Bacterial endophthalmitis following anti-VEGF intravitreal injections: a retrospective case series

Abstract

Background: To describe the incidence of endophthalmitis and the treatment outcomes of acute bacterial endophthalmitis following intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections in a Brazilian hospital. The analysis was based on the timing of infection after intravitreal injection, culture results, visual acuity, and the presence of epiretinal membrane after a 1-year follow-up period, spanning nine years.

Methods: This retrospective case series, conducted over a 9-year period, aimed to evaluate the treatment outcomes of acute endophthalmitis following intravitreal Bevacizumab injections. The inclusion criteria involved a chart review of 25 patients who presented clinical signs of acute endophthalmitis out of a total of 12,441 injections administered between January 2011 and December 2019. Negative culture results of vitreous samples or incomplete data were excluded. Ultimately, 23 patients were enrolled in the study. Eight patients were treated with intravitreal antibiotic injections (IVAI) using vancomycin 1.0 mg/0.05mL and ceftazidime 2.25 mg/0.05mL, while 15 patients underwent pars plana vitrectomy (PPV) followed by intravitreal antibiotic injections at the end of surgery (IVAIES). The main outcome measures were the efficacy of controlling the infection with IVAI as a standalone therapy compared to early PPV followed by IVAIES. Data collected included pre-infection and one-year post-treatment best corrected visual acuity (BCVA), optical coherence tomography (OCT) abnormalities, and enucleation/evisceration rates. To compare groups, Mann-Whitney and ANOVA tests were employed for statistical analysis.

Results: The incidence rate of bacterial endophthalmitis was 0.185% (1/541 anti-VEGF injections), with the highest infection rates observed in 2014 and 2017. Patients presented clinical symptoms between 2 and 7 days after injection. The most common isolated organisms were coagulase-negative Staphylococci and Streptococci spp. Treatment outcomes showed that both IVAI and PPV + IVAIES effectively controlled the infection and prevented globe atrophy. After one year, the PPV group with BCVA better than Light Perception had a significantly better BCVA compared to the IVAI group (p 0.003). However, PPV group had higher incidence of epiretinal membranes formation compared to the IVAI group. (P 0.035) CONCLUSION: Anti-VEGF injections carry a risk of developing acute bacterial endophthalmitis. Isolated antibiotic therapy could be an effective treatment to control the infection, but performing PPV + IVAIES as a primary treatment showed promising results in terms of improving BCVA after one year, despite a higher rate of epiretinal membrane formation. Further studies are needed to confirm these findings.

Keywords: Anti-VEGF; Endophthalmitis; Intravitreal injections; Retina; Vitrectomy.

Fig. 1

The mean VA levels before treatment compared with after 1 year. Analysis of all patients shows no significant difference between the logarithm of the logMAR BCVAs before and 1 year after development of endophthalmitis

Fig. 2

The mean VA levels before treatment: groups worse-vision PPV vs. injection vs. better-vision PPV. No significant difference in the logarithm of the logMAR best-corrected VAs is seen before the endophthalmitis developed (worse-vision PPV vs. injection vs. better-vision PPV, P = 0.508)

Fig. 3

The mean VA levels after 1 year: injection vs. vitrectomy. The mean logMAR best-corrected VAs after 1 year of treatment in the injection group are 1.56 ± 0.86 and 1.60 ± 0.95 in the vitrectomy group. No significant (P = 0.647) difference is seen between them

Fig. 4

The VA levels after 1 year: worse-vision PPV vs. injection vs. better-vision PPV. A post-hoc analysis among the three groups shows a significant difference only between the vitrectomy groups, with better best-corrected VA after 1 year in the better-vision PPV group (P = 0.01)