Abstract
BackgroundWhile the development of targeted molecular therapy to inhibit vascular endothelial growth factor (VEGF) has revolutionized the treatment and visual prognosis of highly prevalent retinal diseases such as diabetic retinopathy and age-related macular degeneration, each intravitreal injection of these agents carries a small risk of endophthalmitis which can be visually devastating. In the absence of specific guidelines, current management of post-injection endophthalmitis is typically extrapolated from data regarding endophthalmitis occurring after cataract surgery despite potential differences in pathogenic organisms and clinical course. Here, we assess the contribution of intravitreal injections of anti-VEGF agents to all cases of endophthalmitis at our tertiary care referral center and characterize the clinical outcomes and microbial pathogens associated with post-injection endophthalmitis in order to inform management of this serious iatrogenic condition.ResultsDuring the 7-year study period analyzed, 199 cases of endophthalmitis were identified using billing records. Of these, the most common etiology was post-surgical, accounting for 62 cases (31.2 %), with bleb-associated, endogenous, and corneal ulcer-related infections representing the next most frequent causes, comprising 15.6 % (31/199), 13.1 % (26/199), and 13.6 % (27/199) of all cases, respectively. Intravitreal injections of anti-VEGF agents represented 8.5 % of endophthalmitis (17/199 cases). Intraocular cultures yielded positive results in 75 % of post-injection cases, with the majority associated with coagulase-negative Staphylococcus. Consistent with prior literature, a case of Strep viridans displayed more rapid onset and progression. We also report the first association of Enterobacter cloacae and Lactococcus garvieae with post-injection endophthalmitis. While all but one patient were treated with initial vitreous tap and intravitreal injection of antibiotics, both patients with these rare organisms exhibited persistent vitritis requiring subsequent vitrectomy. Long-term outcomes of post-injection endophthalmitis indicated visual recovery to baseline levels, even with resumption of anti-VEGF agents following resolution of the acute infection.ConclusionsAcute endophthalmitis following intravitreal injections of anti-VEGF agents is an uncommon but potentially devastating complication which may be managed effectively with vitreous tap and injection of intravitreal antibiotics. However, persistent vitritis requiring subsequent vitrectomy should raise suspicion for unusual pathogens.
Highlights
While the development of targeted molecular therapy to inhibit vascular endothelial growth factor (VEGF) has revolutionized the treatment and visual prognosis of highly prevalent retinal diseases such as diabetic retinopathy and age-related macular degeneration, each intravitreal injection of these agents carries a small risk of endophthalmitis which can be visually devastating
Regarding the management of post-injection endophthalmitis, in the absence of evidence-based guidelines, many ophthalmologists use the severity of visual acuity on presentation to inform their decision to treat initially with either “tap and inject” versus primary vitrectomy based on the results and recommendations of the Endophthalmitis Vitrectomy Study (EVS) [12]
In order to analyze the experience at our tertiary care academic institution, we reviewed all cases of endophthalmitis during a 7-year period and investigated the microbial pathogens and clinical course of those cases which occurred following intravitreal injection of an anti-VEGF agent to identify patterns which may inform treatment, especially in those cases caused by organisms other than coagulase-negative Staphylococcus
Summary
While the development of targeted molecular therapy to inhibit vascular endothelial growth factor (VEGF) has revolutionized the treatment and visual prognosis of highly prevalent retinal diseases such as diabetic retinopathy and age-related macular degeneration, each intravitreal injection of these agents carries a small risk of endophthalmitis which can be visually devastating. We assess the contribution of intravitreal injections of anti-VEGF agents to all cases of endophthalmitis at our tertiary care referral center and characterize the clinical outcomes and microbial pathogens associated with post-injection endophthalmitis in order to inform management of this serious iatrogenic condition. While the advent of molecular therapeutics targeting vascular endothelial growth factor (VEGF) has revolutionized the management and visual prognosis for patients with age-related macular degeneration, retinal vein occlusion, diabetic macular edema, and other diseases resulting in retinal vascular leakage or choroidal neovascularization, each injection of these agents carries a small associated risk of endophthalmitis. A recent large retrospective analysis from France, where standard practice involves use of a face mask when performing intravitreal injections, described a much lower incidence of post-injection endophthalmitis due to Streptococcus species (only 1 case out of 23 culture-positive cases) compared with most studies from the USA [5]. A recent literature review highlighted the lack of current data regarding the most appropriate initial management of post-injection endophthalmitis [16]
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