Kleris Renee S, Keswani Anjeni, Lugar Patricia
Department of Pediatrics, Duke University Medical Center, Durham, North Carolina.
Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.
Allergy Rhinol (Providence). 2018 May 1;9:2152656718763385. doi: 10.1177/2152656718763385. eCollection 2018 Jan-Dec.
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.
To assess the culprit medication(s) responsible for hypersensitivity reactions following anti-VEGF injections for macular degeneration.
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.
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.
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. Eyelid swelling and rash after ophthalmic procedures for macular degeneration.
一名79岁患有黄斑变性的女性被转诊至过敏/免疫科，以评估其对抗血管内皮生长因子（抗VEGF）治疗的潜在过敏反应。该患者在视网膜注射阿柏西普后立即出现荨麻疹和眼睑肿胀，而她之前对阿柏西普耐受。她之前在注射雷珠单抗和贝伐单抗后曾发生过敏反应。鉴于对过敏的担忧以及患者疾病的进展，抗VEGF治疗注射被停用。
评估导致黄斑变性抗VEGF注射后超敏反应的罪魁祸首药物。
查阅每次视网膜注射的用药记录。对每个操作中使用的所有药物进行评估，包括抗VEGF治疗药物（阿柏西普）、局部麻醉剂（丁卡因和盐酸丙美卡因）和防腐剂（聚维酮碘），进行皮肤试验。由于既往史提示她可能对这些药物过敏，因此还对她进行了替代抗VEGF治疗药物（雷珠单抗和贝伐单抗）的检测。完成了阿柏西普、雷珠单抗和贝伐单抗的试验剂量激发试验。
对阿柏西普、雷珠单抗、贝伐单抗和聚维酮碘的皮肤点刺试验和皮内试验均为阴性。对丁卡因和盐酸丙美卡因的皮内试验为阳性。患者通过了阿柏西普、雷珠单抗和贝伐单抗的试验剂量激发试验。由于她对2种酯类麻醉剂的超敏试验呈阳性，因此对酰胺类麻醉剂利多卡因进行了皮肤点刺试验和皮内试验。结果为阴性，患者耐受了利多卡因的分级激发试验。她被认为对酯类局部麻醉剂存在免疫球蛋白E（IgE）介导的超敏反应。她成功地使用酰胺类局部麻醉剂恢复了抗VEGF治疗。
此次会诊的原因是担心对生物抗VEGF药物过敏。如果没有评估操作过程中使用的所有药物，罪魁祸首过敏原——局部麻醉剂可能会被忽视。该病例凸显了对操作过程中使用的所有药物进行全面过敏评估以确定病因的重要性。黄斑变性眼科手术后的眼睑肿胀和皮疹。
