Rayess N, Obeid A, Storey PP, et al. Long-Term Visual Outcomes and Clinical Features After Anti-Vascular Endothelial Growth Factor Injection-Related Endophthalmitis. Retina 2019;39:2070-2076.
In the era of anti-vascular endothelial growth factor (anti-VEGF) therapy for retinal disease, endophthalmitis is arguably the most dreaded post-procedural complication for retina specialists. Fortunately, post-injection endophthalmitis is rare, but visual prognosis can vary widely. In a recent article published in Retina, Rayess et al sought to determine long-term visual outcomes after post-injection endophthalmitis and their correlation with clinical features.
This was a multicenter, retrospective case series of patients who developed endophthalmitis after anti-VEGF therapy over the course of 57 months. The primary outcome was final visual acuity (ranging from 1-5 years of follow-up) and secondary outcomes included other clinical features, such as culture results, that may have influenced final visual outcomes.
The authors identified 56 cases of endophthalmitis out of 168,247 anti-VEGF injections (0.033%, 1/3004). 51 eyes met inclusion criteria, and 47% of these eyes reached 5-year follow up. Average pre-injection visual acuity was 20/102, and decreased to counting fingers at the time of diagnosis. At 6 months, average visual acuity was 20/480, and the authors interestingly found that these visual outcomes remained stable for up to 5 years (P = 0.907).
The authors then divided eyes into two groups – those whose final visual acuity was within one line of baseline visual acuity (n = 20, 39.2%, visual recovery group), and all others (n = 31, 60.8% visual deterioration group). Those in the visual recovery group were more likely to grow coagulase-negative Staphylococcus, and those in the visual deterioration group were more likely to grow Streptococcus species, Staphylococcus aureus, and Enterococcus faecalis (P = 0.002). Most eyes in the visual deterioration group were culture-positive. However, the authors note that eyes in the visual recovery group were more likely to have a worse baseline visual acuity compared to eyes in the visual deterioration group (20/174 vs 20/74, P = 0.046).
While there are inherent limitations to this study, including its retrospective nature, there are important learning points that we, as retina specialists, can glean from this paper. It is encouraging that roughly 40% of patients can still have a good visual outcome after post-injection endophthalmitis. When these patients ask us what their prognosis is, we may be able to use culture results to help guide our answers. Furthermore, we can counsel patients that their vision, on average, should begin to stabilize around 6 months.
Andrew Tye, MD
The Permanente Medical Group
Union City, CA