Endophthalmitis following intravitreal injections

Intravitreal triple therapy with vancomycin, ceftazidime, and moxifloxacin for bacterial endophthalmitis: A Twelve-year experience

PURPOSE

Increasing rates of antibiotic resistance in endophthalmitis have been reported. This study examines outcomes of triple therapy with intravitreal vancomycin, ceftazidime, and moxifloxacin for endophthalmitis.

METHODS

Retrospective, consecutive series of all patients treated with abovementioned intravitreal antibiotics from January 2009 to June 2021. Percentages of eyes attaining greater than or equal to 20/200 and 20/50 Snellen visual acuities and adverse events were evaluated.

RESULTS

112 eyes met inclusion criteria. 63 of 112 eyes (56%) achieved a visual acuity of 20/200 during follow-up, with 39 (35%) returning to at least 20/50. In subgroup analysis, 23 of 24 (96%) eyes with post-cataract endophthalmitis obtained ≥ 20/200 acuity and 21 of 24 (88%) obtained ≥ 20/50 acuity during follow-up. There were no cases of macular infarction.

CONCLUSIONS

Intravitreal moxifloxacin (160 µg/0.1 mL) was well tolerated as an adjunct to vancomycin and ceftazidime for bacterial endophthalmitis. Use of this novel combination offers several theoretical advantages compared to standard therapy with two antibiotics, including expanded gram-negative coverage and potential synergy, and may be particularly valuable in geographies where the local antibiogram supports empiric use. Further study is merited to verify the safety and efficacy profile.

Bacterial endophthalmitis following anti-VEGF intravitreal injections: a retrospective case series

BACKGROUND

To describe the incidence of endophthalmitis and the treatment outcomes of acute bacterial endophthalmitis following intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections in a Brazilian hospital. The analysis was based on the timing of infection after intravitreal injection, culture results, visual acuity, and the presence of epiretinal membrane after a 1-year follow-up period, spanning nine years.

METHODS

This retrospective case series, conducted over a 9-year period, aimed to evaluate the treatment outcomes of acute endophthalmitis following intravitreal Bevacizumab injections. The inclusion criteria involved a chart review of 25 patients who presented clinical signs of acute endophthalmitis out of a total of 12,441 injections administered between January 2011 and December 2019. Negative culture results of vitreous samples or incomplete data were excluded. Ultimately, 23 patients were enrolled in the study. Eight patients were treated with intravitreal antibiotic injections (IVAI) using vancomycin 1.0 mg/0.05mL and ceftazidime 2.25 mg/0.05mL, while 15 patients underwent pars plana vitrectomy (PPV) followed by intravitreal antibiotic injections at the end of surgery (IVAIES). The main outcome measures were the efficacy of controlling the infection with IVAI as a standalone therapy compared to early PPV followed by IVAIES. Data collected included pre-infection and one-year post-treatment best corrected visual acuity (BCVA), optical coherence tomography (OCT) abnormalities, and enucleation/evisceration rates. To compare groups, Mann-Whitney and ANOVA tests were employed for statistical analysis.

RESULTS

The incidence rate of bacterial endophthalmitis was 0.185% (1/541 anti-VEGF injections), with the highest infection rates observed in 2014 and 2017. Patients presented clinical symptoms between 2 and 7 days after injection. The most common isolated organisms were coagulase-negative Staphylococci and Streptococci spp. Treatment outcomes showed that both IVAI and PPV + IVAIES effectively controlled the infection and prevented globe atrophy. After one year, the PPV group with BCVA better than Light Perception had a significantly better BCVA compared to the IVAI group (p 0.003). However, PPV group had higher incidence of epiretinal membranes formation compared to the IVAI group. (P 0.035) CONCLUSION: Anti-VEGF injections carry a risk of developing acute bacterial endophthalmitis. Isolated antibiotic therapy could be an effective treatment to control the infection, but performing PPV + IVAIES as a primary treatment showed promising results in terms of improving BCVA after one year, despite a higher rate of epiretinal membrane formation. Further studies are needed to confirm these findings.

Postoperative exogenous endophthalmitis caused by Escherichia coli: a rare case report and literature review

Aim: We report a rare case of postoperative endophthalmitis caused by Escherichia coli. Case description: The diagnosis of postoperative endophthalmitis in our patient was established based on the clinical signs of hypopyon along with vitritis. The patient underwent pars plana vitrectomy, anterior chamber washout, intraocular lens removal, and intravitreal antibiotics (amikacin and vancomycin) injection. The culture of both the vitreous sample and the intraocular lens, revealed a heavy growth of Escherichia coli. Conclusion: Escherichia coli is an unusual microorganism to cause postoperative endophthalmitis. A major breach in the sterilization may explain this infection. Proper sterilization and prophylactic measures are crucial to avoid this disastrous complication.

Preventive factors, diagnosis, and management of injection-related endophthalmitis: a literature review

BACKGROUND

Intravitreal medication injections represent the gold standard treatment for a variety of potentially blinding chorioretinal vascular diseases. Despite their excellent safety profile, they are associated with the feared complication of injection-related endophthalmitis (IRE). Though the overall incidence of IRE is low, due to the ever-increasing number of injections being performed, it is a complication that all retina specialists are likely to encounter. This article reviews various factors that could potentially influence the risk of IRE and discusses evidence-based strategies for management.

METHOD

PubMed was searched for keywords "intravitreal injection" and "endophthalmitis" from the period of 1995-2021. Relevant articles were reviewed and selected articles were analyzed with respect to the incidence, potential preventive factors, clinical presentation, microbial profile, management, and outcomes for IRE.

RESULTS

There is strong consensus supporting the use of povidone iodine topical antiseptic, eyelid retraction away from the injection site, and avoiding treatment of eyes with active surface or eyelid disease, but there is less agreement on the use of face masks versus "no-talking" policies and optimal anesthetic technique. Current evidence comparing tap and inject or early vitrectomy for treatment of IRE is inadequate to determine an optimal treatment strategy.

CONCLUSION

Intravitreal injections are sight saving, but even using established prophylactic measures there remains a small but real risk of infectious injection-related complications. Further investigations comparing tap and inject versus vitrectomy may help to establish optimal treatment, although the rarity of IRE makes designing adequately powered prospective trials a difficult task.

Polymer based sustained drug delivery to the ocular posterior segment: barriers and future opportunities for the treatment of neovascular pathologies

There is an increasing momentum in research and pharmaceutical industry communities to design sustained, non-invasive delivery systems to treat chronic neovascular ocular diseases that affect the posterior segment of the eye including age-related macular degeneration and diabetic retinopathy. Current treatments include VEGF blockers, which have revolutionized the standard of care for patients, but their maximum therapeutic benefit is hampered by the need for recurrent and invasive administration procedures. Currently approved delivery systems intended to address these limitations exploit polymer technology to regulate drug release in a sustained manner. Here, we critically review sustained drug delivery approaches for the treatment of chronic neovascular diseases affecting the ocular posterior segment, with a special emphasis on novel and polymeric technologies spanning the spectrum of preclinical and clinical investigation, and those approved for treatment. The mechanism by which each formulation imparts sustained release, the impact of formulation characteristics on release and foreign body reaction, and special considerations related to the translation of these systems are discussed.

Development of lipid-based microsuspensions for improved ophthalmic delivery of gentamicin sulphate

Aim: Anterior eye segment disorders are treated with eye drops and ointments, which have low ocular bioavailability necessitating the need for improved alternatives. Lipid microsuspension of gentamicin sulphate was developed for the treatment of susceptible eye diseases. Materials & methods: Lipid microsuspensions encapsulating gentamicin sulphate were produced by hot homogenization and evaluated. Ex vivo permeation and ocular irritancy tests were also conducted. Results & conclusion: Stable microsuspensions with high entrapment efficiency and satisfactory osmolarities were obtained. Release studies achieved 49-88% in vitro release at 12 h with sustained permeability of gentamicin compared with conventional gentamicin eye drop (Evril^®). No irritation was observed following Draize's test. The microsuspensions have great potential as ocular delivery system of gentamicin sulphate.

Inflammatory Complications of Intravitreal Anti-VEGF Injections

Intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents is a commonly used therapy for numerous retinal diseases. The most commonly used of these medications are bevacizumab, ranibizumab, aflibercept, and brolucizumab. However, intravitreal administration of these agents is also associated with several inflammatory and non-inflammatory adverse events. The three inflammatory adverse events are sterile intraocular inflammation, brolucizumab-associated retinal vasculitis, and post-injection endophthalmitis. This narrative review summarizes the current literature regarding these conditions, including their epidemiology, presentation, management, outcomes, and pathogenesis. The inflammatory adverse events also share a number of overlapping features, which can make them difficult to discern from one another in a clinical context. This review discusses certain distinguishing features of these conditions that may aid providers in discerning between them and establishing the correct diagnosis.

Comparison of the effect of teicoplanin and vancomycin on experimental methicillin-resistant staphylococcus aureus keratitis

PURPOSE

To evaluate the early efficacy and safety of intrastromal injection of teicoplanin as the alternative treatment for the methicillin-resistant Staphylococcus aureus (MRSA) keratitis by comparing it with vancomycin.

MATERIALS AND METHODS

Twenty-four eyes of 24 New Zealand white rabbits were included in the study. MRSA keratitis was induced in the right eye of each rabbit by injecting 0.1 mL MRSA suspension containing 1000 colony-forming units (CFU) intrastromally to the central cornea. The rabbits were divided into three treatment groups 24 h after the inoculation of MRSA. Eight rabbits received intrastromal teicoplanin therapy, eight received intrastromal vancomycin therapy, and eight received balanced salt solution and served as the control group. Nine hours after the treatment, all rabbits were sacrificed and corneal tissues were collected for microbiological analysis. We also examined and scored all the rabbits clinically before and after the treatment.

RESULTS

The control group scored higher with regard to conjunctival injection, iritis, fibrin, hypopyon, epithelial erosion, and corneal infiltrate than the vancomycin and teicoplanin groups (p = 0.031, 0.010, < 0.001, 0.029, 0.009, and < 0.001, respectively). Chemosis and corneal oedema were similar in all groups (p = 0.731 and 0.075, respectively). The severity of all clinical parameters was similar in both the vancomycin and teicoplanin groups after the treatment. The bacterial load was the highest (7.83 ± 0.71 log₁₀ CFU/g) in the control group. The eyes treated with vancomycin and teicoplanin had similar bacterial loads (6.40 ± 0.69 vs. 6.31 ± 0.75 log₁₀ CFU/g, p = 0.809).

CONCLUSION

The efficiency of teicoplanin seems to be comparable to that of vancomycin when administered intrastromally in the early treatment of MRSA keratitis. The former may be preferred in the treatment of selected cases with vancomycin hypersensitivity or resistance.

Dual-acting therapeutic proteins for intraocular use

Intravitreally injected antibody-based medicines have revolutionised the treatment of retinal disease. Bispecific and dual-functional antibodies and therapeutic proteins have the potential to further increase the efficacy of intraocular medicines.

Noninfectious endophthalmitis following intravitreal triamcinolone acetonide: clinical case and literature review

OBJECTIVE

To review the literature on noninfectious endophthalmitis (NIE) following intravitreal triamcinolone acetonide (IVTA).

DESIGN

A literature review and case report.

PARTICIPANTS

Individuals who developed NIE after IVTA injection.

METHODS

A review of the literature was undertaken using Ovid MEDLINE and EMBASE databases, and articles available up to and including December 30, 2019, were included. A total of 518 articles were identified, of which 27 were selected. We also present an illustrative case report.

RESULTS

The incidence rate of NIE lies between 0.1% and 7.3% in most studies. Although the etiology of NIE is still the subject of investigation, proposed mechanisms include excipients and rheologic stress caused by small crystals. The time to presentation of NIE is often 1-3 days after IVTA injection, with symptoms of moderate to marked reduction in visual acuity along with signs of anterior chamber inflammatory reaction, hypopyon, and vitritis. Resolution occurs in 1-3 weeks in the majority of patients, and almost all return to their pre-injection visual acuity. Differences in the presentations of NIE, infectious endophthalmitis, and pseudo-endophthalmitis are discussed. We also present an illustrative case report of an 80-year-old woman who developed NIE after an IVTA injection for cystoid macular edema.

CONCLUSIONS

It is important to distinguish NIE from other forms of endophthalmitis because they have different natural histories and require different interventions and follow-up. NIE is rarely accompanied by significant pain or conjunctival erythema. Visual acuity is inconsistently affected and is therefore not a good criterion for identifying the type of presenting endophthalmitis.

[Modern diagnosis and treatment of endophthalmitis]

Endophthalmitis is characterized by inflammation of intraocular fluids and tissues, which can lead to irreversible loss of vision if the disease is not treated timely and properly. Endophthalmitis can be classified as exogenous or endogenous depending on the route of infectious agent transmission. Exogenous endophthalmitis occurs when pathogens enter the eye through direct inoculation, while endogenous endophthalmitis develops when pathogens get into the eye through the hematogenous route from a distant infection focus. Classification of endophthalmitis helps determine the etiology and probable causative organisms of the disease. Diagnosis of endophthalmitis is based on clinical data. Early diagnosis and treatment are keys to preserving the eye. Best results are achieved by rapid initiation of an empirical broad-spectrum antimicrobial therapy.

Association of Acute Endophthalmitis With Intravitreal Injections of Corticosteroids or Anti-Vascular Growth Factor Agents in a Nationwide Study in France

Importance

The number of patients affected by retinal diseases treated with intravitreal injections (IVTs) has resulted in a rapidly growing number of procedures. One of the worst complications after these injections is endophthalmitis.

Objective

To evaluate the incidence of acute endophthalmitis after IVTs of corticosteroids or anti-vascular endothelial growth factor (anti-VEGF) agents.

Design, Setting, and Participants

This population-based cohort study included patients undergoing IVTs from January 1, 2012, through December 31, 2015, in France. Data were acquired from the French medical-administrative database (Système National d'Information Inter-Régime de l'Assurance Maladie), which collects hospitalization discharge abstracts and out-of-hospital care information for the whole country. Data were analyzed from March through July 2017.

Exposures

Intravitreal injections of corticosteroid or anti-VEGF agents.

Main Outcomes and Measures

Incidence of acute endophthalmitis within 6 weeks after IVT by means of billing codes from a national database.

Results

During the study period, 1 811 977 IVTs of corticosteroids or anti-VEGF agents performed on 254 927 patients (60.4% female; median age, 79 years [interquartile range, 70-85 years]) were analyzed. A total of 444 acute endophthalmitis cases (crude incidence, 0.0245%) were recorded. In multivariable analysis, which did not include adjustment for when the endophthalmitis occurred during the study period, the risk of endophthalmitis was lower in male patients (incidence rate ratio [IRR], 0.78; 95% CI, 0.63-0.96; P = .02), higher for corticosteroids than for anti-VEGF agents (IRR, 3.21; 95% CI, 2.33-4.44; P < .001), and higher for nonprefilled syringes of anti-VEGF medications than prefilled syringes for ranibizumab (IRR, 1.63; 95% CI, 1.15-2.30) and aflibercept (IRR, 1.82; 95% CI, 1.25-2.66; P < .001).

Conclusions and Relevance

The findings from this study of a nationwide database appear to have confirmed the low incidence rate of acute endophthalmitis after IVTs of corticosteroids or anti-VEGF agents. Although an association may not necessarily indicate a cause and effect, the risk for acute endophthalmitis after IVTs appeared to be higher for corticosteroids compared with anti-VEGF agents, while a lower risk of endophthalmitis appeared to be found with prefilled syringes of anti-VEGF medications.

Research on the comparison of the demethylvancomycin's diffusion-deposition characteristics in the ocular solid tissues of sustained subtenon drug delivery with subconjunctival injection

PURPOSE

To compare the demethylvancomycin's diffusion-deposition characteristics in the ocular solid tissues of sustained subtenon drug delivery with subconjunctival injection.

METHOD

Sixty adult white rabbits were randomly assigned to the subtenon drug delivery group and the subconjunctival injection group. The subtenon drug delivery group was continuously infused demethylvancomycin to the subtenon of rabbits. The subconjunctival injection group was injected demethylvancomycin to the subconjunctival of rabbits. Cornea, iris and sclera were collected for high-performance liquid chromatography analyses to determine drug concentrations at one hour, three hours, six hours, 12 h and 24 h of drug administration. WinNonlin 6.3 was used to calculate the parameters of cumulative area under the curve (AUCcum) of demethylvancomycin.

RESULTS

The peak levels of demethylvancomycin concentration of the subtenon drug delivery group and the subconjunctival injection group were 92.406 ± 21.555 and 51.778 ± 14.001 μg/g in cornea, 28.451 ± 10.229 μg/g and 42.271 ± 27.291 μg/g in iris, 153.166 ± 51.738 μg/g and 57.423 ± 18.480 μg/g in sclera. The differences of concentrations between the two groups in cornea and sclera were statistically significant (F = 487.775, p < 0.001; F = 132.748, p < 0.001). The difference in iris was not statistically significant (F = 4.848, p = 0.064). The maximum of AUCcum of the subtenon drug delivery group and the subconjunctival injection group was 1808.23 h * μg/g and 273.73 h * μg/g in cornea, 489.12 h * μg/g and 216.16 h * μg/g in iris and 2166.34 h * μg/g and 392.57 h * μg/g in sclera at 24 h of drug administration.

CONCLUSION

The sustained subtenon drug delivery had a better drug permeability and accumulation in the intraocular solid tissue compared to subconjunctival injection, which demonstrated it was probably a promising and effective approach for treating posterior segment diseases and endophthalmitis.

Therapeutic effects of a novel siRNA-based anti-VEGF (siVEGF) nanoball for the treatment of choroidal neovascularization

Age-related macular degeneration (AMD) is the leading cause of blindness in developed countries and is characterized by the development of choroidal neovascularization (CNV). Therapies for AMD have focused on suppressing angiogenic factors, such as vascular endothelial growth factor (VEGF), mainly via conventional anti-VEGF antibody agents. However, additional efforts have been made to develop effective small-interfering RNA (siRNA)-based intracellular therapeutic agents. In this study, we have manufactured a novel siRNA-based anti-VEGF nanoball (siVEGF NB). The siVEGF NB was composed of a siRNA hydrogel with a core of anti-VEGF sequence siRNA coated with branched PEI (bPEI) and hyaluronic acid (HA) in order by applying an electrical force. The novel siVEGF NBs, which were employed in a laser-induced CNV mouse model, were optimized as a retinal and choroidal delivery system through the vitreous humor to the sub-retinal space via CD44 receptor endocytosis on the inner limiting membrane, and showed therapeutic effects via pathways bypassing the TLR3-induced siRNA-class effect. The therapeutic effects of siVEGF NBs lasted for 2 weeks after intravitreal injection showing high targeting efficiency to the sub-retinal space. Thus, the newly developed siVEGF NB may have great potential for the delivery of RNAi-based therapeutics for ocular diseases, including AMD.

Incidence and Determinants of Endophthalmitis within 6 Months of Surgeries over a 2-Year Period at King Khaled Eye Specialist Hospital, Saudi Arabia: A Review

BACKGROUND

We present the incidence and determinants of endophthalmitis between July 2010 and June 2012 at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia. On its basis, we recommended recommendations to strengthen the infection prevention and control strategies.

METHODS

This is a retrospective review of health records type of study. The details of cases reported having endophthalmitis among those operated in 2 years of study period were studied. The incidence of endophthalmitis was calculated for different eye surgeries and epidemiological variables. The causative organisms in vitreous tap were reviewed. The visual outcomes 6 weeks following intervention/treatment of endophthalmmitis were also studied.

RESULTS

Of the 22,554 cases operated, 17 developed endophthalmitis. The incidence was 0.08% (95% confidence interval [CI] 0.04-0.11). The incidence of endophthlamitis among cataract surgeries was 0.12% (95% CI 0.04-0.21). Five specimens did not show any bacteria or fungus. Staphylococcus epidermis (3 cases) was the main pathogen identified. In 8 (47%) eyes, vision deteriorated in spite of treatment. In 5 (29%) eyes, it became stable and in 4 (23.5%) eyes, it improved following treatment. Signs of infection were noted in 1(st) week, 3 weeks and 12 weeks in 4, 6 and 5 eyes respectively. Late presentation of infection (6 months postoperatively) was reported in two eyes.

CONCLUSIONS

A vigilant infection control unit in a large eye hospital helps in monitoring endophthalmitis related catastrophes and suggests timely preventive measures to reduce the occurrence and appropriate measures to limit visual disabilities following eye surgery related endophthalmitis.

Endophthalmitis: state of the art

Endophthalmitis is an uncommon diagnosis but can have devastating visual outcomes. Endophthalmitis may be endogenous or exogenous. Exogenous endophthalmitis is caused by introduction of pathogens through mechanisms such as ocular surgery, open-globe trauma, and intravitreal injections. Endogenous endophthalmitis occurs as a result of hematogenous spread of bacteria or fungi into the eye. These categories of endophthalmitis have different risk factors and causative pathogens, and thus require different diagnostic, prevention, and treatment strategies. Novel diagnostic techniques such as real-time polymerase chain reaction (RT-PCR) have been reported to provide improved diagnostic results over traditional culture techniques and may have a more expanded role in the future. While the role of povidone-iodine in prophylaxis of postoperative endophthalmitis is established, there remains controversy with regard to the effectiveness of other measures, including prophylactic antibiotics. The Endophthalmitis Vitrectomy Study (EVS) has provided us with valuable treatment guidelines. However, these guidelines cannot be directly applied to all categories of endophthalmitis, highlighting the need for continued research into attaining improved treatment outcomes.

Prevention and treatment of injection-related endophthalmitis

BACKGROUND

Intravitreal injections are the fastest growing cause of endophthalmitis and can result in severe vision loss. The prevention, diagnosis and management of such infections remain unclear and at times controversial.

METHODS

We searched Pubmed for keywords "prophylaxis," "endophthalmitis," "intravitreal injection." We focused on studies published in the last 2 years as well as other recent studies with particular attention to data on the incidence, microbiology, prevention, and treatment of injection-related endophthalmitis.

RESULTS

Over 20 relevant studies were found. With povidone-iodine preparation, the per-injection endophthalmitis rate is low at about 0.03%. Antibiotics do not appear to be beneficial for prevention of post-injection endophthalmitis. The best timing of vitrectomy is unclear.

CONCLUSIONS

Antibiotic prophylaxis is probably not needed when giving intravitreal injections. More data is needed to help determine the proper treatment for post-injection endophthalmitis.

Changes in the etiology of endophthalmitis from 2003 to 2010 in a large tertiary medical center

PURPOSE

To ascertain the leading causes of endophthalmitis at the Tel Aviv Medical Center between 2003 and 2010.

METHODS

The design of the study is retrospective chart review. The medical records of all patients diagnosed with endophthalmitis in our center between 2003 and 2010 were reviewed for visual acuity and results of ophthalmologic examination at admission, treatment, complications, laboratory investigations, and final visual results. The etiologies of endophthalmitis after cataract surgery were compared for each year from 2003 to 2010, and after intravitreal (IVT) injection from 2006 to 2010.

RESULTS

Eighty patients were diagnosed with endophthalmitis between 2003 and 2010: 46 male and 34 female, average age 70.7 years. A total of 27.5% were treated with IVT antibiotic injection only and 68.8% needed pars plana vitrectomy. Final visual acuity was better than counting fingers in 56.3% of cases. Surgery was almost the sole cause of endophthalmitis until 2005, when IVT injection became an important etiology. The incidence of postcataract endophthalmitis decreased significantly after 2007 and that following IVT injection decreased significantly after 2008.

CONCLUSIONS

The leading etiology of endophthalmitis changed from postoperative endophthalmitis to endophthalmitis after IVT injection from 2003 to 2010, and the incidence of the infection as a complication of those procedures decreased.

Adverse events and complications associated with intravitreal injection of anti-VEGF agents: a review of literature

Intravitreal injection of anti-vascular endothelial growth factor (VEGF) agents is increasingly used for the treatment of a wide variety of retinal diseases, including age-related macular degeneration, diabetic retinopathy and retinal vascular occlusions, and retinopathy of prematurity. Despite encouraging results in halting the disease and improving the vision, intravitreal injection of anti-VEGF agents may be associated with systemic adverse events and devastating ocular complications. In this review, we provide an overview of safety data for intravitreal injection of common anti-VEGF agents.

Acute-Onset Endophthalmitis Caused by Alloiococcus otitidis following a Dexamethasone Intravitreal Implant

PURPOSE

To report the first case of acute endophthalmitis caused by Alloiococcus otitidis after a dexamethasone intravitreal implant.

METHODS

A 74-year-old female was treated with intravitreal Ozurdex(®) in her left eye for central retinal vein occlusion (CRVO). Best-corrected visual acuity (BCVA) in the eye was 4/20. Intravitreal injection was uneventful. At 48 h after injection, she developed ocular pain and visual acuity had dropped to light perception. Endophthalmitis associated with intravitreal injection was suspected.

RESULTS

The patient did not show a favorable clinical response following systemic, intravitreal, and topical fortified antibiotics. We then performed a vitreous biopsy and removed the Ozurdex implant by pars plana vitrectomy. A vitreous culture was positive for A. otitidis. At the 2-month follow up, no inflammation was observed, but due to CRVO and probably aggravated by endophthalmitis, the fundus showed macular fibrosis. The final BCVA was finger counting at 30 cm in her left eye.

CONCLUSIONS

In cases of an intravitreal implant associated with endophthalmitis, we recommend removal of the device because it may act as a permanent reservoir of organisms if it remains in the vitreous cavity.

Therapeutic potential of intravitreal pharmacotherapy in retinal vein occlusion

Retinal vein occlusion (RVO) is the most common visually disabling disease affecting the retina after diabetic retinopathy. Although the disease entity has long been known, its management is still controversial. Macular edema is the main reason for decreased visual acuity (VA) in this retinal vascular disorder. Recently the vitreous cavity has increasingly been used as a reservoir of drugs for the direct treatment of macular edema through intravitreal injection route. The most widely injected drugs so far have been triamcinolone acetonide (TA) and bevacizumab. The objective of this review is to evaluate the evidence and discuss the rationale behind the recent suggestions that intravitreal pharmacotherapy by corticosteroids and anti-vascular endothelial growth factors may be useful in the treatment of retinal vein occlusion.

Post-intravitreal anti-VEGF endophthalmitis in the United Kingdom: incidence, features, risk factors, and outcomes

PURPOSE

To describe the incidence, features, management, and risk factors of post-intravitreal anti-VEGF endophthalmitis (PIAE) in patients undergoing treatment for exudative age-related macular degeneration in the United Kingdom.

METHODS

Prospective observational case control study. Forty-seven cases of PIAE were identified through the British Ophthalmological Surveillance Unit from January 2009 to March 2010. Data collected at diagnosis and at 6 months follow-up included patient demographics, intravitreal injection details, pre- and post-injection management, visual acuity, clinical features and management of PIAE, causative organisms, and clinical outcomes. Details were compared with 200 control cases from 10 control centres to identify potential risk factors.

RESULTS

Estimated PIAE was 0.025%. Culture-positive PIAE incidence was 0.015%. Mean age of presentation was 78 years. Mean number of intravitreal injections before PIAE was 5. Mean days to presentation was 5 (range 1-39). Positive microbiology culture was found in 59.6%. The majority of causative organisms were Gram positive (92.8%). Significant risk factors were failure to administer topical antibiotics immediately after the injection (P=0.001), blepharitis (P=0.006), subconjunctival anaesthesia (P=0.021), patient squeezing during the injection (P=0.021), and failure to administer topical antibiotics before anti-VEGF injection (P=0.05).

DISCUSSION

The incidence of PIAE in the United Kingdom is comparable to other studies at a rate of 0.025%. The most common causative organisms were Gram positive. Measures to minimise the risk of PIAE include treatment of blepharitis before injection, avoidance of subconjunctival anaesthesia, topical antibiotic administration immediately after injection with consideration to administering topical antibiotics before injection.

Topical azithromycin or ofloxacin for endophthalmitis prophylaxis after intravitreal injection

BACKGROUND

The number of patients who have undergone intravitreal injections has increased enormously in recent years, but a consensus is still lacking on prophylaxis for endophthalmitis. The aim of this prospective, observational study was to evaluate the prophylactic effect of azithromycin eye drops versus ofloxacin eye drops.

METHODS

The study was conducted in five hospitals in Spain and included all patients undergoing intravitreal injections of triamcinolone, bevacizumab, ranibizumab, or pegaptanib over one year. Patients received azithromycin 15 mg/g eye drops (twice daily on the day prior to injection and for another 2 days) or ofloxacin 3 mg/g eye drops (every 6 hours on the day prior to injection and for another 7 days).

RESULTS

In the azithromycin group, there were 4045 injections in 972 eyes of 701 patients. In the ofloxacin group, there were 4151 injections in 944 eyes of 682 patients. There were two cases of endophthalmitis (0.049%) in the azithromycin group and five (0.12%) in the ofloxacin group. The odds ratio of presenting with endophthalmitis in the ofloxacin group compared with the azithromycin group was 2.37 (95% confidence interval [CI] 1.32-3.72, P < 0.001). There were two cases of noninfectious uveitis after triamcinolone injection in the azithromycin group (0.049%) and two (0.048%) in the ofloxacin group; no significant differences were observed (odds ratio 0.902, 95% CI 0.622-1.407, P = 0.407). Conjunctival hyperemia was observed in 12 cases in the azithromycin group and none in the ofloxacin group.

CONCLUSION

The risk of endophthalmitis was significantly greater with ofloxacin than with azithromycin. These findings provide a valuable addition to the ever-increasing pool of information on endophthalmitis prophylaxis after intravitreal injection, although further large-scale studies are required to provide definitive conclusions.

Evaluation of verteporfin pharmakokinetics--redefining the need of photosensitizers in ophthalmology

INTRODUCTION

The benzoporphyrine derivative verteporfin has lost its importance to the treatment of the most frequent neovascular eye diseases. Nevertheless, it is still mandatory to define the remaining applications, role, and potential of verteporfin in ocular photodynamic therapy (PDT), including the dosages of administration, effectiveness, and safety profile.

AREAS COVERED

Although verteporfin PDT has forfeited the first-line status and value of treating subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration or pathologic myopia, the treatment remains the standard of care for choroidal haemangioma and polypoidal choroidal vasculopathy. PDT is effective in less pigmented choroidal melanoma as well as in retinal vascular proliferations and retinal angioma. Verteporfin was granted the orphan drug designation for the treatment of chronic or recurrent central serous chorioretinopathy (CSC).

EXPERT OPINION

Evidence-based data regarding optimized parameters (low fluence, reduced dose, fractionated irradiation) adapted to the treated diseases (target structure, dosimetry, blood supply) are scarce. Prospective and large clinical trials are missing, although the scientific community agrees on the fact that the standard treatment protocol does not necessarily provide the optimal efficacy to the specific disease or individual patient. Within the reviewed indications, the adverse effect profile is favorable compared with other therapies.

Endophthalmitis: A review of recent trends

Endophthalmitis is a feared complication of trauma, surgical procedures and septicemia. Although uncommon, its potential for significant visual loss is well recognized. Especially over the past decade, complicated surgeries and medical techniques have increased and seriously ill patients are being sustained in ever increasing numbers. New pathogens are being recognized and known ones reclassified thanks to advances in molecular analysis. Continuously evolving PCR methodologies also add a new dimension to the diagnosis of infectious endophthalmitis. As well, medical literature is now truly international, encompassing studies from around the world that expand our understanding of ocular infectious disease. This report reviews some of these changes as they relate to endophthalmitis and particularly to the spectrum of organisms involved.

The movement of self-assembled amphiphilic polymeric nanoparticles in the vitreous and retina after intravitreal injection

The purpose of this study is to determine the correlation between the distribution of nanoparticles in the vitreous and retina and their surface properties after intravitreal injection. For this purpose, we synthesized seven kinds of nanoparticles through self-assembly of amphiphilic polymer conjugates in aqueous condition. They showed similar size but different surface properties. They were labeled with fluorescent dyes for efficient tracking. After intravitreal injection of these nanoparticles into a rodent eye, their time-dependent distribution in the vitreous and retina was determined in stacking tissue images by confocal microscopy. The results demonstrated that the surface property of nanoparticles is a key factor in determining their distribution in the vitreous and retina after intravitreal injection. In addition, immunohistochemistry and TEM images of retina tissues suggested the important mechanism related with Mülller cells for intravitreally administered nanoparticles to overcome the physical barrier of inner limiting membrane and to penetrate into the deeper retinal structures. Therefore, we expect that this study can provide valuable information for biomedical researchers to develop optimized nanoparticles as drug or gene carriers for retinal and optic nerve disorders such as glaucoma, age-related macular degeneration, and diabetic retinopathy.