title: Outcomes and risk factors associated with endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents.
abstract: OBJECTIVE
  To describe outcomes of and risk factors for endophthalmitis after intravitreal anti-vascular endothelial growth factor (VEGF) injection.
  
  
  METHODS
  Single-center, consecutive, case series and retrospective case-control study.
  
  
  METHODS
  Between January 1, 2009, and May 31, 2010, 16 vitreoretinal surgeons administered a total of 27 736 injections. During this period, 23 cases of presumed infectious endophthalmitis occurred. Each surgeon used his own preferred injection technique.
  
  
  METHODS
  Vitreous or aqueous tap, or both, with intravitreal antibiotic injection and subsequent topical antibiotic and steroid drops.
  
  
  METHODS
  Visual acuity, bladed lid speculum use, conjunctival displacement, hemisphere of injection, bevacizumab versus ranibizumab, and infectious organism.
  
  
  RESULTS
  Seven of 23 cases had positive culture results; 3 grew coagulase-negative Staphylococcus. All cases had pain and vitritis on average 3.4 days (range, 1-6 days) after injection, with no difference between culture-positive and culture-negative groups. Eighteen (78%) of 23 cases had a hypopyon. Fifteen of 23 cases returned to baseline vision (±2 lines) within 3 months. Neither lid speculum use (0.10% vs. 0.066% in the no-use group; P = 0.27), conjunctival displacement (0.11% vs. 0.076% in the no-displacement group; P = 0.43), hemisphere of injection (0.11% superior vs. 0.079% inferior; P = 0.56), or bevacizumab versus ranibizumab (0.11% vs. 0.066%; P = 0.21) affected risk. Analysis of only culture-positive results yielded similar results. There was no statistically significant difference between the proportion of culture-negative cases after bevacizumab injection (83%) versus ranibizumab injection (55%; P = 0.13).
  
  
  CONCLUSIONS
  Most patients in whom presumed infectious endophthalmitis develop after anti-VEGF injection regained baseline vision after treatment. Bladed lid speculum use, conjunctival displacement, hemisphere of injection, and type of anti-VEGF agent did not affect risk. No difference in culture-negative endophthalmitis rates was detected after bevacizumab versus ranibizumab injection. Neither the presence of pain, vitritis, decreased vision, hypopyon, nor the interval between injection and development of symptoms differentiate culture-positive from culture-negative cases. Because a subgroup of patients had poor outcomes, a low threshold for vitreous tap with intravitreal antibiotic injection may be warranted.
  
  
  BACKGROUND
  The author(s) have no proprietary or commercial interest in any materials discussed in this article.
authors.affiliation: Ophthalmic Consultants of Boston, Boston, Massachusetts, USA.
authors.forename: Chirag P
authors.initials: CP
authors.lastname: Shah
authors.forename: Sunir J
authors.initials: SJ
authors.lastname: Garg
authors.forename: James F
authors.initials: JF
authors.lastname: Vander
authors.forename: Gary C
authors.initials: GC
authors.lastname: Brown
authors.forename: Richard S
authors.initials: RS
authors.lastname: Kaiser
authors.forename: Julia A
authors.initials: JA
authors.lastname: Haller
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D020533:Angiogenesis Inhibitors / Q000008:administration & dosage / Q000009:adverse effects*; D061067:Antibodies, Monoclonal, Humanized / Q000008:administration & dosage / Q000009:adverse effects; D001082:Aqueous Humor / Q000382:microbiology; D000068258:Bevacizumab; D016022:Case-Control Studies; D002442:Ceftazidime / Q000627:therapeutic use; D009877:Endophthalmitis / Q000188:drug therapy / Q000382:microbiology* / Q000503:physiopathology; D015818:Eye Infections, Bacterial / Q000188:drug therapy / Q000382:microbiology* / Q000503:physiopathology; D005260:Female; D006801:Humans; D058449:Intravitreal Injections; D008268:Macular Degeneration / Q000188:drug therapy; D008297:Male; D000069579:Ranibizumab; D012189:Retrospective Studies; D012307:Risk Factors; D014031:Tobramycin / Q000627:therapeutic use; D016896:Treatment Outcome; D014640:Vancomycin / Q000627:therapeutic use; D042461:Vascular Endothelial Growth Factor A / Q000037:antagonists & inhibitors*; D014792:Visual Acuity / Q000502:physiology; D014822:Vitreous Body / Q000382:microbiology
chemical_list: D020533:Angiogenesis Inhibitors; D061067:Antibodies, Monoclonal, Humanized; C467484:VEGFA protein, human; D042461:Vascular Endothelial Growth Factor A; D000068258:Bevacizumab; D014640:Vancomycin; D002442:Ceftazidime; D014031:Tobramycin; D000069579:Ranibizumab