ReviewEndophthalmitis following intravitreal injection of anti-vascular endothelial growth factor agents
Section snippets
Incidence
The reported incidence of postinjection endophthalmitis following anti-VEGF agents has varied widely. Published studies have reported incidence rates per injection ranging from 0.095% (1 in ∼1050 injections) to as low as 0.0053% (1 in ∼19 000 injections).2, 3, 4, 5 The wide range of incidence rates across different studies may be owing to the inclusion of false-negative cultures as well as postinjection inflammatory reactions.6, 7, 8 The majority of large series has reported incidence rates in
Presentation
Patients with endophthalmitis following intravitreal injection of anti-VEGF agents generally present with redness, pain, decreased vision, and vitritis, although not all signs or symptoms are required for diagnosis.9,12 Eyes that develop endophthalmitis after intravitreal injection may have more early posterior inflammation than eyes with infection following cataract surgery owing to an increased prevalence of more virulent bacteria. Endophthalmitis cases typically present within 3 days of
Treatment
Even though a vitreous or aqueous tap is generally performed for postinjection endophthalmitis, some evidence suggests that vitreous culture results may have a limited impact on clinical management. In a recent study of over 200 000 intravitreal injections, 60 cases of suspected endophthalmitis were identified.14 Six of 60 eyes (10%) had a change in clinical management of endophthalmitis. However, in all cases, management changes were based on declining visual acuity or worsening clinical
Outcomes
Visual outcomes of patients with endophthalmitis following anti-VEGF injection vary considerably. In several large retrospective studies of endophthalmitis secondary to anti-VEGF injection, roughly half of patients returned to baseline visual acuity within 3 months of infection.5,9 However, approximately 40% of patients may have vision of count fingers or worse.9 In one study, less than one-fifth of eyes with culture-positive endophthalmitis returned to baseline vision at 6 months compared with
Povidone Iodine
Povidone iodine (PI) application before intravitreal injection is the most commonly used method to reduce the risk of endophthalmitis. Povidone is typically applied in either a 5% or a 10% formula to the ocular surface for at least 30 seconds before injection. Povidone is broadly effective against gram-positive and gram-negative bacteria, viruses, and fungi. Although no trial has directly compared rates of infection with and without PI, reported rates of endophthalmitis with the use of PI are
Minimizing Risk Factors
Although there are no absolute contraindications to intravitreal injection of anti-VEGF medications, some studies have noted factors that may be associated with an increased risk of infection. In a study of 47 cases of endophthalmitis in patients with age-related macular degeneration, active blepharitis was associated with nearly 20 times higher odds of infection. Additionally, eyelid squeezing or moving during the injection also was significantly associated with increased risk of
Minimizing Oral Flora Exposure
Multiple studies have reported an increased prevalence of endophthalmitis secondary to oral flora, particularly Streptococcus and Enterococcus species, after intravitreal injection. A study including over 100 000 intravitreal injections reported that Streptococcus species represented 31% of culture-positive endophthalmitis. In contrast, studies of postcataract and postvitrectomy endophthalmitis have reported Streptococcus species in only 0%–9.0% of culture-positive cases.57 One study evaluated
Conclusions
Intravitreal injections of anti-VEGF agents are typically safe and generally effective for retinal vascular diseases. Although postinjection endophthalmitis is rare, visual outcomes may be poor, particularly when endophthalmitis is caused by oral pathogens. A range of prophylactic techniques have been developed to attempt to reduce the risk of endophthalmitis. The application of topical PI has the strongest clinical evidence and remains the most widely used approach to mitigate infectious risk.
Footnotes and Disclosure
The authors have no proprietary or commercial interest in any materials discussed in this article.
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