Noninfectious Inflammation After Intravitreal Injection of Aflibercept: Clinical Characteristics and Visual Outcomes

ROGER A. GOLDBERG, CHIRAG P. SHAH, TORSTEN W. WIEGAND, AND JEFFREY S. HEIER

PURPOSE: To report the presenting features and clin- PPROVED IN NOVEMBER 2011, (EYLEA; ical outcomes of a series of patients with noninfectious Regeneron, Tarrytown, New York, USA) has inflammation after intravitreal aflibercept injection. been widely adopted for the treatment of neovas- A DESIGN: Noncomparative consecutive case series. cular age-related (AMD) and, METHODS: Medical records of patients who presented more recently, retinal vein occlusion (RVO). In the pivotal with noninfectious inflammation after intravitreal afliber- phase III studies leading to US Food & Drug Administra- cept injection between November 18, 2011 and June 30, tion approval, intravitreal aflibercept injection was well 2013 were retrospectively reviewed. tolerated and associated with a low overall complication 1 RESULTS: A total of 20 cases of postinjection inflamma- rate. tion were identified in 5356 aflibercept injections. The Since then, however, cases of noninfectious inflamma- patients presented 1–13 days after aflibercept injection tion after aflibercept injection have surfaced, prompting a (median 3 days); all noted decreased vision, while 3 of pharmaceutical surveillance committee of the American 20 (15%) had pain and 2 of 20 (10%) had conjunctival Society of Specialists to investigate further.2 Differ- injection. One patient had a hypopyon (0.5 mm), and entiating inflammation from infectious , a the average anterior chamber cell was 1.8D (range 0 to feared complication of intravitreal injection, is critical for 4D). All eyes had some degree of vitritis (average patients and clinicians alike. To that end, we herein report 1.8D; range 0.5D to 4D). Patients on average had a large series of noninfectious inflammation after afliber- received 6 prior aflibercept injections (range 0–16). cept injection, including a description of its clinical presen- Only 1 patient—the first to present with inflammation tation and course. We also estimate its incidence and in this series—received an intravitreal tap (culture nega- describe investigative efforts into its cause. tive) and injection of . All patients were managed with frequent topical and were followed closely for signs of improvement. All but 1 patient regained their preinjection visual acuity (average: METHODS 33 days; range: 7–73 days). Four patients were subse- quently rechallenged with aflibercept, and 1 developed INSTITUTIONAL REVIEW BOARD EXEMPTION WAS GRANTED inflammation again after 5 additional aflibercept injec- from Chesapeake Research Review, Inc, Columbia, Mary- tions. The overall incidence of inflammation after intravi- land, USA, which waived the requirement for informed treal aflibercept injection was 20 of 5356 injections consent. This report is compliant with the Health Insur- (0.37%) or 19 of 844 patients (2.25%). However, a ance Portability and Accountability Act requirements, disproportionate number of cases clustered around 1 pro- the Declaration of Helsinki, and all state and federal laws. vider (17/20, 85%; P < .001 vs all other providers) and The medical records of all patients treated by the retina around the 2 office locations where this physician primar- service at Ophthalmic Consultants of Boston (Boston, ily worked (16/20, 75%; P < .001 vs 5 other offices). Massachusetts, USA) who developed noninfectious inflammation after intravitreal aflibercept injection be- CONCLUSIONS: Noninfectious inflammation after intravitreal aflibercept injection typically presents tween November 18, 2011 and June 30, 2013 were retro- without pain, conjunctival injection, or hypopyon, and re- spectively reviewed. sponds to topical therapy. The visual outcomes are The data collected include the age and sex of each pa- generally favorable, though the return to baseline acuity tient, the affected eye and its lens status, the date of the can take many weeks. (Am J Ophthalmol 2014;158: inciting intravitreal aflibercept injection, the number of 733–737. Ó 2014 by Elsevier Inc. All rights reserved.) prior aflibercept injections and other anti–vascular endo- thelial growth factor (VEGF) injections, the underlying diagnosis and clinical indication for intravitreal injection, Accepted for publication Jun 25, 2014. and the preinjection visual acuity. The lot number, office From the Retina Service, Ophthalmic Consultants of Boston, Boston, location, injecting physician, and preparation technique, Massachusetts. as well as use of postinjection antibiotics, were recorded. Inquiries to Roger A. Goldberg, Bay Area Retina Associates, 122 La Casa Via #223, Walnut Creek, CA 94598; e-mail: rgoldberg.eyemd@ Presentation and diagnostic data were collected as well, gmail.com including the date of presentation, the visual acuity and

0002-9394/$36.00 Ó 2014 BY ELSEVIER INC.ALL RIGHTS RESERVED. 733 http://dx.doi.org/10.1016/j.ajo.2014.06.019 TABLE. Summary of Patients With Noninfectious Inflammation After Intravitreal Aflibercept Injection

Presenting Symptoms and Signs No. of Needle Days to Case Age (y) Officea MDb Dx Eye Prior IAI InjVA Gauge Pres Pres VA Pain Conj AC Cellc Vitreous Cell T&I VA Return (d)

1 79.3 A 1 AMD OD 2 20/25 32 3 3/200 No 0 0 3þ Yesd 73 2 81.9 B 2 AMD OS 1 20/70 32 5 20/200 No 0 1 1þ No 71 3 91.3 C 1 AMD OS 2 20/50 32 6 20/70 No 0 1 1þ No 63 4 88.0 C 1 AMD OD 6 20/30þ 32 4 20/200 No 0 1.5 2þ No 34 5 70.1 B 3 AMD OS 2 20/40 32 1 20/400 No 0 4 4þ No 42 6 87.8 C 1 AMD OS 8 20/200 32 3 20/400 No 0 1 1þ No 28 7 80.2 C 1 AMD OS 6 20/200 32 3 20/300 No 0 2 1þ No 34 8 66.7 C 1 AMD OS 8 20/70 30 1 20/300 No 0 3 2þ No 15 9 61.3 C 1 CRVO OD 0 20/70 30 13 20/60 No 0 0 1þ No 13 10 82.1 A 1 AMD OS 5 20/30 30 2 1/200 No 0 2 3þ No 46 11 70.7 D 3 AMD OD 7 20/30 30 3 20/40 No 0 2 1þ No 21 12 75.8 C 1 AMD OD 2 20/40 30 1 20/100 Yes 2þ 4 0.5þ No 14 13 87.0 C 1 AMD OD 5 20/60 30 4 20/200 Yes Trace 4 2þ No 28e 14 79.1 A 1 AMD OD 10 20/70 30 2 HM Yes 0 4c 3þ No 42 15 84.2 A 1 AMD OD 10 20/50 30 2 2/200 No 0 3 3þ No 28 16 85.3 A 1 AMD OS 11 6/200 30 4 1/200 No 0 Rare 2þ No 14 17 84.6 A 1 AMD OS 4 6/200 32 3 1/200 No 0 0 3þ No 7 18 71.4 C 1 AMD OD 5 20/25 30 1 20/50 No 0 Rare 2þ No 69 19 81.5 E 1 AMD OD 9 20/50 30 1 20/70 No 0 2þ 1þ No 14 20 77.2 C 1 AMD OD 16 20/30 30 3 20/40 No 0 2þ 0.5þ No 7

AC ¼ anterior chamber; AMD ¼ age-related macular degeneration; Conj ¼ conjunctival injection (0–4þ); CRVO ¼ central retinal vein occlu- sion; Dx ¼ diagnosis; HM ¼ hand motions vision; IAI ¼ intravitreal aflibercept injection; InjVA ¼ Snellen visual acuity on day of IAI; MD ¼ physi- cian; Pres ¼ presentation; Pres VA ¼ Snellen visual acuity on the day of presentation; T&I ¼ tap and inject; VA return ¼ time (in days) for return of vision to baseline VA on the day of IAI. aSeven office locations (A–G) injected aflibercept during the study time period (November 18, 2011 - June 30, 2013). bSix physicians (1–6) injected aflibercept during the study time period. cCase 14 involved the only patient to present with a hypopyon (0.5 mm height). dCulture-negative. eCase 13 involved resolution of inflammation by day 28 after IAI, though the visual acuity remained at 20/200.

, the pain score, the presenting symp- from 20/25 to count fingers. All but 1 patient had received toms and signs, and the initial management. The patients’ prior aflibercept injection without incident (average 6 prior clinical courses, including the visual acuity over time and injections, range 0–16). No patient had a history of or response to additional intravitreal aflibercept injections, inflammation after intravitreal injection with another agent. were documented. In these cases, all patients complained of decreased An estimate of incidence was obtained by determining vision and were seen on average 3.25 days after aflibercept the total number of aflibercept injections between injection (median 3 days, range 1–13 days). Lines of visual November 18, 2011, and June 30, 2013. All eyes were pre- acuity lost between injection and presentation averaged 3.5 pared for injection with subconjunctival or topical anes- (median 3 lines, range 0–9 lines lost). Pain was not a com- thesia and povidone-iodine antisepsis. The practice mon presenting symptom—noted in 3 of 20 cases (15%)— includes 6 retina providers and 7 office locations. and was mild in nature when present. The was rarely injected (2/20, 10%), and hypopyon was seen in only 1 patient (Case 14; 0.5 mm in height). The degree of ante- RESULTS rior chamber inflammation ranged from 0 to 4þ cell (me- dian 2þ cell), and vitreous inflammation was noted in all A TOTAL OF 20 CASES IN 19 EYES OF 19 PATIENTS WERE 20 cases (median 2þ cell, range 0.5þ to 4þ cell). The included in this study. The average age at the time of pre- Table summarizes the pertinent clinical findings for each sentation with noninfectious inflammation after intravi- case. treal aflibercept injection was 79.3 (range 70–93) years; All patients were treated with frequent topical steroid 19 of 20 cases were being treated for neovascular AMD, eye drops (prednisolone acetate 1% dosed every hour the other for RVO. Preinjection visual acuities ranged while awake) and were followed closely for signs of

734 AMERICAN JOURNAL OF OCTOBER 2014 improvement. Though suspicion of infection was low Consistent with prior reports of noninfectious inflamma- given the lack of pain, conjunctival injection, and ante- tion after intravitreal injections,12 the visual outcomes in rior chamber hypopyon, the first patient to present with this series were generally good. All but 1 case returned to inflammation after aflibercept injection, in Case 1, baseline visual acuity, on average within 1 month; one- received an intravitreal tap and injection of antibiotics; third of patients were substantially better by 2 weeks post culture results were negative. injection. Although the patients in this series responded Nineteen of 20 cases regained their preinjection visual promptly to topical steroid eye drops, other therapies, acuity, on average 33 days after intravitreal aflibercept in- such as topical nonsteroidal antiinflammatory drugs, may jection (median 28 days; range 7–73 days). The 1 patient also be effective. (Case 13) whose vision did not return to baseline had res- Differentiating noninfectious inflammation from infec- olution of inflammation by day 28, though the visual acuity tious endophthalmitis is important, as infectious endoph- remained at 20/200 from a baseline of 20/60; he was lost to thalmitis requires early intravitreal therapy further follow-up. and can result in poor visual outcomes.13 Clues to the Four patients were treated subsequently with aflibercept, noninfectious nature of these cases included lack of pain, and 1 patient (Cases 16 and 17) developed noninfectious lack of conjunctival injection, and lack of hypopyon, inflammation a second time after 5 uneventful aflibercept though none of these alone should be considered diag- injections. Four patients received bilateral injections with nostic.14 Patients were managed with aggressive topical aflibercept from the same manufacturing lot number, and and were followed closely initially (often in all cases only 1 eye was affected (2 right eyes, 2 left eyes). later the same day or the next morning) for signs of stabi- During the study period, the incidence of noninfectious lization and improvement. inflammation after aflibercept injection was 0.37% The estimated incidence of noninfectious inflammation (20 cases in 5356 aflibercept injections during the study after intravitreal aflibercept injection was 0.37% in this se- period). Alternatively, 19 patients out of 844 who received ries (2.25% of patients). This is consistent with a previous at least 1 aflibercept injection during the study period were report from another retina practice, which estimated an affected (2.25% of patients). incidence of 0.28% (Koji M, et al. IOVS 2013; 54: E-Ab- However, 17 of 20 cases (85%) were from one of the stract 1104). However, given the clustering of cases seen practice’s 6 retinal specialists. This represents a 0.94% inci- in this series, the estimates of incidence should be dence for this provider vs 0.08% for all others (P < .001). approached with caution. In the 8 months since the study This provider disproportionately practices in 2 office loca- period ended (July 2013 through February 2014), 3222 tions, where 16 of 20 cases originated (80%, P < .001 vs 5 additional injections of aflibercept have been performed other office locations). in the practice, with only 1 additional case of noninfectious The 20 cases developed from 10 different manufacturing inflammation (0.03%). This is consistent with Regeneron’s lots of aflibercept, including lot 8073400023, which was postmarketing surveillance data: between November 2011 involved in 6 of 20 cases (30%). An investigation conduct- and December 2013, during which time over 1 million ed by the practice into the drug handling and storage, doses of aflibercept were administered, the reported rate needle type used, and injection technique did not reveal a of postinjection inflammation was 0.04% (personal com- cause for these cases of noninfectious inflammation. The munication, Andrea Gibson, Director, Ophthalmology cases were reported to the manufacturer as they occurred. Medical Affairs, Regeneron, March 27, 2014). Interestingly, these cases clustered around 1 provider and the 2 office locations where this doctor practiced primarily. A previous report of noninfectious inflammation after afli- DISCUSSION bercept injection also demonstrated this clustering effect, with 9 of 11 cases from 1 provider within a Connecticut- 15 NONINFECTIOUS HAS BEEN REPORTED based practice. This clustering effect may further skew es- after intravitreal injections of , , timates of incidence, but does raise interesting questions and ,3–9 as well as aflibercept.2 regarding etiology. Speculation regarding the cause of these cases of noninfec- The cause of these and other cases of noninfectious tious inflammation has largely focused on contaminants inflammation after aflibercept injection has not been deter- associated with syringe preparation and storage in the mined. Speculation regarding protein denaturation of afli- cases of bevacizumab, which is aliquoted from a 4 mL or bercept, perhaps owing to the more viscous nature of the 16 mL vial by a compounding pharmacy, or on preserva- molecule compared to bevacizumab or ranibizumab, has tives in the cases associated with triamcinolone. However, been implicated as a possible etiology.15 When passed both ranibizumab and aflibercept are delivered in single- through the provided 19 gauge filter needle, aflibercept dose, sterile glass vials without preservatives, and are often forms small bubbles (Figure), which are difficult to drawn into an individual patient syringe at the time of remove from the syringe barrel prior to injection. Denatur- the injection.10,11 ation can occur at these hydrophobic–hydrophilic

VOL. 158,NO. 4 INFLAMMATION AFTER AFLIBERCEPT INJECTION 735 The supply chain within the practice from delivery, internal distribution and storage, and day of use was intact; refriger- ation conditions were assessed at each stage and for each office and found to be within the manufacturer’s recommen- ded range (36–46 F).11 Injection preparation technique, including choice of anesthesia, use of povidone-iodine, and use of postinjection antibiotics, also does not appear to be a factor in these cases: the same technique was used by each provider for all intravitreal injections, and no cases of inflammation developed during this period associated with other anti-VEGF agents. No patients in this series had a history of uveitis, which might predispose an eye to developing inflammation. Addi- tionally, although 1 patient (Case 9) developed inflamma- tion after the first aflibercept injection, most patients had received multiple prior aflibercept injections without inci- dent. Additionally, 4 patients were rechallenged with afli- bercept subsequently, and only 1 patient developed recurrent inflammation, after 5 uneventful injections. Though impurities may have stimulated these inflamma- tory reactions, it seems unlikely that they are related to the manufacturing process. The 20 cases in this series arose from 10 different manufacturing lot numbers, and 4 pa- FIGURE. Aflibercept syringe. Small air bubbles introduced tients received bilateral same-day injections with drug into the syringe when drawing aflibercept from its single-use from the same lot number, with only 1 eye developing m vial through the 19 gauge, 5- m, 1.5-inch filter needle provided inflammation. with the vial. An impurity may be associated with the provided 5-mm filter needle, perhaps entering the syringe when the more viscous aflibercept is drawn rapidly through the filter into interfaces, as the protein tries to orient its hydrophobic the syringe. The physician in this series associated with groups in the nonaqueous layer.16 17 of the cases had the same senior technician preparing The process of denaturation may be accelerated by sheer the aflibercept syringes for injection. Since drawing up stress exerted when injecting through a 32 gauge vs a 30 the aflibercept syringes personally, with attention to the gauge needle, which has a 33% smaller internal lumen speed with which the medication is pulled into the syringe diameter.17 However, the manufacturer reports that afliber- barrel, this physician has not had any additional cases of cept has a high degree of molecular stability across a range inflammation after aflibercept injection. Further testing, of tested conditions, including multiple freeze–thaw cycles, however, is required to evaluate this hypothesis in a numerous passes through the filter needle, and injection controlled setting. through 30 gauge and 32 gauge needles (personal commu- In conclusion, noninfectious inflammation after intravi- nication, Andrea Gibson, Director, Ophthalmology Medi- treal aflibercept injection has a generally favorable visual cal Affairs, Regeneron, March 27, 2014). Additionally, outcome, but it can be carefully distinguished from infec- whereas the first 7 cases in this series occurred with a 32 tious endophthalmitis. Suspected cases should be reported gauge needle, the remaining 13 used the provided 30 gauge to the manufacturer for postmarketing surveillance. needle. Further investigations to elucidate the cause—and ulti- Investigative efforts conducted by the practice managers mately to prevent the occurrence—of postinjection inflam- and physicians did not reveal a specific cause for these cases. mation is warranted.

ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST and have made the following disclosure(s): R.A.G., C.P.S., T.W.W.—Sub-investigator on studies with the following sponsors: Alcon, Alimera, Allergan, Fovea, Genentech, Genzyme, Partners, Novartis, Ohr, Ophthotech, Regeneron; JSH—Consultancy: Acucela, Aerpio, Allergan, Bausch & Lomb, Bayer, Endo Optiks, Fovea, Genentech, Genzyme, GlaxoSmithKline, Kanghong, Notal Vision, Oraya, Paloma, QLT, Regeneron, Sequenom; Research Grant: Alcon, Alimera, Allergan, Fovea, Genentech, Genzyme, GlaxoSmithKline, Neovista, Notal Vision, Novartis, Ophthotech, Paloma, Regeneron. Funding support was received from The Center for Eye Research and Education Foundation, Boston, Massachusetts, USA. Contributions of authors: All authors listed have made substantive intellectual contributions to this study including the conception and design, acquisition of data, analysis/interpretation of data, revisions, and final approval of the version to be published.

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VOL. 158,NO. 4 INFLAMMATION AFTER AFLIBERCEPT INJECTION 737 Biosketch

Roger A. Goldberg, MD, MBA is a vitreoretinal specialist at Bay Area Retina Associates in California. He completed his residency at the Bascom Palmer Eye Institute, and his fellowship at Tufts/Ophthalmic Consultants of Boston. A graduate of Yale College, he spent a year as a Rotary Scholar at the University of Leiden, The Netherlands. After working as a healthcare consultant at McKinsey & Co., he obtained an MD and MBA from Yale. His interests include vitreoretinal diseases and surgery, innovation and technology development, and healthcare policy.

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