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Ghalibafan S, Flynn HW, Yannuzzi NA. Changes in Rates of Postprocedural Endophthalmitis and Treatments. JAMA Ophthalmol 2024:2821943. [PMID: 39088210 DOI: 10.1001/jamaophthalmol.2024.2805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Affiliation(s)
- Seyyedehfatemeh Ghalibafan
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Harry W Flynn
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Nicolas A Yannuzzi
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
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Liddle C, Capone A, Trese M. PATIENT-PHYSICIAN FACE MASKING'S INFLUENCE ON THE POST-INTRAVITREAL INJECTION ENDOPHTHALMITIS. Retina 2024; 44:1203-1208. [PMID: 38363792 DOI: 10.1097/iae.0000000000004072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
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.
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Affiliation(s)
- Conner Liddle
- Department of Ophthalmology, Oakland University William Beaumont School of Medicine, Rochester, Michigan; and
| | - Antonio Capone
- Department of Ophthalmology, Oakland University William Beaumont School of Medicine, Rochester, Michigan; and
- Department of Ophthalmology, Associated Retinal Consultants, Royal Oak, Michigan
| | - Matthew Trese
- Department of Ophthalmology, Oakland University William Beaumont School of Medicine, Rochester, Michigan; and
- Department of Ophthalmology, Associated Retinal Consultants, Royal Oak, Michigan
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Pakravan P, Patel V, Lai J, Shaheen A, Kalahasty K, Reyes-Capo DP, Chau V, Rosenfeld PJ, Haddock LJ, Schwartz SG, Smiddy WE, Kovach JL, Sridhar J, Flynn HW, Albini TA, Yannuzzi NA. INTRAOCULAR INFLAMMATION INCIDENCE AFTER INTRAVITREAL BROLUCIZUMAB INJECTION FOR EXUDATIVE AGE-RELATED MACULAR DEGENERATION. Retina 2023; 43:1717-1722. [PMID: 37320859 DOI: 10.1097/iae.0000000000003862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
PURPOSE We evaluated the clinical outcomes of intraocular inflammation (IOI) of eyes with neovascular age-related macular degeneration (AMD) injected with brolucizumab in our tertiary referral center. METHODS A retrospective case series for which clinical records of all eyes that received intravitreal brolucizumab at Bascom Palmer Eye Institute between December 1, 2019, and April 1, 2021, were reviewed. RESULTS There were 345 eyes of 278 patients who received 801 brolucizumab injections. IOI was detected in 16 eyes of 13 patients (4.6%). In those patients, baseline Logarithm of Minimu Angle of Resolution (logMAR) best-corrected visual acuity was 0.32 0.2 (20/42), while it was 0.58 0.3 (20/76) at IOI presentation. The mean number of injections among eyes experiencing IOI was 2.4, and the interval between the last brolucizumab injection and IOI presentation was 20 days. There was no known case of retinal vasculitis. Management of IOI included topical steroids in seven eyes (54%), topical and systemic steroids in five eyes (38%), and observation in one eye (8%). Best-corrected visual acuity returned to baseline and inflammation resolved in all eyes by the last follow-up examination. CONCLUSION Intraocular inflammation after brolucizumab injection for neovascular AMD was not uncommon. Inflammation resolved in all eyes by the last follow-up visit.
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Affiliation(s)
- Parastou Pakravan
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
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Montolío-Marzo S, Vidal-Oliver L, Montolío-Marzo E, Dolz-Marco R, Gallego-Pinazo R. Differential diagnosis of endophthalmitis after intravitreal drug injection for age related macular degeneration: Sterile vs. infectious. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2023:S2173-5794(23)00091-9. [PMID: 37285959 DOI: 10.1016/j.oftale.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/13/2023] [Indexed: 06/09/2023]
Abstract
The recent release of brolucizumab and the development of new antiangiogenic molecules as abicipar pegol has increased the interest towards inflammatory complications after intravitreal drug injection. Those drugs are associated to a higher rate of inflammatory adverse events compared to classic drugs. In this context it is essential to differentiate between sterile and infectious cases for a fast and effective treatment. The clinical similarities between infectious and sterile cases, the high rate of culture negative patients and the heterogeneity in the terminology used are obstacles for a correct diagnosis and report of these complications. Sterile cases appear early after the injection, before 48 hours; or 20 days after in brolucizumab-related vasculitis cases. Infectious cases show up around the third day after injection and up to a week after it. A severe visual impairment, severe pain, severe hyperemia, hypopyon and a more severe intraocular inflammatory process are signs of a likely infectious origin. If the cause of the inflammation is uncertain we must follow up the patient closely or "tap and inject" antimicrobial agents in order to prevent the eventual complications of an infectious endophthalmitis. On the other hand, sterile endophthalmitis might be observed in mild cases or treated with steroids according to the severity of the inflammation.
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Baumal CR, Sørensen TL, Karcher H, Freitas RL, Becher A, Balez S, Clemens A, Singer M, Kodjikian L. Efficacy and safety of brolucizumab in age-related macular degeneration: A systematic review of real-world studies. Acta Ophthalmol 2023; 101:123-139. [PMID: 36117281 DOI: 10.1111/aos.15242] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 06/30/2022] [Accepted: 08/19/2022] [Indexed: 12/01/2022]
Abstract
Intravitreally injected anti-vascular endothelial growth factor (anti-VEGF) agents are first-line treatment for neovascular age-related macular degeneration (nAMD). Phase 3 trials demonstrated non-inferiority of anti-VEGF therapy with brolucizumab compared with aflibercept in best corrected visual acuity (BCVA) gains, with superior anatomical outcomes after brolucizumab. The purpose of the review was to summarize real-world efficacy and safety data on brolucizumab in patients with nAMD. The review protocol was registered with PROSPERO (ID: CRD42021290530). We conducted systematic searches in Embase, Medline and key ophthalmology congress websites (19 October 2021). Original reports of efficacy and/or safety in patients receiving brolucizumab to treat nAMD in clinical practice were eligible. The descriptive summary includes reports describing at least 10 brolucizumab-treated eyes. In total, 2907 brolucizumab-treated eyes from 26 studies were included. Outcomes were available for treatment-naive eyes (six studies), eyes switched to brolucizumab from other anti-VEGFs (16 studies), and/or treatment-naive and switch eyes combined (eight studies). Follow-up time points ranged from 4 weeks to 1 year post-brolucizumab initiation. For BCVA, significant improvements compared with brolucizumab initiation were reported in four of six studies in treatment-naive eyes (mean BCVA improvement, range: +3.7 to +11.9 Early Treatment Diabetic Retinopathy Study [ETDRS] letters) and in three of 12 studies in switch eyes (range: +9.0 to +15 ETDRS letters) (all p < 0.05); remaining studies reported no significant post-brolucizumab BCVA changes. For central subfield thickness (CST), improvements post-brolucizumab initiation were reported in all six studies in treatment-naive eyes (mean CST improvement, range: -113.4 to -150.1 μm) and in eight of 11 studies in switch eyes (range: -26 to -185.7 μm) (all p < 0.05). The 14 studies reporting on intraretinal, subretinal and/or total fluid observed improvements post-brolucizumab initiation. The four studies comparing treatment intervals observed extension of the interval between injections after switching to brolucizumab from other anti-VEGFs. Incidence of intraocular inflammation ranged from 0% to 19%. In conclusion, real-world efficacy and safety data concur with brolucizumab pivotal trials. Additionally, reduction of disease activity in anti-VEGF switch eyes was demonstrated by fluid reduction and/or visual acuity gain, along with prolongation of the interval between injections.
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Affiliation(s)
- Caroline R Baumal
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Torben Lykke Sørensen
- University of Copenhagen, Copenhagen, Denmark.,Department of Ophthalmology, Zealand University Hospital Roskilde, Roskilde, Denmark
| | | | - Rita L Freitas
- Novartis Farma - Produtos Farmacêuticos, S.A., Porto Salvo, Portugal
| | | | | | - Andreas Clemens
- Novartis Pharma AG, Basel, Switzerland.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Singer
- University of Texas Health Science Center and Medical Center Ophthalmology, San Antonio, Texas, USA
| | - Laurent Kodjikian
- University of Lyon and Croix-Rousse University Hospital UCBL, INSA Lyon, CNRS, MATEIS, UMR5510, Hospices Civils de Lyon, Lyon, France
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Schwartz SG, Flynn HW, Smiddy WE. Infectious Endophthalmitis vs Noninfectious "Pseudohypopyon" After Intravitreal Triamcinolone Acetonide. JOURNAL OF VITREORETINAL DISEASES 2023; 7:178-181. [PMID: 37006659 PMCID: PMC10037753 DOI: 10.1177/24741264231153027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Introduction: To describe a patient who presented with visual loss and an apparent hypopyon but none of the other symptoms or signs most common with infectious endophthalmitis. Methods: A case and its findings were analyzed. Results: A 73-year-old woman was treated with intravitreal triamcinolone acetonide (IVTA) for cystoid macular edema. The eye had 12 previous injections without complication. After the 13th injection, the patient noted painless visual loss. An examination showed a visual acuity (VA) of finger counting and an apparent hypopyon, which shifted after a head-tilt test, suggesting a noninfectious "pseudohypopyon." Two days later, the VA worsened to hand motions and the hypopyon had increased in size. The eye was treated with a vitreous tap and injection with vancomycin and ceftazidime. The inflammation resolved, VA improved to 20/40, and cultures showed no growth. Conclusions: Distinguishing infectious endophthalmitis from noninfectious inflammation remains challenging. There is no definitive technique by which to distinguish between the 2 conditions; thus, clinicians must use their best judgment and follow the patient closely.
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Affiliation(s)
- Stephen G. Schwartz
- Department of Ophthalmology, Bascom Palmer
Eye Institute, University of Miami Miller School of Medicine, Naples, FL, USA
| | - Harry W. Flynn
- Department of Ophthalmology, Bascom Palmer
Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - William E. Smiddy
- Department of Ophthalmology, Bascom Palmer
Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
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Merani R, Johnson MW, McCannel CA, Flynn HW, Scott IU, Hunyor AP. Clinical Practice Update: Management of Infectious Endophthalmitis After Intravitreal Anti-VEGF Injection. JOURNAL OF VITREORETINAL DISEASES 2022; 6:443-451. [PMID: 37009541 PMCID: PMC9954776 DOI: 10.1177/24741264221116487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Rohan Merani
- Concord Repatriation General
Hospital, Sydney, NSW, Australia
- Save Sight Institute, Specialty
of Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health,
University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health
Sciences, Macquarie University, Sydney, NSW Australia
| | - Mark W. Johnson
- Department of Ophthalmology and
Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, MI,
USA
| | - Colin A. McCannel
- UCLA Stein Eye Institute;
Department of Ophthalmology, David Geffen School of Medicine at UCLA,
University of California, Los Angeles, CA, USA
| | - Harry W. Flynn
- Department of Ophthalmology,
Bascom Palmer Eye Institute, Miami, FL, USA
| | - Ingrid U. Scott
- Departments of Ophthalmology and
Public Health Sciences, Penn State College of Medicine, Hershey,
Philadelphia, PA, USA
| | - Alex P. Hunyor
- Save Sight Institute, Specialty
of Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health,
University of Sydney, Sydney, NSW, Australia
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Herwig-Carl MC, Holz F, Löffler KU. [Ophthalmopathologic Aspects of Endophthalmitis]. Klin Monbl Augenheilkd 2022; 239:867-875. [PMID: 35858597 DOI: 10.1055/a-1782-8061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Endophthalmitis is one of the most severe ophthalmic emergencies. Most patients experience a permanent decrease in visual acuity after the event, but the eye can be preserved in most cases. However, when the eye is enucleated after endophthalmitis, ophthalmopathologic investigation of the globe with respect to the clinical history can provide valuable information regarding the ultimately frustrating course of the disease that can be helpful for the treatment of future patients. Often, valuable aspects also emerge with regard to the therapeutic approach. For example, in therapy-resistant fungal endophthalmitis the necessity of penetrating keratoplasty with a large graft diameter and possibly even removal of the lens including the capsular bag should be stressed. In the following, five enucleated eyes with a different spectrum of endophthalmitis, as well as different potential pathways of exogenous and endogenous endophthalmitis, are illustrated clinically and ophthalmopathologically. In summary, endophthalmitis requires urgent intervention; however, various differential diagnoses must be excluded. Histopathologic examination of enucleated eyes is helpful for understanding the course of the disease and may also have forensic significance.
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Affiliation(s)
| | - Frank Holz
- Universitäts-Augenklinik, Universitätsklinikum Bonn, Deutschland
| | - Karin U Löffler
- Universitäts-Augenklinik, Universitätsklinikum Bonn, Deutschland
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The Pandemic Is Not Associated with Endophthalmitis Decrease after Anti-Vascular Endothelial Growth Factor Injections. Ophthalmology 2022; 129:719-721. [PMID: 35041903 PMCID: PMC8813207 DOI: 10.1016/j.ophtha.2022.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/22/2021] [Accepted: 01/10/2022] [Indexed: 01/13/2023] Open
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