Outcomes and Practice Preferences After Endophthalmitis Following Anti-VEGF Intravitreal Injection

Abstract

Purpose: This study examines treatment-based outcomes of endophthalmitis due to antivascular endothelial growth factor (anti-VEGF) intravitreal injection and its effect on subsequent management of neovascular disease. Methods: A retrospective multicenter study was conducted of 157 patients with a diagnosis of endophthalmitis following anti-VEGF intravitreal injection at 10 major ophthalmic centers. Results: The median number of injections before endophthalmitis was 10 (range, 1 to 84 injections). Initial treatment with tap and inject with or without subsequent vitrectomy trended toward smaller visual acuity changes from baseline (4 ETDRS [Early Treatment Diabetic Retinopathy Study] letter difference vs 19 ETDRS letter difference) compared with initial vitrectomy, but the difference was not statistically significant. There was no significant change in medication choice among injections after endophthalmitis. There was a statistically significant shift away from regular interval (1- to 2-month) injections and a shift toward treat-and-extend and as-needed injection algorithms. Conclusions: The visual outcomes were not significantly different between patients who initially underwent tap and injection of antibiotics and those who underwent vitrectomy. There was no significant change in medication choice before and after endophthalmitis but there was a shift toward lower-frequency injection algorithms after postintravitreal injection endophthalmitis compared with prior.

Management Patterns and Outcomes for Intravitreal Injection–Related Endophthalmitis

“…In our cohort, 30% of cases were culture positive, which was consistent with the range of 30% to 60% described in previous reports. 22,24 -27 Although culture-positive and culture-negative cases in our study did not significantly differ in VA at presentation or at 6 months, Xu et al have found in a larger cohort that culture-positive cases are more likely to have worse VA. 27…”

“…In our cohort, 30% of cases were culture positive, which was consistent with the range of 30% to 60% described in previous reports. 22,[24][25][26][27] Although culture-positive and culture-negative cases in our study did not significantly differ in VA at presentation or at 6 months, Xu et al have found in a larger cohort that culture-positive cases are more likely to have worse VA. 27 As in other studies, 3,27,28 the most commonly isolated organism in our cohort was coagulase-negative Staphylococcus, with other cases growing S viridans, S maltophilia, and P acnes. Other studies have suggested that S viridans-associated endophthalmitis may be due to aerosol contamination from oral or respiratory flora during intravitreal injection and is often associated with a more severe clinical course.…”

“…18,21 Chen et al reported no statistically significant difference in visual outcomes between eyes undergoing needle vitreous tap and eyes undergoing PPV, although those that had undergone vitreous tap trended toward smaller changes in VA from baseline (4 vs 19 Early Treatment Diabetic Retinopathy Study letter difference). 22 In our cohort, no eyes underwent initial PPV, and overall mean VA improved from 20/1145 at presentation to 20/113 at 6 months. However, the eyes that underwent subsequent PPV after initial treatment had worse VA not only at presentation (20/7129) but also at 6 months (20/1002).…”

“…18,21 Chen et al reported no statistically significant difference in visual outcomes between eyes undergoing needle vitreous tap and eyes undergoing PPV, although those that had undergone vitreous tap trended toward smaller changes in VA from baseline (4 vs 19 Early Treatment Diabetic Retinopathy Study letter difference). 22…”

Clinical Practice Update: Management of Infectious Endophthalmitis After Intravitreal Anti-VEGF Injection

“…30 The culture-positive rate in various reports of postinjection endophthalmitis was lower than that in the EVS, ranging from 30% to 60%. 3,19–22…”