Acute bacterial endophthalmitis following intravitreal dexamethasone implant: A case report and review of literature

ACUTE ATYPICAL ENDOPHTHALMITIS FOLLOWING INTRAVITREAL SUSTAINED-RELEASE DEXAMETHASONE IMPLANT: A CASE SERIES

PURPOSE

To present three cases of acute endophthalmitis following intravitreal sustained-release dexamethasone (Ozurdex) with atypical presentation and to discuss the management of these patients.

METHODS

A retrospective case series of three patients with endophthalmitis following intravitreal sustained-release dexamethasone (Ozurdex) implantation who presented between July 2020 and August 2020.

RESULTS

Two of three patients who were treated with topical steroid and antibiotic therapy alone showed favorable outcomes and were managed without the need for intravitreal antibiotics or implant removal. One patient who showed initial response to topical therapy subsequently required pars plana vitrectomy, implant removal, and a single empirical dose of intravitreal antibiotics and antifungal agent due to persistent inflammation.

CONCLUSION

Postintravitreal Ozurdex endophthalmitis, although a rare entity, can present with atypical features of a painless white eye and a delayed onset intraocular inflammation. Although all cases of endophthalmitis should be treated as infective until proven otherwise, it is fair to consider a trial of conservative treatment with topical steroids and antibiotics initially with close monitoring. In cases with poor response to topical therapy, pars planar vitrectomy and implant removal should be strongly considered.

Incidence and Visual Outcomes of Endophthalmitis After Intravitreal Injection of Dexamethasone Implant vs Ranibizumab

Purpose

To compare the incidence and visual outcomes of endophthalmitis after injection of an intravitreal dexamethasone implant and injection of intravitreal ranibizumab.

Methods

This retrospective cohort study assessed endophthalmitis in eyes receiving an intravitreal injection of a 0.7 mg dexamethasone implant (DEX group), 0.5 mg ranibizumab (R5 group), or 0.3 mg ranibizumab (R3 group) between January 1, 2016, and May 31, 2018, at 2 large retina practices in the United States.

Results

Suspected endophthalmitis occurred in 5 eyes after 4973 DEX injections, 43 eyes after 163 974 R5 injections, and 6 eyes after 18 954 R3 injections. Suspected endophthalmitis was significantly more common in the DEX group (1/995) than in the R5 group (1/3813) (P = .008) but not than in the R3 group (1/3159) (P = .10). Visual acuity outcomes were similar in the 3 groups.

Conclusions

Suspected endophthalmitis might be more common after 0.7 mg dexamethasone injections than after 0.5 mg ranibizumab injections. Culture-positive endophthalmitis rates were similar across all 3 medications.

CASE REPORT OF ABIOTROPHIA DEFECTIVA ENDOPHTHALMITIS AFTER REPEATED INJECTIONS OF DEXAMETHASONE INTRAVITREAL IMPLANT (OZURDEX)

PURPOSE

To present a case of endophthalmitis caused by Abiotrophia defectiva after repeated injections of dexamethasone intravitreal implant (Ozurdex), in a patient already on systemic immunosuppressive therapy, and discuss the management of this challenging situation.

METHODS

Case report and review of literature.

RESULTS

A 70-year-old female patient with history of idiopathic pulmonary fibrosis presented for urgent evaluation due to left eye vision loss and mild discomfort 12 days after receiving her seventh dexamethasone implant injection. Ocular history was pertinent for recurrent macular edema resulting from a remote branch vein occlusion. Twelve days after her last injection, visual acuity decreased from 20/30 to counting fingers at 5 feet. Slit-lamp examination showed anterior chamber cell without fibrinoid membranes or hypopyon. Within hours, the patient's clinical appearance progressed. A vitreous tap followed by intravitreal injection of vancomycin (1 mg/0.1 mL) and ceftazidime (2.25 mg/0.1 mL) was performed. The culture from the vitreous sample revealed heavy growth of A. defectiva. Owing to limited improvement, patient was taken to the operating room, and the presence of a full-thickness scleral defect at the site of most recent dexamethasone implant injection was confirmed. Vitrectomy with removal of implant, closure of all sclerotomies, including nonhealing full-thickness scleral defect, and repeated intravitreal antibiotic injection were performed. At the 3-month follow-up, no inflammation was observed, but visual acuity remained poor.

CONCLUSION

Intravitreal dexamethasone implant-associated endophthalmitis in the setting of systemic immunosuppression is a rare and challenging situation. Both local and systemic immunosuppression may delay wound healing, predisposing to wound leakage and consequent endophthalmitis. Despite repeated intravitreal antimicrobial injection and vitrectomy with implant removal, A. defectiva endophthalmitis carried a poor visual outcome.

Visual outcomes of post-cataract endophthalmitis caused by Mycobacterium fortuitum

Background: Endophthalmitis caused by Mycobacterium fortuitum as a complication of cataract surgery is rare in China and globally. This study aimed to report the clinical features, surgical treatment strategies, antibiotic susceptibilities and treatment outcomes in patients with endophthalmitis caused by Mycobacterium fortuitum.

Patients and methods: A case series of 15 patients (15 eyes) with post-cataract endophthalmitis caused by Mycobacterium fortuitum treated at the Ophthalmology Clinic of Shengjing Hospital between June 2008 and June 2017 was reviewed retrospectively. Information about Mycobacterium fortuitum culture results, clinical features, surgical procedures, and final visual acuity were obtained.

Results: The vitreous samples were all positive. These eyes underwent total capsulectomy and intraocular lens explantation and vitrectomy combined with intravitreal and intravenous injections of antibiotics. Finally, 14 eyes had controlled inflammation and retained eyeballs. One eye had panophthalmitis and enucleation of the eyeball. Presenting visual acuity ranged from counting fingers to no light perception. Final visual acuity was better than 20/400 in 4 of 15 eyes (26.67%), 20/400 to hand motions in 7 of 15 eyes (46.67%), and light perception to no light perception in 4 of 15 eyes (26.67%) at 6-month follow-up visit.

Conclusion:Mycobacterium fortuitum might be an etiologic agent in postoperative endophthalmitis. The Mycobacterium fortuitum endophthalmitis might be treated with early vitrectomy and targeted antibiotic therapy approach.