`
`SOPHEE l. BAKE}. MD, NOHA S. EKDAWL MD
`
`Purpose: To present the finding of tiny silicone oil droplets in 15 eyes of 15 patients after
`intravitreal injections of an antiuvascular endothelial growth factor agent or triarncinolone
`acetonide and to discuss the likely source of silicone oil.
`Methods:
`in an observationai case series. charts of patients who had undergone
`intravitreal injections by one surgeon were reviewed retrospectively. The finding of intra—
`vitreal silicone oil droplets was noted. The following information was also documented:
`number and type of injections before the appearance of silicone oil droplets, symptoms
`and evidence of ocular inflammation, visual acuity before and after silicone oil droplets,
`length of follow—up, and visual acuity at the last examination.
`Results: Fifteen eyes of 15 patients were tound to have silicone oil droplets docu~
`mented after a various number of injections (range. 1-16). Patients were asymptomatic,
`and there were no adverse side effects associated with the presence of silicone oil droplets
`at examination.
`
`Conclusions: Silicone oil droplets may occur in the vitreous cavity after intravitreal drug
`injections. There were no adverse effects found associated with silicone oil in the vitreous
`after injections of anthvascular endothelial growth factor agents or triamcinoione ace
`tonide. The likely source of silicone oil is the needles and syringes used for the injections.
`RETENA. 283964 001, 2008
`
`
`
`he use of intravitreal injections for the treatment
`of retinal disorders has become a much more
`
`in light of the development of
`comrnon procedure.
`drugs specifically designed to block vascular endothe-
`lial growth factor and the efficacy of intravitreal ste-
`roids.
`lntravitrcal drugs that are US Food dc Drug
`Atlrninistration~apprtwed for the treatment of choroi-
`dal neovascularization associated with age—related
`macular degeneration include pogaptanih (Macngen;
`OSl/Eyetech. New York, NY)1 and ranihizurnah (Lu-
`centis; Genentech, 1110., South San Francisco, CA).2+3
`in addition.
`intravittcal hevacizurnah tAvastin; Ge—
`
`Eront the Department of Ophthalmology, Vitreorctinal Diseases
`and Surgery. Mayo Clinic, Rochester, Minnesota.
`Supported by Research to Prevent Blindness lnc. (New York. NY).
`Reprint request Sophie Ji Balm, MD, Department of Ophthalmol—
`
`ogy. Vitrcorctinal
`_
`asses and Surgery, Mayo Clinic, 300 First Strcct
`SW, Rochester. MN 35905: email: shakn @hotmailicorn
`
`nentech, inc.) is used off label for the treatment of
`choroidal ncovascnlarization. diahctic rctinopathy. reti-
`nal venous occlusive disease and other vascular cn~
`
`dothelial growth factor—mediated discasesfl lntravit—
`real triamcinolonc has been shown to he effective in
`
`the treatment of macular cdcmafis‘é Known compliesw
`tions of intravitrcal injections include sterile and in—
`fectious endophthalinitis, retinal detachment, intraoc~
`ular inflammation. vitreous hemorrhage, retinal tears,
`and damage to the crystalline lens. Most of these corn—
`plications are. procedure related. l-lowcver, the curnu~
`lative damage from repeated injections has not been
`addressed. We present a series or" if: eyes of 15 patients
`with intravitreal silicone droplets as a consequence of
`intravitrcal injections with an anti--~vascular endothe
`lial growth factor agent or triarncinolone and discuss
`the likely source of silicone oil.
`
`$96
`
`NOVITC(US)OO313517
`
`Regeneron Exhibit 1067.001
`
`

`

`INTRAVI'IREAL SILICONE OIL USAGE AFTER INTRAVITREAL DRUG INJECTIONS - BAKRI AND EKDAWI 997
`
`Methods
`
`After receiving approval from the Mayo Clinic Insti-
`tutional Review Board (Rochester, MN), a retrospective
`review of charts of patients who had received intravitreal
`injections of pegaptanib, bevacizumab, triamcinolone, or
`ranibizumab by one surgeon (S.J.B.) between July 2005
`and November 2007 was performed. The charts were
`reviewed for the presence of intravitreal silicone oil
`droplets. The number and type of injections before the
`appearance of silicone oil droplets were documented.
`In addition, symptoms and evidence of ocular inflam-
`mation were noted. Visual acuity was also docu—
`mented before and after silicone oil droplets were
`noted during examination;
`length of follow-up and
`final visual acuity were measured as well.
`
`Results
`
`A total of 1,529 intravitreal injections between July
`2005 and November 2007 were reviewed. Fifteen eyes
`of 15 patients had documented intravitreal silicone oil
`droplets noted during examination. All 15 eyes had
`tiny silicone oil droplets in the vitreous that were
`visible by slit—lamp or funduscopic examination (Figs.
`1—3). At examination in various head positions, the
`silicone oil droplets were found to float superiorly. All
`patients were asymptomatic. There was no ocular in-
`flammation, as evidenced by anterior chamber or vit-
`reous cell throughout the follow—up period. The num—
`ber of injections before silicone oil droplets were
`noted varied from 1
`to 16 (Table 1) of pegaptanib,
`bevacizumab, triamcinolone, or ranibizumab. Patients
`were being treated for choroidal neovascularization
`and cystoid macular edema due to branch or central
`retinal vein occlusions. As expected from the course
`of disease treatment, visual acuity fluctuated through-
`out treatment, depending on the activity of choroidal
`
`
`
`Fig. 2. Patient 5. A tiny silicone oil droplet noted in the vitreous cavity
`during slit—lamp examination. The large yellow area is alight reflection.
`The red reflex is shown.
`
`neovascularization or macular edema. Visual acuity
`was not affected by the presence of silicone oil drop-
`lets but was consistent with the course of the disease
`
`(Table 1). The presence of silicone oil was confirmed
`with ultrasonography (Fig. 4 [Patient 1]). The high
`echogenicity matched that of silicone oil. No interven-
`tion was necessary in our group of patients, and the
`patients were observed without complications for the
`follow—up period (range, 0713.9 months; median, 7.0
`months).
`
`Discussion
`
`Intravitreal silicone oil droplets may occur after
`intravitreal injection. In our case series, there was no
`association with a specific agent. As shown in Table 1,
`10 of 15 patients had received bevacizumab injections
`before silicone oil droplets were noted during exami—
`nation. The other five patients had received injections
`
`
`
`
`
`Fig. 1. A tiny silicone oil droplet noted just anterior to the optic nerve.
`
`Fig. 3. Patient 5. A tiny silicone oil droplet noted in the vitreous cavity.
`
`Regeneron Exhibit 1067.002
`
`NOVITC(US)00313518
`
`Regeneron Exhibit 1067.002
`
`

`

`
`Table 1. Description of Patients With lntravitreel Silicone Oil Bubbles Seen During Examina'tien
`Total No. of
`Visual Acuity
`Visual Acuity
`Duration (mo) of
`
`Visual Acuiiy
`lntraviireal Agerilm)
`lnlravilreal Agenl(s)
`injections
`Before
`Aller
`No. of lniectmns
`ow—up Afier
`Before Silicone
`Throughem
`Used Before
`Used by Final
`Silicone Oil
`Silicone Oil
`ai Final
`Silicone Oil
`
`Patieni
`Disease
`011 Noted
`Follaw‘up
`81
`.«one Qil Noted
`Follow-up
`Was Noted
`Was Noted
`Follow-up
`Was Nola-Ki
`1
`CME one to nemi—CRVO
`1
`1
`Bev
`azuma‘e
`Bevacizumab X 1
`20/20
`20/25
`5.6
`
`Bevac
`2
`CM! due i0 AMD
`8
`12
`Bevac .umab X 2;
`20/25
`20/4‘0
`5.3
`
`ran:
`ranibiaumeb Z 9;
`
`bevaczzumab and
`iriamcinolorie
`Bevacizumab X 10;
`
`
`.
`. mcinolone 3:
`.
`Pegzip mil) ix: 3;
`r'anibizumab X 9
`Bevacizumab X 7
`
`Pegar nib
`3
`Pegaptzmib ix: 3;
`bevaclzumab X '1';
`ranibizumab >»’ 10
`Bevacizumab X 5
`Pegamanib z: 1;
`bevaczumab X 4
`
`0
`
`4
`5
`F:
`7
`
`8
`9
`10
`
`11
`12
`
`13
`14
`
`CME due to radialzon
`i‘etrncpathy
`CNV Lie to AMD
`CME due 10 CRVO
`CNV due. to AMD
`CNV ' Lie to AM D
`
`CME due to BRVO
`ON! we to AMD
`ON“! u 09 10 AMD
`
`ONE due to BRVC‘
`(3?le 2 Lie to AMD
`
`CNV 2 me 10 AMD
`CNV we :0 AMD
`
`
`
`3
`
`7
`2
`3
`16
`
`3
`3
`4:
`
`8
`
`12
`7
`3
`20
`
`5
`4
`10
`
`10
`15
`
`5
`15
`
`11
`16
`
`6
`15')
`
`3evaoizumab
`
`Jegaptani‘o,
`rambizumab
`Bevaoizumab
`Pegaplanib
`Jegaptanib,
`
`new 'izuma‘o,
`.
`
`363/210 Lumab
`’egaptanib.
`bevacizumab
`
`
`Bevaoizumab
`3egaptanib,
`
`.
`:2 =
`dexamethasone
`
`
`
`
`
`20/40
`
`20/30
`20/40
`20/20
`20/80
`
`20/30
`20/40
`20/150
`
`20/100
`
`20/25
`20/40
`20/20
`20/40
`
`20/50
`20/30
`20/100
`
`20/40
`
`20/25
`20/40
`20/30
`20/80
`
`20/30
`20/60
`20/100
`
`12.4
`
`5.4
`13.7
`33
`5.1
`
`5.6
`13.9
`7.4
`
`
`
`1
`
`20/40
`20/50
`
`20/50
`20/30
`
`20/50
`20/40
`
`20/40
`20/25
`
`20/50
`20/40
`
`20/40
`20/25
`
`0.0
`0.0
`
`0.0
`0.0
`
`_. aclzumab X 1
`
`Peg .
`ib X 6;
`ranibizumab X 8:
`dexametlaaeene X 1;
`beva .zumab x ‘1
`Rzznibizumab
`
` Rari'
`lab X 6
`jegapi‘anib,
`Pegamanib r1 12;
`
`#‘an‘b‘zumab
`ranibizumeb 2/. 3
`
`2.4
`20/70
`20/70
`20/60
`Bevao
`nab X 2;
`7
`6
`CME due 10 radiation
`15
` trial .siriolone
`
`
` pellxy pqalriamclnol-‘Jne ,1 ~
`
`CME, cyetoid maeular edema;
`occluelen.
`
`CRVO‘ central retinal vein oeclueien; CNV, choroidal neov-ascular membrane; AMD, age—related maculer degeneralimn; BRVO, branch retinal vein
`
`866
`
`
`
`
`
`
`
`1;.338100104'88Iii/0010.0“8$0051'Es'fiSVflgiflSQQHHHA{INV31010313800'EVNHHOE‘HHL‘VNELEEH
`
`
`
`
`
`
`
`NOVITC(US)00313519
`
`Regeneron Exhibit 1067.003
`
`

`

`mid/Hm SillCfihlE Oil; USAGE AFTER ENTRAVH‘REAL DRUG ENJECTEGNS a EAKRI AME EKDAWE
`
`395}
`
`
`
`Fig. 4° Patient l. Silicone oil droplets shown by A-scan zmd B~scan
`ulnasonography. A, B—-Scan showing three droplets of silicone o in the
`Vitreous cavity. B, A—Scan showing the highly ecliogenic pattern.
`
`with pegaptanib, ranibizuinab, or a combination, Be-
`cause none of the patients had received triarncinolone
`alone, we cannot implicate this drug to be associated
`with this finding. The agents used did not have sili—
`cone oil in their drug vehicle. There were no adverse
`effects on vision, and there was no ocular inflamma—
`tion during the follow—up period, lntravitreal silicone
`oil is used commonly in retinal detachment surgery,
`and its ocular adverse effects include migration of
`silicone oil into the anterior chamber, ernulsiiication
`of silicone oil, and keratopathy. Other known side
`effects are more applicable in the presence of a near—
`complete silicone oil fill in the vitreous and include
`pupillary block, angle closure without papillary block,
`and idiopathic open~angle glaucoma even with the
`absence of silicone oil in the anterior chamber? None
`of these side effects were seen in our series.
`
`Freund er. alm described a series of three eyes of
`three patients where silicone oil was noted after intra-
`vitreal injections, Ultrasonography showed a highly
`echogenic pattern, characteristic of silicone oil. These
`
`investigators questioned whether this is due to the
`silicone oil lubricant on the syringes or needles used
`for intravitreal injections. Pegaptanih is packaged in a
`sterile,
`l—inL, USP type l, graduated, prefilled glass
`syringe fitted with a sterile 27~gange needle, All nee~
`dies used in our series were of varying gauges, man~
`ufactured by Becton Dickinson and Company (Frank—
`lin Lakes, NJ), ’l‘riarncinolone is drawn up with a
`ZO—gauge needle and injected with a 27—gange needle.
`Ranihizumab is drawn up with a l9~gange iilter needle
`lid-tun filter) and injected intravitreally using a 30~
`gauge 0.5—in needle tPrecisionGlide, Becton Dickin—
`son and Company, Franklin Lakes, NJ j). Bevacizumab
`is fractionated by our hospital pharmacy from a large
`vial into GAS—lulu doses supplied in a tuberculin sy~
`ringe (Becton Dickinson and Company), Either a 30—
`gauge 0.5~i,n needle is placed on this or it is transferred
`into a 3 l ~gauge needle attached to a syringe (Ultrafine ll,
`Becton Dickinson and Company, Franklin Lakes, NJ),
`During the manufacturing process, these needles were
`extruded with silicone oil as well as lubricated. The
`
`tuberculin syringes were also lubricated with silicone oil,
`'l‘he lubricant used was most likely 365 Dow Corning
`surfactant according to a discussion with representatives
`from Becton Dickinson and Company. Material sup—
`plied by the Dow Corning Corporation states that the
`components of the surfactant and preservative pack~
`age used in the emulsion are present at
`levels of
`fractions of a percent in the final product. They esti—
`mated that the product had 2% to 3% of silicone oil
`before application of the lubricant in the syringe. They
`report, no adverse effects due to the extremely low
`levels of silicone oil. They further highlight that these
`additives are used in other industries that have human
`
`contact including food applications. They, however,
`recommend that users determine if these additives
`
`create a problem in their specific application.“
`There have been many previous reports, especially
`in the diabetes literature, regarding the contamination
`of skin and insulin with silicone oil found on needles
`
`and syringes.” A granulonratous reaction was found
`in one series of three cases.13 Miller et al14 reported on
`the amount of silicone oil extruded from syringes after
`flushing with distilled water. They found that more
`silicone oil was flushed from lO-niL syringes when
`exhibiting accumulation of lubricant on the tips of
`plungers (l,0.7----ll.3 mg) than when none was seen (0
`mg). Most notably,
`the plunger tip was thought to
`have 124% of the silicone lubricant, This report also
`confirmed that washing the same syringe multiple
`times continued to provide an equal amount of sili~
`cone oil in each washing, Speculating that pumping
`the syringe hack and forth caused more silicone oil to
`be added into the washings, Chantelau et al'15 in 1986
`
`NOVITC(US)00313520
`
`Regeneron Exhibit 1067.004
`
`

`

`Eiiiiii
`
`RETENA. THE JOURNAL OF REl‘lNAlL AND WTREOUS DESEASES e Eddd 9 VOLUME 28 8 NUMBER 7
`
`used syringes to draw insulin into a syringe and then
`pushed the plunger in to expel air droplets three times.
`They noted that tilt? mg to 0.25 mg of silicone oil had
`been expelled from each syringe. Another report by
`Baldwin”? speculated on how silicone oil became in-
`corporated in insulin during vigorous pumping back
`and forth on the syringe. hi the diabetes literature, there
`are also multiple instances when insulin contaminated
`with silicone oil was found to have less efficacyfifivl7
`Typically,
`to draw up a medication leg. ranihi—
`zumah or triamcinolone), a larger—bore needle is
`placed on the syringe, and the plunger is pulled back
`to withdraw more medication than is needed. Then the
`
`smaller—bore reg, 30—gauge} needle used for the in-
`travitreal injection is placed on the syringe, and the
`plunger is pushed up to the amount needed. which also
`eliminates air droplets drawn up from the vial. if
`residual air droplets are seen, the syringe is tapped to
`force the droplets up toward the hub of the syringe.
`Compounded agents may have. been subjected to be-
`ing placed in more syringes, needles, and tubing, with
`more friction occurring between the agent and the
`syringe and needle.
`On the basis of compelling evidence in the diabetes
`literature, the presence of silicone oil as a lubricant in
`our needle and syringes is most likely the source seen
`in our patients. Although the presence of silicone oil
`has not caused any adverse effects, there is a need to
`review the methods of injections and utilization of
`syringes to decrease the amount. of silicone oil that is
`inadvertently injected. it has been previously reported
`that silicone oil when left, in the eye for long periods
`(>l2—l8 months) can be engulfed by the trabecular
`rnesliworlt and Muller cells of the retina.” Sugges-
`tions tor reducing silicone oil contamination include
`pulling back the plunger as minimally as necessary to
`withdraw the drug to reduce the rislr of unnecessary
`contamination by additional material, in addition, re-
`ducing the amount of manipulation and tubing that the
`drug is subjected to during repackaging or compound—
`ing may be important. it is also important to perform
`drug stability testing in new packaging, especially for
`prefilled syringes. The medication may interact with
`the silicone oil layer. and this may affect drug degra-
`dation. As previously discussed, silicone oil may de—
`tach from the syringe or plunger and form droplets in
`the medication. The use of syringes and needles with
`non—siliconebased lubricants is another option worth
`considering to eradicate this possible adverse effect.
`Because this is a retrospective review of charts of
`patients seen in a busy clinic. it is possible that more
`patients had silicone oil droplets, which are difficult to
`see. than reported. ’ihe silicone oil droplets had been
`seen and noted incidentally when the patients were
`
`examined with a 9G—diopter or 78—diopter lens on a
`slit~lamp bioinicroscope. The droplets were not spe-
`cifically looked for. Therefore, we cannot adequately
`address the true prevalence of silicone oil droplets
`after intravitreal injections. These tiny droplets are diffi~
`cult to see, and the amount of silicone oil is difficult to
`
`quantify; some droplets may be hidden from view
`anterior to the era serrata. it is difficult to assess, on
`
`the basis of this case. series. whether certain types of
`syringes are more likely to produce this adverse effect.
`Although we do have ultrasonographic evidence that
`this finding is consistent with silicone oil, we do not
`have any pathologic evidence. because no vitreous
`biopsies were done in any of our cases. However. we
`believe that this not necessary because there has been
`no affect on visual function to substantiate the risk. of
`
`biopsy for these patients.
`
`Key words: anti—vascular endothelial growth fac-
`tor, hevacizumab (Avastin), droplet, intravitreal,
`in—
`jection, needle, pegaptanib, ranibizurnah (Lucentis),
`silicone oil, syringe, triarncinolone.
`
`References
`
`LA)
`
`SJ}
`
`l. VEGF inhibition Study in Ocular Neovascularization tVlSlON}
`Clinical ’l‘n‘al Group. Year 2 efficacy results of 2. random—
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`2. Roscnfeld Pl, Brown Dix/l, Heier lS, et al. Ranihimmah for
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`Brown UM, Kaiser PK, Michels M. et al. Ranibizumah
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`Ekdawi NS Bakri SI. lntravitrcal triamcinolonc and bowel—
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`_\.l
`
`ii}.
`
`NOVITC(US)OO313521
`
`Regeneron Exhibit 1067.005
`
`

`

`WEE/Em SMEONE GEL USAGE AFEER ENTRAVHREAL DRUG ENJECTEGNS 8 EAKRI AME EKDAWI Willi
`
`Corporatinn DC. Corning® 365. 35% Dimethieene NE limui~
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`l5.
`
`l6.
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`Chantelan ii. Berger Mi, lfiohlken B, Silicene Oil released tram
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`Baldwin RN. Contamination of insulin by silicone Oil:
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`52789—790.
`Bernstein RK. Clontling and deactivatinn of Clear (regular)
`human insulin: asgoeiatioir with silicone oil from disposable
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`Suzuki M, Okada T. Takeuehi 87 et al. Effect Of silicone nil
`an, ocular tissues. Jpn J Ophthalmel 1991;35:282—291.
`
`NOVITC(US)OO313522
`
`Regeneron Exhibit 1067.006
`
`