Systemic Side Effects and Risks Associated With Bilateral Anti-VEGF Injections

Abstract

Purpose: : To study the systemic safety profile of anti-VEGF agents (pegaptanib, bevacizumab, and ranibizumab) after bilateral intravitreal injections.

Methods: : We assumed that bilateral intravitreal injections posed a greater systemic risk to major vascular events than unilateral injections. The charts of 45 patients undergoing bilateral intravitreal injections of an anti-VEGF agent within one week, for different etiologies, were reviewed. Side effects were documented.

Results: : Among the 45 patients who received bilateral intravitreal injections within one week, no patients developed major systemic vascular events including cerebral vascular accidents or myocardial infarcts. The average number of total injections per patient was 10.4 with a range of 2-24. The average number of bilateral injections per patient within one week was 2.4, with a range of 1-7. Two patients developed cranial nerve palsies during their course of treatment with anti-VEGF therapy. Patient AG is an 83 year-old male who developed a pupil sparing third nerve palsy one month after bilateral injections of bevacizumab OD and ranibizumab OS given one week apart for choroidal neovascularization associated with macular degeneration. His symptoms resolved in 2 months. A microvascular etiology was assumed. Patient LM is a 64 year-old male who developed a sixth nerve palsy 1 week after bevacizumab injection OS. He had previously undergone bilateral injections of bevacizumab for refractory diabetic macular edema. They were 1 week apart and 2 months prior to his development of a sixth nerve palsy. His cranial neuropathy also resolved in 2 months and was attributed to a microvascular etiology related to his diabetes. Neurologic work up and imaging were negative for both patients. Both patients developed a cranial neuropathy more than 1 month after bilateral injections.

Conclusions: : Bilateral anti-VEGF intravitreal injections within one week do not seem to pose an increased risk to major systemic vascular complications such as myocardial infarction and stroke.

Keywords: vascular endothelial growth factor • retina • clinical (human) or epidemiologic studies: risk factor assessment