Severe vision loss secondary to retinal arteriolar occlusions after multiple intravitreal brolucizumab administrations

Abstract

Purpose: To describe a case of unilateral retinal arteriolar occlusion following multiple intravitreal brolucizumab injections for neovascular age-related macular degeneration (nAMD).

Observations: A 92-year-old Caucasian woman presented with blurry vision in her left eye (OS) after receiving the third dose of intravitreal brolucizumab. At the time of presentation, visual acuity (VA) was 20/40 in her right eye (OD) and had decreased from 20/150 to count finger (CF) at 1-foot OS. On examination, there was no evidence of active inflammation in the anterior chamber OU. Dilated fundus examination showed no vitritis in OD and 1+ vitreous cells OS, flame-shaped hemorrhage at the superior optic disc margin, and retinal whitening surrounding the proximal portion of the supero-temporal branch of the central retinal artery. There were drusen in OS and retinal pigment epithelial (RPE) changes in the maculae of OU. Intra-arteriolar greyish deposits were seen OS. Fluorescein angiography (FA) showed hyper-fluorescence in the maculae corresponding to fibrovascular pigment epithelial detachments (PED) OU. No peri-vascular leakage was noted OU. Delayed filling of multiple arterioles in early and late phases OS was observed on FA. The patient was diagnosed with retinal arteriolar occlusion associated with repeated intravitreal brolucizumab administrations.

Conclusion: Retinal arteriolar occlusion with severe vision loss, possibly secondary to inflammatory responses, can occur after subsequent intravitreal brolucizumab injections, even if no inflammation occurred after initial administrations. Vaso-occlusive disease should be considered as a potential ocular complication, with acute as well as delayed onset, following intravitreal brolucizumab therapy.

Keywords: Age-related macular degeneration; Brolucizumab; Intravitreal; Neovascular; Retinal occlusive vasculitis; Retinal vasculitis; Vaso-occlusion.

Fig. 1

Fundus photograph (FP) of both eyes. FP of the right eye before (1A) and after (1B–1C) bevacizumab injection are within normal limits. Left eye before (1D) the third intravitreal brolucizumab injection showing drusen (yellow arrow); three weeks post-third intravitreal brolucizumab injection (1E) showing drusen (yellow arrow), whitish lesions near the disc (red arrow), small intra-arteriolar greyish depositions (black arrow); and four weeks post-third intravitreal brolucizumab injection (1F) showing whitish lesions near disc (red arrow), small intra-arteriolar greyish depositions (black arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

Fig. 2

Optical coherence tomography (Spectralis, Heidelberg Engineering, Heidelberg, Germany) of the right (OD) and left (OS) eyes. OCT of OD after multiple intravitreal bevacizumab injections (2A, 2C, 2E). Before the third intravitreal brolucizumab injection in OS (2B), three weeks post-third intravitreal brolucizumab injection (2D) and four weeks post-third intravitreal brolucizumab injection (2F). Pigmented epithelial detachment can be seen at all visits in both OD and OS (red arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

Fig. 3

Fluorescein angiography of right eye (OD) post-bevacizumab injection (top row) and post-third intravitreal brolucizumab injection (bottom row) in left eye (OS). No leakage of optic nerve and peri-vasculature can be seen in OD (3A-3C). Hyper-fluorescence in the peri-foveal region with no active leakage can be seen OU (white arrows). Delayed arteriolar filling in early phase (yellow arrow) can be seen in early phase FA in OS (3D). Hyper-fluorescence of the superior retinal arteriole near the optic disc (red arrows) can be seen without leakage in mid to late FA in OS (3E-3F). (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)