Vitreous Noise on Optical Coherence Tomography as an Early Finding of Brolucizumab-Related Intraocular Inflammation

Abstract

We describe a case of brolucizumab-related intraocular inflammation (IOI) detected using vitreous haze on optical coherence tomography (OCT) at an early stage before the patient was aware of any symptom. A 69-year-old female presented with decreased right vision. The patient was diagnosed with pachychoroidal neovasculopathy and started intravitreal aflibercept (IVA) with a 3+ treat-and-extend strategy (TAE). Although the serous retinal detachment (SRD) disappeared after IVA treatment, the patient was managed with treatment every 4 weeks without extending the treatment interval To shorten the treatment interval, intravitreal brolucizumab (IVBr) was started 44 weeks after starting IVA treatment. After initiating IVBr treatment, the SRD completely disappeared. However, 16 weeks after starting IVBr, OCT showed noise in the vitreous cavity, which had not been seen before, and infrared images showed a black smoke-like shadow over the macula. Despite these findings, the patient had no subjective symptoms, and so IVBr was re-administered with an 8-week TAE interval. Five days after IVBr treatment, vitreous inflammatory cells were observed, and the noise in the vitreous cavity and the smoke-like shadow in the infrared image were further enhanced. We diagnosed the patient with brolucizumab-related IOI, and anti-inflammatory treatment was initiated. After extensive treatment, the vitreous opacity gradually disappeared, and the vitreous noise on OCT and the black smoke-like shadow on infrared images disappeared. IOI may have already been present 16 weeks after starting IVBr treatment, when we judged that there was no inflammation and IVBr was re-administered. When following patients receiving IVBr, IOI may be detected by OCT at an earlier stage by evaluating vitreous haze.

Safety and Effectiveness of Intravitreal Brolucizumab Injection in Combination With Sub-Tenon's Capsule Triamcinolone Acetonide Injection for Polypoidal Choroidal Vasculopathy During the Loading Phase

“…In a sub-analysis focusing on Japanese PCV patients within the HAWK and HARRIER studies, the incidence of intraocular inflammation was reported in 15.4% [38]. Furthermore, the incidence of intraocular inflammation in Japanese patients ranges from 9.4% to 28.6% in clinical studies [23][24][25][26][27][28][29][30][31]. Thus, brolucizumab-related intraocular inflammation is a significant concern for the Japanese population.…”

“…The heightened risk includes the potential occurrence of occlusive retinal vasculitis occurrence, which can lead to irreversible visual impairment [22]. Although brolucizumab is expected to be an effective therapeutic agent for PCV treatment, intraocular inflammation management, which frequently occurs in the Japanese population [23][24][25][26][27][28][29][30][31], is a major challenge. In clinical practice, measures are being taken to prevent the onset of intraocular inflammation by the concomitant use of sub-tenon's capsule triamcinolone acetonide injection (STTA) [23,30].…”

Vitreous Opacity Following Intravitreal Brolucizumab Injection: A Case Series Review

“…Other reported adverse effects include lenticular opacities, punctate keratitis, corneal abrasion, posterior capsule opacification, cataracts, increased intraocular pressure, blepharitis, conjunctivitis, and iritis [ 9 ]. Meanwhile, Yoshikawa et al [ 10 ] reported a case of brolucizumab-associated inflammation in the vitreous cavity, manifesting as a black smoke-like shadow on optical coherence tomography (OCT) examination. In our retinal clinic, we encountered several cases of vitreous opacity (VO) after intravitreal brolucizumab injection, with an appearance similar to that of asteroid hyalosis (AH).…”