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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 698-699

Brolucizumab-induced retinal vasculitis – An Indian perspective


1 Department of Retina, Grewal Eye Institute, Chandigarh, India
2 Department of Ophthalmology, Duke University, Durham, NC, USA

Date of Submission29-Jan-2022
Date of Acceptance24-May-2022
Date of Web Publication16-Jul-2022

Correspondence Address:
Dr. Manpreet Brar
Grewal Eye Institute, SCO: 168-169, Sector 9C, Chandigarh - 160 009
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_295_22

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  Abstract 


The case of retinal vasculitis in a one-eyed elderly diabetic female after use of brolucizumab injection (second dose) for neovascular age-related macular degeneration.

Keywords: Brolucizumab, neovascular age-related macular degeneration (nAMD), retinal vasculitis


How to cite this article:
Brar M, Dogra MR, Grewal S P, Sharma M, Grewal D. Brolucizumab-induced retinal vasculitis – An Indian perspective. Indian J Ophthalmol Case Rep 2022;2:698-9

How to cite this URL:
Brar M, Dogra MR, Grewal S P, Sharma M, Grewal D. Brolucizumab-induced retinal vasculitis – An Indian perspective. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 11];2:698-9. Available from: https://www.ijoreports.in/text.asp?2022/2/3/698/351161



Anti-VEGF agents including Aflibercept Ranibizumab and Bevacizumab has been the gold standard of treatment of neovascular age-related macular degeneration (nAMD) and are generally well tolerated. Brolucizumab has also been recently approved for treatment of nAMD based on data from Phase 3 Hawk and Harrier trials. Brolucizumab was found to be effective to maintain visual gains to week 96 but few serious ocular side effects has been reported in Feb 2020 by American society of Retina Specialists (ASRS).


  Case Report Top


An 85-year-old diabetic female presented with complaints of blurred vision and floaters in her right eye 5 days after receiving the second dose of brolucizumab (BZM) injection. She had previously been treated with multiple intravitreal aflibercept injections in her right eye for neovascular age-related macular degeneration (nAMD) [Figure 1]a since her initial diagnosis in 2018, and her left eye was blind as a consequence of massive subretinal hemorrhage and vitreous hemorrhage resulting from an aggressive nAMD in the year 2015.
Figure 1: (a) Color fundus montage image of an 85-year-old female with neovascular AMD: An irregular elevated patch of retinal irregularities with minute subretinal hemorrhages is seen in the macular area (arrow), suggestive of nAMD. Retinal vessels and the mid-peripheral retina appear normal (b) Color fundus montage image 5 days after receiving BZM injection for neovascular AMD: Multiple retinal hemorrhages perivenous and scattered all along the retinal mid-periphery could be seen (arrow 1). Focal sheathing of retinal veins is evident as segmental, elongated patches of retinal whitening along the veins (arrow 2)

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At presentation, her best corrected visual acuity in the right eye was 20/200 and the left eye recorded no perception of light. Anterior segment examination on slit lamp of the right eye showed a posterior chamber intraocular lens; 1+ cells were seen in the anterior chamber, and +1 cells were seen in the anterior 1/3rd vitreous cavity. Left eye examination showed seclusion pupilla. Fundus examination of the right eye showed an irregular elevated grayish-white patch of retinal pigment epithelium irregularities with minute subretinal hemorrhages in the macular area, suggestive of neovascular AMD. Also, multiple retinal hemorrhages, mostly peri-venous and scattered all along the retinal mid-periphery, could be seen. Focal sheathing of retinal veins is evident as segmental, elongated patches of retinal whitening along the veins [Figure 1]b. Spectral domain optical coherence tomography (OCT) scan showed hyper-reflective tiny dots in the clear hypo-reflective vitreous space above the retina, suggestive of inflammatory cells. The presence of a thick irregular hyper-reflective lesion under the fovea, with associated retinal thickening and intra-retinal fluid, was consistent with nAMD [Figure 2]. Based on the typical clinical findings, she was diagnosed as a case of retinal vasculitis with intra-ocular inflammation induced by BZM, and she was started on oral and topical corticosteroids.
Figure 2: Spectral domain OCT in a case of BZM-induced retinal vasculitis and intra-ocular inflammation in a patient with nAMD Hyper-reflective tiny dots (arrow1) in the clear hypo-reflective vitreous space above the retina, suggestive of inflammatory cells. The presence of a thick irregular hyper-reflective lesion (arrow 2) under the fovea with associated retinal thickening and intra-retinal fluid (arrow3) was consistent with the chronic form of nAMD

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  Discussion Top


Retinal vasculitis with or without intra-ocular inflammation with the use of BZM has been well reported in the western literature with an incidence rate of 4.6%.[1] However, Chakraborty et al.[2] reported no such case in their large study on an Indian population, hypothesizing the role of race and genetics as a likely cause for the absence of such a complication in an Indian scenario.

Our case highlights the development of such a potential serious complication in an Indian population as well. To the best of our knowledge, this is the first reported case of retinal vasculitis after receiving BZM in an Indian population. Narayanan R et al.[3] have also reported a single case of intense ocular inflammation with hypopyon after intravitreal injection of BZM in a case of polypoidal choroidal vasculopathy. Although BZM has potential benefits and provides a 12 week duration in between treatments in patients with nAMD as compared to other standard anti-vascular endothelial growth factor (anti-VEGF) injections, this benefit comes with a potential risk of vision-threatening retinal vasculitis which has been rarely reported with other standard anti-VEGF therapies.[4]


  Conclusion Top


Physicians should be aware of such serious complications, and extreme caution is advisable in selection of BZM as a treatment option in one-eyed patients. Locally available standard of care anti-VEGF therapy should be considered for all one-eyed patients with neovascular AMD, and if BZM has to be used in rare situations, retinal vasculitis as a serious potential complication need to be discussed with the patients.

Declaration of patient consent

The author certify that we have obtained the appropriate patient consent form. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patients understand that her 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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Monés J, Srivastava SK, Jaffe GJ, Tadayoni R, Albini TA, Kaiser PK, et al. Risk of inflammation, retinal vasculitis, and retinal occlusion-related events with brolucizumab: Post hoc review of hawk and harrier. Ophthalmology 2021;128:1050-9.  Back to cited text no. 1
    
2.
Chakraborty D, Maiti A, Sheth JU, Boral S, Mondal S, Nandi K, et al. Brolucizumab in neovascular age-related macular degeneration-Indian real-world experience: The Braille study. Clin Ophthalmol 2021;15:3787-95.  Back to cited text no. 2
    
3.
Narayanan R, Tyagi M, Gupta SR, Nayaka A, Jayadev C. Immediate onset of sterile endophthalmitis with hypopyon after intravitreal Brolucizumab in a case of polypoidal choroidal vasculopathy. Indian J Ophthalmol 2021;69:469-70.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Cox JT, Eliott D, Sobrin L. Inflammatory complications of intravitreal anti-VEGF injections. J Clin Med 2021;10:981.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

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