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Alexander Barnes, Mohan Iyer, Stephen Rathbun, Steven Yeh, Chris Bergstrom, G Baker Hubbard; Management of a Cluster of Endophthalmitis Cases due to Nutritionally Variant Streptococcus Following Intravitreal Bevacizumab. Invest. Ophthalmol. Vis. Sci. 2019;60(9):2035.
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© ARVO (1962-2015); The Authors (2016-present)
To report a cluster of endophthalmitis cases following intravitreal bevacizumab (IVB), describe the probability of a cluster occurring, and offer insight into its management.
Retrospective single-center consecutive case series of 4 patients who developed endophthalmitis after IVB from a single lot and subsequent 34 eyes treated with prophylactic intravitreal antibiotics. Data collected include visual acuity (VA), time to presentation of endophthalmitis, intervention, microbiological culture, and clinical outcome. A statistical analysis using binominal tail probabilities determined the likelihood of such a disease cluster occurring and offers a basis for decision-making in the setting of endophthalmitis clusters.
Forty-five eyes that received IVB belonging to a single batch from a compounding pharmacy were reviewed. Four patients developed endophthalmitis (VA range: 20/80-Light Perception) from 2-4 days post IVB. The first patient underwent vitreous tap with intravitreal antibiotics, and the remaining 3 patients underwent pars plana vitrectomy and intravitreal antibiotics. Cultures in all 4 cases grew Granulicatella adiacens, a nutritionally variant Streptococcus species. Of the remaining 41 eyes, 34 were treated prophylactically with intravitreal vancomycin starting at day 4. There were no adverse events or additional cases of endophthalmitis. Binominal tail probabilities demonstrate that clusters from a single batch are rare (~1 in 10,000 for 2 cases and 1 in 2 million for 3 cases, Table 2A). However, given the scale of IVB in the USA, there is an 87% chance of a cluster ≧2 cases and a 1% chance of a cluster ≧3 cases yearly.
Endophthalmitis clusters following IVB pose unique challenges and require rapid responses. Determination of the best management of such clusters by the Retina community should be considered given the likelihood of a cluster in the USA and the sight-threatening consequences of endophthalmitis.
This abstract was presented at the 2019 ARVO Annual Meeting, held in Vancouver, Canada, April 28 - May 2, 2019.
A: Endophthalmitis from Granulicatella adiacens B: Kaplan-Meier estimates of proportion without infection for this series
A: Binomial tail probabilities of ≥ n number of cases of endophthalmitis in a batch of 70 bevacizumab injections B: Probabilities of πn of clusters exceeding various sizes in at least 1 batch among those administered in the USA as a function of estimated incidence assuming the number of batches M = 21,428
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