite this URL:
Ashkenazy N, Baumal CR, Berrocal AM. Retinal pigment epithelial tear following intravitreal injection of brolucizumab. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Apr 20];1:213-4. Available from: https://www.ijoreports.in/text.asp?2021/1/2/213/312390

  Case Report Top

A 79-year-old woman received three bilateral monthly intravitreal injections (IVI) of aflibercept 2 mg/0.05 mL (Eylea, Regeneron, New Jersey) for exudative age-related macular degeneration (AMD). Four weeks after her third aflibercept IVI, she had an unresolved foveal pigment epithelial detachment [PED, [Figure 1]a] with subretinal hyperreflective material [Figure 1]b. Due to persistent subretinal fluid, she was switched to brolucizumab 6 mg/0.05 mL (Beovu, Novartis, New Jersey) in her right eye.[1] Two weeks following the first brolucizumab IVI, she experienced an acute decline in vision from 20/50 to 20/100 + 2, secondary to a large retinal pigment epithelial tear with subretinal hemorrhage at the border of the PED [Figure 1]c and [Figure 1]d. There was no intraocular inflammation or vasculitis.[2]
Figure 1: (a) Fundus photograph (Optos, UK) of retinal pigment epithelial detachment (PED) in the right macula (b) Optical coherence tomography (OCT, Spectralis®; Heidelberg Engineering, Germany) of an elevated PED with RPE corrugation and a prechoroidal cleft at its border (asterisk) (c) Two weeks after brolucizumab IVI, there is subretinal hemorrhage with a curvilinear margin outlining the scrolled edge of RPE (Topcon, NJ) (d) OCT demonstrates a discontinuity in the RPE at the site of the tear in the retinal pigment epithelium (RPE, arrow)

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  Discussion Top

Brolucizumab is the most recent anti-vascular endothelial growth factor (anti-VEGF) agent, approved by the Food and Drug Administration (FDA) in October 2019 for exudative AMD.[2] Two phase-3 pivotal (HAWK and HARRIER) trials demonstrated noninferiority of visual acuity in treatment-naïve eyes managed for AMD with brolucizumab 6 mg/0.05 mL compared to aflibercept 2 mg/0.05 mL at 48 weeks.[1] Secondary outcomes favoring brolucizumab 6 mg/0.05 mL over aflibercept 2 mg/0.05 mL were greater central subfield thickness reduction and extended dosing intervals of every 12 weeks in over half of brolucizumab-treated eyes after 3 monthly loading doses.[1] These findings may relate to brolucizumab's small molecular weight (26kDa), stability, high solubility and tissue penetration, allowing it to achieve 10 times higher molar concentrations than aflibercept.[3]

RPE tears may develop spontaneously or after anti-VEGFs in eyes with vascularized PEDs, particularly when preceded by a hyporeflective cleft signifying sub-RPE contraction [Figure 1]b.[4],[5] In the HAWK and HARRIER trials, RPE tears were reported in 2.5% of brolucizumab 6 mg eyes as compared to 1.1% of aflibercept 2 mg eyes.[1] It is unknown if the increased anti-VEGF effect of brolucizumab amplifies contraction of fibrovascular tissue in PEDs hypothesized to produce RPE tears.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Grant Information: Supported in part by the NIH Center Core Grant P30EY014801, Research to Prevent Blindness Unrestricted Grant.

Financial Disclosures:

N Ashkenazy: none.

CR Baumal: Novartis (speaker), Genentech (speaker)

AM Berrocal: Alcon (advisory board)

Conflicts of interest

There are no conflicts of interest.

  References Top

Dugal PU, Koh A, Ogura Y, Jaffe GJ, Schmidt-Erfurth U, Brown DM, et al. HAWK and HARRIER: Phase 3, multicenter, randomized, double-masked trials of brolucizumab for neovascular age-related macular degeneration. Ophthalmology 2020;127:72-84.  Back to cited text no. 1
Baumal C, Spaide RF, Vajzovic L, Freund KB, Walter SD, John V, et al. Retinal vasculitis and intraocular inflammation after intravitreal injection of brolucizumab. Ophthalmology 2020;127:1345-59.  Back to cited text no. 2
Tietz J, Spohn G, Schmid G, Konrad J, Jampen S, Maurer P, et al. Affinity and Potency of RTH258 (ESBA1008), a novel inhibitor of vascular endothelial growth factor A for the treatment of retinal disorders. Invest. Ophthalmol Vis Sci 2015;56:1501.  Back to cited text no. 3
Doguizi S, Ozdek S. Pigment epithelial tears associated with anti-VEGF therapy: Incidence, long-term visual outcome, and relationship with pigment epithelial detachment in age-related macular degeneration. Retina 2014;34:1156-62.  Back to cited text no. 4
Sarraf D, Joseph A, Rahimy E. Retinal pigment epithelial tears in the era of the intravitreal pharmacotherapy: Risk factors, pathogenesis, prognosis, and treatment (An American Ophthalmological Society Thesis). Trans Am Ophthalmol Soc 2014;112:142-59.  Back to cited text no. 5


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