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Anti-VEGF re-injection protocols differ after endophthalmitis
In the United States, a tap-and-inject strategy or vitrectomy is standard practice in most cases of post-injection endophthalmitis.
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Patients received fewer anti-VEGF injections after being diagnosed with post-injection endophthalmitis than before diagnosis, a speaker told colleagues at the American Society of Retina Specialists meeting in San Francisco.
Additionally, tap and injection of intraocular antibiotics yielded slightly better final visual acuity than vitrectomy, but the difference was not statistically significant, Yicheng Chen, MD, said.
In a subsequent interview with Ocular Surgery News, Chen said that either tap and injection or vitrectomy is generally standard practice in cases of post-injection endophthalmitis.
“Standard practice is to err on the side of caution. If you suspect endophthalmitis, you do the tap and inject or vitrectomy,” Chen said.
Patients
Chen and colleagues set out to gauge the outcomes of treatment protocols used in eyes with post-injection endophthalmitis.
The retrospective study included medical records of 158 patients from 10 major ophthalmology centers who received intravitreal anti-VEGF injections, developed endophthalmitis and had at least 3 months of follow-up time. Patients with a recent history of ocular surgery, those who received non-anti-VEGF intravitreal injections at the time of diagnosis, and those who received initial treatment for endophthalmitis at a different institution were excluded from the analysis.
The mean interval from injection to presentation of endophthalmitis was 4.53 days (median 3 days). The mean number of injections before endophthalmitis diagnosis was nine.
Fifty percent of cultures tested positive for microbial infection.
Mean follow-up was 279 weeks, with a median interval of 82 weeks. Average visual acuity before endophthalmitis was 20/70 in the affected eye.
Seventy-one percent of patients with post-injection endophthalmitis and counting fingers visual acuity underwent a tap-and-inject protocol with intraocular antibiotics and 29% underwent vitrectomy. Five patients had light perception vision in the tap-and-inject group. In the vitrectomy group, 14 patients had light perception vision and one had no light perception.
Among patients with hand motion vision or better, visual acuity at 3 months after diagnosis of endophthalmitis was 20/200 in the tap-and-inject group and 20/400 in the vitrectomy group. Final visual acuity was 20/200 in the tap-and-inject group and 20/400 in the vitrectomy group.
Anti-VEGF injection protocols
Forty-four percent of patients received a subsequent injection in the affected eye; median time to re-injection in the affected eye was 79 days.
“Your gut reaction is to be conservative with injections, but we are often dealing with sight-threatening diseases such as macular degeneration, retinal vein occlusion and macular edema,” Chen said. “On one hand there are risks such as infection, but on the other hand you can also risk vision loss with untreated primary disease. These are difficult decisions that physicians have to make.”
Sixteen percent of patients received a subsequent injection in the unaffected eye; median time to re-injection in the unaffected eye was 99 days.
Before diagnosis of endophthalmitis, 38% of patients received Avastin (bevacizumab, Genentech), 32% received Lucentis (ranibizumab, Genentech) and 30% received Eylea (aflibercept, Regeneron).
In the 3 months after endophthalmitis, there was no significant change in medication choice between bevacizumab vs. ranibizumab or aflibercept.
“We didn’t see much of a difference in switching from Avastin to those prepackaged drugs or vice versa. That was interesting because, before we started, we thought that people would shy away from compounded drugs if they developed endophthalmitis on Avastin. We didn’t see that,” Chen said.
Before endophthalmitis, 32% of injections were regularly scheduled, 40% were given on a treat-and-extend basis and 28% were as-needed.
After endophthalmitis, 11% of injections were regularly scheduled, 37% were treat-and-extend and 52% were as-needed.
“A lot of people changed their treatment protocols,” Chen said. “We think physicians are probably more conservative after an episode of endophthalmitis. Perhaps they are more cautious and hesitant because the risks seem larger in their minds now that the patient has had endophthalmitis.”
Tap-and-inject vs. vitrectomy
Also at the ASRS meeting, Kourous A. Rezaei, MD, presenting results of the International Global Trends Survey, reported that in the U.S., 72% of respondents said they would manage post-injection endophthalmitis with a tap-and-inject strategy, while 49.6% in Africa and the Middle East, 20.9% in the Asia-Pacific region, 16.9% in Central and South America and 49.4% in Europe would use this method.
In a separate interview with OSN, Chen’s co-author Gaurav K. Shah, MD, said that vitrectomy is the preferred treatment for post-injection endophthalmitis in the worst cases.
“The really bad cases, appropriately so, they do vitrectomy, even in the U.S. I think the Europeans are a little bit more aggressive in terms of the use of vitrectomy in general,” Shah said.
However, vitrectomy is not indicated in most patients, and intravitreal antibiotics can be used to manage infection, Shah said.
Shah said the most important result of the study was the rate at which clinicians changed treatment protocols after endophthalmitis.
“I use the same criteria as the Endophthalmitis Vitrectomy Study in two different types of patients. If it’s light perception or worse, we do vitrectomy. If it’s counting fingers or hand motions, we do a tap. In the vast majority of the patients, we can tap-and-inject and they’ll do fine,” Shah said.
Results of the Endophthalmitis Vitrectomy Study, performed in the 1990s, showed no difference in final visual outcomes in patients who underwent tap-and-inject or vitrectomy if presenting visual acuity was better than light perception. Those who underwent initial vitrectomy were three times more likely to achieve 20/40 vision or better, twice as likely to maintain 20/100 vision or better, and had a nearly 50% reduced risk of severe visual loss compared with patients who underwent tap-and-inject. – by Matt Hasson
- References:
- Chen Y. Outcomes and practice preferences after anti-VEGF injection endophthalmitis. Presented at: American Society of Retina Specialists 34th annual meeting; Aug. 9-14, 2016; San Francisco.
- Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol. 1995;doi:10.1001/archopht.1995. 01100120009001.
- For more information:
- Yicheng Chen, MD, a fellow at The Retina Institute, can be reached at The Retina Institute, 1600 Brentwood Blvd., Suite 800, St. Louis, MO 63144; email: yicheng.chen@gmail.com.
- Gaurav K. Shah, MD, can be reached at Barnes Retina Institute Center for Advanced Medicine, 4921 Parkview Place, Suite B, Floor 12, St. Louis, MO 63110; email: gkshah1@gmail.com.
Disclosures: Chen and Shah report no relevant financial disclosures.