Dr. Neeraj Israni

1. Severe Inflammation following intravitreal injection
Ranibizumab leading to choroidal effusion.
Presenting Author : Dr. Neeraj Israni
Co Authors: Dr. Saurabh Shrivastava
Dr. Reshma Ramakrishnan
Dr. Swetha Narayanam
Financial intrests : Nil

2. INTRODUCTION
 A 30-year-old male, a known case of idiopathic unilateral multifocal choroiditis in the left eye and
amblyopic in the right eye with vision of Finger counting at 2 meters developed Subretinal neovasular
membrane (SRNVM) in the left eye for which 2 intravitreal injections of Bevacizumab were given.
 He felt symptomatically better after the injection but for a temporary duration of time.
 He developed cataract iatrogenically due to lens touch while giving 2nd intravitreal Bevacizumab
injection.
 He was operated for the same with Posterior Chamber Intraocular Lens implantation; a posterior
capsule tear was noted intra operatively.

3.  One year after surgery he presented with blurring of vision in the left eye of 15
days duration.
 On examination his vision was Finger counting at 2 meters. Anterior segment
showed quiet pseudophakia.
 Fundus examination showed recurrent SRNVM as seen below.
 4) Intravitreal injection Bevacizumab was given however the patient did not
respond.
 Hence keeping tachyphylaxis in mind intravitreal injection Ranibizumab was
given in a standard manner.

4.  The procedure was uneventful.
 Patient was started on Fluroquinolone with Non steroidal anti-inflammatory drugs (NSAID)
topically.
 Patient was advised follow up on the next day but presented only 3 days later with chief
complaints of sudden diminution of vision associated with pain in the left eye in which
intravitreal injection was given.
 His vision was finger counting at 1 metre. On examination he had corneal edema, anterior
chamber was normal, severe reaction, mid-dilated pupil and a PCIOL in situ.
 Severe vitritis was also present. Fundus showed vitreous haze and hazy details. Digital
tension was normal.
 Patient was asked to continue topical Moxifloxacin. Oral and topical steroids were added to
the treatment.
 Patient was advised an anterior chamber tap however patient wanted the procedure to be
done in presence of his relative and hence was asked to follow up coming morning.

5.  On reporting the next day for anterior chamber tap, he was symptomatically
better. Vision was recorded to be the same.
 On examination corneal edema has reduced. Anterior chamber was shallow and
reaction had reduced to +1cells.
 Superior haptic of PCIOL had prolapsed in the anterior chamber and touching
the endothelium (as seen below)Pupil was mid dilated. Intra ocular pressure was
unrecordably low.
 Vitritis had reduced. Fundus examination showed faintly clear media and
choroidal detachment.

6.  In view of haptic endothelial touch patient was taken for choroidal tap and
repositioning of the lens. Post operatively he was given oral, topical steroids
and antibiotics.
 Patient has been following up regularly and is symptomatically better. Visual
acuity is 6/24 on Snellen’s chart, anterior segment is quiet as seen below and
IOP is 14 mmHg.
 Fundus showed clear media with resolution of the choroidal detachment.

7. Discussion:
 Intravitreal anti VEGF injections are now given routinely in ophthalmic practice.
 Many complications are associated with these injections. We report three serious complications
occurring in the same patient though not at the same time.
 The first complication was an iatrogenic lens touch during a Bevacizumab injection resulting in a
traumatic cataract. Lens touch during intravitreal injections is very rare.
 In fact the incidence of this complication was very low even in the study by Meyer CH et.al.
 The cataract was managed by standard phacoemulsification – but a posterior capsular opening
was noted intraoperatively. An intraocular lens was implanted in the sulcus after anterior
vitrectomy
 The second complication was severe uveitis occurring after Ranibizumab injection. Uveitis has
been reported after intravitreal Ranibizumab injections in several studies. It was presumed to be
infectious at the time of presentation in our case.

8.  An anterior chamber tap was planned for PCR but before it could be done due to logistic reasons there
was dramatic improvement with systemic steroids prompting us to think of inflammatory rather than
infectious.
 The inflammation subsided with systemic and topical steroids only to result in the third complication.
 Choroidal detachments have been reported infrequently after Intravitreal injections and inflammation.
 This patient developed large total choroidal detachment a few days after the injection which was
associated with severe uveitis. It is reasonable to speculate that the inflammation rather than the drug
was responsible.
 Choroidal detachment in our patient resulted in shallowing of the anterior detachment and
malpositioning of the IOL prompting an immediate surgical intervention.
 Choroidal detachment after inflammation following Bevacizumab has been reported but post
Ranibizumab injection is hence a very rare complication and to the best of knowledge has not been
reported as yet.