To report a case of recurrent transient cranial nerve neuritis affecting varying cranial nerves in a patient receiving Aflibercept.

Aflibercept is a VEGF-inhibitor developed for wet macular degeneration and subsequently approved for diabetic macular edema and other stages of diabetic retinopathy. Systemic adverse events of intravitreal injections are increasingly recognized. A thorough review of possible side effects via PubMed revealed cases of isolated sixth nerve palsy with Bevacizumab but no previously reported cases of VEGF-inhibitor-induced cranial nerve neuritis. 

This case report describes a 68-year-old man presenting with recurrent, transient episodes of left facial droop and the inability to close the left eye, associated with a frontotemporal headache, dysphagia and nose-tip numbness. He was treated with prednisone with only partial effectiveness. The headache, dysphagia and numbness would resolve within days, but the facial droop could persist for weeks to months. An MRI brain performed during one of these episodes showed moderately intense enhancement of the intratemporal portion of the left facial nerve, in keeping with left facial nerve neuritis. Subsequent episodes involved a unilateral right facial droop, and some were associated with ipsilateral upper limb weakness; these likely represented recurring neuritis of other cranial and peripheral nerves or spinal nerve roots. Symptoms would recur every few weeks until our patient noticed that the palsies invariably succeeded the intravitreal Aflibercept injections.

He has a complex ophthalmologic history including corneal transplants, glaucoma and diabetic macular edema and experienced significant visual improvements with the Aflibercept injections. Therefore, a decision was made with the patient to continue the intravitreal injections, despite the risk of permanent cranial nerve damage. 

Cranial nerve neuritis is a possible rare adverse event post-intravitreal injections of Aflibercept and likely other VEGF-inhibitors. Neurologists and ophthalmologists should be aware of this rare side effect of intravitreal VEGF-inhibitor injections.