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Douros S, Mostafavi D, Danias M. Retinal vasculitis following intravitreal pegcetacoplan administration. Am J Ophthalmol Case Rep 2024; 33:101999. [PMID: 38298266 PMCID: PMC10828598 DOI: 10.1016/j.ajoc.2024.101999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/04/2023] [Accepted: 01/12/2024] [Indexed: 02/02/2024] Open
Abstract
Purpose To describe a case of retinal vaso-occlusive vasculitis with associated lid edema and conjunctivitis following intravitreal pegcetacoplan administration in a patient with geographic atrophy (GA). Observation A 78 year old Caucasian woman presented with complaints of lid edema, conjunctival injection, loss of vision, and mild ocular discomfort eleven days after receiving an intravitreal pegcetacoplan injection in the left eye for geographic atrophy. Visual acuity on presentation was decreased to 20/400 from 20/200 previously in that eye. Eyelid edema and conjunctival injection were present with minimal anterior chamber reaction. Dilated fundus examination revealed hemorrhages throughout the retina and signs of retinal vasculitis. The patient subsequently developed hyphema and vitreous hemorrhage. Laboratory evaluations for common infectious and inflammatory causes including aqueous and vitreous cultures for bacteria and Herpes simplex PCR were normal or negative. A delayed hypersensitivity to pegcetacoplan was suspected and was treated with topical, oral subconjunctival and intravitreal steroids. Conclusion This index report illustrates a case of retinal vaso-occlusive vasculitis associated with intravitreal pegcetacoplan associated with lid edema and conjunctival injection and subsequent hyphema and vitreous hemorrhage. Therapy with steroids topically, systemically, periocularly and intravitreally were used to treat the inflammatory process and prevent further visual loss.
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Affiliation(s)
- Stella Douros
- Stella Douros, M.D., P.C., Brooklyn, NY, USA
- SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - David Mostafavi
- SUNY Downstate Medical Center, Brooklyn, NY, USA
- Mostafavi Eye Institute, Staten Island, NY, USA
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Zehden JA, Mortensen XM, Reddy A, Zhang AY. Systemic and Ocular Adverse Events with Intravitreal Anti-VEGF Therapy Used in the Treatment of Diabetic Retinopathy: a Review. Curr Diab Rep 2022; 22:525-536. [PMID: 36053385 DOI: 10.1007/s11892-022-01491-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Intravitreal anti-vascular endothelial growth factor (VEGF) agents are used routinely in the management of neovascular conditions including proliferative diabetic retinopathy and diabetic macular edema. While the efficacy of anti-VEGF agents has been well-validated, their ocular and systemic adverse events should always be considered and discussed with patients. The aim of this review is to discuss the most recent literature reports regarding the various ocular and systemic adverse events associated with intravitreal anti-VEGF treatment in diabetic retinopathy. RECENT FINDINGS The most frequently reported adverse ocular events include subconjunctival hemorrhage, vitreous hemorrhage, increased intraocular pressure, uveitis, endophthalmitis, ocular surface disease, and traumatic cataract. Subconjunctival hemorrhage and vitreous hemorrhage are the most common ocular adverse events reported with intravitreal anti-VEGF treatment. The most serious (though rare) ocular adverse events include endophthalmitis and rhegmatogenous retinal detachment. A consensus regarding the association of systemic adverse events (such as myocardial infarction, stroke, and death) with intravitreal anti-VEGF treatments has not been established. Intravitreal anti-VEGF therapy is used in the treatment of diabetic retinopathy, macular degeneration, and other diseases. These agents are associated with a variety of ocular and systemic adverse events that ophthalmologists should always consider.
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Affiliation(s)
- Jason A Zehden
- Department of Ophthalmology, University of North Carolina at Chapel Hill, 2226 Nelson Hwy Suite 200, Chapel Hill, NC, 27517, USA
| | - Xavier M Mortensen
- Department of Ophthalmology, University of North Carolina at Chapel Hill, 2226 Nelson Hwy Suite 200, Chapel Hill, NC, 27517, USA
| | - Ashvini Reddy
- Athena Eye Institute, San Antonio, TX, USA
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Alice Yang Zhang
- Department of Ophthalmology, University of North Carolina at Chapel Hill, 2226 Nelson Hwy Suite 200, Chapel Hill, NC, 27517, USA.
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3
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Moret E, Ambresin A, Gianniou C, Bijon J, Besse-Hayat C, Bogiatzi S, Hohl D, Spertini F, Mantel I. Non-immediate drug hypersensitivity reactions secondary to intravitreal anti-vascular endothelial growth factors. Graefes Arch Clin Exp Ophthalmol 2021; 260:1005-1014. [PMID: 34529134 PMCID: PMC8850288 DOI: 10.1007/s00417-021-05353-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/21/2021] [Accepted: 07/27/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose To describe a series of non-immediate drug hypersensitivity reactions after intravitreal anti-vascular endothelial growth factors (anti-VEGFs). Patients and methods Retrospective report of 6 patients with cutaneous non-immediate drug hypersensitivity reactions following intravitreal anti-VEGF injections, 4 after ranibizumab, 1 after bevacizumab and 1 after aflibercept. Results Clinical manifestations ranged from mild maculopapular rash, purpura to severe generalized erythroderma, with or without systemic involvement such as microscopic hematuria and proteinuria or fever. In two out of the six patients, reintroduction of either the same or an alternative anti-VEGF drug did induce a recurrence of the drug hypersensitivity reaction, while 4 patients showed no recurrence. Conclusion Cutaneous non-immediate drug hypersensitivity reactions secondary to intravitreal anti-VEGF may occur. Continuation of the same drug or switch to another anti-VEGF may either induce recurrence or be well supported by the patient. The decision of drug discontinuation should be guided by the severity of the disease.
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Affiliation(s)
- E Moret
- Department of Ophthalmology, Jules-Gonin Eye Hospital, University of Lausanne, Foundation Asile des Aveugles, Lausanne, Switzerland
| | - A Ambresin
- Department of Ophthalmology, Jules-Gonin Eye Hospital, University of Lausanne, Foundation Asile des Aveugles, Lausanne, Switzerland
| | - C Gianniou
- Department of Ophthalmology, Jules-Gonin Eye Hospital, University of Lausanne, Foundation Asile des Aveugles, Lausanne, Switzerland
| | - J Bijon
- Department of Ophthalmology, Jules-Gonin Eye Hospital, University of Lausanne, Foundation Asile des Aveugles, Lausanne, Switzerland
| | - C Besse-Hayat
- Department of Ophthalmology, Jules-Gonin Eye Hospital, University of Lausanne, Foundation Asile des Aveugles, Lausanne, Switzerland
| | - S Bogiatzi
- Department of Medicine, Division of Dermatology and Venereology, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - D Hohl
- Department of Medicine, Division of Dermatology and Venereology, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - F Spertini
- Department of Medicine, Division of Immunology and Allergy, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - I Mantel
- Department of Ophthalmology, Jules-Gonin Eye Hospital, University of Lausanne, Foundation Asile des Aveugles, Lausanne, Switzerland.
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Kataoka K, Horiguchi E, Kawano K, Ushida H, Nakano Y, Ito Y, Terasaki H. Three cases of brolucizumab-associated retinal vasculitis treated with systemic and local steroid therapy. Jpn J Ophthalmol 2021; 65:199-207. [PMID: 33543352 DOI: 10.1007/s10384-021-00818-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/31/2020] [Indexed: 01/10/2023]
Abstract
PURPOSE To describe three Japanese cases of retinal vasculitis that occurred following intravitreal brolucizumab injections and the systemic and local steroid treatment administered. CASES Three patients developed intraocular inflammation (IOI) and retinal vasculitis following the first injection of brolucizumab for age-related macular degeneration. For two eyes, monthly aflibercept injections did not control exudation, and therapy was changed to brolucizumab; one eye was treatment-naïve. All three patients noticed blurry vision and floaters 11-18 days after brolucizumab injections, and the treated eyes exhibited anterior chamber cells, fine keratic precipitates, vitreous cells, and vitreous haze. Ultra-widefield color images of the fundus showed retinal hemorrhage in the peripheral retina and, in two cases vascular sheathing. Ultra-widefield fluorescein angiography (FA) showed segmental vascular leakage in all eyes and leakage from the optic disc in two eyes. Vascular filling defects were noted in the peripheral retinae of two eyes. Brolucizumab-associated retinal vasculitis was diagnosed, and treated with 30 mg/day of oral prednisolone, subtenon triamcinolone acetonide injection (20 mg/0.5 ml), and 0.1% betamethasone sodium phosphate solution. After 1 week, color fundus images and FA showed improvements in vascular sheathing, leakage from retinal vessels, and optic disc leakage, but the vascular filling defects remained. Visual acuity was restored in all three eyes 6 weeks after the onset. CONCLUSION Brolucizumab-associated IOI, including retinal vasculitis and retinal occlusion, is a rare but important adverse event that can cause severe vision loss. Prompt diagnosis with FA and treatment with systemic or local steroids should be considered.
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Affiliation(s)
- Keiko Kataoka
- Department of Ophthalmology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Etsuyo Horiguchi
- Department of Ophthalmology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Kenichi Kawano
- Department of Ophthalmology, Yokkaichi Municipal Hospital, Mie, Japan
| | - Hiroaki Ushida
- Department of Ophthalmology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yuyako Nakano
- Department of Ophthalmology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yasuki Ito
- Department of Ophthalmology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Hiroko Terasaki
- Department of Ophthalmology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Nissen TPH, Vorum H, Aasbjerg K. Biologic Therapy and Treatment Options in Diabetic Retinopathy with Diabetic Macular Edema. Curr Drug Saf 2020; 16:17-31. [PMID: 32881673 DOI: 10.2174/1574886315666200902154322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/22/2020] [Accepted: 07/23/2020] [Indexed: 11/22/2022]
Abstract
Proliferative diabetic retinopathy and diabetic macular edema can be a potentially sightthreatening disease if not treated correctly. It is directly correlated to the duration of diabetes and how well managed the patients' diabetes is. In the last 15 years, the treatment of diabetic eye disease has taken a quantum leap in methodology due to the group of biological agents named antivascular endothelial growth factor (anti-VEGF). The introduction of the first biological agent has revolutionized the treatment, not only in diabetic eye disease but also across most inflammatory eye diseases, causing leakage of fluid from the blood vessels i.e., in age-related macular degeneration. The availability of these biological agents, despite their considerable costs, have significantly improved the outcomes measured in visual acuity compared to more traditional treatments of diabetic retinopathy in the form of sole laser treatment and glycemic control. The agents demonstrate a favorable safety profile, but if the rarest and most severe side effects occur, there is a potential total loss of vision. This review aims to make an overview of the current pharmaceutical therapeutic options in the treatment of diabetic macular edema. This includes laser therapy, intravitreal steroids, and a primary focus on intravitreal antivascular endothelial growth factors.
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Affiliation(s)
- Tobias P H Nissen
- Department of Ophthalmology, Aalborg University Hospital Hobrovej 18-22, 9000Aalborg, Denmark
| | - Henrik Vorum
- Department of Ophthalmology, Aalborg University Hospital Hobrovej 18-22, 9000Aalborg, Denmark
| | - Kristian Aasbjerg
- Department of Ophthalmology, Aarhus University Hospital, Palle Juul-Jensens Blvd. 161, 8200Aarhus, Denmark
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Gülsen A, Wedi B, Jappe U. Hypersensitivity reactions to biologics (part I): allergy as an important differential diagnosis in complex immune-derived adverse events*. ALLERGO JOURNAL 2020; 29:32-61. [PMID: 32546899 PMCID: PMC7289641 DOI: 10.1007/s15007-020-2550-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Askin Gülsen
- Division of Clinical and Molecular Allergology, Research Center Borstel, Borstel, Germany
| | - Bettina Wedi
- Klinik u. Poliklinik f. Dermatologie u. Venerologie, OE 6600 - Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Uta Jappe
- Klinische und Molekulare Allergologie - Forschungszentrum Borstel, Parkallee 35, 23845 Borstel, Germany
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Haug SJ, Hien DL, Uludag G, Ngoc TTT, Lajevardi S, Halim MS, Sepah YJ, Do DV, Khanani AM. Retinal arterial occlusive vasculitis following intravitreal brolucizumab administration. Am J Ophthalmol Case Rep 2020; 18:100680. [PMID: 32258827 PMCID: PMC7125319 DOI: 10.1016/j.ajoc.2020.100680] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 03/27/2020] [Accepted: 03/28/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To describe retinal arterial occlusion and vasculitis following intravitreal brolucizumab administration in a patient with neovascular age-related macular degeneration (nAMD). OBSERVATION An 88-year-old Caucasian woman with neovascular age-related macular degeneration (nAMD) complained of painless loss of vision with light sensitivity in both eyes (OU) four weeks after bilateral intravitreal brolucizumab. Upon examination, her visual acuity decreased to 20/40 in the right eye (OD) and 20/50 in the left eye (OS). Examination revealed 0.5+ and 1+ anterior chamber cells in OD and OS, respectively. The patient was treated with 1% prednisolone acetate eyedrops in both eyes, and after several weeks, the anterior chamber cells resolved. However, the patient still reported a decline in visual acuity (VA). Fluorescein angiography (FA) revealed retinal arterial occlusion, vasculitis, and optic nerve inflammation in the left eye. Retinal intra-arterial grayish materials were also detected. Laboratory evaluations were performed for common infectious and inflammatory causes and were normal or negative. A delayed inflammatory reaction to brolucizumab was suspected as the cause of the ocular inflammation and retinal vasculitis. An intravitreal dexamethasone implant was inserted into the left eye to treat the inflammation. One week after the dexamethasone implant, VA improved to 20/40 in OU; FA showed improvement, but residual peri-vascular leakage remained. CONCLUSION Medication-associated uveitis is a rare adverse effect that can lead to vision loss. The index report illustrates a case of intraocular inflammation, retinal arterial vaso-occlusion and vasculitis associated with intravitreal brolucizumab. The delay in developing uveitis suggests that the inflammation is due to a delayed hypersensitivity reaction which can occur several days or weeks after administration of the inciting agent. Recently, several cases of uveitis and vasculitis associated with brolucizumab have been presented and those cases have similar features compared to the index case (1). Therapy with steroids (either intraocular or systemic), after infectious etiologies have been excluded, may be beneficial in halting inflammation and preventing further vision loss.
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Affiliation(s)
| | - Doan Luong Hien
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Gunay Uludag
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Than Trong Tuong Ngoc
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Sherin Lajevardi
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
- University of California, Davis, CA, USA
| | - M. Sohail Halim
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
- Ocular Imaging Research and Reading Center (OIRRC), Sunnyvale, USA
| | - Yasir J. Sepah
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
- Ocular Imaging Research and Reading Center (OIRRC), Sunnyvale, USA
| | - Diana V. Do
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Arshad M. Khanani
- Sierra Eye Associates, Reno, NV, USA
- University of Nevada, Reno, NV, USA
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Hypersensitivity reactions to biologics (part I): allergy as an important differential diagnosis in complex immune-derived adverse events. ACTA ACUST UNITED AC 2020; 29:97-125. [PMID: 32421085 PMCID: PMC7223134 DOI: 10.1007/s40629-020-00126-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/31/2020] [Indexed: 12/15/2022]
Abstract
Purpose Biotechnological substances (BSs) are strongly relied upon to prevent rejection of transplanted organs, and to treat oncological, allergological, and other inflammatory diseases. Allergic reactions to partly foreign biologics can occur due to their potential immunogenicity. The severity of an immune response to a biological drug may range from no clinical significance to a severe, life-threatening anaphylactic reaction. Methods Detailed searches were performed on Pubmed, Web of Science, and Google Scholar to include all available publications. In addition, the Food and Drug Administration, the European Medicines Agency, and British Columbia Cancer Agency Drug Manual databases were screened for hypersensitivity reaction (HSR), infusion reaction, injection site reaction, urticaria, and anaphylaxis for individual BSs. Results Treatment with BSs can cause various types of HSR. These are mentioned in the literature with definitions such as allergic reactions, anaphylactoid reactions, anaphylaxis, HSR, infusion reactions, injection site reactions, cytokine release syndrome, and urticaria. Due to the overlap in signs and symptoms in the reported descriptions, it is not always possible to differentiate these reactions properly according to their pathomechanism. Similarly, many data reported as anaphylaxis actually describe severe anaphylactic reactions (grades III or IV). Conclusion There is an urgent need for a simpler symptom- or system-based classification and scoring system to create an awareness for HSRs to BSs. A better understanding of the pathophysiology of HSRs and increased clinical experience in the treatment of side effects will provide timely control of unexpected reactions. As a result, immunotherapy with BSs will become safer in the future.
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Association between HLA-B∗46:01 and cutaneous adverse drug reactions in Han Chinese. JOURNAL OF BIO-X RESEARCH 2018. [DOI: 10.1097/jbr.0000000000000011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Kleris RS, Keswani A, Lugar P. The Eyes Have It: Eyelid Swelling and Rash in a 79-year-old Woman With Macular Degeneration. ALLERGY & RHINOLOGY 2018; 9:2152656718763385. [PMID: 29977647 PMCID: PMC6028157 DOI: 10.1177/2152656718763385] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction A 79-year-old woman with macular degeneration was referred to the Allergy/Immunology clinic for the evaluation of a potential allergy to anti-vascular endothelial growth factor (anti-VEGF) treatments. The patient developed urticaria and eyelid swelling immediately following a retinal injection of aflibercept, which she had previously tolerated. She previously had allergic reactions following ranibizumab and bevacizumab injections. Injections of anti-VEGF treatments were discontinued given concern for allergy with progression of the patient’s disease. Objective To assess the culprit medication(s) responsible for hypersensitivity reactions following anti-VEGF injections for macular degeneration. Methods Medication records were reviewed for each retinal injection. All medications used in each procedure, including the anti-VEGF therapy (aflibercept), topical anesthetics (tetracaine and proparacaine hydrochloride), and antiseptic (povidine), were evaluated with skin testing. She was additionally tested for alternative anti-VEGF therapies (ranibizumab and bevacizumab) as she was thought to have allergies to these agents by prior history. A test dose challenge was completed for aflibercept, ranibizumab, and bevacizumab. Results Skin prick and intradermal testing were negative to aflibercept, ranibizumab, bevacizumab, and povidine. Intradermal testing was positive to tetracaine and proparacaine hydrochloride. The patient passed test dose challenges to aflibercept, ranibizumab, and bevacizumab. Due to her positive hypersensitivity testing to 2 ester anesthetics, the patient underwent skin prick and intradermal testing to the amide anesthetic, lidocaine. This was negative and the patient tolerated a graded challenge to lidocaine. She was deemed to have an immunoglobulin E (IgE)-mediated hypersensitivity to ester-type local anesthetics. She successfully resumed anti-VEGF therapy with an amide local anesthetic. Conclusions The reason for this consult was the concern for hypersensitivity to a biologic anti-VEGF medication. The culprit allergen, the local anesthetic, could have been overlooked without an assessment of all medications used during the procedure. This case highlights the importance of a thorough allergy evaluation of all medications used during procedures to determine the causative agent. Chief Complaint: Eyelid swelling and rash after ophthalmic procedures for macular degeneration.
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Affiliation(s)
- Renee S Kleris
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Anjeni Keswani
- Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Patricia Lugar
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
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