THE EFFECT OF ENDOPHTHALMITIS ON RECURRENCE OF MACULAR EDEMA IN EYES RECEIVING INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR

Disease quiescence in endophthalmitis patients treated with anti-VEGF injections for retinal pathologies

BACKGROUND

The most feared complication of intravitreal injections is the development of endophthalmitis, which could lead to irreversible visual loss. The aim of this study was to characterize the clinical profiles, causative pathogens, and clinical outcome of patients post-endophthalmitis.

METHODS

Retrospective, single center case series study. Clinical records, causative pathogens and management of all cases of endophthalmitis post intravitreal anti-vascular endothelial growth factor (VEGF) injections recorded between January 1st, 2006 and May 30th, 2022; were retrieved. The visual and anatomic changes prior to the episode of endophthalmitis and up to 2 years post-treatment were compared.

RESULTS

Eleven post-injection endophthalmitis eyes of 10 patients (n = 3 females; 30%) were recruited at mean age of 64.5 ± 20.4 years. The median last recorded BCVA, up to 3 months prior to the episode of endophthalmitis was 60 (Interquartile range (IQR) 55-75) ETDRS letters. Then, it dropped to 30 (IQR 0-57.5), 35 (IQR 0-52.5) and 35 (IQR 0-57.5) ETDRS letters at presentation, 6- and 12-months follow-up; respectively (p = 0.027, p = 0.017 and p = 0.012). However, at 24 months, the median BCVA returned to similar baseline values prior to the episode of endophthalmitis; BCVA 50 (IQR 0-60) ETDRS letters, p = 0.062. Interestingly, two eyes with neovascular age-related macular degeneration (NVAMD), 1 with myopic choroidal neovascularization (CNV) and 1 with retinal vein occlusion (RVO), experienced disease quiescence and did not require additional anti-VEGF injections up to 2 years of follow-up.

CONCLUSION

This study demonstrates long-term recovery of vision loss due to endophthalmitis post anti-VEGF injections, regained up to 2 years later. It also indicates that disease quiescence post endophthalmitis may not only occur in eyes treated for NVAMD, but also with myopic CNV and RVO.

Rapid treatment of endophthalmitis with intravitreal antibiotics is associated with better vision outcomes

BACKGROUND

To discover whether the timing of intravitreal antibiotics, from the time of presentation to injection, affects the visual outcomes of patients with endophthalmitis from all causes.

METHODS

A retrospective study of consecutive patients managed at Auckland District Health Board between 1 January 2004 and 1 July 2021. The main outcome measure was final visual acuity at follow-up and the proportion of subjects with severe vision loss (≤6/60).

RESULTS

Three hundred and seventy-four eyes were included in the study, with a median age of 69.7 years at presentation; 192 subjects (51.6%) were female. The median presenting visual acuity was hand movements and hypopyon was present in 194 subjects (51.9%). Cataract surgery was the most frequent aetiology in 115 subjects (30.7%), followed by intravitreal anti-vascular endothelial growth factor injections in 89 subjects (23.8%) and endogenous endophthalmitis in 54 subjects (14.4%). Median time to injection of intravitreal antibiotics was 3.5 h (Interquartile range 2-6). On multivariate analysis, early treatment with intravitreal antibiotics was associated with better visual outcome, particularly for those treated within 2 h, while poor presenting visual acuity and culture-positive endophthalmitis were associated with worse outcomes.

CONCLUSION

Rapid intravitreal antibiotic administration is associated with better final visual acuity outcomes, particularly for those receiving treatment within 2 h of presentation. Patients with severe vision loss on presentation, benefit the most with improved final visual acuity following expedited treatment.

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.

Urgent Vitrectomy with Vancomycin Infusion, Silicone Oil Endotamponade, and General Antibiotic Treatment in Multiple Cases of Endophthalmitis from a Single Day of Intravitreal Injections-Case Series

The aim of this study was to report on the anatomical and functional results of surgical management of seven cases of endophthalmitis related to a single day of intravitreal aflibercept injections. Patients with signs of endophthalmitis who underwent aflibercept injections (seven eyes) performed on the same day were retrospectively evaluated. The data of visual acuity and optical coherence tomography (OCT) within nine months of the follow-up and the treatment and results of microbiological cultures are reported. Four of the total seven cases had a positive bacterial culture outcome (Streptococcus mitis). All patients underwent vitrectomy combined with phacoemulsification when the eyes were not pseudophakic, vancomycin infusion, and silicone oil tamponade within 24 h; additionally, systemic antibiotics were administered intravenously. The final best-corrected visual acuity (BCVA) after the treatment was finger counting or light perception in all cases, and all eyes were saved with disruption of the inner retinal layers and stabilization of the retina in regard to changes related to the wet age-related macular degeneration (AMD). Although the retinal anatomy was mostly preserved, most of the patients affected by Streptococcus mitis-induced endophthalmitis did not regain baseline vision after the therapy.