The Association between Intravitreal Steroids and Post-Injection Endophthalmitis Rates

Abstract

Purpose: To determine whether there is a difference in the risk of endophthalmitis after an intravitreal steroid injection compared with an anti-vascular endothelial growth factor (VEGF) agent injection.

Design: Retrospective cohort study.

Participants: A total of 75,249 beneficiaries in a large national US medical claims database representing 406 380 intravitreal injections.

Methods: Data were searched for all intravitreal injections (Current Procedural Terminology 67028) performed between 2003 and 2012. Cohorts were created on the basis of 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 (International Classification of Diseases 9th Revision 360.0x) and a "tap-and-inject" procedure (Current Procedural Terminology 67015, 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: A total of 387,714 anti-VEGF injections and 18 666 steroid intravitreal injections were performed and 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 (OR) for endophthalmitis occurring was 6.92 (95% confidence interval, 3.54-13.52, P<0.001) times higher post-steroid injection compared with 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 OR of 6.92 for endophthalmitis compared with anti-VEGF agents.