Risk factors for emerging intraocular inflammation after intravitreal brolucizumab injection for age-related macular degeneration.

PURPOSE: To analyze the risk factors associated with emerging intraocular inflammation (IOI) after intravitreal brolucizumab injection (IVBr) to treat age-related macular degeneration (AMD).
METHODS: This study included 93 eyes of 90 patients. The incidence of emerging IOI was analyzed. The patients were classified into IOI or non-IOI groups, and background clinical characteristics in each group were compared.
RESULTS: IOI occurred in 14 eyes of 14 cases (16%; five women, nine men [5:9]; IOI group) after IVBr; contrastingly, no IOI occurred in 76 patients (10 women, 66 men [10:66]; non-IOI group). The mean ages in IOI and non-IOI groups were 79.4 ± 8.1 and 73.8 ± 8.9 years old, respectively, and the average age in the IOI group was significantly higher than that in the non-IOI group (P = 0.0425). In addition, the percentages of females in the IOI and non-IOI groups were 43% and 13%, respectively, and IOI occurred predominantly in females (odds ratio: 4.95, P = 0.0076). Moreover, the prevalence of diabetes in the IOI and non-IOI groups was 64% and 32%, respectively, with a significant difference (odds ratio: 3.90, P = 0.0196). In contrast, the prevalence of hypertension in the IOI and non-IOI groups was 36% and 57%, respectively, with no significant difference (P = 0.15).
CONCLUSION: The comparison of clinical profiles of IOI or non-IOI cases in IVBr treatment for AMD suggests that the risk factors for IOI are old age, female sex, and history of diabetes; however, IOI with vasculitis or vascular occlusion in this cohort does not seem to cause severe visual impairment. Further studies are required to investigate potential risk factors for IOI.

Introduction

Age-related macular degeneration (AMD) is currently the most prevalent cause of blindness in both the western and eastern hemispheres [1, 2]. Since 2006, intravitreal injection of anti-vascular endothelial growth factor (VEGF) antibodies is the major treatment for patients with neovascular AMD [3, 4]. In this era, visual acuity can improve in most patients after continuous treatment with anti-VEGF agents for several years, and this improvement can be maintained for at least 7 years [5-7]. However, treatment with anti-VEGF drugs such as ranibizumab and aflibercept can potentially induce vascular occlusive diseases and severe adverse events including cardiovascular events or cerebral infarction; although the frequencies of these events are very low [8-10].

Recently, brolucizumab, a novel anti-VEGF agent, has been shown to have a prolonged effect and is potentially effective against choroidal neovascularization beneath the retinal pigment epithelium, as shown in phase 3 studies such as HAWK and HARRIER [11]. However, in these reports, unexpected cases of intraocular inflammation (IOI) after intravitreal brolucizumab (IVBr) injection have been noted having an incidence of 4.6% [12]; this was higher than that of ranibizumab and aflibercept injection groups (1.5% and 0.5–1.1% respectively) [13]. To date, the clinical profiles of these cases are unclear.

This report clarifies the risk factors for emerging IOI after IVBr injection.

Methods

This retrospective study obtained institutional review board approval from the Gunma University Graduate School of Medicine and adhered to the Declaration of Helsinki. The requirement for written informed consent was waived owing to the retrospective nature of the study. All patients with a clinical diagnosis of typical AMD, polypoidal choroidal neovasculopathy (PCV), and pachychoroid neovasculopathy (PNV) at the Department of Ophthalmology of Gunma University Medical Hospital between June 2020 and January 2021 were included in this study. All participants were examined using a fundus ophthalmoscope, fluorescein angiography (FA), indocyaninegreen angiography (IA; Heidelberg Engineering, Heidelberg, Germany), and swept-source optical coherence tomography (SS-OCT; Plex Elite 9000; Carl Zeiss Meditec, Dublin, CA, USA) incorporating a tunable laser with a central wavelength of 1050 nm and acquiring 100,000 A-scans/s. SS-OCT has an axial resolution of 1.95 μm and a lateral resolution of 20 μm. SS-OCT volume images were obtained using a raster scan protocol of 500 × 500 B scans per second, covering an area of 6 × 6 mm centered on the fovea.

Three monthly injections of brolucizumab (Beovu, 6.0 mg/0.05 mL; Novartis, Basel, Switzerland) were administered as a loading phase treatment for treatment-naïve patients. After three months injections, patients were followed-up using Treat and Extend (TAE) regimen. If persistent signs of active disease were present, injections were continued bimonthly until the macula was dry. Once the macula was dry, the interval between injections increased to 4 weeks initially and the maximum interval was 16 weeks. Contrastingly, for non-treatment naïve cases, TAE regimen was applied after first brolucizumab injection.

In this study, 7 physicians performed IVBr, in accordance with guidelines for intravitreal injection for macular disease [14].

Patients were monitored for emergence of IOI starting from one week after the first injection and monthly thereafter for 3 months. For the purpose of our study, IOI included iritis, vitritis, and vasculitis or occlusion of vessels. To precisely detect IOI, a detailed slit lamp test and fundus examination were performed. Additionally, we analyzed the patients’ eyes with an ultra-wide field scanning laser ophthalmoscope (Optos 200Tx; Optos, Dunfermline, Scotland), during monitoring, to broadly detect vascular changes. To diagnose occlusion of vessels as IOI, we performed FA and IA angiography at the initial visit and at the visit after the loading dose. SS-OCT (DRI-OCT triton, Tokyo, Japan) were performed at every visit.

To determine whether patients had diabetes (HbA1c) or hypertension, we assessed medical records in all cases. In addition, before performing the first angiography, systolic and diastolic blood pressures were checked in all cases.

Statistics

The Mann-Whitney U test was used to compare the mean age between the IOI and non-IOI groups. A chi-square test was performed to analyze the odds ratio and p-value for the prevalence of diabetes and hypertension and the dominance of males or females in each group. Data analysis was performed using GraphPad Prism version 9 software (GraphPad Software, La Jolla, CA, USA).

Results

Ninety-three eyes of 90 patients were included in this study. Seventy five eyes (81%) were treatment naïve. IOI occurred in 14 eyes of 14 cases (16%; five women, nine men [5:9]; IOI group) after IVBr; contrastingly, IOI did not occur in 76 cases (10 women, 66 men [10:66]; non-IOI group) during 3 months. The mean ages in IOI and non-IOI groups were 79.4 ± 8.1 and 73.8 ± 8.9 years, respectively, and the average age in the IOI group was significantly higher (P = 0.0425) than that in non-IOI group. In addition, the percentages of females in the IOI and non-IOI groups were 43% and 13%, respectively, and IOI occurred predominantly in females (odds ratio: 4.95, P = 0.0076). Moreover, the prevalence of diabetes in the IOI and non-IOI groups was 64% and 32%, respectively, with a significant difference (odds ratio: 3.90, P = 0.0196). In contrast, the prevalence of hypertension in the IOI and non-IOI groups was 36% and 57%, respectively, with no significant difference (P = 0.15). The mean systolic and diastolic blood pressures before the first injection in the IOI and non-IOI groups were 133 ± 18/74 ± 11 mm of Hg and 141 ± 17/79 ± 12 mm of Hg, respectively, without a significant difference (P = 0.11 and 0.10, respectively) (Tables 1 and 2).

Table 1

Comparison of clinical characteristics between cases with and without intraocular inflammation after brolucizumab injection.

	Total	With IOI	Without IOI	P value
Patients	90	14	76
Number(eyes)	93	14	79
Age	74.8±9.0	79.4±8.1	73.8±8.9	0.0425
Female: Male	15:75	5:9	10:66	0.0076
General condition
Diabetes	32(36%)	9(64%)	23(32%)	0.0196
Hypertension	45(50%)	5(36%)	40(57%)	0.15
Systolic pressure	139±17	133±18	141±17	0.11
Diastolic pressure	78±12	74±11	79±12	0.1
Lesion types				0.74
Typical AMD	32	4	28
PCV	44	7	37
PNV	14	3	11

IOI: intraocular inflammation. PCV: polypoidal choroidal vasculopathy, PNV: pachychoroid neovasculopathy.

Table 2

Clinical profiles of cases with intraocular inflammation after brolucizumab injection.

General conditions	Liver dysfunction	DM(Hba1c8.9)	Post CI(’98),HT,DM(HbA1c:7.1%)	HT,DM(HbA1c:7.2%)	Border line DM(HbA1c:5.7%)	Alzheimer (HbA1c:6.4%)	Liver dysfunction, Thrombocytopenia	Border line DM(BS;175,HbA1c:5.5%)	HT,CKD	DM(HbA1c:7.2%),HT,HL,HU	DM(HbA1c:8.3%)	DM(HbA1c:7.7%), Post coronary artery bypass ICA stenosis,Old CI(’10),RA	Old MCI(’18),ASO	DM(HbA1c:10.7),HT,HU
BCVA at the last visit	20/25	20/2000	12.5/20	20/40	25/20	25/20	4/6.3	20/25	20/25	20/25	4/6.3	16/20	20/40	20/63
BCVA at the initial visit	20/63	20/1000	20/40	20/50	4/6.3	20/20	20/25	20/20	4/6.3	4/6.3	20/32	4/6.3	20/50	20/63
Local steroid	+	0	+	+	+	+	0	+	+	+	+	+	+	+
Vascular occlusion	0	0	+	0	+	+	0	0	0	0	0	0	0	0
Periphlebitis	+	0	+	0	+	+	0	+	0	0	0	0	+	0
Arteritis	+	+	+	0	+	+	0	+	+	0	+	0	+	+
Vitritis	+	+	+	0	+	+	0	+	+	+	+	+	+	+
Iritis	0	0	0	+	+	+	+	+	0	+	0	0	+	+
IOI onset (days) after last injection	20	27	28	5	28	26	12	21	19	25	28	15	30	3
Number of Injections prior to IOI	2	1	2	1	3	3	1	1	1	1	2	2	1	3
Lesion	PCV	Occult	PCV	PCV	PCV	PCV	Occult	PNV	PCV	PNV	PNV	Occult	Occult	PCV
Naïve/Switch	Naïve	Naïve	Naïve	Naïve	Naïve	Naïve	Switch	Switch	Naïve	Naïve	Naïve	Naïve	Naïve	Naïve
Sex	F	M	M	M	F	F	M	F	M	M	F	M	F	M
Age	77	86	88	76	72	90	65	72	94	75	78	77	76	85
Cases	1	2	3	4	5	6	7	8	9	10	11	12	13	14

IOI: intraocular inflammation, PCV: polypoidal choroidal vasculopathy, BCVA: best corrected visual acuity, DM: diabetes mellitus, CI: cerebral infarction, HT: hypertension, CKD: chronic kidney disease, HL: hyperlipidemia, HU: hyperuremia, ICA: internal carotid artery, RA: rheumatoid arthritis, ASO: arteriosclerosis obliterans.

Discussion

Overall, IOI occurred in 16% of AMD cases treated with IVBr injections. Female sex, history of diabetes, and older age were risk factors for emerging IOI after IVBr in our cohort.

In IOI cases, blurred vision, eye floaters, ocular pain, and conjunctival injection were reported as the primary symptoms. Particularly, 11/14 patients (79%) claimed to experience eye floaters, but no patients complained of pain. Neither hypopyon nor ciliary injection was detected in these patients. Based on the aforementioned findings, it is unlikely that these patients had endophthalmitis.

In the Beovu safety site [15], IOI was reported in 4.3% of cases of total injections (HAWKS and HARRIER) [12]. At this site, 5.1/10000 shots were accompanied by vasculitis and 3.4/10000 with occlusive vasculitis. In our previous report, IOI occurred in 19% of cases (8/42 eyes), primarily in women [16]. Furthermore, in an early experience study, IOI was observed in 8.1% of cases (14/172 eyes), and the female sex showed a relative risk of 1.27 for IOI [17]. Moreover, the American Society of Retina Specialists analyzed reports of inflammation following IVBr injection for neovascular AMD [18]. In this analysis, 26 eyes showed IOI, and 22 eyes with IOI occurred in women. Tendency and female dominance were similar to those reported previously. However, Maruko reported that IOI was detected in 9% (4/43 eyes) of treatment-naïve patients and 10% in a switched group, and in his report, no sex-related disease association was observed [19].

IOI with vasculitis or vascular occlusion in this cohort did not seem to cause severe visual impairment (Table 2). Additionally, IOI with vasculitis did not worsen the visual acuity. Early treatment with steroids could relieve IOI and restore visual outcome. In two cases with reduced vision after IOI, exudative macular neovascularization seemed to contribute to the visual deterioration. Old age, female sex, and history of diabetes seemed to contribute to the occurrence of IOI in this cohort; however, these factors did not seem to be associated with vision threatening in the eyes with IOI.

During treatment with protein therapeutics, the emergence of anti-drug antibodies (ADA) has been the focus of recent attention because ADA potentially works as a neutral antibody for a parent drug or an inducer of adverse reactions [20]. With the use of ADA against tumor necrosis factor-α (TNF-α) inhibitors for treatment of rheumatoid arthritis, TNF-α was detected in a maximum of 87% of cases [21]. In the form submitted to the FDA where brolucizumab was filed as a new drug, it was suggested that ADA may form after the use of brolucizumab [22]. Sharma speculated that ADA might be associated with IOI in the use of brolucizumab [23].

Generally, there may be sex differences in the immune response. Taken together, males and females may differ in their responses to brolucizumab injection.

Higher age can be a risk factor for emerging IOIs in this cohort. The mean ages of the cohorts used in the HAWK and HARRIER studies [12] were 76.6 and 74.8 years, respectively, and the average age of IOI cases reported by Ophthalmology was higher than these ages [12]. In four vision loss cases, after treatment with brolucizumab, the ages were 88, 92, 77, and 76 years [22-25]. Higher age has been identified as a high-risk factor for cardiovascular events [26]. In addition, one of the positive predictors of stroke after myocardial infarction is advanced age [20]. Overall, higher age can potentially be a high-risk factor, not only for cardiovascular events, but also for occlusive events, even in the retina and choroid.

Diabetes can accompany microangiopathy and macroangiopathy, which are caused by sclerosis [27, 28]. Hyperglycemia due to diabetes, tissue resistance against insulin, hyperinsulinemia accompanied with insulin tolerance, and obesity, specifically visceral fat obesity, can promote arteriosclerosis in diabetes [29]. Mortality due to coronary artery diseases and the frequency of cardiac infarction increase in cases of diabetes [30]. Advanced glycation end-products or glycation proteins can induce the release of pathophysiological substances such as IL-6, IL-8, MCP-1, ICAM-1, and IP-10 in conditions such as diabetic retinopathy [31]. In addition, microinflammation can cause diabetic retinopathy mediated by circulating monocytes, tissue-resident macrophages, and monocyte-derived inflammatory macrophages [32]. Patients with severe diabetes mellitus sometimes have accompanying iritis clinically, with hyperpermeability due to impairment of blood aqueous humor barrier due to damage of endothelial cells in capillary vessels. Histopathological sections of the vitreous, aspirated from patients with vasculitis that developed after brolucizumab injection, revealed infiltration of CD20 positive B cells, CD3, 4, and 8 positive T cells and CD68 positive histiocytes [33]. IOI consists of iritis, OCV, vasculitis, and vascular occlusion, and such pathogeneses if accompanied by diabetes mellitus can potentially promote further inflammation. Of the 14 patients with IOI after brolucizumab injection, nine had diabetes mellitus, and diabetic retinopathy progressed in the retina in 6/9 of these cases (67%). Based on these findings, we believe that IVBr injections in patients with diabetes mellitus may result in occlusive or inflammatory changes in the retina.

In conclusion, the risk factors for emerging IOI after IVBr injection are old age, female sex, and history of diabetes; however, IOI with vasculitis or vascular occlusion in this cohort does not seem to cause severe visual impairment. Further studies are required to investigate potential risk factors for IOI. In almost 80% of the cases, patients had eye floaters before or after the onset of the IOI. Thus, it is important to pay attention to the claims of floaters after IVBr injection.

Clinical characteristics of treatment naïve and non-treatment naïve cases.

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14 Jul 2021

PONE-D-21-16802

Risk factors for emerging intraocular inflammation after intravitreal bevacizumab injection for age-related macular degeneration

PLOS ONE

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Reviewer #1: The authors present an interesting study on a topic of very high interest: intraocular inflammation after brolucizumab. They are invited to consider the following recommendations to further strengthen their work:

The very title of the article is not in agreement with the article. Do the authors investigate bevacizumab (Avastin) or Brolucizumab (Beovu) ?

Define ’others’ in abstract results

Please correct syntax in the last phrase of your abstract: ‘elders’ is not a ‘risk factor’.

Please be more specific in your introduction tha, ‘relatively frequently’.

Describe the percentages for IOI for bevacizumab, ranibizumab and aflibercept and directly compare with the percentages in the brolucizumab studies.

Seems like not all the eyes included in this study were treatment naive. if not, how many weeks/months since the last antiVEGF injection? define your inclusion and exclusion criteria in more detail.

Was FA, IA and SS-OCTA performed to all eyes at every single visit ? This would be interesting in terms of how many imaging tests were the patients undergoing in their regular visits, since this was a retrospective review, not a prospective study.

Methods should be overall more detailed.

What exactly was the technique/protocol followed when injecting?

Were all the injections preformed by the same person ?

If not, what was the technique/protocol of all different treating physicians exactly the same ?

You should define intraocular inflammation in a very strict and precise manner

It would be interesting to investigate whether the injection technique/protocol had any effect on the occurrence of IOI.

Statistical analysis: did the authors check whether their data are normally distributed ?

The authors need to go more in depth and try to explain why the factors they found that were associated with higher IOI rates are risk factors. Please elaborate more in your discussion.

Reviewer #2: The authors present a study regarding "Risk factors for emerging intraocular inflammation after intravitreal bevacizumab injection for age-related macular degeneration". This is a very interesting topic as we are trying to understand the safety profile of this new agent Brolicizumab even though they have the wrong name of medicine in the title which makes it very confusing...

However, the study the authors have presented has very limited analysis and does not add anything to the literature and is missing significant information eg time when IOI was diagnosed, severity of IOI, number of previous anti VEGF injection, what type of of anti VEGF injection, also majority of oateintas had PCV in the IOI group- was it the same as in the IOI group? What about degreee of existing DR in addition to DM. Authors should do a much more through review of all characteristics of patients to provide an analysis of the risk factors in involved in IOI group.

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25 Aug 2021

Dear Dr. Vavvas,

Thank you for giving me the opportunity to submit a revised draft of my manuscript titled “Risk factors for emerging intraocular inflammation after intravitreal brolucizumab injection for age-related macular degeneration” to PLOS ONE. We appreciate the time and effort that you and the reviewers have dedicated to providing your valuable feedback on my manuscript. We are grateful to the reviewers for their insightful comments on our paper. We have been able to incorporate changes to reflect most of the suggestions provided by the reviewers. We have indicated the changes within the manuscript in red font. Here is a point-by-point response to the reviewers’ comments and concerns.

Submitted filename: @Dear_Dr.docx

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20 Oct 2021

PONE-D-21-16802R1Risk factors for emerging intraocular inflammation after intravitreal bevacizumab injection for age-related macular degenerationPLOS ONE

Dear Dr. Mukai,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The manuscript has improved. There remain some areas for clarification and expansion and we look forward to hte revised version.

Please submit your revised manuscript by Dec 04 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Demetrios G. Vavvas

Academic Editor

PLOS ONE

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Reviewer #1: The authors have substantially improved their work. They are invited to consider the following additional recommendations:

1. Your abstract’s conclusion seems more like a purpose. Please provide a conclusion that sums up the findings of your study and why they might be clinically relevant. (same way as in the conclusion ion the manuscript)

2. Injection technique varies between different treating physicians. This is well documented for antiVEGF injections. How can the authors be sure that injection technique did not affect the rates of IOI since per line 72, 7 different physicians performed the brolucizumab injections.

3. Please clarify the device used for SS-OCT (line 80)

4. Table 2 is confusing. What do all the ‘1’s represent ? If its individual parents please number the patients.

5. Did the number of previous injections in the non-treatment naive eyes affect the rate of IOI ?

Reviewer #2: Even though the manuscript has improved from pervious version, it still lacks in depth analysis in particular regarding the vision outcomes of IOI and the vision threatening forms of IOI of vasculitis and how they responded and if risk factors described for all IOI also apply for the vision threatening one that is the most concerning

**********

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Reviewer #1: No

Reviewer #2: No

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27 Oct 2021

Dear Editor and reviewers,

Reviewer #1: The authors have substantially improved their work. They are invited to consider the following additional recommendations:

1. Your abstract’s conclusion seems more like a purpose. Please provide a conclusion that sums up the findings of your study and why they might be clinically relevant. (same way as in the conclusion ion the manuscript)

Response:

In our cohort, three factors might have influenced the occurrence of IOI after IVBr injections. IOI with vascular occlusion by itself did not seem to cause severe visual impairment in this cohort. Thus, it is likely that these factors were not associated with vision threatening in the eyes with IOI. Considering the possibility of further indication of IVBr for diabetic macular edema, “Further studies are required to investigate potential risk factors for IOI” should be added to the conclusion. We have added this information to the Abstract and Discussion section, as follows

“The comparison of the clinical profiles of IOI or non-IOI cases in IVBr treatment for AMD suggests that the risk factors for IOI are old age, female sex, and history of diabetes; however, IOI with vasculitis or vascular occlusion in this cohort does not seem to cause severe visual impairment. Further studies are required to investigate the potential risk factors for IOI.”

2. Injection technique varies between different treating physicians. This is well documented for antiVEGF injections. How can the authors be sure that injection technique did not affect the rates of IOI since per line 72, 7 different physicians performed the brolucizumab injections.

Response:

As we responded to your comment in the previous revision, we published an article that aimed to standardize the injection techniques for individual physicians. All staff were trained using this manual. We performed 4093 injections of anti VEGF drugs, except for brolucizumab, for one year and no IOIs occurred. We also participated in a multicenter study, which investigated the incidence of endophthalmitis after anti VEGF injections in 2020, but no infections were reported during this period. These results suggested that standardization was successful.

Ganka Rinsho Kiyo　2018 Vol 11,No 9 P.688 (Domestic journal)

Sci Rep 2020 Dec 17;10 (1): 22122

3. Please clarify the device used for SS-OCT (line 80)

Response:

We used DRI-OCT Triton (Topcon, Tokyo, JAPAN). We have added this information to the Methods section.

4. Table 2 is confusing. What do all the ‘1’s represent ? If its individual parents please number the patients.

Response

We erased “1” and added “+” or “0” instead.

5. Did the number of previous injections in the non-treatment naive eyes affect the rate of IOI ?

Response:

In two patients with IOI in the non-treatment naïve eyes, one month prior to brolucizumab injection, aflibercept was injected. Just before brolucizumab injection, no IOI was detected on slit lamp and fundus examination and optical coherence tomography. IOI in these two cases occurred on 12- and 21-days post brolucizumab injections. Thus, we believe that IOI was mostly associated with brolucizumab injection.

Reviewer #2: Even though the manuscript has improved from pervious version, it still lacks in depth analysis in particular regarding the vision outcomes of IOI and the vision threatening forms of IOI of vasculitis and how they responded and if risk factors described for all IOI also apply for the vision threatening one that is the most concerning

Response:

Thank you so much for your comment. First, IOI with vascular occlusion in this cohort did not seem to cause severe visual impairment. Additionally, IOI with vasculitis did not worsen the visual acuity. Early treatment with steroids could relieve IOI and restore visual outcome.

In two cases with decreased vision after IOI, exudative change of MNV seemed to contribute to the visual deterioration. Finally, old age, female sex, and history of diabetes seemed to contribute to the occurrence of IOI in this cohort; however, these factors did not seem to be associated with vision threatening in the eyes with IOI.

We have added this description to the Discussion section.

Submitted filename: @Reviewer.docx

Click here for additional data file.

29 Oct 2021

Risk factors for emerging intraocular inflammation after intravitreal brolucizumb injection for age-related macular degeneration

PONE-D-21-16802R2

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PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

9 Nov 2021

PONE-D-21-16802R2

Risk factors for emerging intraocular inflammation after intravitreal brolucizumab injection for age-related macular degeneration

Dear Dr. Mukai:

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Academic Editor

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