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Visual acuity regained with antibiotics alone after endophthalmitis
Ninety percent of patients in the antibiotics-only group recovered visual acuity within one line of baseline.
Patients who contracted endophthalmitis after receiving intravitreal anti-VEGF injection were more likely to regain vision if they only needed a vitreous tap and injection of intravitreal antibiotics rather than a tap, antibiotics and subsequent pars plana vitrectomy, according to a study.
Investigators found that 90% of patients in the tap and injection group achieved best corrected visual acuity within one line of baseline vision as opposed to only 46% of patients in the combination tap, injection and subsequent vitrectomy group.
“One of the most important studies in recent history is the Endophthalmitis Vitrectomy Study, which looked at treatment interventions for patients who were diagnosed with endophthalmitis following cataract surgery,” principal investigator Khurram M. Chaudhary, MD, told Ocular Surgery News.“Most retinal surgeons extended these study findings to patients with bleb-related endophthalmitis, post-injection endophthalmitis, endogenous endophthalmitis, etc. However, there have not been any major studies on a large scale looking at these different diseases.”
Given the administration route of anti-VEGF agents, Chaudhary and colleagues surmised that the source of the infection would be in the vitreous and that patients with endophthalmitis after these injections would benefit more from intravitreal antibiotics and pars plana vitrectomy than from a tap and injection of intravitreal antibiotics without vitrectomy.
Predicting progression
The study, published in Retina, retrospectively reviewed the medical records of all patients treated for endophthalmitis at Long Island Vitreoretinal Consultants from January 2007 to December 2011. The authors identified 23 patients who met the criteria of endophthalmitis after receiving intravitreal anti-VEGF injection.
Among these 23 patients, 10 were treated with tap and injection and 13 with the tap, injection and vitrectomy combination. The median time from last injection to presentation of symptoms was 4 days.
“It was difficult to deduce predictive factors for advancing to vitrectomy,” Chaudhary said. “For example, some patients who presented with pain did well with a tap and injection, while others required vitrectomy. This applied to patients who presented with a hypopyon, as well.”
Still, more patients in the vitrectomy group had a vision of counting fingers or worse at presentation. Median follow-up was 15 months.
There were nine culture positive cases; eight of them ended up in vitrectomy.
“When analyzing our data, we observed that positive cultures may indicate a worse prognosis,” Chaudhary said. “Patients who were culture-positive, especially if they were positive for Streptococcus species and methicillin-susceptible Staphylococcus aureus, were significantly less likely to recover baseline VA than were culture-negative patients. While a positive culture may indicate a more virulent infection, our study is not sufficiently powered to determine if the clinical decision to proceed with vitrectomy can be based on culture results alone.”
Unexpected findings
The study’s findings failed to support the authors’ hypothesis that early vitrectomy accelerates visual recovery or leads to a better overall final outcome.
“We thought that if patients underwent vitrectomy, the scaffold for the bacteria to grow on would be removed and, thus, the infection would be cleared at a faster rate,” Chaudhary said. “But this was not the case. However, we would still recommend early vitrectomy for those cases with vision of light perception or worse at presentation, as recommended by the Endophthalmitis Vitrectomy Study.”
Intravitreal injections were obtained from different lots over the 5-year period. Nineteen patients received Avastin (bevacizumab, Genentech) injections and four patients received Lucentis (ranibizumab, Genentech) injections.
“However, we are unable to come to any specific conclusion about safety, due to the small size of our cohort,” Chaudhary said.
In this series, the incidence of post-intravitreal injection endophthalmitis is rare, 0.035%. To decrease the likelihood of endophthalmitis, sterilization is key, according to Chaudhary.
“The use of a sterile or clean lid speculum and 0.5% povidone-iodine solution is important to diminish the incidence,” Chaudhary said. “My mentors have also advised that neither physician nor patient should talk while the injection is being administered. This may decrease the incidence of endophthalmitis following intravitreal injections.” – by Bob Kronemyer