Endophthalmitis after intravitreal injection: the importance of viridans streptococci

POSTINTRAVITREAL INJECTION AND POSTCATARACT EXTRACTION ENDOPHTHALMITIS VISUAL OUTCOMES BY ORGANISM: A SYSTEMATIC REVIEW AND META-ANALYSIS

PURPOSE

To compare visual outcomes of endophthalmitis following intravitreal injections (IVIs) and cataract extraction by causative organism.

METHODS

Searches in Cochrane Central Register of Controlled Trials, MEDLINE, and Embase identified articles reporting visual outcomes by causative organisms in post-IVI and cataract extraction endophthalmitis cases from January 2010 to February 2022. A random-effects meta-analysis compared visual improvement among endophthalmitis cases caused by causative organisms.

RESULTS

Eighty-five out of 3,317 retrieved studies were included. The highest degree of visual acuity improvement in both post-IVI and postcataract extraction endophthalmitis was seen in cases caused by coagulase-negative staphylococci, followed by gram-negative organisms and other gram-positive organisms such as streptococci and enterococci. Culture-negative cases showed more visual acuity improvement than culture-positive cases in post-IVI endophthalmitis. These results remained consistent when accounting for endophthalmitis treatment, IVI type, condition requiring IVI treatment, follow-up period, and initial preprocedural visual acuity.

CONCLUSION

Coagulase-negative staphylococci and gram-negative organisms show the most visual acuity improvement in both post-IVI and postcataract extraction endophthalmitis. Other gram-positive organisms such as streptococci and enterococci are associated with less visual improvement. This updated systematic review and meta-analysis revealed that the results of the Endophthalmitis Vitrectomy Study are consistent decades later despite advancements in surgical practices and the evolution of microorganisms over time.

Presenting Characteristics, Treatment, and Visual Outcomes in Streptococcal Compared to Non-Streptococcal Endophthalmitis

PURPOSE

Report the clinical findings, risk factors, treatment, and visual outcomes associated with Streptococcus endophthalmitis in comparison to culture-positive endophthalmitis associated with non-Streptococcus species.

METHODS

A retrospective chart review of adults between 18 and 89 years of age diagnosed with exogenous culture-positive endophthalmitis between January 1, 2009, and January 1, 2018, at the Duke Eye Center (Durham, North Carolina) with at least six months of follow-up from time of initial diagnosis was conducted. Clinical data including patient demographics, ocular history, baseline corrected visual acuity (VA) prior to presentation, time to presentation, presenting exam findings, VA at presentation, presumed etiology of endophthalmitis, medical and surgical management, and VA at the six-month follow-up was extracted and statistically analyzed.

RESULTS

Fifty-six eyes from 56 patients with culture-positive endophthalmitis were identified. Eyes with Streptococcus (n=18) had elevated intraocular pressure (IOP) at presentation (p=0.002), worse mean VA (Snellen) at presentation (20/14159 vs. 20/3098, p<0.001), and worse mean VA (Snellen) at six months (20/3475 vs. 20/235, p<0.001) compared to non-Streptococcus cases (n=38). Time to presentation (days) (median, IQR) was longer in eyes that underwent glaucoma surgery for both Streptococcus (2241 (836, 3709) vs. 3 (2, 31), p=0.003) and non-Streptococcus endophthalmitis (1236 (125, 3582) vs. 6 (4, 25), p<0.0001). There was no difference in VA at six months between Streptococcus and non-Streptococcus eyes based on treatment.  Conclusions: Streptococci are rare but important causes of exogenous endophthalmitis, and in our study, they were associated with worse visual outcomes than non-Streptococci. A history of any glaucoma surgery, even procedures performed years earlier, should be elicited when evaluating patients with ocular symptoms.

PATIENT-PHYSICIAN FACE MASKING'S INFLUENCE ON THE POST-INTRAVITREAL INJECTION ENDOPHTHALMITIS

PURPOSE

The authors sought to determine if universal face mask guidelines implemented during the coronavirus disease 2019 pandemic significantly influenced the incidence of endophthalmitis following intravitreal injections (IVI).

METHODS

This retrospective cohort study reviewed the electronic health records from a retina-only practice located in Michigan. This study evaluated patients receiving IVIs over two distinct time periods of April 2019 to March 2020 and April 2020 to March 2021, which comprised our unmasked and masked groups, respectively. The authors then calculated the incidence of endophthalmitis following IVI and evaluated the cases of post-injection endophthalmitis for both time periods.

RESULTS

A total of 121,384 IVIs performed over the 2-year period of interest. Of these, 63,114 were unmasked and 58,270 were masked patient encounters. A total of 46 post-injection endophthalmitis cases were identified. Of these, 29 cases were from the unmasked period and 17 were from the masked period. This resulted in an incidence of endophthalmitis of 0.046% and 0.038% in the masked and unmasked groups, respectively. This difference did not rise to the level of statistical significance ( P = 0.1336).

CONCLUSION

This study suggests that the incidence of post-injection endophthalmitis was not influenced by the implementation of ophthalmologist-patient face masking after IVI during the coronavirus disease 2019 pandemic.

Evaluating the efficacy of pars plana vitrectomy in the management of endophthalmitis after following the endophthalmitis vitrectomy study: A systematic review and meta-analysis

Endophthalmitis is a devastating eye complication that requires prompt and effective treatment. A pivotal study in the field of endophthalmitis treatment is the endophthalmitis vitrectomy study (EVS), conducted over a decade ago. The primary objective of this study was to assess the effectiveness of pars plana vitrectomy (PPV) as a treatment option for endophthalmitis following the EVS study. We conducted a comprehensive search across three databases: PubMed, EBSCO host, and ProQuest. Reference lists of published articles were searched. Our study encompassed research conducted between January 2013 and January 2023 to ensure the most up-to-date findings. The best-corrected visual acuity (BCVA) in logMar, causative agents, and predicting factors for visual outcome were evaluated. Nine studies involving 351 eyes were included in the study; however, only eight were included in the meta-analysis. We observed a significant BCVA improvement compared to baseline at 1 month, >1-3 months, >3-6 months, and ≥12-month follow-up, with mean differences of 1.06 (P < 0.001), 1.25 (P < 0.001), 1.41 (P < 0.001), and 1.01 (P < 0.001), respectively. A causative organism was cultured in 61.4% of cases, and the majority of them were Coagulase-negative Streptococcus, Staphylococcus aureus, and Streptococcus sp. Factor associated with better visual acuity includes a younger age, lower intraocular pressure, and culture-negative endophthalmitis. Meanwhile, culture-positive endophthalmitis particularly Streptococcus sp., lower baseline vision, and presence of retinal detachment at initial presentation were identified as a prognostic for poorer visual outcome. PPV demonstrated a significant visual gain in patients with endophthalmitis in the 1st, 3rd, and 6th months. However, caution is warranted in drawing a definitive conclusion.

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.

Pars plana vitrectomy versus intravitreal antibiotics for endophthalmitis management following intravitreal anti-VEGF agents: A meta-analysis

In this meta-analysis, we aim to compare the efficacy and safety of pars plana vitrectomy (PPV) versus tap-and-inject (TAI) of intravitreal antibiotics for the management of endophthalmitis secondary to intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents. A systematic literature search was conducted on Ovid MEDLINE, EMBASE, and Cochrane Central (January 2005-October 2022). The primary analysis compared initial PPV versus TAI and the secondary analysis examined the efficacy and safety of TAI alone compared to TAI followed by PPV. The quality of non-randomized observational studies was assessed using the Newcastle-Ottawa Scale. The quality of the evidence was assessed for each outcome. A random effects meta-analysis was performed. Weighted mean differences (WMDs) with 95% confidence intervals were reported. Of the 7474 screened studies, nine studies reporting on 153 eyes were included. The change in mean best corrected visual acuity (BCVA) between endophthalmitis presentation and last follow-up did not significantly differ between the initial TAI versus PPV groups (WMD = 0.05 units; 95% CI -0.12 to 0.22; p = 0.59; heterogeneity p = 0.41). The difference in pre- to post-treatment mean BCVA did not significantly differ between eyes that received TAI alone or TAI followed by PPV (WMD = 0.04 units; 95% CI -0.42 to 0.51; p = 0.85; heterogeneity p = 0.74). While the meta-analysis revealed no significant difference in the change in BCVA between PPV and TAI to treat endophthalmitis secondary to anti-VEGF agents, the quality of evidence was low with potential for confounding and selection bias. Further well-designed studies in this setting are needed.

Postintravitreal Injection Endophthalmitis: Incidence, Characteristics, Management, and Outcome

Purpose

Postintravitreal injection (IVI) endophthalmitis is a rare but devastating complication. Herein, we report the incidence ,and clinical and microbiological characteristics, as well as the visual outcome, in IVIs endophthalmitis in two medical centers.

Methods

All patients undergoing intravitreal injections between 1/2018 and 12/2019 in two large medical centers were analyzed for post-IVI endophthalmitis.

Results

Of the total of 51,356 IVIs performed, 23 cases of post-IVI endophthalmitis were diagnosed, yielding an overall incidence of 0.045%. The median interval from IVI to symptoms onset was 2 days (IQR: 1-5). Cultures were positive in 56% of the cases (100% Gram-positive bacteria and 76% coagulase-negative staphylococcus). Parameters associated with higher culture-positive rates included samples taken during vitrectomy, WBC on vitreous smear, the number of IVIs in the 12 months prior to presentation, and the time interval from last IVI to diagnostic sampling. At 6- and 12-month follow-up, the median change in VA (logMAR) was -1.10 (IQR: (-1.32)-(-0.40)) and -1.02 (IQR: (-1.10)-(-0.30)), respectively. Younger age and better BCVA at presentation were associated with better VA outcome, while positive culture result and systemic steroids treatment were each associated with the worse visual outcome. We found no difference in visual outcomes between PPV and TAI as a primary procedure.

Conclusion

Post-IVI endophthalmitis is a rare complication, and most patients do not regain their initial VA. Certain parameters (clinical, microbiological, and therapeutic) may help anticipate the outcome and guide decision making regarding diagnosis and treatment.

Endophthalmitis following cataract surgery: visual outcomes, microbial spectrum and complications

PURPOSE OF REVIEW

The aim of this study was to update visual outcomes, microbial spectrum and complications in eyes with endophthalmitis following cataract surgery.

RECENT FINDINGS

A single-institution, retrospective review of eyes treated for endophthalmitis following cataract surgery between 2 January 2014 and 10 January 2017. This study included 112 cases of endophthalmitis following cataract surgery, 58 of which were culture-positive (51.8%). The most isolated organisms were coagulase-negative Staphylococci (56.9%). Oral flora were present in 17.2% of cases. At 6 months, 71.7% of patients achieved visual acuity of at least 20/200 and 51.7% achieved at least 20/40 or better. Visual acuity was better in culture-negative vs. culture-positive cases (∼20/290 vs. ∼20/80, P   =  0.03), and in nonoral flora-associated vs. oral flora-associated culture-positive cases (∼CF vs. ∼20/150, P   <  0.01).

SUMMARY

Following postcataract surgery endophthalmitis, approximately 70% of eyes achieved vision of 20/200 or better and half achieved vision of 20/40 or better 6 months after treatment. Poor visual outcomes were seen in eyes with positive bacterial cultures and with oral flora.

Ocular streptococcal infections: A clinical and microbiological review

Streptococcus is a diverse bacterial genus that is part of the ocular surface microbiome implicated in conjunctivitis, keratitis, endophthalmitis, dacryocystitis, and orbital cellulitis which can lead to decreased visual acuity and require surgical intervention. The pathophysiology of S. pneumoniae is well established and the role of the polysaccharide capsule, pneumolysin, neuraminidases, and zinc metalloproteinases in ocular infections described. Additionally, key virulence factors of the viridans group streptococci such as cytolysins and proteases have been outlined, but there is a paucity of research on the remaining streptococcus species. These virulence factors tend to result in aggressive disease. Clinically, S. pneumoniae is implicated in 2.7-41.2% of bacterial conjunctivitis cases, more predominant in the pediatric population, and is implicated in 1.8-10.7% of bacterial keratitis isolates. Streptococcus bacteria are significantly implicated in acute postoperative, post-intravitreal, and bleb-associated endophthalmitis, responsible for 10.3-37.5, 29.4, and 57.1% of cases, respectively. Group A and B streptococcus endogenous endophthalmitis is rare, but has a very poor prognosis. Inappropriate prescription of antibiotics in cases of non-bacterial aetiology has contributed to increasing resistance, and a clinical index is needed to more accurately monitor this. Furthermore, there is an increasing need for prospective, surveillance studies of antimicrobial resistance in ocular pathogens, as well as point-of-care testing using molecular techniques.

Endophthalmitis: Microbiology and Organism Identification Using Current and Emerging Techniques

Endophthalmitis is an ophthalmological emergency requiring timely and appropriate diagnosis and treatment. Microbiological methods of microscopy (Gram's staining) and culture are the current gold standard for organism identification. However, a significant proportion of endophthalmitis remains culture-negative-perhaps the inflammation is non-infectious in origin, results from a novel organism are unidentifiable or because the causative organism is non-culturable often due to pre-treatment with antibiotics. This review outlines the microbiological profile of endophthalmitis, current clinically used methods for organism identification, and the newer molecular techniques of polymerase chain reaction (PCR) and next-generation sequencing (NGS) technology as diagnostic tools for endophthalmitis. They offer the potential to improve organism identification rates and clinical outcomes in infectious diseases, representing an exciting future direction for organism identification in endophthalmitis. Based on the largest ophthalmic hospital in Australia, we highlight the key practical challenges faced by Australian diagnostic laboratories for their use in a clinical setting.

ENDOPHTHALMITIS PRESENTING AS RETINAL VASCULITIS LESS THAN 24 HOURS AFTER AFLIBERCEPT INJECTION: A CASE REPORT

PURPOSE

We describe a case of endophthalmitis caused by Streptococcus salivarius presenting as a retinal vasculitis less than 24 hours after intravitreal injection.

METHODS

A case report.

RESULTS

The patient progressed from a hemorrhagic retinal vasculitis to severe endophthalmitis with no view to the posterior segment within 24 hours. The visual acuity progressed from 20 of 20 preinjection to light perception within less than 48 after injection. Vitreous tap and injection was performed within 24 hours of intravitreal aflibercept injection, followed by pars plana vitrectomy the next day. The final visual acuity was hand motions.

CONCLUSION

Streptococcus salivarius is a virulent organism that may cause an endophthalmitis early after intravitreal injection with an unusual presentation of hemorrhagic retinal vasculitis. A high index of suspicion for infectious endophthalmitis should be maintained for all patients presenting with ocular inflammation and worsening vision in the days after intravitreal injections.

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

Although infectious endophthalmitis after intravitreal antivascular endothelial growth factor injections is rare, it is the most feared and potentially devastating complication of this procedure. There is no high-level evidence to provide definitive guidance on the management of endophthalmitis occurring after intravitreal injection (IVI). This clinical practice update reviews the published literature regarding post-IVI endophthalmitis and highlights areas in which further research is needed to better guide its management.

Incidence and visual outcomes of acute endophthalmitis post intravitreal injection of anti-vascular endothelial growth factors in a single referral center

BACKGROUND

To describe the incidence and factors predicting visual outcome in patients with infectious endophthalmitis following intravitreal anti-VEGF injection.

METHODS

Retrospective, single-site, cohort study. Patients with acute endophthalmitis within 6 weeks of intravitreal anti-VEGF injection who were referred to our practice after inciting injection or were injected by us between January 2010 and July 2017 were included. All patients received intravitreal antibiotics with either vitreous/anterior chamber tap (TAP) or pars plana vitrectomy. Visual outcomes pre/post treatment, baseline variables (age, gender, ocular disease) and cultures results were studied.

RESULTS

Seventy eyes of 69 patients were included. Presenting VA was the strongest factor associated with final visual outcome after adjusting for other variables including culture status and baseline VA (p = .0002). Cultures were positive in 62.8% of eyes and were associated with worse visual outcome (p = .0087). Growth of Streptococcus or microorganisms other than coagulase negative Staphylococci (CNS) was also associated with worse prognosis, regardless of baseline and presenting VA (p = .0002). The crude incidence of post-injection endophthalmitis was 0.028% in our practice (40 eyes in 143,628 injections) during the study time. No significant difference was found between pre-filled bevacizumab versus ranibizumab or aflibercept drawn from a vial.

CONCLUSIONS

In a large, single center, retrospective study, the incidence of acute endophthalmitis post anti-VEGF injection was relatively low. Worse visual acuity at presentation of endophthalmitis and growth of Streptococcus or organisms other than CNS were associated with the worst visual outcomes.

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.

Seasonal and environmental variations in endophthalmitis after intravitreal anti-vascular endothelial growth factor injection: a six-year review

PURPOSE/AIM

To evaluate seasonal and environmental variations on the incidence and outcomes of post-injection endophthalmitis.

MATERIALS AND METHODS

A single-center, retrospective cohort study was conducted including all patients diagnosed with post-injection endophthalmitis between 2013-2018. Associations between climate variables and endophthalmitis incidence were evaluated.

RESULTS

Of 423,297 injections administered, seasonal distribution in spring, summer, autumn, and winter was 26%, 27%, 25%, and 22%, respectively. Of 171 cases of endophthalmitis identified, seasonal distribution over the spring, summer, autumn, and fall was 25%, 23%, 26%, and 26%, respectively. Endophthalmitis incidence was not correlated with monthly precipitation (p = 0.45), monthly snowfall (p = 0.49), or monthly temperature (p = 0.65). Worse visual outcomes at initial endophthalmitis presentation were correlated with increased precipitation level (p = 0.025), but were not correlated with snowfall level (p = 0.228) or mean monthly temperature (p = 0.132). Although there were no seasonal variations of visual acuity at endophthalmitis presentation (p = 0.894), odds of final visual acuity returning to within two lines of pre-endophthalmitis visual acuity were worse among patients with endophthalmitis diagnosed in the spring (OR, 0.041; p = 0.016).

CONCLUSION

In contrast to previous work on post-cataract endophthalmitis, seasonal and weather factors were not associated with post-injection endophthalmitis risk or bacterial species isolated. Visual outcomes at initial endophthalmitis presentation were correlated with precipitation, and worse visual outcomes were seen in patients who developed endophthalmitis in the spring.

Potential impact of oral flora dispersal on patients wearing face masks when undergoing ophthalmologic procedures

Objective

The purpose of this study is to investigate the amount of oral flora dispersion towards the ocular surface in relation to various face mask scenarios.

Methods and analysis

Thirty participants were recruited for this prospective cross-sectional study. Each participant was seated and instructed to hold a blood agar plate perpendicular to the bridge of their nose and facing downward. Participants then partook in three unique face mask scenarios: no face mask, surgical face mask and surgical face mask with tape securing the superior edge. During each scenario, participants were instructed to forcefully exhale for 5 s three times. The primary outcome measure was the number of colony-forming units (CFUs) grown on each face mask scenario-specific plate.

Results

Thirty participants were recruited for the study, and a total of 90 chocolate agar plates were successfully incubated. The proportion of detecting any CFU was 6.67% (95% CI: 0.818% to 22.1%) for no mask scenario, 0% (95% CI: 0% to 11.6%) for mask scenario and 3.33% (95% CI: 0.0844% to 17.2%) for mask-taped scenario. The mean differences in proportion of detecting any CFU were 3.33% (95% CI: 0% to 10%, p=0.309) for no mask versus mask taped, 3.35% (95% CI: 0% to 10%, p=0.307) for mask taped versus mask and 6.68% (95% CI: 0% to 16.7%, p=0.142) for no mask versus mask.

Conclusion

This study showed no difference in bacterial dispersion towards the ocular surface when comparing no face mask, a surgical face mask without tape or a surgical face mask with tape.

Safety of Receiving Anti-Vascular Endothelial Growth Factor Intravitreal Injection in Office-Based vs Operating Room Settings: A Meta-analysis

Importance

Compared with the operating room (OR), office-based intravitreal injection (IVI) is considered a more cost-effective and convenient approach, yet clinical outcomes of IVIs with anti-vascular endothelial growth factor (VEGF) agents in different settings (office-based vs OR) have not been systematically evaluated.

Objective

To evaluate the safety outcomes of IVI with anti-VEGF agents in the OR vs office-based setting.

Data Sources

PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov were searched from inception to July 2020.

Study Selection

Eligible studies reporting on patients who received IVIs with anti-VEGF drugs with a clearly stated injection setting of the office or OR.

Data Extraction and Synthesis

Two reviewers independently screened studies, extracted data, and assessed risk of bias. A meta-analysis was conducted to determine the rates of endophthalmitis (EO) and culture-positive EO.

Main Outcomes and Measures

Rates of EO and culture-positive EO following anti-VEGF IVIs in the OR and office-based setting.

Results

Thirty-one studies with a total of 1 275 815 injections were included. Comparative analysis suggested no difference between rates of EO after IVIs performed in the office and OR settings (odds ratio, 3.06; 95% CI, 0.07-139.75; P = .57; I2 = 80%) were identified, yet a higher rate of culture-positive EO was found in the office setting (odds ratio, 21.52; 95% CI, 2.39-193.55; P = .006; I2 = 0%). The pooled rates of EO following anti-VEGF IVIs were 0.03% (95% CI, 0.03-0.04) and 0.02% (95% CI, 0.01-0.04) in office and OR settings, respectively, and the pooled rates of culture-positive EO were 0.01% (95% CI, 0.01-0.02) and 0.01% (95% CI, 0-0.02). The pooled rates of other ocular and systemic adverse events were low.

Conclusions and Relevance

The rate of clinically suspected or culture-positive EO following anti-VEGF IVIs was low whether the procedure was performed in the office or OR setting. Bacterial spectrum could differ between the 2 settings. This meta-analysis could not determine if it is more appropriate to give treatment in the OR for safety reasons in low-income compared with higher-income regions in the world.

Hyaluronic Acid-Based Gold Nanoparticles for the Topical Delivery of Therapeutics to the Retina and the Retinal Pigment Epithelium

The ocular immune privilege is a phenomenon brought about by anatomical and physiological barriers to shield the eye from immune and inflammation responses. While this phenomenon is beneficial for eyes protection, it is, at the same time, a hindrance for drug delivery to the posterior segment of the eye to treat retinal diseases. Some ocular barriers can be bypassed by intravitreal injections, but these are associated with several side effects and patient noncompliance, especially when frequent injections are required. As an alternative, applying drugs as an eye drop is preferred due to the safety and ease. This study investigated the possible use of topically-applied hyaluronic acid-coated gold nanoparticles as drug delivery vehicles to the back of the eye. The coated gold nanoparticles were topically applied to mouse eyes, and results were compared to topically applied uncoated gold nanoparticles and phosphate-buffered saline (PBS) solution. Retina sections from these mice were then analyzed using fluorescence microscopy, inductively coupled plasma mass spectrometry (ICP-MS), and transmission electron microscopy (TEM). All characterization techniques used in this study suggest that hyaluronic acid-coated gold nanoparticles have higher distribution in the posterior segment of the eye than uncoated gold nanoparticles. Electroretinogram (ERG) analysis revealed that the visual function of mice receiving the coated gold nanoparticles was not affected, and these nanoparticles can, therefore, be applied safely. Together, our results suggest that hyaluronic acid-coated gold nanoparticles constitute potential drug delivery vehicles to the retina when applied noninvasively as an eye drop.

INVOLUTION OF NEOVASCULAR AGE-RELATED MACULAR DEGENERATION AFTER ENDOPHTHALMITIS

PURPOSE

To report patients who demonstrated an alteration in the clinical and optical coherence tomography features of neovascular age-related macular degeneration after resolution of endophthalmitis.

METHODS

Retrospective case series of the subsequent changes in the macula and need for anti-vascular endothelial growth factor therapy in patients with neovascular age-related macular degeneration who developed endophthalmitis after intravitreal injection.

RESULTS

The study included seven eyes of seven patients with follow-up ranging between 3 months and 11 years. The vitreous cultures (n = 7) before intravitreal antibiotic injection were the following: culture-negative (4) and coagulase-negative Staphylococcus (3). Initial treatment included vitreous tap and injection (4) and pars plana vitrectomy (3). In 5/7 eyes, the optical coherence tomography showed resolution of subretinal fluid and serous pigment epithelial detachment, and there was no additional anti-vascular endothelial growth factor treatment administered.

CONCLUSION

After successful treatment of endophthalmitis in patients with neovascular age-related macular degeneration, there was relative involution of the maculopathy and reduced anti-vascular endothelial growth factor treatment burden in this series.

Identification of microbial agents in tissue specimens of ocular and periocular sarcoidosis using a metagenomics approach

Background: Metagenomic sequencing has the potential to identify a wide range of pathogens in human tissue samples. Sarcoidosis is a complex disorder whose etiology remains unknown and for which a variety of infectious causes have been hypothesized. We sought to conduct metagenomic sequencing on cases of ocular and periocular sarcoidosis, none of them with previously identified infectious causes. Methods: Archival tissue specimens of 16 subjects with biopsies of ocular and periocular tissues that were positive for non-caseating granulomas were used as cases. Four archival tissue specimens that did not demonstrate non-caseating granulomas were also included as controls. Genomic DNA was extracted from tissue sections. DNA libraries were generated from the extracted genomic DNA and the libraries underwent next-generation sequencing. Results: We generated between 4.8 and 20.7 million reads for each of the 16 cases plus four control samples. For eight of the cases, we identified microbial pathogens that were present well above the background, with one potential pathogen identified for seven of the cases and two possible pathogens for one of the cases. Five of the eight cases were associated with bacteria ( Campylobacter concisus, Neisseria elongata, Streptococcus salivarius, Pseudopropionibacterium propionicum, and Paracoccus yeei), two cases with fungi ( Exophiala oligosperma, Lomentospora prolificans and Aspergillus versicolor) and one case with a virus (Mupapillomavirus 1). Interestingly, four of the five bacterial species are also part of the human oral microbiome. Conclusions: Using a metagenomic sequencing we identified possible infectious causes in half of the ocular and periocular sarcoidosis cases analyzed. Our findings support the proposition that sarcoidosis could be an etiologically heterogenous disease. Because these are previously banked samples, direct follow-up in the respective patients is impossible, but these results suggest that sequencing may be a valuable tool in better understanding the etiopathogenesis of sarcoidosis and in diagnosing and treating this disease.

Trends in Endophthalmitis Associated With Intravitreal Injection of Anti-VEGF Agentsat a Tertiary Referral Center

BACKGROUND AND OBJECTIVE

To report the incidence and clinical features of infectious endophthalmitis after intravitreal (IV) injection of anti-vascular endothelial growth factor inhibitors (VEGF) between 2018 and 2020 and to compare to prior rates.

PATIENTS AND METHODS

Retrospective analysis of patients with endophthalmitis after anti-VEGF IV injections treated at Bascom Palmer Eye Institute between January 1, 2018, and December 31, 2020.

RESULTS

Between 2018 and 2020, the rate of clinically diagnosed endophthalmitis was 0.014% (10/71,858) and of culture-positive was 0.008% (6/71,858). Clinically diagnosed endophthalmitis rates per injection were: aflibercept (0.022%); ranibizumab (0.019%); bevacizumab (0%); and brolucizumab (0%). Clinically diagnosed endophthalmitis rates were similar in the present study compared to those from 2005 to 2017 (P = .84). Fifteen eyes were diagnosed with endophthalmitis (10 in-house, five external referrals). Of culture-positive eyes, the organisms were coagulase-negative Staphylococcus (8/11), Streptococcus species (2/11), and Abiotrophia defectiva (1/11). A universal face-masking policy in 2020 did not lower infection rates (P = .73).

CONCLUSION

Endophthalmitis rates after IV anti-VEGF remain low and are similar to prior reports. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:319-326.].

Incidence and outcomes of endophthalmitis with in-house compounded intravitreal bevacizumab injections: A multicentric study

PURPOSE

To evaluate the incidence rate and outcomes of endophthalmitis after intravitreal injection of in-house compounded bevacizumab.

METHODS

In this multicentric study performed from 2014 to 2018, patients who were injected with in-house compounded and sterilized bevacizumab were observed for endophthalmitis. In-house compounded syringes were prepared in compounding pharmacy using sterile standard operating guidelines. All cases of acute endophthalmitis following intravitreal injection were recorded and followed up for final anatomical and visual outcome after management.

RESULTS

A total of 50,361 bevacizumab injections were administered. Incidence of post-injection endophthalmitis was 0.0377%. Incidence of culture-positive endophthalmitis was 0.0178%, with 55.5% culture positivity for Staphylococcus species. A significant improvement in the final visual outcome was noted (p<0.05), and overall five patients (26.3%) achieved visual acuity of 6/18 or more.

CONCLUSIONS

In-house compounded injections of bevacizumab can reduce post-injection endophthalmitis to a minimum, with maintenance of proper asepsis and strict protocols by the compounding pharmacy.

Redox-Responsive Hyaluronic Acid-Based Nanogels for the Topical Delivery of the Visual Chromophore to Retinal Photoreceptors

Delivering therapeutics to the posterior segment of the eye is challenging due to various anatomical and physical barriers. While significant improvements have been realized by introducing direct injections to diseased sites, these approaches come with potential side effects that can range from simple inflammation to severe retinal damage. The topical instillation of drugs remains a safer and preferred alternative for patients' compliance. Here, we report the synthesis of penetratin-complexed, redox-responsive hyaluronic acid-based nanogels for the triggered release and delivery of therapeutics to the posterior part of the eye via topical application. The synthesized nanogels were shown to release their load only when exposed to a reducing environment, similar to the cytoplasm. As a model drug, visual chromophore analog, 9-cis-retinal, was loaded into nanogels and efficiently delivered to the mouse retina's photoreceptors when applied topically. Electroretinogram measurements showed a partial recovery of photoreceptor function in all treated eyes versus untreated controls. To the best of our knowledge, this report constitutes the first attempt to use a topically applied triggered-release drug delivery system to target the pigmented layer of the retina, in addition to the first attempt to deliver the visual chromophore topically.

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.

Bacterial Dispersion Associated With Various Patient Face Mask Designs During Simulated Intravitreal Injections

PURPOSE

We sought to investigate bacterial dispersion with patient face mask use during simulated intravitreal injections.

DESIGN

Prospective cross-sectional study.

METHODS

Fifteen healthy subjects were recruited for this single-center study. Each participant was instructed not to speak for 2 minutes, simulating a "no-talking" policy, while in an ophthalmic examination chair with an blood agar plate secured to the forehead and wearing various face masks (no mask, loose fitting surgical mask, tight-fitting surgical mask without tape, tight-fitting surgical mask with adhesive tape securing the superior portion of the mask, N95 mask, and cloth mask). Each scenario was then repeated while reading a 2-minute script, simulating a talking patient. The primary outcome measures were the number of colony-forming units (CFUs) and microbial species.

RESULTS

During the "no-talking" scenario, subjects wearing a tight-fitting surgical mask with tape developed fewer CFUs compared with subjects wearing the same mask without tape (difference 0.93 CFUs [95% confidence interval 0.32-1.55]; P = .003). During the speech scenarios, subjects wearing a tight-fitting surgical mask with tape had significantly fewer CFUs compared with subjects without a face mask (difference 1.07 CFUs; P = .001), subjects with a loose face mask (difference 0.67 CFUs; P = .034), and subjects with a tight face mask without tape (difference 1.13 CFUs; P < .001). There was no difference between those with a tight-fitting surgical mask with tape and an N95 mask in the "no-talking" (P > .99) and "speech" (P = .831) scenarios. No oral flora were isolated in "no-talking" scenarios but were isolated in 8 of 75 (11%) cultures in speech scenarios (P = .02).

CONCLUSION

The addition of tape to the superior portion of a patient's face mask reduced bacterial dispersion during simulated intravitreal injections and had no difference in bacterial dispersion compared with wearing N95 masks.

Nutritionally variant streptococci causing endophthalmitis associated with intravitreal anti-vascular endothelial growth factor injection

Purpose

To describe the clinical course and microbial properties of the first two reported cases of nutritionally variant Streptococci (Granulicatella adiacens and Abiotrophia defectiva) endophthalmitis following intravitreal anti-vascular endothelial growth factor injection (IVI).

Observations

A 74 year-old female developed Granulicatella adiacens endophthalmitis following IVI. The patient underwent a pars plana vitrectomy and visual acuity recovered to 20/30 in six weeks. Similarly, an 88 year-old male developed Abiotrophia defectiva endophthalmitis after IVI. After a pars plana vitrectomy, the visual acuity recovered to 20/60 at five weeks.

Conclusions and Importance

Endophthalmitis due to Streptococcus species has traditionally resulted in uniformly poor visual outcomes. However, nutritionally variant Streptococci, now reclassified as Granulicatella and Abiotrophia species, appear to have a less aggressive clinical course and better visual acuity outcomes. To the authors’ knowledge, these are the first reports of nutritionally variant Streptococci following IVI related endophthalmitis.

The Impact of Physician Face Mask Use on Endophthalmitis After Intravitreal Anti-Vascular Endothelial Growth Factor Injections

PURPOSE

To evaluate the effect of physician face mask use on rates and outcomes of postinjection endophthalmitis.

DESIGN

Retrospective, comparative cohort study.

METHODS

Setting: Single-center. StudyPopulation: Eyes receiving intravitreal anti-vascular endothelial growth factor injections from July 1, 2013, to September 1, 2019.

INTERVENTION

Cases were divided into "Face Mask" group if face masks were worn by the physician during intravitreal injections or "No Talking" group if no face mask was worn but a no-talking policy was observed during intravitreal injections. MainOutcomeMeasures: Rate of endophthalmitis, visual acuity, and microbial spectrum.

RESULTS

Of 483,622 intravitreal injections administered, 168 out of 453,460 (0.0371%) cases of endophthalmitis occurred in the No Talking group, and 9 out of 30,162 (0.0298%) cases occurred in the Face Mask group (odds ratio, 0.81; 95% confidence interval, 0.41-1.57; P = .527). Sixteen cases of oral flora-associated endophthalmitis were found in the No Talking group (1 in 28,341 injections), compared to none in the Face Mask group (P = .302). Mean logMAR visual acuity at presentation in cases that developed culture-positive endophthalmitis was significantly worse in the No Talking group compared to the Face Mask group (17.1 lines lost from baseline acuity vs 13.4 lines lost; P = .031), though no difference was observed at 6 months after treatment (P = .479).

CONCLUSION

Physician face mask use did not influence the risk of postinjection endophthalmitis compared to a no-talking policy. However, no cases of oral flora-associated endophthalmitis occurred in the Face Mask group. Future studies are warranted to assess the role of face mask use to reduce endophthalmitis risk, particularly attributable to oral flora.

Endophthalmitis following Intravitreal Anti-Vascular Endothelial Growth Factor Therapy: Changes in Incidence and Outcomes over a 9-Year Period

Aims: To evaluate whether the incidence, microbial spectrum, and visual outcomes of endophthalmitis following intravitreal injections have changed over time.Methods: Retrospective cohort study of endophthalmitis in eyes receiving intravitreal injection of anti-vascular endothelial growth factor between 2009-2012 and 2016-2017 at a single, large retina practice.Results: A total of 283,315 injections resulted in 96 suspected infectious endophthalmitis cases. Comparing 2009-2012 and 2016-2017, the rate of suspected endophthalmitis changed from 1 in 2,663 injections to 1 in 3,195 injections (p = .37). Visual outcomes 6 months after endophthalmitis were significantly better during the latter period (p = .04), with an average loss of 6.3 lines of VA in 2009-2012 compared to a loss of 3.6 lines in 2016-2017. In multivariate analysis, a "no-talking" policy during injections resulted in a trend towards a decrease in endophthalmitis incidence (p = .08). Cessation of post-injection topical antibiotic use did not independently decrease endophthalmitis incidence (p = .24) when the effect of a "no-talking" policy was taken into account. A lower rate of endophthalmitis was seen after prefilled vs. conventionally prepared ranibizumab syringe use for injection (0.014% vs. 0.035%, respectively), though this difference did not meet statistical significance (p = .16).Conclusion: The incidence of endophthalmitis after intravitreal injection decreased and visual outcomes improved between the periods of 2009-2012 and 2016-2017. A "no-talking" policy during injections was associated with a trend toward a decrease in endophthalmitis rate.

Successful Treatment of Acute Endophthalmitis after Cat Bite: A Case Report and Review of the Literature

Endophthalmitis after cat bite has poor outcome particularly those associated with scleral injury. A 33-year-old Caucasian female was seen by her ophthalmologist 4 days after cat bite to her right eye with hand motion vision and obvious signs of acute endophthalmitis. She was treated with exploration and repair of scleral puncture wound, anterior chamber and vitreous cultures and intravitreal injections of vancomycin and ceftazidime. Cultures were positive for alpha hemolytic Streptococcus. She underwent a pars plana vitrectomy, cultures and repeat injection of the same antibiotics and intravitreal dexamethasone 2 days later. Cultures grew Bacillus. Endophthalmitis resolved and she regained 20/20 vision after cataract surgery 3 months later. Successful outcome of acute endophthalmitis following a cat bite to the sclera in this case was most likely due to prompt intravitreal antibiotics and early vitrectomy combined with supplemental intravitreal antibiotics and steroid therapy.

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.

Clinical outcomes of 1 + PRN and 3 + Q3M regimens of intravitreal conbercept injection for exudative age-related macular degeneration

This retrospective study aimed to analyze the clinical outcomes of two regimens of intravitreal injections of conbercept [1+pro re nata (PRN) and 3 + Q3M] for the therapy of exudative age-related macular degeneration (AMD). In total, 105 eyes diagnosed with exudative AMD were enrolled. The eyes in the 1+PRN group (n = 51) received intravitreal injection of conbercept one time, followed by PRN retreatment. The eyes in the 3 + Q3M group (n = 54) received intravitreal injection of conbercept on three consecutive monthly, subsequently, once every three months for three times. After treatment, patients were followed up for 12 months. The best-corrected visual acuity (BCVA), central retinal thickness (CRT), and choroidal neovascularization (CNV) leakage area were compared before and after treatment. Moreover, the number of injections and adverse reactions were recorded. Compared with the 1+PRN group, BCVA was significantly improved and CRT was remarkably decreased in the 3 + Q3M group at 3, 6 and 12 months after operation. The disappeared or reduced CNV leakage area (93%) of the 3 + Q3M group was higher than that of the 1 + PRN group at the last follow-up. Moreover, the mean numbers of conbercept injections of the 1 + PRN group were less than the 3 + Q3M group. During the follow-up, there were no serious adverse reactions or ocular complications. This study reveals that intravitreal injection of conbercept using 3 + Q3M regimen has certain advantages than 1 + PRN regimen in extending drug delivery interval, improving patient’s vision, and reducing CRT.

Recurrent fungal endophthalmitis after intravitreal injections of bevacizumab

Purpose

We intend to describe an uncommon case of recurrent post-cataract fungal endophthalmitis after intravitreal injections of Bevacizumab.

Observations

A 73-year-old male, who underwent an uncomplicated cataract surgery 8 months ago, presented to our department with postoperative endophthalmitis 5 days after his fifth intravitreal injection (IVI) of bevacizumab for treatment of cystoid macula edema caused by central retinal venous occlusion 6 months ago. The visual acuity (VA) was 0.1 (20/200). The patient underwent an emergency pars plana vitrectomy. Culture of vitreous tap was negative. Eight weeks later, the patient presented again with recurrent endophthalmitis 2 days after his sixth IVI of bevacizumab. VA was hand motion. The patient was treated with an emergency anterior and posterior segment washout with intracapsular posterior intraocular lens (pIOL) extraction. Culture of pIOL revealed Saccharomyces cervisiae fungi in the capsular bag. Six months later, clinical findings were stable with no signs of intraocular inflammation, VA was 0.3 (20/60).

Conclusions and Importance

we assume that this is a rare case of chronic late-onset post-cataract fungal endophthalmitis, which was activated by repeated intravitreal injections of Bevacizumab.

Comparative Study of Microbiological Profile and Management Outcomes of Acute Endophthalmitis after Microincision Vitrectomy Surgery versus Intravitreal Injections

Purpose: The aim of this study was to evaluate and compare incidence and outcomes of management of acute endophthalmitis after microincision vitrectomy surgery (MIVS) and intravitreal injections (IVIs).Methods: Medical records were retrospectively reviewed from January 2012 to December 2017, and the incidence, clinical and microbiological profiles of acute endophthalmitis were documented.Results: Of 26,332 MIVS and 24,143 IVI performed, incidence of acute endophthalmitis in MIVS group was 0.027% (1 in 3761 cases) against 0.054% (1 in 1857 cases) in IVI. Gram-positive organisms were causative in post IVI group as against gram-negative organisms in MIVS group.Conclusion: Incidence of endophthalmitis after IVI is almost twice that after MIVS. A trend toward poorer outcomes in MIVS eyes was observed. Both MIVS and IVI being pars plana procedures warrant similar kind of aseptic precautions.

Endophthalmitis Associated With Intravitreal Injections of Anti-VEGF Agents at a Tertiary Referral Center: In-House and Referred Cases

BACKGROUND AND OBJECTIVE

To report the incidence rates, causative organisms, and visual acuity (VA) outcomes in patients with endophthalmitis associated with intravitreal injection of anti-vascular endothelial growth factor inhibitors.

PATIENTS AND METHODS

Retrospective case series between 2005 and 2017.

RESULTS

The study included 39 eyes of 39 patients, including 27 (69%) referred and 12 (31%) institutional patients. The use of topical antibiotics after an injection was gradually phased out at the authors' institution, where the preinjection rate of all clinically suspected endophthalmitis was 0.013% (24 of 183,898). The most common isolates were coagulase-negative Staphylococcus and Streptococcus. A VA of 5/200 or better was achieved in 21 of 39 eyes (54%) overall and in two of 15 eyes (13%) infected with Streptococcus.

CONCLUSIONS

The rate of post-intravitreal injection endophthalmitis is low. Outcomes were generally poor, and the worst were associated with Streptococcus. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:313-319.].

The Impact of Prefilled Syringes on Endophthalmitis Following Intravitreal Injection of Ranibizumab

PURPOSE

To compare the rates of infectious endophthalmitis following intravitreal injection of ranibizumab using prefilled syringes vs conventional preparation.

DESIGN

Multicenter retrospective cohort study.

METHODS

All eyes receiving intravitreal injection of 0.5 mg ranibizumab for retinal vascular diseases at 10 retina practices across the United States (2016 to 2017) and Japan (2009 to 2017) were included. The total numbers of eyes and injections were determined from billing codes. Endophthalmitis cases were determined from billing records and evaluated with chart review. Primary outcome was the rate of postinjection acute endophthalmitis. Secondary outcomes were visual acuity and microbial spectrum.

RESULTS

A total of 243 754 intravitreal 0.5 mg ranibizumab injections (165 347 conventional and 78 407 prefilled) were administered to 43 132 unique patients during the study period. In the conventional ranibizumab group, a total of 43 cases of suspected endophthalmitis occurred (0.026%; 1 in 3845 injections) and 22 cases of culture-positive endophthalmitis occurred (0.013%; 1 in 7516 injections). In the prefilled ranibizumab group, 12 cases of suspected endophthalmitis occurred (0.015%; 1 in 6534 injections) and 2 cases of culture-positive endophthalmitis occurred (0.0026%; 1 in 39 204 injections). Prefilled syringes were associated with a trend toward decreased risk of suspected endophthalmitis (odds ratio 0.59; 95% confidence interval 0.31-1.12; P = .10) and a statistically significant decreased risk of culture-positive endophthalmitis (odds ratio 0.19; 95% confidence interval 0.045-0.82; P = .025). Average logMAR vision loss at final follow-up was significantly worse for eyes that developed endophthalmitis from the conventional ranibizumab preparation compared to the prefilled syringe group (4.45 lines lost from baseline acuity vs 0.38 lines lost; P = .0062). Oral-associated flora was found in 27.3% (6/22) of conventional ranibizumab culture-positive endophthalmitis cases (3 cases of Streptococcus viridans, 3 cases of Enterococcus faecalis) compared to 0 cases in the prefilled ranibizumab group.

CONCLUSION

In a large, multicenter, retrospective study the use of prefilled syringes during intravitreal injection of ranibizumab was associated with a reduced rate of culture-positive endophthalmitis, including from oral flora, as well as with improved visual acuity outcomes.

The effect of diluting povidone-iodine on bacterial growth associated with speech

Background

Povidone-Iodine (PI) may be diluted when used as an antiseptic prior to an intravitreal injection in an attempt to decrease patient discomfort. This study aims to investigate the effect of diluting povidone-iodine (PI) on bacterial growth from bacterial droplet dispersal associated with speech.

Methods

Participants read a standardised script for 5 min over a blood agar plate positioned at 20 cm in a simulated position of an intravitreal injection procedure. The blood agar plates were subject to a randomised pre-application of 1% PI; 2.5% PI; 5% PI and no pre-application (control). The plates were incubated at 37 °C for 72 h and the number of Colony Forming Units (CFUs) was determined. CFUs were summarised as median and interquartile range (IQR). Wilcoxon rank sum test was used to assess pairwise comparisons of the various PI concentrations to the control group. Any trend across PI concentration was assessed using Kendall’s tau rank correlation.

Results

Twenty-one subjects participated. Control plates had a median growth of 25 CFUs (interquartile range [IQR]:15–40), 1% PI plates had a median growth of 30 CFUs (IQR:15–82), 2.5% PI had a median growth of 18 CFUs (IQR:10–32) and 5% PI had a median growth of 2 CFUs (IQR:0–5). There was significantly less bacterial growth with 5% PI compared to control (P < 0.001). Bacterial growth at 2.5% PI and 1% PI did not differ significantly from control. There was a statistically significant trend for decreasing colony count as PI concentration increased (P < 0.001).

Conclusions

PI concentrations less than 5% are not effective at reducing bacterial growth from bacterial droplet dispersal associated with speech. When using PI for pre-injection antisepsis, concentrations below 5% should be avoided.

HEMORRHAGIC VASCULITIS AND RETINOPATHY HERALDING AS AN EARLY SIGN OF BACTERIAL ENDOPHTHALMITIS AFTER INTRAVITREAL INJECTION

PURPOSE

To describe a case series of postintravitreal injection, bacterial endophthalmitis heralded by hemorrhagic retinal vasculitis.

METHODS

Observational case series of three patients with a history of intravitreal injections for age-related macular degeneration at a tertiary referral center who presented with vision changes and eye pain that were eventually found to have bacterial endophthalmitis. Clinical course was then followed.

RESULTS

All patients developed bacterial endophthalmitis and hemorrhagic retinal vasculitis.

CONCLUSION

These three cases highlight the importance of hemorrhagic retinal vasculitis as the presenting fundus finding of bacterial endophthalmitis and that this finding in a postinjection patient should be treated as endophthalmitis until proven otherwise.

Culture-Proven Endophthalmitis After Intravitreal Injection: A 10-Year Analysis

BACKGROUND AND OBJECTIVE

To report on the microbiology, management, and visual outcomes of intravitreal injection (IVI)-associated, culture-proven endophthalmitis.

PATIENTS AND METHODS

All patients seen at a tertiary referral center with culture-proven endophthalmitis associated with an IVI between June 2007 and July 2017 were included in this retrospective analysis.

RESULTS

Thirty-five patients with culture-positive endophthalmitis following IVI were identified. All gram-positive organisms (34 of 35) were susceptible to vancomycin. Cases due to pathogens associated with oral or respiratory flora were common (31.4%, n = 11), presented earlier (2.0 days vs. 4.6 days, P < .001), were more likely to undergo pars plana vitrectomy (81.8% vs. 25.0%, P = .002) and had worse visual acuity outcomes.

CONCLUSION

IVI-associated endophthalmitis pathogens and anti-microbial susceptibilities in the Pacific Northwest are similar to those reported from other geographic locations. Bacteria associated with the oral and respiratory flora are common isolates that result in a more aggressive course and worse visual outcomes. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:33-38.].

Antibiotic susceptibility, cytotoxicity, and protease activity of viridans group streptococci causing endophthalmitis

The viridans group streptococci comprise multiple species and have gained more recognition in recent years as common etiologic agents of bacterial endophthalmitis. The purpose of this study was to identify the species of human endophthalmitis isolates of viridans streptococci and to characterize their potential virulence attributes. The species of 22 endophthalmitis strains of viridans streptococci were identified by Matrix Assisted Laser Desorption Ionization Time-of-Flight. Susceptibilities to 3 antibiotics commonly used for bacterial endophthalmitis were determined. The extracellular milieu of each strain was tested for cytotoxicity of retinal pigmented epithelial cells, hemolysis of sheep erythrocytes, and protease activity using gelatin zymography. Identified species were Streptococcus mitis/oralis, S. salivarius, S. vestibularis, S. parasanguinis, S. mutans, S. constellatus, and S. gordonii. One strain of S. pseudoporcinus was also identified. All strains were sensitive to vancomycin, 77% were resistant to amikacin, and 27% had intermediate resistance to ceftazidime. Extracellular milieu from all strains except one (S. pseudoporcinus) were largely devoid of toxicity to retinal pigmented epithelial cells and sheep erythrocytes. Twelve strains, 10 of which were S. mitis/oralis, produced protease activity. Interestingly, not all of the S. mitis/oralis strains were proteolytic. These findings highlight the diversity of virulence factor production in ocular strains of the viridans streptococci not only at the group level but also at the species level.

Endophthalmitis Rates after Bilateral Same-Day Intravitreal Anti-Vascular Endothelial Growth Factor Injections

PURPOSE

To evaluate practice patterns for bilateral same-day intravitreal anti-vascular endothelial growth factor (VEGF) injections and determine the rate of unilateral and bilateral postinjection endophthalmitis after bilateral same-day intravitreal anti-VEGF injections.

DESIGN

Retrospective cohort study.

METHODS

The records of a large academic private practice were electronically queried for all office visits, during which bilateral intravitreal anti-VEGF injections were performed between April 1, 2012 and August 21, 2017 for patients with a diagnosis of neovascular age-related macular degeneration, diabetic macular edema, or retinal vein occlusion. Demographic information and indication for injection were recorded for each patient and office visit. Charts of patients with endophthalmitis were reviewed, and information was collected on presentation examination, culture data, and visual outcomes.

RESULTS

During the study period, 101 932 bilateral same-day intravitreal anti-VEGF injections were performed over 50 966 office visits for 5890 patients. The mean (standard deviation) age of patients in this cohort was 74.2 (14.1) years and 60.6% of patients were female. The 2 most common indications for injection were neovascular age-related macular degeneration (54.3% of patients) and diabetic macular edema (35.4% of patients). Twenty-eight cases of endophthalmitis (0.027% of total injections) occurred during the study period. There were no cases of bilateral endophthalmitis, and no patients had more than 1 occurrence of endophthalmitis.

CONCLUSIONS

In this large cohort of patients undergoing bilateral same-day intravitreal anti-VEGF injections, there were no cases of bilateral endophthalmitis. Additionally, the overall rate of unilateral endophthalmitis was low and comparable to prior studies of unilateral injections. These results support the safety of bilateral same-day intravitreal anti-VEGF treatment.

Causative Pathogens in Endophthalmitis after Intravitreal Injection of Anti-vascular Endothelial Growth Factor Agents

Intravitreal injection of anti-vascular endothelial growth factor is currently the preferred treatment for several posterior segment diseases, including age-related macular degeneration and diabetic retinopathy, as well as macular edema and retinal vein occlusion. As an invasive procedure it involves risks. The most significant risk is infectious endophthalmitis, a sight-threatening and even a globe-threatening acute fulminant condition. Most common pathogens include Streptococcus and Staphylococcus species, surprisingly originating from the patient's, surgeon's, or nurse's mouth. Infectious endophthalmitis may have devastating and irreversible effect, with Streptococcus-induced cases having the worst visual outcome. It is therefore crucial for clinicians to promptly recognize and treat such conditions, and, far more important, to put in place protective and preventive measures against this rare, but sight-threatening complication. To that end, this paper describes the most common pathogens causing endophthalmitis after IVI of anti-VEGF, and defines their source, to aid the physician in developing strategies to prevent this catastrophic infection.

Current Evidence for the Prevention of Endophthalmitis in Anti-VEGF Intravitreal Injections

Intravitreal injection of a therapeutic substance is the most common procedure performed in ophthalmology. It has a low incidence of serious complications but is associated with a small chance of endophthalmitis. Although the rate of endophthalmitis is between 0.019% and 0.09%, the associated visual morbidity is often devastating. Procedural changes have evolved over the years to improve patient comfort and reduce injection-related injury and infection. Despite the availability of published evidence, there remains considerable variations and lack of consensus in practical clinical settings. In addition, emerging literature concerning the use of speculums, the use of prophylactic topical antibiotics, and the setting of injections continues to impact the ophthalmologist's injection practice. This article provides an up to date assessment of various aspects of the procedure such as the setting, ventilation, type of anaesthetic, and control of sterility during the procedure; including discussions on performing bilateral eye same-day injections and the use of antibiotics.

Endophthalmitis after Intravitreal Injection of Vascular Endothelial Growth Factor Inhibitors: Management and Visual Outcomes

PURPOSE

We describe the presentation of patients developing endophthalmitis after intravitreal injection with vascular endothelial growth factor (VEGF) inhibitors. Moreover, we evaluate the management by comparing the outcomes of immediate tap and injection of intravitreal antibiotics (TAI) versus initial surgical pars plana vitrectomy (PPV). Finally, we analyze the predictive factors of visual outcomes at 6-month follow-up.

DESIGN

Retrospective, single-center, nonrandomized interventional study.

PARTICIPANTS

Patients developing endophthalmitis after receiving an intravitreal injection of anti-VEGF agent between 2006 and 2016.

METHODS

All patients received a vitreous biopsy sent for cultures before the initiation of treatment: TAI group versus PPV with intravitreal antibiotics (PPV group).

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA) at 6-month follow-up after treatment for endophthalmitis.

RESULTS

A total of 258 357 intravitreal injections occurred over the course of the 10-year period, of which 40 patients (0.016%) had endophthalmitis within 3 weeks after injection. In total, 34 patients (85.0%) had pain and 25 patients (62.5%) had hypopyon on initial examination. Among 24 culture-positive cases, 66.7% of the causative organisms were coagulase-negative Staphylococcus, followed by Streptococcus species (10.0%). The best-corrected visual acuity (BCVA) (logarithm of the minimum angle of resolution [logMAR]) at 6-month follow-up was significantly worse for patients who had a positive culture for Streptococcus species (4.0; standard deviation [SD], 0.8) (approximately light perception) compared with those who had a positive culture for coagulase-negative Staphylococcus (0.4; SD, 0.3) (∼20/50) (P < 0.0001). Compared with the TAI group, a higher proportion of samples were culture-positive in the PPV group (90.9% vs. 48.3%, P = 0.03). There was no statistically significant difference in BCVA at 6-month follow-up between the TAI and PPV groups. Younger age (<85 years) and lower intraocular pressure (IOP) (≤25 mmHg) at presentation were predictive of achieving a BCVA of 20/400 or better at 6-month follow-up after treatment. Initial management (TAI vs. PPV), duration of symptoms, presence of pain, presence of hypopyon, presenting BCVA, and culture status (positive vs. negative) were not found to be predictive of visual outcomes at 6-month follow-up.

CONCLUSIONS

No significant difference in BCVA at 6-month follow-up was detected between the TAI and PPV groups. Younger age and lower IOP at presentation were associated with better visual outcomes at 6-month follow-up.

POOLED ESTIMATES OF INCIDENCE OF ENDOPHTHALMITIS AFTER INTRAVITREAL INJECTION OF ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR AGENTS WITH AND WITHOUT TOPICAL ANTIBIOTIC PROPHYLAXIS

PURPOSE

To assess the effect of topical antibiotic prophylaxis on postoperative endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents.

METHODS

A systematic literature search was performed from inception to March 2016 using PubMed, Medline, Web of Science, Embase, and the Cochrane Library, to identify articles that reported cases of endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents. We used a pooled analysis to estimate the incidence of cases of endophthalmitis who developed after injections performed with and without topical antibiotic prophylaxis. We used regression analysis to explore the effects of study characteristics on heterogeneity.

RESULTS

From our search of electronic databases, we identified and screened 4,561 unique records. We judged 60 articles to have reported findings for cohorts of patients who met our inclusion criteria, (12 arms of randomized clinical trials, 11 prospective cohort studies, and 37 retrospective cohort studies), which included 244 cases of endophthalmitis and 639,391 intravitreal injections of anti-vascular endothelial growth factor agents. The final pooled estimate endophthalmitis proportions were 9/10,000 (95% confidence interval, 7/10,000-12/10,000) in the antibiotic-treated group and 3/10,000 (95% confidence interval, 2/10,000-5/10,000) in the untreated group. The estimated incidence of endophthalmitis with topical antibiotic prophylaxis was approximated three times the incidence without prophylaxis. Random effects regression showed that none of the study characteristics significantly affected the effect size in either group.

CONCLUSION

Topical antibiotic after intravitreal injection of anti-vascular endothelial growth factor agents is associated with a higher risk of endophthalmitis.