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Low endophthalmitis rate found after intravitreal injections
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Analysis of 12 years of data on intravitreal injections in a large tertiary referral center showed a low rate of endophthalmitis as a complication. No difference was found among anti-VEGF agents, and the least favorable visual acuity results were related to Streptococcus infection.
The authors performed a retrospective review of the clinical and microbiology records of all patients who presented to Bascom Palmer Eye Institute between January 2005 and December 2017 with a diagnosis of endophthalmitis after intravitreal anti-VEGF injections. This population included patients who had been treated on site as well as patients referred from outside practices.
At Bascom Palmer, a strict antisepsis protocol was followed, and starting from 2008, the use of topical antibiotics was gradually phased out.
In total, 39 eyes were culture-positive for endophthalmitis, 12 of which were injected at Bascom Palmer and 27 at outside practices. Nine of the outside cases were associated with an outbreak of Streptococcus endophthalmitis from contaminated pharmacy-compounded bevacizumab.
The authors noted that the overall rate of endophthalmitis at Bascom Palmer was low and decreased from 0.019% to 0.009% after complete cessation of topical antibiotic prophylaxis. The overall rate over the past decade was 0.013%, approximately one in 7,000, and did not differ among anti-VEGF agents.
The most common isolates were Staphylococcus and Streptococcus species. Intravitreal vancomycin and ceftazidime (amikacin in one case) were used for the initial treatment.
Visual acuity results were variable, with 54% of eyes achieving 5/200 or better. Outcomes were worse with Streptococcus infection, possibly due to the earlier onset of more virulent organisms in cases presenting within 3 days after injection.
“The current study corroborates previous reports that establish a consistently low rate of infection after intravitreal injection,” the authors wrote. “Furthermore, prophylactic antibiotics do not appear necessary to maintain a low incidence of infection. Indeed, current evidence suggests that the rate of endophthalmitis with antibiotic prophylaxis may even be higher.”– by Michela Cimberle
Disclosures: Yannuzzi reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Carl D. Regillo, MD, FACS
The good news in this study is that the rate of post-injection endophthalmitis was very low, and it was very low without the use of topical antibiotics after an intravitreal injection. This supports prior publications that indicated that post-injection topical antibiotics are not likely to reduce infection rates more than the using of povidone-iodine application alone at the time of the injection. The bad news is that about one-third of the infections were caused by the very virulent Streptococcus species of bacteria, and the visual prognosis of a Streptococcus-related endophthalmitis is very poor. Only rarely is there good visual recovery with this type of infection.
The study supports the clinical practice of not having patients use antibiotic drops after an injection. Furthermore, because Streptococcus species are common oral flora bacteria, the study should also reinforce the practice of having a “no-talk zone” around the patient after the eye has been prepped with povidone-iodine. The source of such virulent oral flora can be the patient, the assistant or the physician. Therefore, everyone in the injection room must be cognizant of the potential to contaminate the eye with oral flora-based bacteria.
The study reports an overall rate of final visual acuity of 5/200 or better in 54% of eyes. What is not known is the visual potential of the patient undergoing injection therapy. In terms of the ability to fully recover from the bacterial infection event, it would be more useful for the clinician to know what is the percentage of affected eyes that recover their pre-infection vision. This is likely to be relatively high with coagulase-negative Staphylococcus infections, but unfortunately still low with infections from Streptococcus.
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