Cluster endophthalmitis from contaminated bevacizumab: Clinical features, outcomes and experiences from a tertiary care referral centre

Session Details

Session Title: Free Paper Session 10: Uveitis

Session Date/Time: Friday 08/09/2017 | 11:00-12:30

Paper Time: 11:42

Venue: Room 111

First Author: : S.Singh INDIA

Co Author(s): :    A. Aggarwal   D. Katoch   R. Singh   M. Dogra   V. Gupta                 

Abstract Details

Purpose:

Anti-Vascular Growth Factor Agents (anti-VEGF) are the mainstay of therapy for various vitreoretinal conditions such as Neovascular Age Related Macular Degeneration (ARMD), Diabetic Macular Edema (DME), Retinal Vein Occlusion (RVO), and Uveitic Cystoid Macular Edema (CME), among others. Bevacizumab, Ranibizumab and Aflibercept have all shown to effective anti-VEGF agents in most of these indications. Bevacizumab has a significant cost advantage over the other anti-VEGF agents, especially in the developing world with low medical insurance coverage. We report our experience with dealing with large cluster endophthalmitis patients following intravitreal bevacizumab.

Setting:

Retina clinic of the Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India – A tertiary care referral centre in Northern India.

Methods:

In this prospective, interventional case series, patients who presented with post-bevacizumab cluster endophthalmitis were included. All patients given the injection on the day were called back for examination irrespective of them being symptomatic or not. The pre-injection and post-injection baseline best corrected visual acuity (BCVA), intraocular pressure (IOP), cellular reaction, flare and media clarity were documented. The patients were managed based on the severity of their presentation with either vitreous tap with injection of intravitreal antibiotics or core vitrectomy with injection of intravitreal antibiotics. Samples were sent for microbiological staining and culture sensitivity for all patients. Postoperatively the patients were closely followed for improvement in cellular reaction, media clarity and visual acuity. Repeat injections of antibiotics and vitrectomy were done for those not improving sufficiently. The patients were regularly followed up with serial visual acuity assessment and comprehensive ophthalmic examination for a period of 1 year post the episode of endophthalmitis.

Results:

A total of 28 patients received Bevacizumab injection on the given day. There were 23 males and 5 females. All were detected with endophthalmitis post injection. Four patients presented within 24 hours of the injection with painful diminution of vision, while the rest were actively called back for examination. The mean age was 5913 years. There were 2 distinct clinical presentations. A toxic anterior segment like picture with corneal edema, fibrin and high IOP in 12 eyes and large hypopyon with severe vitritis in 16 eyes. Seventeen eyes underwent vitrectomy + Intravitreal Vancomycin and Ceftazidime injection as a primary procedure while 11 eyes underwent Tap and Inject. Among these, 4 eyes required vitrectomy due to persistent inflammation. Four eyes required repeat Tap and Inject after 48 hours due to persistent inflammation. Eleven eyes showed positive Gram staining for Gram Negative Bacilli and 7 eyes were culture positive for Stenotrophomonas Maltophilia. The same organism was cultured from the vial of Bevacizumab that was utilized. The mean pre-injection BCVA was 0.77±0.48 LogMAR units which dropped to 2.52±0.82 after bevacizumab. The BCVA at last follow up was 1.32±0.86. Useful vision could be salvaged in all the eyes.

Conclusions:

Although endophthalmitis following intravitreal injections have been previously reported, our data represents the largest series on cluster endophthalmitis from contaminated/counterfeit Bevacizumab. A majority of the patients recovered their pre-injection BCVA and have a clear media and quiet anterior chambers. Prompt intravitreal antibiotics, early vitrectomy and expedited culture sensitivity reports greatly aided in salvaging all eyes from our cohort. A quick response and active call back of all patients is of utmost importance in effective management of cluster endophthalmitis.

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