Elsevier

Ophthalmology

Volume 125, Issue 8, August 2018, Pages 1279-1286
Ophthalmology

Original article
Endophthalmitis after Intravitreal Injection of Vascular Endothelial Growth Factor Inhibitors: Management and Visual Outcomes

https://doi.org/10.1016/j.ophtha.2018.01.022Get rights and content

Purpose

We describe the presentation of patients developing endophthalmitis after intravitreal injection with vascular endothelial growth factor (VEGF) inhibitors. Moreover, we evaluate the management by comparing the outcomes of immediate tap and injection of intravitreal antibiotics (TAI) versus initial surgical pars plana vitrectomy (PPV). Finally, we analyze the predictive factors of visual outcomes at 6-month follow-up.

Design

Retrospective, single-center, nonrandomized interventional study.

Participants

Patients developing endophthalmitis after receiving an intravitreal injection of anti-VEGF agent between 2006 and 2016.

Methods

All patients received a vitreous biopsy sent for cultures before the initiation of treatment: TAI group versus PPV with intravitreal antibiotics (PPV group).

Main Outcome Measures

Best-corrected visual acuity (BCVA) at 6-month follow-up after treatment for endophthalmitis.

Results

A total of 258 357 intravitreal injections occurred over the course of the 10-year period, of which 40 patients (0.016%) had endophthalmitis within 3 weeks after injection. In total, 34 patients (85.0%) had pain and 25 patients (62.5%) had hypopyon on initial examination. Among 24 culture-positive cases, 66.7% of the causative organisms were coagulase-negative Staphylococcus, followed by Streptococcus species (10.0%). The best-corrected visual acuity (BCVA) (logarithm of the minimum angle of resolution [logMAR]) at 6-month follow-up was significantly worse for patients who had a positive culture for Streptococcus species (4.0; standard deviation [SD], 0.8) (approximately light perception) compared with those who had a positive culture for coagulase-negative Staphylococcus (0.4; SD, 0.3) (∼20/50) (P < 0.0001). Compared with the TAI group, a higher proportion of samples were culture-positive in the PPV group (90.9% vs. 48.3%, P = 0.03). There was no statistically significant difference in BCVA at 6-month follow-up between the TAI and PPV groups. Younger age (<85 years) and lower intraocular pressure (IOP) (≤25 mmHg) at presentation were predictive of achieving a BCVA of 20/400 or better at 6-month follow-up after treatment. Initial management (TAI vs. PPV), duration of symptoms, presence of pain, presence of hypopyon, presenting BCVA, and culture status (positive vs. negative) were not found to be predictive of visual outcomes at 6-month follow-up.

Conclusions

No significant difference in BCVA at 6-month follow-up was detected between the TAI and PPV groups. Younger age and lower IOP at presentation were associated with better visual outcomes at 6-month follow-up.

Section snippets

Study Design

A retrospective study was conducted adhering to the tenets of the Declaration of Helsinki with Salus institutional review board approval. This study is HIPAA compliant. The study sample is composed of all patients with endophthalmitis after anti-VEGF injections at a multicentered single subspecialty (retina only) private practice institution (VitreoRetinal Surgery, PA, Minneapolis, MN) over a 10-year period between 2006 and 2016.

Injection Technique

All eyes were injected with an anti-VEGF agent (bevacizumab

Results

A total of 40 patients (0.016%) developed endophthalmitis after 258 357 anti-VEGF agent injections during a 10-year period (2006–2016). The mean age of the study sample was 81.4 years (SD, 10.9), and 67.5% of the patients were female. A small percentage of patients were smokers (12.5%).

The majority of patients received anti-VEGF agents for exudative AMD (72.5%), followed by diabetic macular edema (15.0%) and retinal vein occlusion (12.5%). The average total number of injections of anti-VEGF

Discussion

In our study, the incidence of endophthalmitis after intravitreal anti-VEGF agent injection was 0.016%, which is comparable to the incidences reported in the literature.3, 7, 8, 9 Younger age and lower IOP at presentation were predictive of achieving a BCVA of 20/400 or better at the 6-month follow-up after treatment. There was no statistical difference in BCVA at 6-month follow-up after treatment or change in vision between the TAI and PPV groups.

Patients who were younger than 85 years of age

References (21)

There are more references available in the full text version of this article.

Cited by (0)

Financial Disclosure(s): The authors have made the following disclosures: E.K.C.: other – Regeneron, Ophthotec, Alcon, Allergan, EyeNuk, Alimera.

D.R.P.A.: Honoraria – Alcon, Allergan, Genentech, Regeneron.

HUMAN SUBJECTS: Human subjects were part of this study protocol. A retrospective study was conducted adhering to the tenets of the Declaration of Helsinki with Institutional Ethics Review Board approval committee of Salus IRB. This study is HIPAA compliant.

No animal subjects were used in this study.

Author Contributions:

Conception and design: Xu, Chin, Bennett, Williams, Ryan, Dev, Mittra, Quiram, Parke, Almeida, Davies

Data collection: Xu, Almeida

Analysis and interpretation: Xu, Chin, Bennett, Williams, Ryan, Dev, Mittra, Quiram, Parke, Johnson, Cantrill, Almeida, Davies

Obtained funding: N/A

Overall responsibility: Xu, Chin, Bennett, Williams, Ryan, Dev, Mittra, Quiram, Parke, Johnson, Cantrill, Almeida, Davies

View full text
© 2018 by the American Academy of Ophthalmology