Can Intravenous Immunoglobulin (IVIG) cause or exacerbate floaters?

IVIG and Ocular Floaters: Potential Association and Management

Intravenous immunoglobulin (IVIG) therapy has not been specifically linked to causing or exacerbating floaters in the available evidence, but it does carry risks of ocular complications through its thromboembolic effects.

Mechanism of Potential Association

IVIG therapy may potentially affect vision and cause floaters through several mechanisms:

1. Thromboembolic events:

   • IVIG can increase blood viscosity and activate platelets, potentially leading to thromboembolic complications 1, 2
   • These events could theoretically affect retinal blood vessels, potentially causing floaters

2. Vascular effects:

   • IVIG can cause vasospasm and blood pressure changes 3
   • Retinal vasculature may be affected, potentially leading to visual disturbances

Risk Factors for IVIG-Related Complications

Patients with the following risk factors are at higher risk for thromboembolic complications from IVIG that could potentially affect vision:

• Advanced age
• Previous thromboembolic diseases
• Immobilization/being bedridden
• Diabetes mellitus
• Hypertension
• Dyslipidemia
• High-dose IVIG administration
• Rapid infusion rate 1, 3

Management Recommendations

If a patient reports new or worsening floaters during or after IVIG therapy:

1. Immediate ophthalmologic evaluation to rule out serious ocular complications

2. Modify IVIG administration protocol:

   • Slow infusion rate
   • Use lower concentration of IVIG products
   • Ensure adequate hydration before, during, and after infusion 1, 3

3. Consider alternative treatments if floaters persist or worsen with IVIG therapy

Prevention Strategies

For patients requiring IVIG who have pre-existing floaters or are concerned about ocular complications:

• Pre-treatment ophthalmologic evaluation to establish baseline
• Ensure proper hydration before and during IVIG administration
• Use non-sucrose-containing IVIG products which have lower risk of adverse effects 1
• Administer at slow infusion rates (0.01-0.02 ml/kg/min initially, gradually increasing as tolerated) 4
• Monitor for early signs of complications during infusion

Special Considerations

While IVIG is generally considered safe, patients should be informed about potential adverse effects including visual disturbances. In patients with Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), IVIG has been used to treat ocular complications 5, but paradoxically, in one pediatric series, higher rates of ophthalmic complications were seen in children given IVIG compared with those who were not 5.

For patients with primary immunodeficiency disorders requiring ongoing IVIG therapy, regular ophthalmologic follow-up may be warranted to monitor for any visual changes, including new or worsening floaters.