Recurrent intraocular inflammation after faricimab and aflibercept 8 mg despite intervening tolerance of aflibercept 2 mg: a case report and literature review

Background Intraocular inflammation (IOI) has been reported after both faricimab and aflibercept 8 mg. Continued anti-vascular endothelial growth factor (VEGF) treatment can be challenging when a standard-dose alternative does not cause recurrent inflammation but provides an incomplete anatomical response. We report recurrent presumed noninfectious IOI after faricimab and later aflibercept 8 mg, with an intervening inflammation-free exposure to aflibercept 2 mg and no inflammation after the first two aflibercept 8 mg injections. Case presentation A 62-year-old woman with neovascular age-related macular degeneration in the left eye had received nine bevacizumab injections without inflammation. Four days after the third faricimab injection, visual acuity declined from 20/125 to counting fingers, with 1 + anterior vitreous cells and grade 1–2 vitreous haze despite a quiet anterior chamber. Visual acuity recovered to 20/50 with systemic and topical corticosteroids. A single aflibercept 2 mg injection caused no inflammation, but subretinal fluid decreased without completely resolving over approximately 10 weeks. Treatment was escalated to aflibercept 8 mg. The first two 8 mg injections caused no inflammation; 4 days after the third injection, visual acuity again declined to counting fingers, with 1 + anterior vitreous cells and grade 2–3 vitreous haze despite a quiet anterior chamber. Visual acuity recovered to 20/50 after systemic and topical corticosteroid treatment. Aflibercept 8 mg was discontinued. At the most recent assessment approximately 3.5 months later, visual acuity remained 20/50, with no intraocular inflammation, subretinal fluid, or intraretinal fluid despite no further intravitreal treatment. Conclusions In this patient, the absence of inflammation after one aflibercept 2 mg injection and the first two aflibercept 8 mg injections did not preclude later IOI after the third 8 mg exposure. This temporal association does not establish cross-reactive immunogenicity or a dose-response relationship but indicates that prior uneventful exposure cannot be assumed to eliminate the possibility of later inflammation. Clinical trial number Not applicable. This manuscript describes a single-patient case report and does not report a clinical trial.