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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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Year : 2013  |  Volume : 20  |  Issue : 1  |  Page : 87-88  

Acute bilateral endophthalmitis following bilateral intravitreal bevacizumab (avastin) injection

Farabi Eye Hospital, Tehran University of Medical Science, Tehran, Iran

Date of Web Publication23-Jan-2013

Correspondence Address:
Alireza Khodabande
Farabi Eye Hospital, ghazvin sq., Tehran
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-9233.106402

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The clinical presentation and management of two patients who presented with acute bilateral endophthalmitis following bilateral intravitreal bevacizumab injection. Both cases were diagnosed clinically and subsequent to a vitreous sample, intravitreal ceftazidime (2.25 mg/0.1ml) and vancomycin (1 mg/0.1ml) were injected. One patient had a significant improvement in signs and symptoms after intravitreal antibiotics. However, there were was no improvement in the other patient and pars plana vitrectomy was performed bilaterally. Vitreous cultures were positive in both cases for Staphylococcus epidermidis.

Keywords: Bevacizumab, Endophthalmitis, Intravitreal Injection

How to cite this article:
Tabatabaii A, Ahmadraji A, Khodabande A, Mansouri M. Acute bilateral endophthalmitis following bilateral intravitreal bevacizumab (avastin) injection. Middle East Afr J Ophthalmol 2013;20:87-8

How to cite this URL:
Tabatabaii A, Ahmadraji A, Khodabande A, Mansouri M. Acute bilateral endophthalmitis following bilateral intravitreal bevacizumab (avastin) injection. Middle East Afr J Ophthalmol [serial online] 2013 [cited 2022 May 22];20:87-8. Available from: http://www.meajo.org/text.asp?2013/20/1/87/106402

   Introduction Top

Bevacizumab (Avastin; Genentech Inc., San Francisco, CA) is a monoclonal antibody against vascular endothelial growth factor (VEGF) which was approved by the United States Food and Drug Administration for the treatment of metastatic colorectal cancer. [1] Ophthalmologists have used intravitreal injection of Avastin off-label, for a number of indications including age-related macular degeneration, diabetic macular edema, cystoid macular edema and retinal vascular accidents. [2]

Acute endophthalmitis is a rare but devastating complication of intravitreal bevacizumab (IVB) injection. The incidence of endophthalmitis varies in the literature from 1:1000 to 1:5233 per injection. [3],[4],[5] Potentially, bilateral intravitreal injection of bevacizumab can lead to bilateral endophthalmitis. Our literature review during the research for this case report did not yield any reports of bilateral endophthalmitis following IVB injection. Here we describe the first two cases in peer review literature of bilateral endophthalmitis after IVB.

   Case Reports Top

Case 1

A 76-year-old female was referred to our emergency clinic with complaints of bilateral ocular pain and decreased vision 1 day after receiving bilateral IVB injection for diabetic macular edema.

On examination, her visual acuity was hand movement and light perception in right and left eyes, respectively. There was severe cellular reaction in anterior chamber and vitreous in the right eye. Significant anterior chamber reaction with a 0.7-mm hypopyon and severe vitritis were present in the left eye. The red reflex was absent bilaterally. B-scan ultrasonography revealed inflammatory cells in the vitreous of both eyes.

Due a high index of suspicion for bilateral postoperative endophthalmitis, the patient underwent diagnostic and therapeutic vitreous tap and intravitreal injection of 2.25 mg/0.1 ml ceftazidime and 1 mg /0.1 ml vancomycin. The vitreous sample was turbid. Two days after antibiotic injection, visual acuity improved to 20/400 in both eyes and there was a significant improvement in the symptoms and signs of inflammation. Cultures of the vitreous sample were positive for Staphylococcus epidermidis.

Case 2

A 52-year-old female with a history of bilateral IVB injection for diabetic macular edema, presented with bilateral ocular pain and photophobia 2 days after IVB injections. On examination, visual acuity was light perception in both eyes. There was significant anterior chamber inflammation and hypopyon in both eyes. There was 4+ cell in the vitreous. The retina was not visible due to media opacity.

B-scan ultrasonography showed diffuse vitreous opacity bilaterally. The patient underwent diagnostic and therapeutic vitreous tap and intravitreal injection of 2.25 mg/0.1 ml ceftazidime and 1 mg/0.1 ml vancomycin. Two days later despite intravitreal antibiotics therapy, the signs and symptoms progressed and pars plana vitrectomy and intravitreal antibiotic injection was performed in both eyes. During vitrectomy, the retina appeared necrotic, especially in the macular region. Five days after vitrectomy, the signs and symptoms of endophthalmitis resolved. However, there was no improvement in visual acuity due to the retinal necrosis. Vitreous culture inoculated onto blood agar was positive for S. epidermidis.

   Discussion Top

Postoperative endophthalmitis is a rare devastating complication observed after IVB injection. Similar to our cases, most reports of endophthalmitis document decreased vision, ocular pain and redness, soon after IVB injection. [3],[4],[5],[6] Recently, some standardization has been advocated to minimize the risk of postoperative endophthalmitis after IVB injection. These measures include preoperative cleansing of eyelids and conjunctiva with a 5% povidone-iodine solution, isolation of lids and lashes from the surgical field and treatment of high-risk patients with topical antibiotics.

Sterile and infectious endophthalmitis after intravitreal injection presents with similar sign and symptoms such as a rapid decrease in visual acuity. Hence, prompt diagnosis of infectious or noninfectious endophthalmitis is imperative. Signs of infectious endophthalmitis include, inflammation, pain, fibrin, sudden and significant loss of vision within days of IVB. S. epidermidis was isolated in both cases in the current paper. S. epidermidis is the most common pathogen isolated from the vitreous samples. [7],[8] The cause of infectious endophthalmitis after IVB remains contentious. Some studies have implicated the needle used during IVB as it contacts the ocular surface and inoculates the vitreous. [8] Others suggest pharmacological compounding during preparation of bevacizumab for ophthalmic use as the cause of infection. [9]

Prophylactic measures are particularly important for bilateral procedures. In the current cases, both patients were diabetic and received bilateral IVB. We recommend performing IVB injection in diabetics or immunocompromised patients in separate sessions for each eye. Moreover, it is imperative to adhere to all prophylactic measures for each eye in all patients undergoing bilateral injection. We believe separate, surgical grade instruments (including speculum, drug vial and calipers) should be used for each eye in a bilateral procedure.

   References Top

1.CATT Research Group; Martin DF, Maguire MG, Ying GS, Grunwald JE, Fine SL, Jaffe GJ. Ranibizumab and bevacizumab for neovascular age-related macular degeneration. N Engl J Med 2011;364:1897-908.   Back to cited text no. 1
2.Gunther JB, Altaweel MM. Bevacizumab (Avastin) for the treatment of ocular disease. Surv Ophthalmol 2009;54:372-400.  Back to cited text no. 2
3.Jonas JB, Spandau UH, Rensch F, Von Baltz S, Schlichtenbrede F. Infections and noninfections endophthalmitis after intravitreal bevacizumab. J Ocul Pharmacol Ther 2007;23:240-2.  Back to cited text no. 3
4.Mason JO 3 rd , White MF, Feist RM, Thomley ML, Albert MA, Persaud TO, et al. Incidence of acute onset endophthalmitis following interavitreal bevacizumab (avastin) injection. Retina 2008;28:564-7.  Back to cited text no. 4
5.Fintak DR, Shah GK, Blinder KJ, Regillo CD, Pollack J, Heier JS, et al. Incidence of endophthalmitis related to intravitreal injection of bevacizumab and ranibizumab. Retina 2008;28:1395-9.  Back to cited text no. 5
6.Arturay O, Yzbasioglu E, Rasier R, Sengul A. Incidence and management of acute endophthalmitis after intravitreal bevacizumab (Avastin) injection. Eye (Lond) 2009;23:2187-93.  Back to cited text no. 6
7.Cavalcante LL, Cavalcante ML, Murray TG, Vigoda MM, Piña Y, Decatur CL, et al. Intravitreal injection analysis at the Bascom Palmer Eye Institute: Evaluation of clinical indications for the treatment and incidence rates of endophthalmitis. Clin Ophthalmol 2010;4:519-24.  Back to cited text no. 7
8.Stewart JM, Srivastava SK, Fung AE, Mahmoud TH, Telander DG, Hariprasad SM, et al. Bacterial contamination of needles used for intravitreal injections: A prospective, multicenter study. Ocul Immunol Inflamm 2011;19:32-8.   Back to cited text no. 8
9.Gonzalez S, Rosenfeld PJ, Stewart MW, Brown J, Murphy SP. Avastin doesn't blind people, people blind people. Am J Ophthalmol 2012;153:196-203.  Back to cited text no. 9

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