Meta-analysis of infectious endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents

[Anatomical and functional outcomes of the "3+PRN" therapeutic protocol in the treatment of diabetic macular edema]

PURPOSE

To evaluate the anatomical and functional results of the "3+PRN" protocol in the treatment of diabetic macular edema (DME), determine the predictive factors for good final visual acuity, and compare it to other protocols.

MATERIALS AND METHODS

We conducted a retrospective, descriptive, comparative, cross-sectional study of patients with DME, which we dubbed HTSM. All patients were treated with three monthly initial intravitreal injections (IVT) of 1.25mg bevacizumab and followed according to the pro re nata (PRN) protocol for a period of 3years. The protocol was based on a monthly monitoring schedule for the first 3months, then increasingly spaced out over time. "On-demand" treatment was indicated with resumption of bevacizumab IVT in the event of worsening of DME.

RESULTS

A total of 52 patients were included. The mean age was 65years. Type 2 was the most frequently observed type of diabetes. The mean duration of the PRN protocol was 6months, and the mean number of injections was 6. The mean visual acuity (VA), initially 1/10, improved to 3/10 by the conclusion of the 3+PRN protocol, with an improvement of more than 5 letters in 77.6% of cases. The mean initial central macular thickness (CMT) was 451.5μm. The final mean EMC decreased to 298.5μm, which corresponds to a reduction of 153μm compared to the initial value. The mean subfoveal choroidal thickness, initially 304.2μm, decreased to a mean of 284.5μm at completion. Comparative analysis of the results before and after the PRN protocol confirmed the existence of a statistically significant correlation between VA and CMT (P<0.05). No correlation was observed between age and visual acuity or between initial and final VA. The analysis of the various tomographic parameters and VA revealed a significantly better visual improvement in the group in whom the external limiting membrane (MLE) and ellipsoid zone (ZE) were intact (P=0.04), as well as in the group in whom serous retinal detachment (SRD) was absent (P<0.001). Posterior vitreous detachment (PVD) was the most frequently observed vitreomacular anomaly. The final VA was similar in the groups with and without PVD (P=0.04).

CONCLUSION

The 3+PRN protocol is effective both functionally and tomographically in the treatment of DME. Various tomographic parameters might influence therapeutic efficacy. However, further in-depth studies are needed to better investigate these parameters.

Risk of post-injection endophthalmitis peaks within the first three injections of anti-vascular endothelial growth factor therapy: A nationwide registry-based study

PURPOSE

To report the incidence of post-injection endophthalmitis (PIE) and the cumulative risk associated with repeated injections of intravitreal anti-vascular endothelial growth factor (anti-VEGF).

METHODS

We employed nationwide registries in Denmark to include all individuals aged ≥40 years who received at least one intravitreal anti-VEGF injection in 2007-2022. Our primary endpoint PIE was identified using specific diagnostic codes for endophthalmitis and procedure codes for vitreous biopsy within 10 days prior to and 120 days post-injection. Patients were stratified according to the underlying diagnoses for which they received the treatment. The relative risk (RR) for PIE was calculated between groups based on the number of injections received by the patients.

RESULTS

We identified 60 825 patients who received intravitreal anti-VEGF treatment during study time, with a median age of 77.2 years and females constituting 58.1%. We identified 232 cases of PIE after 1 051 549 injections during follow-up, resulting in an incidence of 0.022% [95% CI 0.019%-0.025%]. Despite a linear growth in annual anti-VEGF use, the incidence remained stable at 0.020% [95% CI 0.017%-0.023%] from 2013 to 2022. Compared to patients receiving 1-3 injections, RR for patients receiving 4-20, 21-40, and >40 injections were 0.46 [95% CI 0.34-0.63], 0.32 [95% CI 0.21-0.50], and 0.54 [95% CI 0.36-0.81], respectively. Findings were similar across the different diagnoses.

CONCLUSIONS

Based on 16 years of nationwide registry data, this study identified a low and stable incidence of PIE. Notably, the highest risk of endophthalmitis was within the first three anti-VEGF injections.

Risk of Endophthalmitis Based on Cumulative Number of Anti-VEGF Intravitreal Injections

PURPOSE

To determine the risk of endophthalmitis in eyes undergoing intravitreal injections (IVIs) of anti-VEGF based on cumulative number of injections per eye.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients from a single center undergoing IVIs of ranibizumab, aflibercept, or bevacizumab.

METHODS

Eyes were divided into quartiles based on injection number causative of endophthalmitis between January 1, 2011, and June 1, 2022.

MAIN OUTCOME MEASURES

Interquartile clinical outcomes and cumulative risk of endophthalmitis per injection and per eye.

RESULTS

A total of 43 393 eyes received 652 421 anti-VEGF injections resulting in 231 endophthalmitis cases (0.035% per injection, 1 in 2857), of which 215 were included. The cumulative endophthalmitis risk increased from 0.0018% (1 in 55 556) after 1 injection to 0.013% (1 in 7692) after 11 injections (0.0012 percentage point change), versus 0.014% (1 in 7143) after 12 injections to 0.025% (1 in 4000) after 35 injections (0.00049 percentage point change), versus 0.025% (1 in 4000) after 36 injections to 0.031% (1 in 3226) after 66 injections (0.00017 percentage point change), versus 0.031% (1 in 3226) after 63 injections to 0.033% (1 in 3030) after 126 injections (0.000042 percentage point change) (P < 0.001). Likewise, the cumulative endophthalmitis risk per eye increased from 0.028% (1 in 3571) to 0.20% (1 in 500) between injections 1 and 11 (0.018 percentage point change), versus 0.21% (1 in 476) to 0.38% (1 in 263) between injections 12 and 35 (0.0075 percentage point change), versus 0.38% (1 in 263) to 0.46% (1 in 217) between injections 36 and 66 (0.0026 percentage point change), versus 0.46% (1 in 217) to 0.50% (1 in 200) between injections 67 and 126 (0.00063 percentage point change) (P < 0.001).

CONCLUSIONS

The cumulative endophthalmitis risk per injection and per eye increased with greater number of injections received but appeared to do so at a higher rate during earlier injections and at a lower rate further into the treatment course.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Coenzyme Q10 eyedrops conjugated with vitamin E TPGS alleviate neurodegeneration and mitochondrial dysfunction in the diabetic mouse retina

Diabetic retinopathy (DR) is a leading cause of blindness and vision impairment worldwide and represents one of the most common complications among diabetic patients. Current treatment modalities for DR, including laser photocoagulation, intravitreal injection of corticosteroid, and anti-vascular endothelial growth factor (VEGF) agents, target primarily vascular lesions. However, these approaches are invasive and have several limitations, such as potential loss of visual function, retinal scars and cataract formation, and increased risk of ocular hypertension, vitreous hemorrhage, retinal detachment, and intraocular inflammation. Recent studies have suggested mitochondrial dysfunction as a pivotal factor leading to both the vascular and neural damage in DR. Given that Coenzyme Q10 (CoQ10) is a proven mitochondrial stabilizer with antioxidative properties, this study investigated the effect of CoQ10 eyedrops [in conjunction with vitamin E d-α-tocopheryl poly(ethylene glycol) 1000 succinate (TPGS)] on DR-induced neurodegeneration using a type 2 diabetes mouse model (C57BLKsJ-db/db mice). Utilizing a comprehensive electroretinography protocol, supported by immunohistochemistry, our results revealed that topical application of CoQ10 eyedrops conjugated with vitamin E TPGS produced a neuroprotective effect against diabetic-induced neurodegeneration by preserving the function and histology of various retinal neural cell types. Compared to the control group, mice treated with CoQ10 exhibited thicker outer and inner nuclear layers, higher densities of photoreceptor, cone cell, and rod-bipolar cell dendritic boutons, and reduced glial reactivity and microglial cell density. Additionally, the CoQ10 treatment significantly alleviated retinal levels of MMP-9 and enhanced mitochondrial function. These findings provide further insight into the role of mitochondrial dysfunction in the development of DR and suggest CoQ10 eyedrops, conjugated with vitamin E TPGS, as a potential complementary therapy for DR-related neuropathy.

Topical Antiseptics in Minimizing Ocular Surface Bacterial Load Before Ophthalmic Surgery: A Randomized Controlled Trial

PURPOSE

To investigate the reduction of the ocular surface bacterial load induced by 2 commercially available ophthalmic antiseptic formulations, povidone-iodine (PVI) 0.6% and chlorhexidine (CLX) 0.02%, before ocular surgery.

DESIGN

Randomized controlled trial.

METHODS

Seventy adult patients undergoing intraocular surgery (phacoemulsification) were randomized to receive in the index eye PVI (group A) 4 times a day for 3 days or CLX (group B) 4 times a day for 3 days before surgery. The untreated eye was used as control. A conjunctival swab was taken in both eyes before (T0) and after (T1) therapy. Microbial DNA was quantified with real-time polymerase chain reaction (PCR) analysis. The Mick algorithm was used to compare the abundance of each genus/genera against the distribution of abundances from the reference. At T1, patients filled a questionnaire to evaluate therapy-induced symptoms. Primary outcome was the reduction of bacterial DNA at T1 (microbial load), vs control arm, expressed as mean number of real-time PCR cycle times (CTs). Secondary outcomes were taxonomic composition, differential abundance, and therapy-induced ocular symptoms.

RESULTS

The T0-T1 difference in CT was significant in group B, but not in group A (mean [95% CI], 0.99 [0.33] vs 0.26 [0.15], P < .001, and 0.65 [0.3] vs 0.45 [0.41], P = .09, respectively). The taxonomic composition, alpha, and beta diversity remained consistent at all time points in both groups. The rate of patients reporting therapy-induced ocular symptoms and the mean discomfort grade were greater in group A than in group B (97% vs 26% and 4.97±2.48 vs 0.66±1.53, respectively).

CONCLUSIONS

Compared with PVI 0.6%, CLX 0.02% induced a greater reduction of ocular surface bacterial load, with no significant alterations of the taxonomic composition. Moreover, CLX was better tolerated than PVI.

Endophthalmitis following same-day bilateral anti-VEGF injections: a systematic review

PURPOSE

To review the risk of endophthalmitis in same-day bilateral anti-VEGF injections.

METHODS

We searched 12 literature databases for studies on the risk of endophthalmitis after same-day bilateral intravitreal anti-VEGF injections. Data extraction was made independently by two authors and discussed afterward until reaching consensus.

RESULTS

Seventeen studies were included with a total of 138,478 intravitreal anti-VEGF injections (69,239 bilateral injections sessions) given in at least 7579 patients. In total, 33 cases of endophthalmitis had occurred, and no cases were bilateral. The incidence of endophthalmitis ranged from 0 to 0.53% per intravitreal injection across studies.

CONCLUSIONS

We suggest that clinicians can consider same-day treatment of both eyes of patients in need of bilateral intravitreal anti-VEGF injection therapy, but larger studies are needed to quantify the exact risk of endophthalmitis.

Literature- and Experience-Based Consensus for Acute Post-operative Endophthalmitis and Endogenous Endophthalmitis in Taiwan

Clinical practices on acute post-operative and endogenous endophthalmitis (EnE) are highly variable among clinicians due to a lack of up-to-date, high-quality evidential support. An expert consensus is thus much needed. A panel consisting of ten retinal specialists in Taiwan was organized. They evaluated relevant literature and developed key questions regarding acute post-operative and EnE that are cardinal for practice but yet to have conclusive evidence. The panel then attempted to reach consensus on all the key questions accordingly. There were eight key questions proposed and their respective consensus statements were summarized as follows: Gram staining and culture are still the standard procedures for the diagnosis of endophthalmitis. Vitrectomy is recommended to be performed earlier than the timing proposed by the Endophthalmitis Vitrectomy Study (EVS). Routine intracameral antibiotic injection for post-cataract surgery endophthalmitis prophylaxis is not recommended because of potential compounding error hazards and a lack of support from high-quality studies. Routine fundus examination is recommended for all patients with pyogenic liver abscess. In EnE, vitrectomy is recommended if diffused and dense vitritis is present, or if the disease progresses. These consensus statements may work as handy guidance or reference for clinical practices of acute post-operative and EnE.

Visual outcome of 25 Gauge vitrectomy for acute post operative infectious endophthalmitis

BACKGROUND

The correlation between the change in foveal thickness measured using optical coherence tomography (OCT) following surgery for infectious endophthalmitis and preoperative and postoperative visual acuity is uncertain, and there are few pertinent studies on this topic.

OBJECTIVE

We explored the variations in macular thickness using OCT after emergency vitrectomy for post-cataract infectious endophthalmitis and the relationship between macular thickness with changes in visual function.

METHODS

We included 10 cases of post-cataract infectious endophthalmitis. Each patient underwent 25-G vitrectomy.

RESULTS

The infection in all 10 patients was under control and visual function improved. Postoperative vitreous humor culture was positive in 8 patients, including 7 cases of coagulase-negative Staphylococcus epidermidis and 1 case of Lactobacillus acidophilus. The average age of these 10 patients was 71.60 ± 8.71 years (P< 0.05, two-tailed). There was no significant correlation between time 2 (the time of onset after cataract surgery) and visual prognosis. The average time 1 (the time of the vitrification surgery caused by the onset of the disease) was 1.45 ± 0.76 days (P< 0.05, two-tailed). The postoperative 3dVA ranged from 0.20 to 3.00, with an average visual acuity of 1.87 ± 1.12, which was superior to the preoperative value (P< 0.01, two-tailed). The correlation between the post3dVA and post 1mVA was significant. The post 1mVA ranged from 0.05 to 2.20, with an average visual acuity of 0.94 ± 0.74 (P< 0.05, two-tailed). The correlation between post 1mVA and post3mVA was significant. Also, paired t-tests comparing preoperative and postoperative visual acuity revealed a significant correlation (P< 0.05, two-tailed). The post3mVA was 0-1.00 with an average visual acuity of 0.44 ± 0.41. The postoperative foveal thickness ranged from 176.00 to 514.00 μm, with an average thickness of 281.10 ± 113.12 μm.

CONCLUSION

Emergency 25-G minimally invasive vitrectomy can improve visual acuity and decrease the reoperation rate for patients who have acquired post-cataract infectious endophthalmitis. There were significant correlations between age, disease onset to operation time, preoperative and postoperative visual acuity, and postoperative macular thickness.

Comparison of Endophthalmitis Rates after Alcohol-Based Chlorhexidine and Povidone-Iodine Antisepsis for Intravitreal Injections

OBJECTIVE

Intravitreal injections (IVIs) are the most frequently performed intraocular procedure in Canada. Povidone-iodine (PI) is the current gold standard for antisepsis for IVI and is widely used; chlorhexidine (CH) is a possible alternative antiseptic agent. This study aims to compare rates of endophthalmitis after IVI with 0.05% chlorhexidine with a 4% alcohol base antisepsis to rates of endophthalmitis after IVI with 10% PI antisepsis.

DESIGN

Retrospective cohort study.

SUBJECTS

Eyes that received IVI between May 2019 and October 2022 at a group retina practice in Edmonton, Canada.

METHODS

Eyes at a single center received focal conjunctival application of either 10% PI antisepsis or 0.05% CH in 4% alcohol antisepsis for 30 seconds before each IVI.

MAIN OUTCOME MEASURE

Rates of endophthalmitis between the PI and CH groups.

RESULTS

A total of 170 952 IVIs were performed during the study period. A total of 31 135 were performed using CH prophylaxis compared with 139 817 with PI prophylaxis. Among all IVIs there were 49 total cases of endophthalmitis, 29 in the PI group (0.021%) and 20 in the CH group (0.064%). There was a statistically significant difference in the rates of endophthalmitis between the 2 groups (P < 0.001). The odds ratio for developing endophthalmitis with CH antisepsis was 3.1 (95% confidence interval, 1.9-5.2) compared with PI antisepsis. There were increased odds of developing endophthalmitis with aflibercept injection compared with bevacizumab (odds ratio, 3.48; 95% confidence interval, 2.09-7.24).

CONCLUSIONS

There is a statistically significant difference in rates of endophthalmitis between alcohol-based CH and PI antisepsis for IVI in our patient population utilizing the methods discussed. In our center, alcohol-based CH is now considered a second-line antiseptic agent. Further studies are warranted to further assess the endophthalmitis rate utilizing these 2 antiseptic agents.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Cost-effectiveness of the anti-vascular endothelial growth factor intravitreal injection and panretinal photocoagulation for patients with proliferative diabetic retinopathy in South Korea

BACKGROUND

We determined the cost-effectiveness of the anti-vascular endothelial growth factor (VEGF) intravitreal injection versus panretinal photocoagulation (PRP) for patients with proliferative diabetic retinopathy (PDR) in South Korea.

METHODS

We simulated four treatment strategies using PRP and the anti-VEGF injection by constructing a Markov model for a hypothetical cohort of 50-year-old PDR patients: (1) PRP only; (2) anti-VEGF injection only; (3) PRP first; and (4) anti-VEGF injection first.

RESULTS

In this cost-effectiveness analysis, compared with only-PRP, the incremental cost-effectiveness ratio was $95,456 per quality-adjusted life-year (QALY) for PRP first, $34,375 per QALY for anti-VEGF injection first, and $33,405 per QALY for anti-VEGF injection only from a healthcare perspective. From the societal and payer perspective, strategy (2) was more cost-saving and effective than (1). In the probabilistic sensitivity analysis, only-PRP was cost-effective up to the willingness-to-pay (WTP) of about $42,000, while anti-VEGF injection only was cost-effective from a healthcare perspective. From the societal and payer perspectives, regardless of the value of WTP, anti-VEGF injection only was the most cost-effective strategy.

CONCLUSION

In our study, the anti-VEGF injection for PDR was cost-effective from the payer and societal perspectives.

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.

From randomised controlled trials to real-world data: Clinical evidence to guide management of diabetic macular oedema

Randomised clinical trials (RCTs) are generally considered the gold-standard for providing scientific evidence for treatments' effectiveness and safety but their findings may not always be generalisable to the broader population treated in routine clinical practice. RCTs include highly selected patient populations that fit specific inclusion and exclusion criteria. Although they may have a lower level of certainty than RCTs on the evidence hierarchy, real-world data (RWD), such as observational studies, registries and databases, provide real-world evidence (RWE) that can complement RCTs. For example, RWE may help satisfy requirements for a new indication of an already approved drug and help us better understand long-term treatment effectiveness, safety and patterns of use in clinical practice. Many countries have set up registries, observational studies and databases containing information on patients with retinal diseases, such as diabetic macular oedema (DMO). These DMO RWD have produced significant clinical evidence in the past decade that has changed the management of DMO. RWD and medico-administrative databases are a useful resource to identify low frequency safety signals. They often have long-term follow-up with a large number of patients and minimal exclusion criteria. We will discuss improvements in healthcare information exchange technologies, such as blockchain technology and FHIR (Fast Healthcare Interoperability Resources), which will connect and extend databases already available. These registries can be linked with existing or emerging retinal imaging modalities using artificial intelligence to aid diagnosis, treatment decisions and provide prognostic information. The results of RCTs and RWE are combined to provide evidence-based guidelines.

Consensus and controversies in the science of endophthalmitis management: Basic research and clinical perspectives

Infectious endophthalmitis is a severe intraocular infection caused by bacteria, or less commonly by fungi. It can occur after penetrating eye procedures, trauma, or the spread of infection from contiguous structures or via emboli from distant organs. Because of the time-critical nature of the treatment, endophthalmitis is treated with the clinical diagnosis and modified by the microbiological report of the intraocular contents. The current strategy for managing endophthalmitis relies on pre-clinical literature, case series, and one large multi-center randomized clinical trial on post-cataract surgery endophthalmitis. Culture-susceptibility of the microorganisms from undiluted vitreous guides the definitive treatment in non-responsive cases. Strategies to reduce the incidence of endophthalmitis after penetrating eye procedures have been developed concurrently with refined means of treatment. Despite these advances, outcomes remain poor for many patients. Although consensus articles have been published on managing endophthalmitis, treatment patterns vary, and controversies remain. These include (1) the use of newer methods for early and precise microbiological diagnosis; (2) the choice of intravitreal antibiotics; (3) the need for systemic therapy; (4) early and complete vitrectomy. Here, we review the current consensus and address controversies in diagnosing and managing endophthalmitis. This review is intended to familiarize physicians and ophthalmologists with different aspects of endophthalmitis management to make informed decisions.

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.

Lowering the Incidence of Endophthalmitis Following Intravitreal Anti-VEGF Injection: An Analysis of Aseptic Protocol Adjustment

BACKGROUND AND OBJECTIVE

The impact of anti-sepsis-anesthesia sequence in intravitreal injection (IVI)-associated endophthalmitis is unknown. We compared outcomes of patients who had 10% topical povidone-iodine before or after 2% topical lidocaine gel during IVIs.

PATIENTS AND METHODS

A retrospective study of IVIs in nine clinical sites was undertaken. Group 1 had lidocaine gel applied first. This protocol was changed on March 1, 2020, with Group 2 having povidone-iodine applied first. Visual and micro-biological outcomes were compared.

RESULTS

Among 72 cases (0.07%) from 102,908 IVIs, Group 1 had 59 cases from 65,307 IVI (0.09%) and Group 2 had 13 cases from 37,601 IVI (0.03%; P = 0.001). There was no significant difference in the best-corrected visual acuity between groups. Highly virulent bacteria were predominantly isolated in Group 1, but proportions of gram-positive bacterial growth were similar.

CONCLUSIONS

Application of povidone-iodine before lidocaine gel, compared to after, significantly decreased rate of IVI endophthalmitis, with no significant changes in visual and microbiological outcomes. [Ophthalmic Surg Lasers Imaging Retina 2023;54:520-525.].

Impact of Prefilled Syringes and Masking on Postintravitreal Injection Endophthalmitis

Purpose: To compare rates of endophthalmitis (1) following intravitreal injection of antivascular endothelial growth factor therapies with glass-vial preparation (GVP) vs prefilled syringes (PFS) and (2) before and after masking protocols were implemented. Methods: Medical records within a multicenter retina practice in Houston, Texas, from January 2015 to August 2021 were retrospectively reviewed. The primary outcome was rate of endophthalmitis after intravitreal injection. Results: A total of 307 349 injections were performed during the study period and 101 cases of endophthalmitis were identified (0.033%). PFS use was associated with a decreased risk of endophthalmitis (relative risk [RR], 0.320; 95% CI, 0.198-0.518, P < .001); 54 cases of endophthalmitis occurred in the GVP group of aflibercept and ranibizumab (0.052%) compared with 24 in the PFS group (0.017%). There was no difference in the endophthalmitis rates with or without universal masking (RR, 0.953; 95% CI 0.616-1.473, P = .91). Discussion: PFS use was associated with a significant reduction in the rate of endophthalmitis while the use of surgical face masks did not appear to significantly impact the rate of endophthalmitis.

Targeting the Gut-Eye Axis: An Emerging Strategy to Face Ocular Diseases

The human microbiota refers to a large variety of microorganisms (bacteria, viruses, and fungi) that live in different human body sites, including the gut, oral cavity, skin, and eyes. In particular, the presence of an ocular surface microbiota with a crucial role in maintaining ocular surface homeostasis by preventing colonization from pathogen species has been recently demonstrated. Moreover, recent studies underline a potential association between gut microbiota (GM) and ocular health. In this respect, some evidence supports the existence of a gut-eye axis involved in the pathogenesis of several ocular diseases, including age-related macular degeneration, uveitis, diabetic retinopathy, dry eye, and glaucoma. Therefore, understanding the link between the GM and these ocular disorders might be useful for the development of new therapeutic approaches, such as probiotics, prebiotics, symbiotics, or faecal microbiota transplantation through which the GM could be modulated, thus allowing better management of these diseases.

Effect of fenestrated sterile drape and face mask on bacterial dispersion toward the periocular area during intravitreal injection

This experimental crossover study was performed to investigate whether fenestrated surgical drapes (covering the nose and mouth but with an opening over the periorbital area) with or without patients' surgical face masks increase periorbital bacterial dispersion during simulated intravitreal injection conditions. Each of the 16 healthy volunteers performed 14 scenarios involving different mask and drape conditions in both silent and speaking situations. In each scenario, the subject lay down flat on the back with a blood agar plate being held at the inferior orbital rim perpendicular to the face to capture airflow from breathing/speaking. Another blood agar plate placed 50 cm away from the subject served as an experimental control. A total of 224 experiments were performed. Speaking situations significantly showed more colony forming units (CFUs) compared with their controls (P = 0.014). There were no significant differences in CFUs between wearing vs not wearing the masks (P = 0.887 for speaking and P = 0.219 for silent) and using vs not using the drapes (P = 0.941 for speaking and P = 0.687 for silent). Reusable and disposable drapes were also not significantly different (P = 1.00 for speaking and P = 0.625 for silent). Streptococcus spp., the oropharyngeal microbiota, were only cultivated from speaking scenarios. While refraining from speaking (for both practitioners and patients) is the mainstay of reducing bacterial dispersion and risks of post-injection endophthalmitis, the use of fenestrated surgical drapes or patients' face masks did not significantly affect the amount of bacterial dispersion toward the periorbital area.

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.

Intravitreal injections as a leading cause of acute postoperative endophthalmitis-a regional survey in England

BACKGROUND

To evaluate the characteristics, treatment patterns and outcomes of acute postoperative endophthalmitis.

METHODS

Patients presenting with acute postoperative endophthalmitis between January 2017 to December 2019 were identified from hospital records in this multicentre retrospective cohort study. Clinical records were reviewed for visual acuity (VA) at various timepoints, cause of endophthalmitis, microbiological results, treatments and complications.

RESULTS

Forty-six eyes of 46 patients were included. Intravitreal injections were the leading cause of acute postoperative endophthalmitis (n = 29; 63%), followed by cataract surgery (n = 8; 17%), vitreoretinal surgery (n = 7; 15%), and secondary intraocular lens insertion (n = 2, 4%). The absolute risk of endophthalmitis was 0.024% (1:4132) for intravitreal injections, 0.016% (1:6096) for cataract surgery, and 0.072% (1:1385) for vitreoretinal surgery. The majority of patients (n = 38; 83%) had better VA at 6 months compared to presentation, although fewer (n = 13; 28%) maintained similar or better VA compared to before the precipitating surgery. Twenty-four cases yielded positive culture results, of which staphylococcus epidermidis was the most commonly isolated organism. Microbiological yield was not associated with better final visual outcomes. Patients who underwent therapeutic vitrectomy (n = 15; 33%) had poorer VA at presentation, but subsequently achieved visual outcomes comparable to those who received medical treatment alone. There was no difference in time to presentation, visual outcome and retinal detachment rates among the different causative procedures.

CONCLUSION

Intravitreal injections were the most common cause of endophthalmitis in our region, primarily because of their higher frequency compared to other intraocular procedures. In this cohort, the primary procedure had no effect on presentation, management or visual outcomes.

Ocular surface microbiome in diabetes mellitus

This cross-sectional, age- and gender-matched study included 20 eyes of non-diabetic subjects (non-DM group) and 60 eyes of type 2 diabetes mellitus (DM group). Subgroups of DM were classified by diabetic retinopathy (DR) staging into no DR (DM-no DR), non-proliferative DR (DM-NPDR), proliferative DR (DM-PDR), and by glycemic control (well-controlled DM; HbA1c < 7%, poorly controlled DM; HbA1c ≥ 7%). Conjunctival swabs were performed for ocular surface microbiome analysis using conventional culture and next-generation sequencing analysis (NGS). A higher culture-positive rate was found in DM (15%) than in non-DM group (5%) (p value = 0.437). Pathogenic organisms and antibiotic-resistant strains were detected in the DR groups (DM-NPDR and DM-PDR). The NGS analysis showed that potentially pathogenic bacteria such as Enterobacteriaceae, Neisseriaceae, Escherichia-Shigella, and Pseudomonas predominated in DM, especially in DR. There was dissimilarity in the ocular surface microbiome between DM and non-DM groups. The subgroup analysis showed that the DR group had significantly different microbial community from DM-no DR and non-DM groups (p value < 0.05). The microbial community in the poorly controlled DM was also significantly different from well-controlled DM and non-DM groups (p < 0.001). Using the NGS method, our study is the first to signify the importance of DR and glycemic control status, which affect the changes in the ocular surface microbiome.

Ocular adverse events associated with anti-VEGF therapy: A pharmacovigilance study of the FDA adverse event reporting system (FAERS)

Background: The purpose of this study is to identify and characterize ocular adverse events (AEs) that are significantly associated with anti-VEGF drugs for treatment of neovascular age-related macular degeneration and compare the differences between each drug, and provide clinical reference. Methods: Ocular AEs submitted to the US Food and Drug Administration were analyzed to map the safety profile of anti-VEGF drugs. The Pharmacovigilance tools used for the quantitative detection of signals were reporting odds ratio and bayesian confidence propagation neural network. Results: A total of 10,608,503 AE reports were retrieved from FAERS, with 20,836 for ranibizumab, 19,107 for aflibercept, and 2,442 for brolucizumab between the reporting period of Q1, 2004 and Q3, 2021. We found and analyzed the different AEs with the strongest signal in each drug-ranibizumab-macular ischaemia (ROR = 205.27, IC-2SD = 3.70), retinal pigment epithelial tear (ROR = 836.54, IC-2SD = 7.19); aflibercept-intraocular pressure increased (ROR = 31.09, IC-2SD = 4.61), endophthalmitis (ROR = 178.27, IC-2SD = 6.70); brolucizumab-retinal vasculitis (ROR = 2930.41, IC-2SD = 7.47) and/or retinal artery occlusion (ROR = 391.11, IC-2SD = 6.10), dry eye (ROR = 12.48, IC-2SD = 2.88). Conclusion: The presence of AEs should bring clinical attention. The use of anti-VEGF drugs should be based on the patient's underlying or present medical condition to reduce any adverse event associated with the treatment.

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.

Topical Antibiotic Prophylaxis and Intravitreal Injections: Impact on the Incidence of Acute Endophthalmitis-A Nationwide Study in France from 2009 to 2018

Background: The dramatic increase in intravitreal injections (IVTs) has been accompanied by a greater need for safer procedures. The ongoing debate about topical antibiotic prophylaxis after IVTs emphasizes the importance of large-scale studies. We aimed to study the role of topical antibiotic prophylaxis in reducing the risk of acute endophthalmitis after IVTs. Methods: Population-based cohort study, in France, from 2009 to 2018, including all French patients receiving IVTs of corticosteroids or anti-VEGF agents. Results: A total of 5,291,420 IVTs were performed on 605,434 patients. The rate of topical antibiotic prophylaxis after IVTs progressively decreased during the study period, with a sharp drop in 2014 (from 84.6% in 2009 to 27.4% in 2018). Acute endophthalmitis occurred in 1274 cases (incidence rate = 0.0241%). Although antibiotic prophylaxis did not alter the risk of endophthalmitis (p = 0.06), univariate analysis showed an increased risk after fluoroquinolone and aminoglycoside prophylaxis. This increased risk was not found in multivariate analysis. However, we observed an increased risk related to the use of fixed combinations of fluoroquinolones and aminoglycosides with corticosteroids (IRR = 1.89; 95% CI = 1.57–2.27%, antibiotics combined with corticosteroids). Conclusion: These results are consistent with the literature. Endophthalmitis rates after IVTs did not decrease with topical antibiotic prophylaxis. The use of a combination of antibiotics and corticosteroids doubles the risk of endophthalmitis and should be avoided. Avoiding antibiotic prophylaxis would reduce the costs and the potential risks of antibiotic resistance.

Update on Current Microbiological Techniques for Pathogen Identification in Infectious Endophthalmitis

Infectious endophthalmitis is a vision-threatening medical emergency that requires prompt clinical diagnosis and the initiation of treatment. However, achieving precision in endophthalmitis management remains challenging. In this review, we provide an updated overview of recent studies that are representative of the current trends in clinical microbiological techniques for infectious endophthalmitis.

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.

Cytokine Expression in Staphylococcal and Streptococcal Endophthalmitis

<b><i>Background:</i></b> Endophthalmitis is an infection of ocular tissues, often with devastating outcomes for vision. Immunomodulation is an emerging avenue for therapeutic intervention in endophthalmitis, with the expression of cytokines central to potential mechanisms. This literature review with a systematic approach characterizes the cytokine expression in both animal and human staphylococcal and streptococcal endophthalmitis. <b><i>Method and Results:</i></b> Four online databases were searched for studies profiling cytokine levels in animal models or human populations with staphylococcal and/or streptococcal endophthalmitis. Of the 1,060 articles identified, 14 studies were included in this review comprising eight animal models and six human populations. Mouse, rat, and rabbit models of <i>Staphylococcus aureus</i>, <i>Staphylococcus epidermidis</i>, and <i>Streptococcus pneumoniae</i> endophthalmitis had elevated levels of IL-1β, IL-6, IFN-γ, TNF-α, and IL-8, with earlier peaks observed in <i>S</i>. <i>epidermidis</i> infection. Human endophthalmitis demonstrated significantly increased mediator levels compared to controls for a range of pro-inflammatory and anti-inflammatory cytokines, chemokines, and growth factors. Several associations were established between cytokine concentrations and both initial visual acuity and visual prognosis, with no consistent correlations across trials. <b><i>Conclusions:</i></b> It may be that virulence factors and the combinations of toll-like receptors activated influence the pathogen-specific visual outcomes observed in endophthalmitis. Furthermore, disease severity and potential therapeutic targets may be dependent on synergistic and compensatory cytokine pathways and the expression of anti-inflammatory mediators. Future research should aim to better characterize the roles of inflammatory mediators and solidify associations between pathogens, inflammation, and endophthalmitis outcomes. This has exciting implications for the prevention and treatment of endophthalmitis in clinical settings.

Management Patterns and Outcomes for Intravitreal Injection–Related Endophthalmitis

Purpose:

This work describes the clinical management and outcomes in cases of presumed infectious endophthalmitis following intravitreal injection at a tertiary academic medical center.

Methods:

A retrospective review took place of eyes that presented to the Duke Eye Center over a 9-year period and were diagnosed with intravitreal injection–related endophthalmitis. Clinical presentation, management, microbiologic yield, visual outcomes, and complications were abstracted from medical records.

Results:

Of 23 eyes diagnosed with postinjection endophthalmitis, 52.2% underwent anterior chamber tap (33.3% of which first underwent dry needle vitreous tap), 47.8% underwent needle vitreous tap, 17.4% underwent neither, and none underwent pars plana vitrectomy (PPV) for initial management. Subsequent PPV was performed in 6 eyes (26.1%). Mean visual acuity (VA) improved by 50 Early Treatment Diabetic Retinopathy Study letters at 6 months. Eyes that underwent initial anterior chamber tap had worse presenting VA than those that did not ( P = .01). Eyes undergoing subsequent PPV had worse VA at presentation ( P = .02) and at 6 months ( P < .001). Eyes presenting with VA of hand motion (20/8000) or worse were more likely to undergo subsequent PPV ( P = .02).

Conclusions:

Eyes with intravitreal injection–related endophthalmitis presenting with VA of hand motion or worse were more likely to undergo subsequent PPV. Future studies with larger cohorts may reveal whether earlier vitrectomy should be considered in these patients.

KSI-301: an investigational anti-VEGF biopolymer conjugate for retinal diseases

INTRODUCTION

KSI-301 is an intravitreal anti-vascular endothelial growth factor (VEGF) agent in clinical trials for the treatment of neovascular age-related macular degeneration (nAMD), diabetic retinopathy, diabetic macular edema (DME), and retinal vein occlusion (RVO). Its antibody-biopolymer conjugate structure is designed to decrease clearance from the eye and increase the duration of the effect.

AREAS COVERED

This article briefly discusses the impact and mechanisms of nAMD, DME, and RVO and evaluates currently approved anti-VEGF therapies. It progresses to examine a new agent, KSI-301 and the results from numerous clinical trials in these disease areas.

EXPERT OPINION

Despite varied results in the phase 2b/3 study for nAMD, there is potential for KSI-301 to serve as a durable therapy for VEGF-mediated retinal disorders. Ongoing phase 3 trials for nAMD, DME, and RVO will provide additional evidence on its efficacy, duration, and safety profiles.

Antiseptics and the Ocular Surface: In Vitro Antimicrobial Activity and Effects on Conjunctival and Corneal Epithelial Cells of a New Liposomal Ocular Spray Containing Biosecur® Citrus Extract

Introduction

Methods

Results

Conclusion

Board Certification Is Associated With a Reduced Risk of Endophthalmitis After Intravitreal Injections

Purpose:

This work investigates associations between physician qualifications and the risk of postintravitreal injection endophthalmitis.

Methods:

This retrospective analysis of data from medical claims studied Medicare beneficiaries undergoing 1 or more intravitreal injections between January 1, 2013, and December 31, 2017. Logistic regression analysis was performed to assess whether board certification status or retina subspecialty training was associated with lower risk of postinjection endophthalmitis, controlling for patient's age, race, and sex, type of agent injected, diagnosis, and year of injection. The main outcome measure was odds ratio (OR) of receiving a diagnosis of endophthalmitis in the 14 days after intravitreal injection. Clinical outcome and quality of care were not evaluated in this study.

Results:

A total of 2 907 324 intravitreal injections were performed on 219 640 patients by 4315 ophthalmologists, 3196 (74%) of whom were retina specialists and 4021 (92%) of whom were certified by the American Board of Ophthalmology (ABO). Overall, there were 1088 (0.037%) cases of postinjection endophthalmitis, of which 1024 (0.037%) were injected by ABO-certified ophthalmologists and 64 (0.050%) by non–board-certified ophthalmologists. Injections by ABO-certified ophthalmologist had 28% reduced odds of endophthalmitis (OR = 0.72; 95% CI, 0.523-0.996, P = .05). Higher odds of endophthalmitis were observed for corticosteroid injections (OR = 3.91; 95% CI, 2.75-5.56, P < .001) and aflibercept injections (OR = 1.47; 95% CI, 1.19-1.80, P < .001). Patients' sex and race, the diagnosis associated with the injection, and providers' retina subspeciality training were not associated with the rate of endophthalmitis ( P < .20 for all comparisons).

Conclusions:

We found evidence that endophthalmitis may be reduced when ABO-certified physicians perform an intravitreal injection.

Exudative versus Nonexudative Age-Related Macular Degeneration: Physiopathology and Treatment Options

Age-related macular degeneration (AMD) is an eye disease typically associated with the aging and can be classified into two types—namely, the exudative and the nonexudative AMD. Currently available treatments for exudative AMD use intravitreal injections, which are associated with high risk of infection that can lead to endophthalmitis, while no successful treatments yet exist for the nonexudative form of AMD. In addition to the pharmacologic therapies administered by intravitreal injection already approved by the Food and Drug Administration (FDA) in exudative AMD, there are some laser treatments approved that can be used in combination with the pharmacological therapies. In this review, we discuss the latest developments of treatment options for AMD. Relevant literature available from 1993 was used, which included original articles and reviews available in PubMed database and also information collected from Clinical Trials Gov website using “age-related macular degeneration” and “antiangiogenic therapies” as keywords. The clinical trials search was limited to ongoing trials from 2015 to date.

Safety Measures for Maintaining Low Endophthalmitis Rate after Intravitreal Anti-Vascular Endothelial Growth Factor Injection before and during the COVID-19 Pandemic

During the COVID-19 pandemic, intravitreal injections are performed with patients wearing masks. The risk of endophthalmitis after intravitreal injection is reported to increase due to an influx of exhaled air containing oral bacteria from the upper part of the mask onto the ocular surface. We retrospectively investigated the incidence of endophthalmitis when intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections were performed using the same infection control measures before and during the pandemic. Vitreoretinal specialists performed intravitreal injections of anti-VEGF agents in the outpatient room of a university hospital. Infection control measures before and during the pandemic included covering the patient’s eye with adhesive face drape and irrigating the ocular surface with 0.25% povidone-iodine before draping, and immediately before and after injection. Before the COVID-19 pandemic (February 2016 to December 2019), one case of endophthalmitis occurred among 31,173 injections performed (0.0032%; 95% confidence interval (CI), 0.000008–0.017872%). During the COVID-19 pandemic (January 2020 to August 2021), one case of endophthalmitis occurred among 14,725 injections performed (0.0068%; 95% CI, 0.000017–0.037832%). There was no significant difference between the two periods (Fisher’s exact test: p = 0.5387). Even during the COVID-19 pandemic, very low incidence of endophthalmitis after intravitreal injection can be maintained by implementing basic infection prophylactic measures, including face draping and 0.25% povidone-iodine irrigation, established before COVID-19 pandemic.

CLINICAL CHARACTERISTICS AND VISUAL OUTCOMES IN ENDOPHTHALMITIS AFTER KERATOPROSTHESIS IMPLANTATION

PURPOSE

To describe the presentation, microbiology, management, and prognosis of eyes with endophthalmitis after Boston keratoprosthesis implantation.

METHODS

Retrospective case series with history, diagnostics, management, and outcomes data in endophthalmitis after keratoprosthesis implantation presenting to a tertiary center between 2009 and 2020.

RESULTS

Of 137 keratoprosthesis-implanted eyes, 7 eyes of 7 patients (5%) developed endophthalmitis. On presentation, 6 (86%) reported decreased visual acuity, and only 1 (14%) reported pain. Peripheral corneal ulcers were present in 2 eyes (29%). Seidel testing was negative in all cases. Six eyes (86%) had retroprosthetic membranes. One (14%) underwent initial pars plana vitrectomy with mechanical vitreous biopsy, whereas 6 (86%) received a needle vitreous tap-half of which were dry. Organisms were isolated after vitreous tap in two eyes: Streptococcus intermedius and Mycobacterium abscessus. The mean visual acuity preendophthalmitis, at presentation, and at 6 months were 20/267, 20/5,944, and 20/734, respectively. The visual acuity improved 9.08 ± 11.78 Early Treatment Diabetic Retinopathy Study lines from presentation to 6 months. Six-month visual acuity was correlated with preendophthalmitis visual acuity (r = 0.92, P = 0.003) but not presenting visual acuity (P = 0.838).

CONCLUSION

Visual acuity at 6 months is correlated with preendophthalmitis visual acuity, not presenting visual acuity. Endophthalmitis should be considered in the differential diagnosis of painless intraocular inflammation any time after keratoprosthesis implantation, even if Seidel negative.

Analysis of urgent follow up visits and complications after intravitreal injections: a retrospective cohort study

BACKGROUND

Intravitreal injections (IVIs), a common treatment in ophthalmology, result in acute complications and urgent follow-up visits causing significant burden to both patient and physician. We evaluated the incidence of acute complications following IVIs which occurred within seven days of injection.

METHODS

A retrospective cohort study conducted at a private retinal practice, in Cleveland, Ohio. Using the practice management software database, we examined 73,286 injections of patients with unscheduled or urgent visits within 7 days of an injection from August 1st,2018 to August 1st,2020. Data collected included: age, gender, eye, medication injected, diagnosis, reason for urgent follow-up, time between injection and urgent follow-up, and type of anesthesia administered. Data was analyzed using SPSS v.28 (SPSS Inc., Chicago IL).

RESULTS

Study included 73,286 injections, with 441 injections (n = 441) resulting in urgent follow-up visits (0.60%). Mean patient age was 72.1 (± 30.4) years, with 187 male (42.4%) and 254 female (57.6%) patients. IVI medications included: aflibercept (60.3%), ranibizumab (22.4%), bevacizumab (13.4%), dexamethasone intravitreal implant (2%), triamcinolone acetonide (1.6%) brolucizumab (1.59%), fluocinolone acetonide intravitreal implant 0.19 mg (0.2%), and fluocinolone acetonide intravitreal implant 0.18 mg (0.03%) (Table 1). Medications associated with urgent visits included: aflibercept (42.9%), bevacizumab (37.4%), ranibizumab (7.9%), dexamethasone intravitreal implant (6.8%), brolucizumab (2.7%), and triamcinolone acetonide (2.3%) (Table 2). Days between injection and urgent follow-up was on average 3.96 ± 2.14 days. Urgent follow-ups included blurred vision in 164 patients (37.2% of urgent visits), flashes, floaters or posterior vitreous detachment (PVD) in 55 (12.5%), pain in 42 (9.5%), 43 (9.8%) corneal abrasions, 33 (7.5%) subconjunctival hemorrhages, corneal dryness or foreign body sensation in 30 (6.6%), endophthalmitis in 20 (4.5%), 18 (4.1%)vitreous hemorrhages, iritis or uveitis in 11 (2.5%), miscellaneous complications in 9 (2.0%), 7 (1.6%) elevated intraocular pressures, choroidal neovascular membrane in 4 (0.9%), 4 (0.9%) retinal detachments or tears, and 2 (0.45%) traumatic cataracts (Table 3).

CONCLUSION

IVIs resulted in 0.60% urgent/unscheduled follow-up visits within 7 days of injection. Most common causes were blurred vision and symptoms of PVD.

Analysis of retinal detachment resulted from post-operative endophthalmitis treated with 23G pars Plana Vitrectomy

Background

To evaluate the rate, risk factors, functional outcome and prognosis in eyes with retinal detachment after post-operative endophthalmitis treated with 23G Pars Plana Vitrectomy.

Methods

Electronic patient files from 2009 until 2018 were screened for the presence of an endophthalmitis. Included were 116 eyes of 116 patients. This population was evaluated for the rate of retinal detachment after 23G Pars Plana Vitrectomy for endophthalmitis following cataract surgery or intravitreal injection. The main outcome measures were retinal detachment and visual acuity.

Results

The reasons for endophthalmitis were previous cataract surgery in 78 patients and following intravitreal injection in 38 patients. The first clinical evidence of endophthalmitis was present in median 5 days after the triggering intervention. Twenty-five eyes (21.55%) developed a retinal detachment an average of 25 days after endophthalmitis. RD is significantly associated with preoperative visual acuity (p = 0.001).

Conclusions

We emphasize the prognostic role of preoperative visual acuity in RD development of the endophthalmitis treated with 23G Pars Plana Vitrectomy.

ENDOPHTHALMITIS AFTER INTRAVITREAL INJECTIONS DURING THE COVID-19 PANDEMIC WITH IMPLEMENTATION OF UNIVERSAL MASKING

PURPOSE

To evaluate the rates of postintravitreal injection-related endophthalmitis during the COVID-19 pandemic with institution of both physician and patient face masking.

METHODS

All eyes receiving intravitreal injections of any kind from a single large tertiary retina practice in Houston, TX before (August 2017-March 22, 2020) and after (March 23, 2020-September 2020) COVID-19 pandemic universal masking protocols. The total number of injections and cases of acute injection-related endophthalmitis were determined from billing records and subsequent retrospective chart review. The primary outcome was the rate of endophthalmitis after intravitreal injection. Secondary outcomes included visual acuity, time until initial presentation, patient age, and differences in the overall number of injections performed monthly pre-COVID-19 and post-COVID-19.

RESULTS

A total of 134, 097 intravitreal injections were performed during the study period (111,679 pre-COVID-19 and 22,418 post-COVID-19 masking protocols). A total of 41 cases of acute endophthalmitis occurred in the pre-COVID group (0.04%, one in 2,500) and 7 cases in the post-COVID group (0.03%, one in 3,333) P = 0.85.

CONCLUSION

In this single center, retrospective study, the implementation of universal patient and physician masking as practiced during the COVID-19 pandemic did not significantly affect the rate of postintravitreal injection endophthalmitis.

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.

Efficacy of a New Commercial Ocular Spray Containing Oftasecur Citrus Extract for Reducing Microbial Load in the Conjunctiva of Patients Receiving Intravitreal Injections

INTRODUCTION

The control of conjunctival microbial load is crucial for patients receiving intravitreal injections (IVTs) in order to reduce the risk of endophthalmitis. The purpose of this work was to assess the antimicrobial activity of a new commercial ocular spray containing Biosecur citrus extract (Oftasecur^®, Off Health, Florence, Italy).

METHODS

This prospective cross-sectional pilot study included patients receiving IVTs who were instructed to apply Oftasecur spray onto the eye to be injected four times daily starting 4 days before surgery. The contralateral eye was considered the control. A conjunctival swab for microbiological analysis was performed in both eyes before starting study treatment and at the time of the injection. The Brief Ocular Discomfort Inventory (BODI) questionnaire was administered to patients based on an 11-point scale (0 for no discomfort and 10 for maximum discomfort).

RESULTS

Thirty patients (15 male, 15 female; mean age 64.7 ± 11.6 [standard deviation, SD] years) were included. Before starting treatment, 53.3% of the total eyes tested positive during the microbiological analysis. After the treatment period, only 20% of the eyes tested positive at the time of injection, showing a significant reduction in the microbial load (p < 0.01). Moreover, in the treated arm, the positive swabs before and after the prophylactic treatment with Oftasecur ocular spray showed a significant reduction (from 70.4% to 29.6%; p = 0.003, McNemar's test). Oftasecur ocular spray was well tolerated, with an average BODI score of 1.2 (± 0.70 SD).

CONCLUSION

Oftasecur ocular spray showed antimicrobial activity that significantly reduced the microbial load in patients receiving intravitreal injections. Therefore, it may have a role in the prophylaxis of infection in the setting of IVTs.

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.

Intravitreal Injection Therapy: Current Techniques and Supplemental Services

Purpose:

Intravitreal injection is the most frequently performed eye procedure in the world and is an essential component in the management of sight-threating retinal diseases and conditions. Given the seriousness and range of diseases treated and the risks of the procedure, retina specialists must weigh the pros and cons of each individual treatment. Complexities guiding injection treatment are multifaceted and involve patient-history review, careful examination, diagnostic testing selection and interpretation, customized medical decision-making, and follow-up considerations.

Methods:

This article by the Intravitreal Injection Task Force Committee of the American Society of Retina Specialists documents the intricacies and necessary components of the intravitreal injection procedure.

Results:

By expert consensus, the task force further recommends ancillary services and decision-making that may accompany intravitreal injection visits, when appropriate, to monitor response to treatment, adjust treatment, and manage additional considerations in the same or fellow eye.

Conclusions:

Retina specialists can optimize safety and therapeutic outcomes with individualized consideration and customization of intravitreal injection treatment for each patient.

Lidocaine Gel Interferes With the Antibacterial Activity of Povidone-Iodine

BACKGROUND AND OBJECTIVE

Retina specialists use lidocaine gel as a topical anesthetic. We determined the antibacterial interaction between povidone-iodine (PI) and lidocaine gel using corneoscleral tissue as a solid phase medium.

MATERIALS AND METHODS

Five pieces of corneoscleral tissue in five trials were inoculated with 1.000 colony-forming units of bacteria isolated from endophthalmitis. Inoculated corneal tissue were overlaid with nothing (control), lidocaine gel, 5% PI, lidocaine gel over 5% PI, and 5% PI over lidocaine gel for 5 minutes prior to placement in growth liquid medium at 37°C. Growth was monitored for 48 hours.

RESULTS

Application of lidocaine gel prior to 5% PI application provided for the growth of the five bacterial isolates, whereas 5% PI prior to lidocaine gel prevented growth.

CONCLUSION

Using corneoscleral tissue, PI and lidocaine gel appear to have an antagonistic interaction when lidocaine gel is applied initially prior to 5% PI, preventing bactericidal activity of PI. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:S13-S16.].

Rates of Suspected Endophthalmitis Following Intravitreal Injections in Clinical Practices in the United States

BACKGROUND AND OBJECTIVE

To evaluate rates of suspected endophthalmitis following intravitreal injections of aflibercept, bevacizumab, ranibizumab (vial and pre-filled), dexamethasone implant, and triamcinolone in clinical practice.

PATIENTS AND METHODS

Retrospective study of aggregated electronic medical records from the Vestrum Health Database. Eyes with a diagnosis of suspected endophthalmitis based on billing codes between January 2013 and June 2019 were included.

RESULTS

Total number of injections, suspected endophthalmitis cases, and medication rate, respectively, were: aflibercept (1,412,699; 687; 0.049%); bevacizumab (1,467,722; 379; 0.026%); ranibizumab vial (884,061; 233; 0.026%), ranibizumab pre-filled (427,763; 96; 0.022%); dexamethasone implant (49,464; 53; 0.107%); and triamcinolone (75,038; 110; 0.147%). Rates were lower for bevacizumab and ranibizumab (vial and pre-filled) compared to aflibercept, dexamethasone implant, and triamcinolone (P < .05). Triamcinolone had a higher rate compared to all of the other medications (P < .05).

CONCLUSIONS

Suspected endophthalmitis rates following anti-vascular endothelial growth factor injections in clinical practice were similar to reported rates in clinical trials. Rates of suspected endophthalmitis following steroid injections trended higher with significantly higher rates with triamcinolone. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:312-318.].

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.].

Effect of Taping Face Masks on Quantitative Particle Counts Near the Eye: Implications for Intravitreal Injections in the COVID-19 Era

Purpose

To determine the effect of taping the top of face masks on air particle counts directed toward the eye during simulated intravitreal injections.

Design

Prospective observational crossover study.

Methods

Thirteen healthy subjects were recruited. Each wore a cloth, surgical, or N95 mask in randomized order. The number of air particles were quantified by using a particle counter suspended over the right eye while each subject breathed normally, deeply, or spoke using a standardized script. Particle counts were obtained with the top of each mask taped and not taped. The main outcome measurements were particle counts of 0.3, 0.5, 1, 3, 5, and 10 μm and total particle counts.

Results

Taping cloth masks while subjects were speaking significantly reduced particle counts for the 0.3- (P = .03), 0.5- (P = .01), and 1-μm (P = .03) particles and total particle counts (P = .008) compared to no taping. Taping the top of cloth masks during normal or deep breathing did not significantly affect particle counts compared to no taping. Taping the top of surgical or N95 masks did not significantly alter particle counts for any breathing condition tested.

Conclusions

Taping the top of cloth masks prior to simulated intravitreal injections significantly reduced air particle counts directed toward the eye when subjects were speaking compared to no taping. This may have implications for decreasing air particles reaching the eye during intravitreal injections, including aerosolized droplets from a patient's mouth that may carry oral pathogens.

Microbial Spectrum and Antibacterial Susceptibility of Endophthalmitis Cultures in a Tertiary Referral Center in the Midwestern United States: An Analysis From 295 Patients

Purpose:

This work evaluates the microbial spectrum and antibiotic susceptibility pattern of endophthalmitis cases in a large tertiary referral center in the Midwestern United States.

Methods:

This retrospective case series included patients with clinically diagnosed endophthalmitis between April 14, 2006 and April 14, 2016, in whom ocular samples were submitted to the Microbiology Department at Indiana University. The patients were assessed by 11 vitreoretinal surgeons from 6 different sites in Indianapolis, including Indiana University and private practices, who receive patients from urban, suburban, and rural agricultural areas. Submitted specimens were cultured with the following media: blood agar, chocolate agar, MacConkey agar, and thioglycolate broth.

Results:

A total of 327 specimens from 295 patients were analyzed, with 96 (32.5%) samples from 90 (30.5%) patients meeting the criteria of confirmed growth. Of these 96 positive specimens, 83 (86.5%) organisms were identified as bacterial, and 13 (13.5%) were identified as fungal. Coagulase-negative Staphylococcus was the most common isolate (37.5%). Fifty gram-positive isolates and 10 gram-negative isolates underwent susceptibility testing. All 40 of the gram-positive isolates tested for vancomycin sensitivity were susceptible, whereas all 7 of the gram-negative isolates tested for ceftazidime sensitivity were susceptible.

Conclusions:

Empiric treatment with vancomycin and ceftazidime remains appropriate in most cases of endophthalmitis in the Midwestern United States, with 100% susceptibility of bacterial organisms tested with these antibiotics in this series. The high fungal culture rates in this study highlight the utility of obtaining vitreous cultures and potential need for antifungal agents in suspicious cases.