Post-intravitreal anti-VEGF endophthalmitis in the United Kingdom: incidence, features, risk factors, and outcomes

Abstract

Purpose: To describe the incidence, features, management, and risk factors of post-intravitreal anti-VEGF endophthalmitis (PIAE) in patients undergoing treatment for exudative age-related macular degeneration in the United Kingdom.

Methods: Prospective observational case control study. Forty-seven cases of PIAE were identified through the British Ophthalmological Surveillance Unit from January 2009 to March 2010. Data collected at diagnosis and at 6 months follow-up included patient demographics, intravitreal injection details, pre- and post-injection management, visual acuity, clinical features and management of PIAE, causative organisms, and clinical outcomes. Details were compared with 200 control cases from 10 control centres to identify potential risk factors.

Results: Estimated PIAE was 0.025%. Culture-positive PIAE incidence was 0.015%. Mean age of presentation was 78 years. Mean number of intravitreal injections before PIAE was 5. Mean days to presentation was 5 (range 1-39). Positive microbiology culture was found in 59.6%. The majority of causative organisms were Gram positive (92.8%). Significant risk factors were failure to administer topical antibiotics immediately after the injection (P=0.001), blepharitis (P=0.006), subconjunctival anaesthesia (P=0.021), patient squeezing during the injection (P=0.021), and failure to administer topical antibiotics before anti-VEGF injection (P=0.05).

Discussion: The incidence of PIAE in the United Kingdom is comparable to other studies at a rate of 0.025%. The most common causative organisms were Gram positive. Measures to minimise the risk of PIAE include treatment of blepharitis before injection, avoidance of subconjunctival anaesthesia, topical antibiotic administration immediately after injection with consideration to administering topical antibiotics before injection.

Figure 1

Presenting symptoms of PIAE (a). Presenting signs of PIAE (b).

Figure 2

Initial intravitreal antimicrobial therapy given to cases of PIAE (V—vancomycin, A—amikacin, Ceft—ceftazidime, Cip—Ciprofloxacin).

Figure 3

Visual outcomes. Grouping of CDVA of cases before developing PIAE, at presentation with PIAE, and at 6-month follow-up. Before developing PIAE, the majority of patients had a CDVA of 6/36 or better. At PIAE presentation, the majority were hand movements (HM) or worse (PL—perception of light and NPL—no perception of light), with some improvement at 6 months follow-up.