The Association between Intravitreal Steroids and Post-Injection Endophthalmitis Rates

Abstract

Objective To determine if there is a difference in the risk of endophthalmitis after an intravitreal steroid injection compared to an anti-vascular endothelial growth factor agent (anti-VEGF) injection Design Retrospective cohort study Participants 75,249 beneficiaries in a large national US medical claims database representing 406,380 intravitreal injections Methods Data were searched for all intravitreal injections (CPT 67028) performed between 2003 and 2012. Cohorts were created based on injections using anti-VEGF agents (bevacizumab, ranibizumab, aflibercept and pegaptanib) and intraocular steroids (triamcinolone and dexamethasone). Endophthalmitis was defined as having a new endophthalmitis diagnosis (ICD9 360.0×) and either a “tap-and-inject” procedure (CPT67015, 67025), a vitrectomy (67036) or an intravitreal antibiotic injection on the same day, between 1 and 14 days post-injection. Exclusion occurred for any history of endophthalmitis, <6 months in the plan or <1 month follow up. The main outcome measure was the odds of endophthalmitis using logistic regression while controlling for injection-associated diagnosis, age, race and gender. Results 387,714 anti-VEGF injections and 18,666 steroid intravitreal injections were performed and were followed by 73 (rate=0.019% or 1/5283 anti-VEGF injections) and 24 (rate= 0.13% or 1/778 steroid injections) cases of endophthalmitis respectively. After controlling for diagnosis, age, race and gender, the odds ratio for endophthalmitis occurring was 6.92 (95% CI: 3.54–13.52, p<0.001) times higher post-steroid injection compared to anti-VEGF injections. Conclusions The rate of endophthalmitis post-intravitreal steroid injection in a national cohort was 0.13% (1/778 injections). This rate conferred a significantly increased odds ratio of 6.92 for endophthalmitis compared to anti-VEGF agents.

Different Ipsi- and Contralateral Glial Responses to Anti-VEGF and Triamcinolone Intravitreal Injections in Rats

“…1,3,7 The use of IVI was restricted for many years because of the various risks associated with the injections. [8][9][10][11][12] Recently, however, the advantages of the injections have outweighed the risks, and their use has become widespread, especially since the introduction of new pharmacologic agents such as anti-vascular endothelial growth factor (anti-VEGF) compounds and corticosteroids.…”

Endophthalmitis rates among patients receiving intravitreal anti-VEGF injections: a USA claims analysis

“…In comparison, a retrospective claims study suggested that the rate of endophthalmitis after IVT steroid injections (N=18,666) was 0.13%, compared with 0.019% for anti-VEGF injections (N=387,714) 6. The reported frequency of ocular inflammation following IVT anti-VEGF injections varies widely in retrospective clinical case series.…”

Cost Advantage of Fluocinolone Acetonide Implant (ILUVIEN®) versus Ranibizumab in the Treatment of Chronic Diabetic Macular Oedema

“…Although the frequency of intravitreal injections is often lower for steroids than anti-VEGF products, intravitreal injections of triamcinolone or dexamethasone (short-acting steroids used in DMO though triamcinolone is not licensed in Europe) appear to be associated with a relatively higher incidence of endophthalmitis per injection -0.13% versus 0.019% with anti-VEGF products (10). Endophthalmitis is an inflammation of the interior of the eye and is a possible complication with all intravitreal injections.…”