Acute Sterile Endophthalmitis Following Intravitreal Rituximab Injection in Primary Vitreoretinal Lymphoma: Case Series.

OBJECTIVE OR PURPOSE: To describe sterile endophthalmitis following intravitreal rituximab (Rituxan, Genentech) injection for treatment of vitreoretinal lymphoma (VRL).

DESIGN: Retrospective case series.

SUBJECTS, PARTICIPANTS, AND/OR CONTROLS: Medical records of biopsy-proven VRL patients who received intravitreal rituximab (RTX) between January 2011 and December 2021 in Kellogg Eye Center, University of Michigan were reviewed. 3 patients presented with sterile endophthalmitis after the second dose of intravitreal RTX were included. Methods, Intervention, or Testing: Intravitreal methotrexate (400µg/0.1ml) and rituximab (1mg/0.1ml) injections given a week apart, monthly. Main Outcome Measures: Clinical presentation and response to treatment including visual acuity, degree of inflammation and intraocular pressure .

RESULTS: All cases had bilateral disease and received the first dose of intravitreal RTX without any side effects. All cases developed bilateral corneal edema with Descemet's folds, mutton-fat keratic precipitates, anterior chamber and vitreous cells with hazy fundus view approximately within 1 week after the second RTX injection. Intraocular pressures were increased in Cases 2 and 3. Clinical findings improved to baseline with topical corticosteroid therapy within 1 month in all cases, and additional topical antiglaucomatous medication in Cases 2 and 3. Additionally, Case 1 received the third dose of RTX injection to the right eye 1 month after the second injection and repeating dense anterior chamber and vitreous cells developed in 1 day. Her vision decreased to counting fingers from 20/40, and intraocular pressure increased. After topical steroids and antiglaucomatous medications, her intraocular inflammation subsided. Her vision improved to 20/30, and intraocular pressure became normal in the right eye.

CONCLUSIONS: To our knowledge, this is the first case series documenting sterile endophthalmitis following intravitreal rituximab in vitreoretinal lymphoma. Recognition of sterile endophthalmitis is important in differentiating from vitreoretinal lymphoma recurrence and infectious endophthalmitis. Close observation and topical steroid drops seem to be effective.