Query: INTRAVITREAL CLUSTER ENDOPHTHAMITIS

title: Klebsiella Cluster Endophthalmitis following Intravitreal Bevacizumab: Role of Early Detection, Pars Plana Vitrectomy, and Intracameral Moxifloxacin.
abstract: To report the clinical profile, outcomes of early vitrectomy for cluster endophthalmitis developing after intravitreal Bevacizumab (IVB) and discuss the role of prophylactic intracameral moxifloxacin for eyes undergoing combined cataract surgery with IVB.  Single center, retrospective analysis of 35 consecutive eyes developing post IVB inflammation.  Of the 35 eyes that were administered IVB (27 eyes 'IVB alone' and 8 eyes 'IVB with cataract surgery' Endophthalmitis developed in 28 eyes, 6 eyes were managed with Intravitreal antibiotic (IVAB) alone, while 22 eyes required early vitrectomy. Only one eye undergoing a combined phacoemulsification with IVB developed endophthalmitis. Majority(26/28) of the eyes achieved visual acuity equal to/greater than pre IVB injection vision over a period of 3.15 3.2 months.  Early detection and prompt PPV were effectual for achieving good functional outcomes in our cluster of post IVB Klebsiella endophthalmitis. Intracameral moxifloxacin was protective in cases undergoing combined cataract surgery with IVB.

title: Intravitreal injection of avastin (Bevacizumab) from a single vial causing pseudo endophthamitis
abstract: To study the occurrence of pseudo endophthalmitis among patients undergoing intravitreal avastin (Bevacizumab) under various indications.  A retrospective analysis of case records of patients who developed an inflammatory reaction after Intravitreal avastin (Bevacizumab) was done.  Eight of the twenty Eight patients (28.5% developed pseudo endophthalmitis. However, the repeated culture of aqueous or vitreous samples did not show any bacterial or fungal growth. All patients showed precipitation of drug in vitreous with the resolution of symptoms after 10 weeks of intensive oral and topical steroid treatment.  Intravitreal avastin (Bevacizumab) can result in pseudo endophthalmitis though it is a diagnosis of exclusion given many complications, a larger clinical trial of intravitreal avastin (Bevacizumab) is needed to rationalize its use. (c)

title: Management of a Cluster of Endophthalmitis Cases due to Nutritionally Variant Streptococcus Following Intravitreal Bevacizumab

title: Noninfectious Inflammatory Response following Intravitreal Bevacizumab Injections: Description of a Cluster of Cases in Two Centers and a Review of the Literature
abstract: To report a cluster of high incidence of noninfectious inflammatory reaction shortly after bevacizumab injection.  Data were collected from medical records of consecutive patients who underwent bevacizumab injections and presented with acute uveitis within 1 4 days.  All 7 patients were injected intravitreally with bevacizumab from different batches and presented with visual deterioration. One patient with anterior uveitis complained of pain. None had hypopyon. Three patients with vitritis underwent a vitreous tap with an intravitreal injection of vancomycin and ceftazidime for possible infectious endophthalmitis. All patients received intensive topical antibiotic drops and steroids, and the intraocular inflammation resolved completely within 1 month. Five patients continued to receive bevacizumab injections without recurrent episodes.  Our series demonstrates an incidence of noninfectious inflammatory reaction shortly after bevacizumab injection that is higher than that reported in the literature. The cause is more likely the preparation process in the same compounding pharmacy.

title: Cluster endophthalmitis due to Stenotrophomonas maltophilia following intravitreal bevacizumab: outcomes of patients from North India
abstract: To study features, management and outcomes of cluster endophthalmitis following intravitreal bevacizumab (BCZ) injection in North India.  In this retrospective study, 28 patients (23 men) (mean age of 59.07+ 13 years) who received intravitreal injection of BCZ were included. Demographic details, best corrected visual acuity (BCVA) clinical features, microbiological findings and management of patients who developed endophthalmitis after injection of contaminated BCZ injections were reviewed. The organism isolated was Stenotrophomonas maltophilia.  All patients suffered from painful diminution of vision within 24 48 hours. Of the 28 eyes, 12 had lid and corneal oedema, raised intraocular pressure (IOP) (difference between mean preinjection and postinjection IOP: 4.42 mm Hg; p=0.005) and toxic anterior segment syndrome like picture. 16 eyes presented with clear cornea, severe vitritis and poor media clarity. Among these, three eyes showed posterior hypopyon. Seventeen eyes underwent primary pars plana vitrectomy (PPV) and intravitreal vancomycin+ceftazidime based on severity of inflammation. Eleven eyes underwent primary tap and inject. Among these, four eyes required PPV due to persistent inflammation. Eleven eyes showed positive staining for Gram negative bacilli. Seven eyes were culture positive for S. maltophilia. Mean preinjection BCVA was 0.77+ 0.48. The first recorded postinjection BCVA was 2.52+ 0.82. BCVA (at 1 month) improved to 0.88+ 0.66. Conclusions S. maltophilia can be found contaminating hospital surfaces and water supply. Early PPV, prompt intravitreal antibiotics and close communication with microbiologists greatly aided in salvaging all eyes from our cohort. Majority of the patients recovered their preinjection BCVA and IOP and achieved quiescence of inflammation.

title: Cluster endophthalmitis following multiple intravitreal bevacizumab injections from a single use vial
abstract: The risk of endophthalmitis is always a concern when an intraocular procedure is performed. Intravitreal injection is a frequently used method for therapeutic management of many diseases, affecting the posterior segment of the eye. Hence, it is important to assess the risk of complications, especially endophthalmitis. Most studies conducted concentrate on risk assessment from single use from single drug vial. The present article reports the occurrence of cluster endophthalmitis following multiple intravitreal bevacizumab injections from a single vial. Intravitreal injection of bevacizumab was administered to eight eyes of eight patients. Administered dose was prepared from single 4 ml vial of bevacizumab and was injected in the eye, after patient preparation and under aseptic conditions. The procedure was repeated for the remaining patients, thereby imparting multiple pricks in the same vial. Four of the eight patients reported to the hospital on the 3rd day after injection with complaints of pain, watering, and diminution of vision. Two patients reported the following day with similar complaints. Two patients who did not report by the 4th day were contacted and recalled for an examination. All the patients were thoroughly examined using slit lamp biomicroscopy and indirect ophthalmoscopy. Six out of eight were clinically diagnosed to have endophthalmitis and were administered intravitreal antibiotics. The present report highlights possibility of microbial contamination of the drug vial or during compounding process. However, from the present incident, we are encouraged to stay vigilant and wary of contamination

title: A cluster of presumed, noninfectious endophthalmitis after intravitreal injection of bevacizumab: long term follow up.
abstract: To report the outcome of 5 consecutive cases of presumed, noninfectious endopththalmitis following intravitreal injection of bevacizumab (IVB) METHODS Ten pre loaded syringes of bevacizumab (1.25 mg/50 uL) furnished by a compounding pharmacy were injected intravitreally. Treatments were performed in the operating room by the same surgeon on 2 consecutive days.  Of 10 eyes, 5 showed moderate to severe ocular inflammation within a few days of injection. All patients were treated in the same surgical session. Vitreous tap performed in the patient presenting with the most severe grade of inflammation was negative for bacteria and fungi. At the time of the vitreous biopsy, this patient was injected with vancomycin 1 mg/100 uL in the vitreous cavity. Other eyes with moderate inflammation received topical and systemic antibiotics and topical steroid treatment. Visual acuity returned to pre endophthalmitis or better levels in all eyes within 1 month. The other 5 patients treated with IVB from the same batch in the other surgical session did not develop inflammation.  IVB can induce noninfectious endophthalmitis. The use of compounded syringes can explain clustering of the inflammation. We were unable to identify the reasons for the variable grade of inflammation we observed in our patients.

title: Results of prompt intravitreal injections in cluster endophthalmitis following cataract surgery
abstract: The purpose of this study was to determine clinical presentation, microbiological spectrum and visual outcome of cluster endophthalmitis patients after cataract surgery The records of cluster endophthalmitis patients were retrospectively reviewed. Intravitreal injection were given to all patients, viterous was sent for culture,smear was sterile in most cases only in 3 cases there was few pus cells.All patients had good visual outcome.

title: Cluster endophthalmitis following multiple intravitreal bevacizumab injections from a single use vial.
abstract: The risk of endophthalmitis is always a concern when an intraocular procedure is performed. Intravitreal injection is a frequently used method for therapeutic management of many diseases, affecting the posterior segment of the eye. Hence, it is important to assess the risk of complications, especially endophthalmitis. Most studies conducted concentrate on risk assessment from single use from single drug vial. The present article reports the occurrence of cluster endophthalmitis following multiple intravitreal bevacizumab injections from a single vial. Intravitreal injection of bevacizumab was administered to eight eyes of eight patients. Administered dose was prepared from single 4 ml vial of bevacizumab and was injected in the eye, after patient preparation and under aseptic conditions. The procedure was repeated for the remaining patients, thereby imparting multiple pricks in the same vial. Four of the eight patients reported to the hospital on the 3rd day after injection with complaints of pain, watering, and diminution of vision. Two patients reported the following day with similar complaints. Two patients who did not report by the 4th day were contacted and recalled for an examination. All the patients were thoroughly examined using slit lamp biomicroscopy and indirect ophthalmoscopy. Six out of eight were clinically diagnosed to have endophthalmitis and were administered intravitreal antibiotics. The present report highlights possibility of microbial contamination of the drug vial or during compounding process. However, from the present incident, we are encouraged to stay vigilant and wary of contamination.

title: Uveitis following intravitreal bevacizumab: a non infectious cluster.
abstract: In this retrospective case series, the authors report seven cases of bevacizumab related uveitis that occurred within a 4 month period.  Seven eyes of six patients developed non infectious uveitis following bevacizumab intravitreal injections in a cohort of 978 consecutive bevacizumab injections.  The mean age of patients was 74.6 years (range: 26 to 92) All patients developed symptom onset within 1 day of injection. Shared signs and symptoms included corneal edema, anterior chamber and vitreous cell, conjunctival injection, ocular pain, and lack of hypopyon. In all patients, visual acuity returned to within one line of baseline acuity. All seven eyes had been previously injected with bevacizumab, with a mean number of antecedent injections of 6.1 (range: 3 to 12)  A cluster of sterile bevacizumab related uveitic reactions was described in this case series. Acute onset of symptoms, absence of hypopyon, a predominant anterior segment reaction, and prompt improvement on topical steroid therapy are useful clinical features distinguishing this uveitic syndrome from infectious endophthalmitis.