Anti-complement drugs for the treatment of geographic atrophy and the release of silicone oil

Intravitreal injections are a common procedure in ophthalmology, often using syringes coated with silicone to aid piston movement and needles coated with silicone oil to facilitate penetration of the sclera. Pegcetacoplan and avacincaptad pegol, recently approved for clinical use by the US Food and Drug Administration, have higher viscosity and seem more susceptible to entrap air bubbles compared to anti-VEGF drugs.It is plausible that both anti-complement drugs could be associated with a higher likelihood of introducing silicone oil in the vitreous because of higher viscosity, with potentially higher friction at the inner surface of syringe barrel, in the vicinity of silicone oil. In addition to this, undesirable agitation might be inadvertently promoted by some retina specialists to remove air bubbles from the drug solution.In conclusion, recent reports of silicone oil droplets in the vitreous of patients receiving pegcetacoplan injection might be related to both its viscosity and to agitation of the syringe to remove air bubbles. Since avacincaptad pegol also is viscous, though with different pH, syringe and filter needle, we might expect similar reports for this agent soon. We also recommend further studies be carried not only to clarify the current matter but also the potential association between the combination of agitation, silicone oil and inflammation or any immune response.

Accuracy, Precision, and Residual Volume of Commonly Used Syringes for Intravitreal Injections and the Impact on Intraocular Pressure

PURPOSE

To compare accuracy, precision, and residual volume of commonly used syringes for intravitreal injections (IVIs) and to assess the intraocular pressure (IOP) rise by variations in volumes delivered.

DESIGN

Experimental laboratory study.

SUBJECTS

No subjects were involved in this study.

METHODS

We tested 8 syringe models with 2 different needle setups, with 2 different solutions (distilled water or glycerin) and target volumes (50 and 70 μL). To obtain the delivered and residual volumes, we weighed the syringe-needle setups with scale before liquid withdrawal, with liquid, and after liquid release. We also created an experimental eye model to determine the transient rise in IOP following stepwise 10-μL increases in injection volumes.

MAIN OUTCOME MEASURES

Delivered and residual volumes, IOP rise.

RESULTS

We tested a total of 600 syringe-needle setups. Becton Dickinson (BD) Ultra-Fine (0.34 ± 0.28 μL), Zero Residual (1.53 ± 1.15 μL), and Zero Residual Silicone Oil-free (1.40 ± 1.16 μL) syringes showed the lowest residual volume (P < 0.001) in comparison with the others (range: 24.86 ± 1.78 μL for Injekt-F to 51.97 ± 3.37 μL for Omnifix-F). The most accurate setups were (percentage deviation from target volume): Zero Residual Silicone Oil-free (+ 0.70%), Zero Residual 0.3 ml (+ 4.49%), BD Ultra-Fine (+ 7.83%), Injekt-F (9.42%), Norm-Ject (+ 15.88%), Omnifix-F (+ 16.96%), BD Plastipak Brazil (+17.96%), and BD Plastipak Spain syringes (+ 19.41%). There was a statistically significant difference between the Zero Residual Silicone Oil-free syringe and all other syringes (P < 0.0001), except for the Zero Residual 0.3-ml syringe (P = 0.029). The coefficient of variation was low for all syringes. The modeled IOP rise ranged from 32.3 (standard deviation [SD], 1.4) mmHg for 20-μL injection volume to 76.5 (SD, 1.0) mmHg for 80-μL injection volume. For the standard 50-μL injection volume, the peak pressure was 50.7 (SD, 0.1) mmHg, and the pressure rise duration was 28 (SD, 2) minutes.

CONCLUSIONS

There were significant differences in accuracy and residual volume between syringes, whereas they showed a high precision. Volume excess results in a considerable increase in IOP rise after injection. These findings may provide a relevant overview to clinicians and to both device and drug manufacturers regarding pharmacoeconomic, safety, and efficacy issues.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Multiple Small Floaters Associated With Silicone Oil Droplets Following Intravitreal Pegcetacoplan Injection

This case series analyzes the presence of floaters associated with silicone oil droplets after intravitreal pegcetacoplan injection.

Incidence of ocular hypertension after anti-VEGF injections: examining the effect of drug filtration and silicone-free syringes

OBJECTIVE

To examine the difference in incidence of ocular hypertension (OHT) following the introduction of filtered anti-vascular endothelial growth factor (anti-VEGF) medication in silicone-free syringes.

DESIGN

Retrospective cohort study.

METHODS

A retrospective review of consecutive treatment-naive patients receiving intravitreal anti-VEGF injections in a group practice was performed. Data from the cohort receiving nonfiltered anti-VEGF in insulin syringes (IS group) was collected from June 2015. Data from the cohort receiving filtered anti-VEGF in silicone-free syringes (SFS group) was collected from June 2019. Follow up data were collected at 1 year. Exclusion criteria included prior anti-VEGF treatment, known glaucoma or diagnosis of glaucoma suspect before anti-VEGF treatment, neovascular glaucoma, steroid use, or vitrectomy during follow-up. Primary outcome was the cumulative incidence of intraocular pressure (IOP) > 21 mmHg and IOP ≥ 30 mm Hg at any follow-up visit. The use of IOP lowering therapy was also recorded.

RESULTS

The mean age (71 ± 13 years), mean number of injections (9.6 ± 2.7), and median follow-up time (392 ± 57 days) were similar between groups. The incidence of IOP ≥ 21 mm Hg was 34% (34/100) in the IS group and 15% (15/100) in the SFS group (p = 0.025). The incidence of IOP ≥ 30 mm Hg was 8% (8/100) in the IS group and 0% (0/100) in the SFS group (p =0.004). The incidence of IOP-lowering therapy was 13% in the IS group and 0% in the SFS group (p =0.0002).

CONCLUSION

The incidence of OHT and treatment with IOP-lowering therapy significantly decreased after the introduction of filtered anti-VEGF medication and silicone-free syringes.

Ocular inflammation after agitation of siliconized and silicone oil-free syringes: a randomized, double-blind, controlled clinical trial

Background

Noninfectious endophthalmitis may be misdiagnosed, leading to serious clinical implications. So far, its causative factors remain unknown. Therefore, this study assessed the role of silicone oil and syringe agitation in the development of inflammation after intravitreal injection of aflibercept.

Methods

A randomized, double-blind, controlled clinical trial included subjects with an indication of intravitreal antiangiogenic therapy prior to vitrectomy for proliferative diabetic retinopathy. Aflibercept was injected 48 h before surgery. The control group received the injection without agitation, while the intervention group was injected with a previously agitated syringe by flicking with either a siliconized or silicone oil-free syringe. The primary endpoint was the presence of anterior chamber reaction (ACR) at 48 h. Aqueous samples were collected and underwent cytometric bead array analysis for quantification of interleukins and chemokines.

Results

Forty-one individuals were included (21 in the agitation group and 20 in the no-agitation group). None of the included eyes showed baseline signs of AC cells, hyperemia or pain complaint, while 10% of control group and 80% of agitation group showed AC cells 48 h after injection of aflibercept with SR syringe. There were no differences in the mean variations of all cytokines and chemokines by agitation status. However, there was a marginally significant increase between the mean variations of IP-10 (p = 0.057) and IL-8 (p = 0.058) in the siliconized one.

Conclusion

This clinical trial discloses a potential role of agitation and siliconized syringes in the development of inflammation after an intravitreal injection of aflibercept. These findings have important clinical implications for all healthcare practitioners who perform intravitreal injections.

Trial Registration: Brazilian Registry of Clinical Trials, RBR-95ddhp. Registered 12 May 2019, http://www.ensaiosclinicos.gov.br/rg/RBR-95ddhp/

Complications of intravitreal injections: 2022

PURPOSE OF REVIEW

This review highlights the complications of both intravitreal injection procedure as well as different intravitreal medications including antivascular endothelial growth factors, antibiotics, antivirals, antifungals, methotrexate, and steroids. Techniques for reducing rates of endophthalmitis will also be discussed.

RECENT FINDINGS

Intravitreal vancomycin can cause hemorrhagic occlusive retinal vasculitis resulting in severe vision loss. Intravitreal brolucizumab is associated with intraocular inflammation and retinal vasculitis resulting in significant vision loss. Face mask use by both patient and physician is not associated with increased risk of endophthalmitis and may decrease culture positive endophthalmitis.

SUMMARY

Intravitreal injections continue to be one of the most commonly performed procedures by ophthalmologists. Although the injections are generally well tolerated, sight-threatening complications can occur including endophthalmitis, retinal detachment, and/or retinal vasculitis. Adverse events associated with specific medications are outlined below. Several safety measures have been shown to reduce rates of endophthalmitis, the most concerning complication of this procedure.

Differences in the incidence of aflibercept-related sterile endophthalmitis according to types of disposable syringes used

PURPOSE

To evaluate the difference between the incidences of sterile endophthalmitis after administration of intravitreal aflibercept injection using two different types of syringes.

METHODS

We administered a total of 498 intravitreal aflibercept injections between September 2017 and August 2021. The disposable syringe used was changed from a 1-mL disposable syringe (Profi syringe, Shinchang Medical., Ltd. Korea) to a 1-mL Becton Dickenson Luer-Lok syringe (BD, Franklin, NJ, USA) in September 2019. Thus, the patients who received injections before and after September 1, 2019, were classified into group 1 and group 2, respectively. The incidence of aflibercept-related sterile endophthalmitis between the two groups was compared.

RESULTS

In group 1, six (2.791%) out of 215 cases were diagnosed with sterile endophthalmitis and prescribed topical or oral steroids. In group 2, one (0.353%) out of 283 cases was diagnosed with sterile endophthalmitis and prescribed a steroid eye drop. The incidence of sterile endophthalmitis was significantly different between the two groups (P = 0.046).

CONCLUSION

The BD Luer-Lok syringe is associated with a lower incidence of aflibercept-related sterile endophthalmitis than the conventional polypropylene syringe. Differences in immunogenicity associated with silicone oil lubricants within the syringes might be one of the potential reasons behind the difference in the incidence of the sterile endophthalmitis.

[Potential pitfalls of anti-VEGF therapy of neovascular age-related macular degeneration]

When administering anti-VEGF therapy for neovascular age-related macular degeneration (nAMD), it is necessary to take into account the fact that treatment outcomes - in addition to factors associated with the disease itself - may be affected by progressive concomitant conditions (for example, macular atrophy) and possible adverse events (AEs). The latter can be divided into two large groups: non-inflammatory and inflammatory. Intraocular inflammation (IOI) is a rare but potentially dangerous AE of anti-VEGF therapy, which can include endophthalmitis, early sterile inflammation and retinal vasculitis. Raising awareness about inflammatory AEs is becoming even more important due to the sheer number of intravitreal injections performed, as well as the frequency of cases of IOI when using new anti-VEGF drugs. The new anti-VEGF drug Brolucizumab is associated with the development of retinal vasculitis, which is considered a type III and IV hypersensitivity reaction (involving cellular and humoral immune responses, respectively). The article presents an overview of publications on the mechanisms, clinical manifestations, differentiation, and methods of treatment of various types of IOI.

Silicone oil-free syringes, siliconized syringes and needles: quantitative assessment of silicone oil release with drugs used for intravitreal injection

PURPOSE

This study aimed to quantify the amount of silicone oil (SO) released across a variety of syringe and needle models routinely used for intravitreal injection.

METHODS

The release of SO was assessed in eight models of syringes, two of which were reported to be 'SO-free', and eleven models of needles with unknown SO content. To evaluate SO release within the context of anti-VEGF therapeutics, syringes were evaluated using aflibercept, bevacizumab, buffer, ziv-aflibercept and formulation buffer. All syringe tests were performed with or without agitation by flicking for syringes. Needles were evaluated without agitation only. Samples were fluorescently labelled to identify SO, and triplicate measurements were collected using imaging flow cytometry.

RESULTS

Seven out of 8 syringe models showed a statistically significant increase in the SO particle count after agitation. The two SO-free syringe models (HSW Norm-Ject, Daikyo Crystal Zenith) released the least SO particles, with or without agitation, whereas the BD Ultra-Fine and Saldanha-Rodrigues syringes released the most. More SO was released when the syringes were prefilled with formulation buffer than with ziv-aflibercept. Syringes filled with aflibercept and bevacizumab had intermediate levels. Agitation increased the release of SO into each of the drug solutions. Silicone oil (SO) was detected in all needles.

CONCLUSIONS

Agitation of the syringe by flicking leads to a substantial increase in the number of SO particles. Silicone oil (SO)-free syringes had the best performance, but physicians must also be aware that needles are siliconized and also contribute to the injection of SO into the vitreous.

Silicone microbubbles after anti-vascular endothelial growth factor injections in patients with wet age-related macular degeneration: incidence, quantification and secondary optical coherence tomography artfacts

PURPOSE

To report the incidence and quantity of silicone oil microbubbles and the relationship with the number of intravitreal anti-vascular endothelial growth factor (VEGF) injections and evaluate if microbubbles induce artefacts on optical coherence tomography (OCT) images.

METHODS

Observational, descriptive, cross-sectional study. Patients with wet age-related macular degeneration were included who had been treated for 1 year minimally with anti-VEGF injections repackaged in the hospital pharmacy. Detection and quantification of silicone microbubbles by mydriatic biomicroscopic examination were conducted 1 month after the last injection. The numbers of microbubbles were quantified on a scale of 0-3: 0, none; 1 scarce (1-10 microbubbles); 2 moderate (10-30); or 3 numerous (>30). Shadowing on OCT images was classified as 0-3: 0, none; 1 obscuring some retinal layers; 2 obscuring all retinal layers; or 3 obscuring the retinal thickness.

RESULTS

The study included 142 eyes of 98 patients (mean age, 82.4 years + 7.3; range, 65-97) treated with 2377 injections. Microbubbles were detected in 127 (89.4%) eyes, 62 (43.6%) with numerous microbubbles and 36 (25.4%) and 29 (20.4%), respectively, with scarce and moderate numbers. A positive correlation was found between the numbers of injections and intravitreal silicone (rho, 0.7). Optical coherence tomography (OCT) artefacts were detected in 11 eyes; the artefacts obscured all retinal layers in three eyes. No significant relationship could be established between the appearance of floaters and the microbubbles.

CONCLUSION

The presence and number of silicone microbubbles were correlated with the number of intravitreal injections. Microbubbles can produce OCT artefacts, which can hinder the treatment decision.

Silicone oil droplets in the vitreous after intravitreal injections: review of literature with clinical examples

Currently, intravitreal injections are firmly in the lead as a drug delivery method for treatment of a wide range of eye diseases. With the accumulation of clinical material, knowledge about the complications and side effects of this technique is expanding. One of the undesirable phenomena that has been actively studied recently is the ingress of silicone oil droplets from single-use syringes and needles used to perform the procedure into the vitreous cavity of patients eyes. The analysis of the results of original studies on this issue is carried out, and the currently available practical recommendations aimed at reducing the risk of this complication are presented. The article is illustrated with original clinical examples. It can be concluded that the penetration of silicone oil into the eye cavity during intravitreal injections is an urgent problem of modern ophthalmology that requires further investigation and solution.

Visual Outcomes after Anti-VEGF Therapy for Exudative Age-Related Macular Degeneration in a Real-Life Setting

BACKGROUND

To report visual outcomes of anti-vascular endothelial growth factor (anti-VEGF) therapy for exudative age-related macular degeneration (AMD) in a real-life setting.

PATIENTS AND METHODS

Retrospective case series of consecutive patients treated with either ranibizumab and/or aflibercept for monolateral or bilateral exudative AMD. A physician established the indication for treatment and administered the injections. An independent physician confirmed the indication for primary treatment. A Pro Re Nata and a Treat and Extend regimen were used. Assessment of subretinal and/or intraretinal fluid, retinal hemorrhage and increase in pigment epithelial detachment served as criteria for further treatment decisions. Visual acuity (VA) was measured in ETDRS letters at each examination and then analyzed using a specialized software. Evolution of mean VA was considered for all study eyes and subgroups of eyes with an initial VA ≥ 70 ETDRS letters (subgroup 1) and ≤ 69 ETDRS letters (subgroup 2).

RESULTS

A total of 102 eyes of 76 patients (30 men, mean age 75.9 years; 46 women, mean age 81.5 years) were included. Subgroup 1 consisted of 47 eyes, and subgroup 2 of 55 eyes. Mean follow-up was 55 months (range 6 to 150 months). For the entire collective as for subgroups 1 and 2, the mean VA was 64, 77, or 51 ETDRS letters at baseline. Mean VA improved at month 12 (68, 80, or 58 ETDRES letters) and then slowly decreased over time until month 150 (62, 72, or 54 ETDRS letters). Maximum improvement of + 5, + 3, or, + 9 ETDRS letters occurred after 9, 8, or 10 months of follow-up. Atrophy and fibrosis were mainly responsible for VA decrease. Ten serious adverse events were reported to Swissmedic: two cases of cardiovascular events and eight cases of intraocular inflammation.

CONCLUSIONS

Anti-VEGF therapy carried out in a real-life setting shows good VA outcomes with a favorable safety profile.

RETAINED, NONDISSOLVING, TUBULAR FOREIGN BODIES IN THE VITREOUS CAVITY AFTER INTRAVITREAL DEXAMETHASONE (OZURDEX) IMPLANTATION

PURPOSE

To describe the retention of large, tubular, nondissolving foreign bodies because of a complication of the intravitreal dexamethasone implant (Ozurdex).

METHODS

This is a single-center, retrospective chart review of patients who were found to have retained, nondissolvable tubular foreign bodies in the vitreous cavity for more than 6 months (the expected dissolution time of the implants) after Ozurdex injections. Ocular symptomatology and multimodal imaging were reviewed.

RESULTS

Five patients had retained, nondissolvable tubular foreign bodies in the vitreous that persisted for months (mean 28.2 months, range 9-67 months) after intravitreal injection of Ozurdex. Two patients were symptomatic due to the foreign bodies and chose alternate local therapy, but none of the patients opted for surgical explantation.

CONCLUSION

Persistent, nondissolving, tubular foreign bodies can be seen in the vitreous cavity for years after injection of the Ozurdex implant. Clinicians should be aware of this complication that has the potential to cause visual symptoms and ocular morbidity.

Agitation of the syringe and release of silicone oil

BACKGROUND/OBJECTIVES

To investigate whether agitation promotes the release of silicone oil by different models of syringe used for intravitreal injection.

METHODS

This lab study analyzed eight syringe models by light microscopy for the release of silicone oil under agitation (flick), without agitation, and positive controls. Fourier-Transform Infrared Spectroscopy (FTIR) was performed to identify the molecular compounds inside the syringes.

RESULTS

A total of 240 syringes were analyzed. The presence of silicone oil droplets was observed in all positive controls. When agitated by flicking, 100% of the samples of the syringes disclosed silicone oil, except the BD Plastipak syringe, which presented 40% of positivity. Without agitation, a smaller percentage of samples with silicone oil was observed. Agitation by flicking had a 265-fold greater chance of presenting oil droplets when compared with the syringes without agitation. There was a statistically significant difference between the three conditions (P < 0.05). Analysis of the tip of the plunger rubber by FTIR indicated the presence of polysiloxane (silicone oil) in all models of syringe.

CONCLUSIONS

Agitation of the syringe promotes the release of silicone oil. It is recommended to improve the technique of injection and the manufacture of specific syringes for ophthalmological use.

A new method for pharmaceutical compounding and storage of anti-VEGF biologics for intravitreal use in silicone oil-free prefilled plastic syringes

Intravitreal injections of antibody-based biologics targeting vascular endothelial growth factor (VEGF) are highly effective and have markedly decreased the risk of visual impairment associated with prevalent retinal diseases, such as neovascular age-related macular degeneration and diabetes macular oedema. The diseases are chronic in their nature, and most patients need long-term therapy to suppress disease activity. We previously reported a compounding method for repackaging and storage of aflibercept (Eylea), a commonly used anti-VEGF biologic, in silicone oil-coated plastic syringes without compromising drug stability or activity. In addition to improving safety and time spent per patient, compounding of anti-VEGF biologics enables single-dose vials to be split into multiple syringes, thereby considerably reducing waste and drug expenses. However, symptomatic silicone oil droplets may deposit in the eye’s vitreous body after repetitive injections. To fully avoid this complication, we here report on a novel pharmaceutical compounding method using silicone oil-free syringes and a 33 G × 9 mm Low Dead Space Needle hub injection needle. We evaluate the method for three anti-VEGF biologics commonly used in ophthalmology: aflibercept, ranibizumab (Lucentis) and bevacizumab (Avastin). Our results show that compounding and storage for one week does not compromise the functional activity of the biologics and allows for safe and cost-effective compounding of anti-VEGF biologics for intravitreal injections in prefilled silicone oil-free syringes.

Prevalence of silicone oil droplets in eyes treated with intravitreal injection

Objective

To assess the number of eyes with silicone oil in the vitreous after intravitreal injection.

Methods

This cross-sectional, comparative study was divided into 2 groups: (1) treatment—eyes subjected to antiangiogenic therapy; (2) control—no history of intravitreal injection. Subjects were assessed regarding age, gender, clinical diagnosis, lens status, visual acuity and number of previous intravitreal injections. All eyes underwent a meticulous slit-lamp and ultrasound examination for the identification of silicone oil. ImageJ software was used to quantify the index of silicone oil (IOS) by ultrasonography.

Results

Sixty-seven eyes (30 controls, 37 treated) were included. Slit-lamp examination found silicone oil droplets in 25 out of 37 (67.57%) treated eyes and in none of the control group. Ultrasonography identified silicone oil in 28 out of 37 (75.68%) treated eyes and in 1 out of 30 (3.33%) controls. An observed agreement of 85.07% and a Cohen’s Kappa coefficient of 69.10% (p < 0.0001) between ultrasonography and biomicroscopy were found. Wilcoxon test showed a statistically significant difference (p = 0.0006) in IOS between controls (0.41 ± 0.43%) and treated eyes (2.69 ± 2.55%). Spearman’s correlation test (0.61; p < 0.0001) showed that the greater the number of injections, the higher the IOS.

Conclusions

Silicone oil droplets were found in the majority of the eyes previously treated with antiangiogenic intravitreal injection. The greater the number of injections, the higher the likelihood of finding silicone oil. An improvement in the technique of injection and better-quality syringes post-injection silicone oil droplets.

Release of silicone oil droplets from syringes

BACKGROUND

Intravitreal silicone oil droplets have been found in the vitreous. The aim of this study is to compare the rates of silicone oil released by different brands of commonly used syringes for intravitreal injection after agitation by flicking.

METHODS

Three models of two brands of syringes were analyzed for their rates of silicone oil release: Saldanha Rodrigues (SR) 1 mL insulin syringe (SR, Brazil, syringe 1), Becton-Dickinson (BD) Plastipak 1 mL insulin syringe (Brazil, syringe 2), and BD Safety-Glide 1 mL insulin syringe (USA, syringe 3). All syringes were tested under four different conditions: positive control (fluid with addition of silicone oil) without agitation (group 1, n = 5); positive control with agitation (group 2, n = 3); fluid only without agitation (group 3, n = 5); and fluid only with agitation (group 4, n = 5). Masked graders performed all analyses using light microscopy.

RESULTS

All syringes (1, 2, and 3) released silicone oil droplets in the positive control group regardless of the agitation status (groups 1 and 2). When no oil was added and the syringes were not agitated, only syringe 1 released silicone oil droplets (40% of samples). After agitation, syringes 1 and 3 released silicone oil droplets in all samples. Quantitative analysis showed a significantly (P = 0.011; 11.2 ± 2.9 vs. 0.6 ± 0.9, respectively) higher mean number of silicone oil droplets released by syringe 1 after agitation compared to no agitation. Syringe 1 also had significantly (P = 0.002, 11.2 ± 2.9 vs. 0.0 ± 0.0 vs. 2.2 ± 0.8, respectively) more droplets than syringes 2 and 3 after agitation.

CONCLUSIONS

Syringes commonly used for intravitreal injections frequently release silicone oil droplets when agitated by flicking, especially the SR insulin ones. We recommend that they not be agitated at the time of intravitreal injection and that the manufacturers consider producing syringes adapted for intraocular use.