Clinical Outcomes and Treatment Course of Eyes with Neovascular Age-Related Macular Degeneration Following the Development of Endophthalmitis
Koulisis N, Moysidis S, Govindaraju V, et al. Clinical Outcomes and Treatment Course of Eyes with Neovascular Age-Related Macular Degeneration Following the Development of Endophthalmitis. Retina 2021; 41(6):1242-1250.
Intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) medication are the current gold standard of care for patients with neovascular age-related macular degeneration (nAMD). A rare but serious complication of serial intravitreal anti-VEGF injections is endophthalmitis, which occurs after 0.027% to 0.15% of injections. The purpose of this study was to investigate the clinical course of patients following resolution of endophthalmitis infection.
A multi-center, retrospective analysis of 196,598 intravitreal anti-VEGF injections performed between April 2013 and October 2018 identified 75 cases of endophthalmitis (incidence 0.0381%). Seventy-two patients (96%) received an immediate intravitreal tap and injection of vancomycin (1mg/0.1mL) and ceftazadime (2.25mg/0.1mL) while three patients (4%) were taken for immediate pars plana vitrectomy with intravitreal injection of antibiotics. Seven patients (9.3%) required repeat tap and injection of antibiotics while nine (12%) had subsequent pars plana vitrectomy. All cases were followed for at least 1.5 years.
Mean logMAR visual acuity worsened from 0.585 ± 0.05 (20/77) prior to infection to 1.02 ± 0.11 (20/209) after infection (P<0.001). Most interestingly, 17 patients (22.7%) did not require re-treatment with anti-VEGF injection after resolution of endophthalmitis; 10 of these (58.8%) were due to involution/regression of the choroidal neovascular complex while 7 (41.2%) were due to a poor prognosis for visual rehabilitation. 58 patients (77.3%) required re-initiation of anti-VEGF treatment but at a longer average interval of 11.6 ± 1.78 weeks compared to 7.36 ± 0.61 weeks prior to endophthalmitis (P=0.003). The authors hypothesize that the overwhelming inflammation associated with endophthalmitis may lead to a reduction of CNV activity.
Overall, better visual acuity on post-endophthalmitis week 1 (P=0.002) and re-initiation of nAMD treatment (P=0.008) was associated with better final visual acuity while presence of streptococcus was associated with worse visual acuity (P=0.028). Patients receiving aflibercept and ranibizumab had longer treatment intervals than those being treated with bevacizumab (P<0.001).