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   Table of Contents      
CASE REPORT
Year : 2019  |  Volume : 67  |  Issue : 3  |  Page : 426-428

Commentary: Endophthalmitis following intravitreal injection of dexamethasone implant


Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, 18 College Road, Chennai, Tamil Nadu, India

Date of Web Publication18-Feb-2019

Correspondence Address:
Ekta Rishi
Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, 18 College Road, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1809_18

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How to cite this article:
Rishi E, Manchegowda PT. Commentary: Endophthalmitis following intravitreal injection of dexamethasone implant. Indian J Ophthalmol 2019;67:426-8

How to cite this URL:
Rishi E, Manchegowda PT. Commentary: Endophthalmitis following intravitreal injection of dexamethasone implant. Indian J Ophthalmol [serial online] 2019 [cited 2019 Jul 17];67:426-8. Available from: http://www.ijo.in/text.asp?2019/67/3/426/252416



Intravitreal dexamethasone implant (DEX; Ozurdex; Allergan, Inc, Irvine, CA) is an efficacious treatment in the management of macular edema due to diabetes, retinal vein occlusions, and posterior uveitis. Its safety and efficacy has been demonstrated by randomized trials such as GENEVA and MEAD study.[1],[2]

Endophthalmitis is a rare but serious ophthalmic complication following injection and intravitreal injection of steroid having 6.92-fold more propensity to cause endophthalmitis when compared with anti-VEGF (0.13% vs 0.019%). There are two hypothesis: first, larger bore of needle used for steroid injection (30 or 32 G for anti-VEGF agents, 27 or 25 G for triamcinolone, and 22 G for the DEX) may facilitate bacterial penetration and second, immunosuppression may cause endophthalmitis with a relatively lower bacterial load.[3] Endophthalmitis rate following DEX range from 0% to 1.3% with 0% in GENEVA study and 1.3% in HURON study. There are few case reports on endophthalmitis following DEX injection.

A PubMed-based search shows report of 11 eyes of endophthalmitis following DEX, the largest case series describing five such cases out of which three were DEX coadministered with bevacizumab.[4] [Table 1] illustrates the 11 published cases of endophthalmitis following DEX with isolation of coagulase negative Staphylococcus (CONS) in 5 eyes, Alloiococcus otitidis in one and four eyes with no bacterial growth. Among 5 CONS cases, Species identification was done in 3 cases which showed Staphylococcus epidermidis (n = 2), Staphylococcus lugdunensis (n = 1), while in other 2 cases, species identification was not done. There were no details available in two eyes. Mean duration of presentation was 4.67 days (median: 3; range: 2–15 days). In 6 out of 10 eyes, implant was removed along with vitrectomy. Visual outcome ranged from counting fingers to 6/7.5, but majority had moderate recovery.
Table 1: Summary of characteristics and treatment outcomes of endophthalmitis following DEX injection

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Endophthalmitis following intravitreal injections are caused by organisms of conjunctival and skin flora. CONS are the major group of organisms responsible for such infections. Several subspecies, such as S. lugdunensis isolated, show high virulence and rapid destructive properties. The organism form characteristic “Biofilm” around host tissue or prosthetic surfaces, hence has been implicated in systemic infections, such as endocarditis, bone and joint infections, and skin and soft tissue infections. Bacterial biofilms exhibit high levels of resistance and evasion from host immune defenses makes them difficulty to treat; these biolfilms or glycocalyx also interfere with the phagocytosis activity of neutrophils and play a role in bacterial colonization. The present issue of the journal has a publication on S. lugdunensis endophthalmitis following DEX injection highlighting the efficacy of the organism to grow on implants and prosthesis.[11] The recent alerts issued by FDA on increased silicone content in the Ozurdex injection and its temporary withdrawal from the market further raise the question of the facilitation of bacterial growth on silicone and thereby increasing the risk of endophthalmitis.

Suppurative keratitis and postoperative endophthalmitis are entities described in the eye.[12] Chiquet et al. studied this organism in postcataract surgery endophthalmitis and observed mean duration of presentation to be 7.4 days (median: 7; range: 5–12 days). Among five patients who developed endophthalmitis, four required Pars plana vitrectomy and three (60%) of them developed retinal detachment and ended up in less than ambulatory vision.[13] A case series of three S. lugdnensis endophthalmitis following intravitreal anti-VEGF injections has been described with poor visual outcomes.[14] Summary of S. lugdunensis endophthalmitis characteristics and outcome are briefed in [Table 2]. The organism is coagulase negative and is sometimes difficult to differentiate from Staphylococcus aureus; it presents with similar aggressive infections and bacterial endocarditis. It has an aggressive clinical course with retinal detachment in many patients warranting an early vitrectomy and poor visual outcome.
Table 2: Staphylococcus lugdunensis endophthalmitis: characteristics and outcome of published studies

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There are no evidence-based guidelines for management of DEX-related endophthalmitis, although they all present with severe vitritis and require aggressive management. There are hypotheses suggesting that implant may act as permanent reservoir of bacteria by protecting them from host immune response; hence, early vitrectomy with implant removal is recommended in most studies (6/10), although few cases were managed with intravitreal antibiotics alone [Table 1]. It is much more obviated in S. lugdunensis endophthalmitis, since its peculiar feature of biofilm formation might cause further difficulty for antibiotics to penetrate. Most of the infections are Gram-positive cocci with majority being CONS and subtyping of the organism is important as S. lugdunensis differs significantly from S. epidermidis in terms of virulence and aggressive clinical course.[12]

CONS are the skin and conjunctival flora and are most common organisms causing endophthalmitis following Ozurdex injections. Hence, breach in aseptic precautions prior to intravitreal injections would become the major factor to look upon. A periocular scrub using 10% povidone iodine and 5% povidone iodine in conjunctival cul-de-sac for adequate contact time should be followed stringently. Any intraocular injection procedure should follow standard precaution of not touching the eye-lids, lashes, or periocular skin before injection to avoid endophthalmitis.

Prompt reporting of cases should be encouraged to add upon to the literature to frame evidence-based guidelines in management of endophthalmitis.



 
  References Top

1.
Haller JA, Bandello F, Belfort R Jr, Blumenkranz MS, Gillies M, Heier J, et al. Ozurdex Geneva Study Group. Randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with macular edema due to retinal vein occlusion. Ophthalmology 2010;117:1134-46.  Back to cited text no. 1
    
2.
Boyer DS, Yoon YH, Belfort R Jr, Bandello F, Maturi RK, Augustin AJ, et al. Ozurdex MEAD Study Group. Three-year, randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with diabetic macular edema. Ophthalmology 2014;121:1904-14.  Back to cited text no. 2
    
3.
VanderBeek BL, Bonaffini SG, Ma L. The association between intravitreal steroids and post-injection endophthalmitis rates. Ophthalmology 2015;122:2311-5.  Back to cited text no. 3
    
4.
Stem MS, Todorich B, Yonekawa Y, Capone A Jr, Williams GA, Ruby AJ. Incidence and visual outcomes of culture-proven endophthalmitis following dexamethasone intravitreal implant. JAMA Ophthalmol 2017;135:379-82.  Back to cited text no. 4
    
5.
Yorgun A, Mutlu M, Toklu Y, Cakmak HB, Caǧıl N. Suspected bacterial endophthalmitis following sustained-release dexamethasone intravitreal implant: A case report. Korean J Ophthalmol 2014;28:275-7.  Back to cited text no. 5
    
6.
Mahalingam P, Topiwalla TT, Ganesan G. Drug-resistant coagulase-negative staphylococcal endophthalmitis following dexamethasone intravitreal implant. Indian J Ophthalmol 2017;65:634-6.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Marchino T, Vela JI, Bassaganyas F, Sánchez S, Buil JA. Acute-onset endophthalmitis caused by alloiococcus otitidis following a dexamethasone intravitreal implant. Case Rep Ophthalmol 2013;4:37-41.  Back to cited text no. 7
    
8.
Lowder C, Belfort R Jr, Lightman S, Foster CS, Robinson MR, Schiffman RM, et al. Ozurdex HURON Study Group. Dexamethasone intravitreal implant for noninfectious intermediate or posterior uveitis. Arch Ophthalmol 2011;129:545-53.  Back to cited text no. 8
    
9.
Goel N. Acute bacterial endophthalmitis following intravitreal dexamethasone implant: A case report and review of literature. Saudi J Ophthalmol 2017;31:51-4.  Back to cited text no. 9
    
10.
Esen E, Sizmaz S, Demircan N. Two cases of acute endophthalmitis after intravitreal dexamethasone implant injection. Retin Cases Brief Rep 2016;10:154-6.  Back to cited text no. 10
    
11.
Salceanu SO, Hamada D, Ursu RG, Saad AA. Staphylococcus lugdunensis endophthalmitis following dexamethasone intravitreal implant. Indian J Ophthalmol 2019;67:424-6.  Back to cited text no. 11
  [Full text]  
12.
Frank KL, Del Pozo JL, Patel R. From clinical microbiology to infection pathogenesis: How daring to be different works for Staphylococcus lugdunensis. Clin Microbiol Rev 2008;21:111-33.  Back to cited text no. 12
    
13.
Chiquet C, Pechinot A, Creuzot-Garcher C, Benito Y, Croize J, Boisset S, et al. French institutional endophthalmitis study group. Acute postoperative endophthalmitis caused by Staphylococcus lugdunensis. J Clin Microbiol 2007;45:1673-8.  Back to cited text no. 13
    
14.
Murad-Kejbou S, Kashani AH, Capone A Jr, Ruby A. Staphylococcus lugdunensis endophthalmitis after intravitreal injection: A case series. Retin Cases Brief Rep 2014;8:41-4.  Back to cited text no. 14
    



 
 
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