ASRS 2023: Special Session – Inflammation Following Intravitreal Injections

Melissa Yuan, MD
Mass Eye and Ear
Boston, MA

The Saturday session kicked off with Dr. Andre Witkin presenting a talk on behalf of the ReST committee entitled, “Update on Intraocular Inflammation after Intravitreal Drug Injections” as part of the Dry AMD symposium. In this late-breaking talk, Dr. Witkin discussed rare instances of intraocular inflammation (IOI) observed after injections of faricimab and pegcetacoplan.

Dr. Witkin first began his talk by discussing faricimab. In the last year, 1.2 million vials of faricimab have been distributed, with 23 cases of IOI reported to the ASRS ReST committee. There were 2 cases of post-faricimab retinal occlusive vasculitis, though these were confounded by prior injections with brolucizumab and systemic autoimmune disease.

He then transitioned to the main focus of his talk, which was on the recently reported cases of IOI and particularly retinal vasculitis after pegcetacoplan injections. Since the FDA approval of pegcetacoplan in February 2023, about 65,000 vials have been distributed. In these post-approval months, there have been 21 cases of IOI reported to ASRS, 17 of which were defined as panuveitis and 8 as retinal vasculitis, with 7 classified as retinal occlusive vasculitis, based on review by the ReST committee and independent uveitis experts and definitions per the SUN criteria. Dr. Witkin described each of the cases of retinal vasculitis with clinical descriptions and images, when available.

One additional case which was not among the official count due to confounding factors was also discussed.

To summarize, there were 7 cases of confirmed panuveitis with retinal occlusive vasculitis (including 2 eyes of one patient), and 1 case of confirmed panuveitis with retinal vasculitis. These cases occurred between 8 and 15 days after the injection of pegcetacoplan, with the majority occurring after the first pegcetacoplan injection and only one case occurring after the second. Hypopyon was not observed in any, and anterior chamber fibrin was observed in only 1 case. Visual outcomes varied; some eyes ended up close to presenting visual acuity, while there was one eye that became NLP. Management also varied and included topical/periocular steroids, tap and inject (with or without intravitreal steroid injections), intravitreal steroid implants, and oral steroids.

There were then several insightful comments and questions from the audience, including whether these cases were more arteritis vs phlebitis, if there is an association of retinal occlusive vasculitis with COVID status, and whether the intravitreal vancomycin could have contributed to the retinal sequelae. Dr. Witkin and Dr. Kaiser, chair of the ReST committee, explained that many of these questions are under investigation. Lastly, several commenters from the audience commended Apellis and their CMO Dr. Caroline Baumal for their swift and transparent response to these recent events, given that the first report of occlusive vasculitis was just in early July.