Sir,

Since the advent of anti-VEGF, it has been widely used for the management of macular edema, especially diabetic macular edema. Bevacizumab being used off-label for that purpose. Rare complications following intravitreal injections include: endophthalmitis, uveitis, retinal tear and retinal detachment.1

Case report

We report a case of a 50-year-old diabetic male patient with diabetic macular edema. He received intravitreal injections of Bevacizumab for five times: three to his right eye and two to the left eye.

Two months after the last intravitreal injection to his right eye, the patient complained of seeing a floater in that eye. Past ophthalmic history included only intravitreal injections and central laser treatment. No intraocular surgeries were performed for him, and there was no history of ocular trauma.

Anterior segment showed no signs of inflammation. Posterior segment exam showed bilateral, severe, nonproliferative diabetic retinopathy. In the right eye, a fine cotton fiber with a length of less than one optic disc diameter was suspended in the posterior vitreous towards the temporal side. No evidence of inflammation in the posterior segment was seen.

Colored fundus photographs showed the short fiber floating in the vitreous, Figure 1. Colored fundus video was done for documentation.

Figure 1
figure 1

Intravitreal foreign body; a fiber suspended in the posterior vitreous (arrow).

Full size image

During a 5-month follow-up period, no signs of inflammation were noticed.

Comment

Previous reports described the appearance of silicone oil droplets in the vitreous which were asymptomatic and were discovered during routine examination following intravitreal injection. The source was found to be the syringes used for the injection, due to siliconization of the inner syringe and outer plunger surfaces to minimize friction.2

Another report described foreign bodies on the ocular surface after uneventful intravitreal injection. Those foreign bodies were found to be small plastic foreign bodies with a maximum size of 1 × 0.5 mm, on the ocular surface immediately after the injection is given, even before the removal of the speculum or the drape. It was proposed that these plastic foreign bodies originated from the surface of the plastic part of the filter-needle.3

To our knowledge, this is the first report about an intravitreal cotton fiber following uneventful intravitreal injection. The source of which could not be ascertained, but could be from any step throughout the procedure of intravitreal injection, and possibly has been introduced into the vitreous with the needle during the injection.

Although intravitreal injections are widely practiced in large numbers, it is still an intraocular procedure where the natural eye defense mechanisms are bypassed and the drug is injected directly into the vitreous. Therefore, meticulous care should be taken when performing any intravitreal injection.