Postmarketing Analysis of Aflibercept-Related Sterile Intraocular Inflammation

Abstract

IMPORTANCE Aflibercept-related sterile inflammation, an event that is poorly understood, has been the subject of ongoing postmarketing reports. OBJECTIVE To analyze cases of aflibercept-related sterile inflammation reported to the American Society of Retina Specialists (ASRS) Therapeutic Surveillance Committee (TSC), an independent task force formed to monitor drug-and device-related safety events. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of 56 cases in 55 patients was performed of all cases of sterile inflammation after aflibercept injection that were voluntarily reported by 12 practices throughout the United States to the ASRS TSC from December 1, 2011, through February 12, 2014. MAIN OUTCOMES AND MEASURES Cases of aflibercept-related sterile inflammation were analyzed for baseline and demographic information, presenting symptoms and findings, visual acuity changes, injection technique, and management details. RESULTS Among 56 reported cases of sterile inflammation, mean time to onset was 3.5 days (median, 2 days; range, 0-30 days). Most cases consisted of initial loss of vision and intraocular inflammation without prominent redness, severe pain, or hypopyon. Thirty-seven cases (66%) were treated with topical corticosteroids and/or observation alone. Mean time to resolution was 28.6 days (median, 28 days; range, 4-84 days). Although final vision was overall unchanged, some patients developed permanent vision loss, which may have resulted from inflammation and/or progression of the underlying disease. Age older than 80 years was associated with worse visual outcomes. No difference in visual outcome was detected in patients with sterile inflammation undergoing topical therapy alone vs invasive procedures (vitreous biopsy and/or intravitreal antibiotic administration and/or vitrectomy). CONCLUSIONS AND RELEVANCE With the largest number of reported cases of aflibercept-related sterile inflammation to our knowledge, this analysis suggests typical findings and an often favorable prognosis of this event. Analysis of real-world, postmarketing data has limitations, and these findings should be considered as hypothesis-generating assessments rather than a definitive reflection of this event or its typical course. Distinguishing sterile inflammation and infectious endophthalmitis at the time of presentation may often be difficult, and cautious evaluation and management of these patients are warranted. The ASRS TSC encourages active postmarketing surveillance by all physicians.

Two-year outcomes of intravitreal ziv-aflibercept

“…Complications included unilateral transient inflammatory reaction that did not return on further bilateral injection consistent with rare instances of sterile inflammation after aflibercept or other anti-VEGF agents 29. Another instance of central retinal artery occlusion 2 months after injection could be related to the anti-VEGF constrictive effect30 or could be coincidental as the onset was after the VEGF blockade has worn off.…”

Endophthalmitis rates among patients receiving intravitreal anti-VEGF injections: a USA claims analysis

“…Endophthalmitis can be infectious or sterile (noninfectious), with limited available evidence suggesting that the 2 forms differ in their pathogenesis, although this is currently not well understood 4. Another consideration is the inability to isolate an organism in some cases of infection.…”

Intraocular Inflammation Following Intravitreal Injection of Anti-VEGF Medications for Neovascular Age-Related Macular Degeneration

“…Furthermore, the American Society of Retina Specialists (ASRS) Therapeutic Surveillance Committee (TSC) recently described 56 unsolicited voluntarily reported cases of sterile intraocular inflammation following aflibercept intravitreal injection. 7 The median time to onset of inflammation following injection was 2 days, compared to 1 day in the study by Souied and colleagues, the median time to resolution was 28 days, and the final vision was overall unchanged, although some patients developed significant vision loss. Thus, non-infectious endophthalmitis appears to be a real complication of intravitreal aflibercept injection that occurs quickly following injection with outcomes seemingly favorable compared to infectious endophthalmitis.…”