The Incidence of Noninfectious Intraocular Inflammation after Intravitreal Aflibercept Injection

Abstract

Purpose: Aflibercept (Eylea), an anti-VEGF agent approved for neovascular age-related macular degeneration (AMD) since November 2011, has been associated with reports of post-injection intraocular inflammation. In February 2012, 14 cases were reported after an estimated 30,000 injections (0.047%), however 11 of these cases came from a single practice. Recent studies have reported post-Aflibercept inflammation ranging from 1.2-6.7%. This study aims to evaluate the incidence and nature of inflammatory reactions, or noninfectious endophthalmitis, in eyes injected with Aflibercept in patients with an initial 120 days of use, and initial 8 months of use.

Methods: The subjects in this study were patients who received intravitreal Aflibercept (IAI) injections. All eyes were prepped with 5% povidine-iodine solution, followed by anesthesia consisting of 4% topical Lidocaine and 2% subconjunctival Lidocaine injection. Injections were administered in the superotemporal quadrant of the eye.

Results: Initial 120 days: *Total of 477 injections in 372 patients. *3 eyes (0.6% of injections, 0.8% of patients) had some adverse reaction. *2 of these (0.4% of injections, 0.5% of patients) had moderate inflammation and vitiritis consistent with noninfectious endophthalmitis—follow-up cultures from these 2 eyes were negative. *The 1 eye other eye had mild anterior chamber reaction and discomfort. Initial 8 months *Total of 2856 injections in 799 patients. *8 eyes in (0.28% of injections, 1.0% of patients) had some adverse reaction *3 eyes (0.1% of injections, 0.4% of patients) with inflammation consistent with noninfectious endophthalmitis—follow-up cultures from these 3 eyes were negative.

Conclusions: Noninfectious endophthalmitis (NIE) can occur after anti-VEGF injections: *0.28% of injections developed some form of an AC reaction which was easily treated with topical steroids, consistent with anti-VEGF associated uveitis. *0.1% of injections developed iritis, vitritis, and vision loss, consistent with noninfectious endophthalmitis. *Clinicians should be aware of possibility of developing uveitis and even NIE after anti-VEGF injections, including Aflibercept (Eylea). Fortunately, these conditions usually resolve without residual vision loss. *Patients should be counseled to return for evaluation for any symptoms of visual blur, even without pain or metamorphopsia, lasting more than 24 hours after an injection.

Keywords: 412 age-related macular degeneration • 609 neovascularization • 557 inflammation