Acute sterile endophthalmitis following intravitreal bevacizumab: case series

Abstract

Background: Since the ophthalmological community adopted the use of intravitreal bevacizumab as an accepted off-label treatment for neovascular diseases, the amount of knowledge regarding its effects and properties has been increasing continually. In the last few years, there have been an increasing number of reports about sterile intraocular inflammation and intraocular pressure elevations after intravitreal bevacizumab. In the following case series, we describe the clinical presentation and outcomes of ten consecutive cases of patients developing mild-to-severe sterile intraocular inflammation after intravitreal bevacizumab and their management.

Methods: This report presents a retrospective case series. We reviewed the medical records of ten consecutive patients from a group of 46, in whom repackaged bevacizumab in individual aliquots from two vials from the same batch were used. All surgical procedures were performed using standard sterile techniques in the operating room. At each follow-up visit, patients underwent a complete ophthalmological examination including visual acuity assessment, intraocular pressure, biomicroscopy, and posterior fundus examination.

Results: Ten patients presented sterile endophthalmitis with an onset time of 3.5±1.95 days. The clinical characteristics were mild pain, slight visual loss, conjunctival hyperemia, and various degrees of intraocular inflammation with microhypopyon. All cultures were negative. All patients were managed with topical steroids and antibiotics, except two, in whom, due to severe vitreous cells, intravitreal antibiotics were used. Three patients showed a transient elevation of intraocular pressure. Only 50% of the patients regained a visual acuity equal or better to the baseline visual acuity on file.

Conclusion: The increasing number of intravitreal injections of bevacizumab applied every day, due to its widespread acceptance, might be one reason why the number of cases of sterile endophthalmitis is rising. Fast recognition and accurate differential diagnosis is important to avoid unnecessary treatments and long-term complications. The low incidence of this event should not preclude the use of intravitreal injections in eyes that could benefit greatly from this therapy.

Keywords: bevacizumab; complications; intravitreal antibiotics; pseudoendophthalmitis; vitrectomy.

Figure 1

Clinical pictures. Notes: (A) Patient number 9, mild conjunctival hyperemia. The small white arrowhead is highlighting the presence of anterior chamber cells. (B and D) Patients numbers 8 and 10, gonioscopy pictures, inferior aspect. The small white arrows show the presence of microhypopyon. (C) Patient number 2, biomicroscopic 10× image. The small black arrowheads show the presence of small keratic precipitates.

Figure 2

Patient number 1, representative case. Notes: Fundus photograph (A) and fluorescein angiography (B) of the left eye show an active choroidal neovascularization with intraretinal fluid and leakage of dye in the fluorescein angiography. Three days later, the patient complained of mild pain, visual loss, and conjunctival hyperemia (C). Fundus photograph shows the presence of important vitreous cells (D).