Incidence and Management of Acute Endophthalmitis after Intravitreal Bevacizumab (Avastin) Injection

O Artunay; E Yuzbasioglu; R Rasier; A Sengül; H Bahcecioglu


Eye. 2009;23(12):2187-2193. 

In This Article

Abstract and Introduction


Introduction The aim of this study was to report the incidence and management of acute endophthalmitis after intravitreal injection of Avastin (bevacizumab), and visual acuity outcomes of three eyes of three patients who developed acute endophthalmitis following intravitreal injection of Avastin.
Methods This clinical retrospective, non-comparative study included 3022 intravitreal injections of 1.25 mg bevacizumab consecutively performed for 1822 eyes with exudative age-related macular degeneration and other retinal diseases. Of 3022 injections, 1200 were reinjections. After clinical appearance of post-injection endophthalmitis, immediate intervention was performed, including injection of intravitreal antibiotics and early pars plana vitrectomy.
Results Three eyes of three patients with acute postoperative endophthalmitis were identified in the first week following intravitreal injections of 1.25 mg bevacizumab. Among of these patients, two cases were culture-positive and one case was culture-negative. Compared with presenting visual acuities, all of three patients improved at the end of follow-up time. The overall incidence rate of post-injection culture-proven endophthalmitis was 0.066%.
Discussion Acute culture-proven endophthalmitis is still a potential complication of intravitreal bevacizumab injection (approximately 0.066%) despite using maximal sterile techniques. Acute post-injection endophthalmitis following intravitreal bevacizumab occurs rapidly and can result in severe loss of vision. Prompt recognition and treatment are key in maximizing outcomes in patients who developed endophthalmitis after intravitreal injection of bevacizumab.


Intravitreal injection of medications is becoming increasingly accepted for treatment of various retinal disorders, with effective intravitreal therapies being commonly administered in the vitreoretinal clinical or surgical environment. With the increase in use of these agents, the risk of endophthalmitis is becoming an important concern. Off-label intravitreal injections of bevacizumab (Avastin; Genentech Inc., South San Francisco, CA, USA) have been given for the treatment of neovascular and exudative ocular diseases since May 2005.[1,2] Since then, the use of intravitreal bevacizumab (IVB) has spread worldwide, but the drug-related adverse events associated with its use have been reported in a few retrospective reviews. IVB is increasingly being used for the treatment of ocular diseases. However, the treatment is not without risks. None of the adverse event rates exceeded 0.21%.[3] Endophthalmitis is a serious intraocular inflammatory disorder resulting from infection of the vitreous cavity. Exogenous endophthalmitis occurs when infecting organisms gain entry into the eye by direct inoculation through intraocular surgery, penetrating trauma, or intravitreal injection.[4] The risk of endophthalmitis after intravitreal injection may vary among agents that are employed.[5] The reported incidence of endophthalmitis per patient in multi-centre clinical trials with anti-vascular endothelial growth factor (VEGF) therapy ranged from 0.019 to 1.6%.[6–8] Although cases of acute endophthalmitis following IVB have occurred, the exact incidence rate remains unknown. Concerns have been raised regarding injection technique and also about the use of bevacizumab because of compounding issues. Generalized categories that lump adverse events are less useful than a clear statement of the rate of individual, clinically relevant endophthalmitis. Treating physician wants to know the specific rates of endophthalmitis and its management. The purpose of our study was to report the incidence rates of culture-positive and culture-negative endophthalmitis for patients receiving IVB. The current study also includes the clinical findings, causative organisms, management, and visual acuity outcomes of three eyes of three patients who developed acute postoperative endophthalmitis after IVB injection.


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