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Ducloyer JB, Deltour JB, Le Meur G, Weber M. [Intravitreal injections: Guidelines, methods and medicolegal issues]. J Fr Ophtalmol 2023; 46:1079-1086. [PMID: 37838497 DOI: 10.1016/j.jfo.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 04/21/2023] [Indexed: 10/16/2023]
Abstract
Intravitreal injection (IVI) of a drug allows for immediate intraocular concentrations of active ingredients higher than those obtained by intravenous injection while reducing the risk of systemic side effects. Today, IVI's play a central role in the treatment of many vitreoretinal diseases. With the aging of the population and the advent of vascular endothelial growth factor (VEGF) antagonists, their indications have increased exponentially, creating structural, organizational and economic difficulties. IVI is now one of the most widely performed medical procedures in industrialized countries, and its indications are expected to expand further in the near future with the development of new molecules. Although the overall safety of this practice is proven, an IVI exposes the patient to a 0.05 % risk of endophthalmitis, the consequences of which are often dramatic. This article details the current recommendations, in particular regarding asepsis and antisepsis, and proposes a typical sequence for performing an IVI.
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Affiliation(s)
- J-B Ducloyer
- Service d'ophtalmologie, CHU de Nantes, Nantes université, 1, place Alexis-Ricordeau, 44093 Nantes, France.
| | - J-B Deltour
- Service d'ophtalmologie, CHU de Nantes, Nantes université, 1, place Alexis-Ricordeau, 44093 Nantes, France
| | - G Le Meur
- Service d'ophtalmologie, CHU de Nantes, Nantes université, 1, place Alexis-Ricordeau, 44093 Nantes, France
| | - M Weber
- Service d'ophtalmologie, CHU de Nantes, Nantes université, 1, place Alexis-Ricordeau, 44093 Nantes, France
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Wu KY, Brister D, Bélanger P, Tran SD. Exploring the Potential of Nanoporous Materials for Advancing Ophthalmic Treatments. Int J Mol Sci 2023; 24:15599. [PMID: 37958583 PMCID: PMC10650608 DOI: 10.3390/ijms242115599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 10/23/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
The landscape of ophthalmology is undergoing significant transformations, driven by technological advancements and innovations in materials science. One of the advancements in this evolution is the application of nanoporous materials, endowed with unique physicochemical properties ideal for a variety of ophthalmological applications. Characterized by their high surface area, tunable porosity, and functional versatility, these materials have the potential to improve drug delivery systems and ocular devices. This review, anchored by a comprehensive literature focusing on studies published within the last five years, examines the applications of nanoporous materials in ocular drug delivery systems (DDS), contact lenses, and intraocular lenses. By consolidating the most current research, this review aims to serve as a resource for clinicians, researchers, and material scientists engaged in the rapidly evolving field of ophthalmology.
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Affiliation(s)
- Kevin Y. Wu
- Department of Surgery—Division of Ophthalmology, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada; (K.Y.W.)
| | - Danielle Brister
- College of Public Health, National Taiwan University (NTU), Taipei 106319, Taiwan
| | - Paul Bélanger
- Department of Surgery—Division of Ophthalmology, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada; (K.Y.W.)
| | - Simon D. Tran
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC H3A 1G1, Canada
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Baudin F, Benzenine E, Mariet AS, Ghezala IB, Bron AM, Daien V, Gabrielle PH, Quantin C, Creuzot-Garcher C. Topical Antibiotic Prophylaxis and Intravitreal Injections: Impact on the Incidence of Acute Endophthalmitis-A Nationwide Study in France from 2009 to 2018. Pharmaceutics 2022; 14:pharmaceutics14102133. [PMID: 36297568 PMCID: PMC9611403 DOI: 10.3390/pharmaceutics14102133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/07/2022] Open
Abstract
Background: The dramatic increase in intravitreal injections (IVTs) has been accompanied by a greater need for safer procedures. The ongoing debate about topical antibiotic prophylaxis after IVTs emphasizes the importance of large-scale studies. We aimed to study the role of topical antibiotic prophylaxis in reducing the risk of acute endophthalmitis after IVTs. Methods: Population-based cohort study, in France, from 2009 to 2018, including all French patients receiving IVTs of corticosteroids or anti-VEGF agents. Results: A total of 5,291,420 IVTs were performed on 605,434 patients. The rate of topical antibiotic prophylaxis after IVTs progressively decreased during the study period, with a sharp drop in 2014 (from 84.6% in 2009 to 27.4% in 2018). Acute endophthalmitis occurred in 1274 cases (incidence rate = 0.0241%). Although antibiotic prophylaxis did not alter the risk of endophthalmitis (p = 0.06), univariate analysis showed an increased risk after fluoroquinolone and aminoglycoside prophylaxis. This increased risk was not found in multivariate analysis. However, we observed an increased risk related to the use of fixed combinations of fluoroquinolones and aminoglycosides with corticosteroids (IRR = 1.89; 95% CI = 1.57–2.27%, antibiotics combined with corticosteroids). Conclusion: These results are consistent with the literature. Endophthalmitis rates after IVTs did not decrease with topical antibiotic prophylaxis. The use of a combination of antibiotics and corticosteroids doubles the risk of endophthalmitis and should be avoided. Avoiding antibiotic prophylaxis would reduce the costs and the potential risks of antibiotic resistance.
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Affiliation(s)
- Florian Baudin
- Department of Ophthalmology, University Hospital, 21000 Dijon, France
- EA7460, PEC2, Cerebral and Cardiovascular Epidemiology, and Physiopathology, 21000 Dijon, France
| | - Eric Benzenine
- Biostatistics and Bioinformatics (DIM), University Hospital, 21079 Dijon, France
- Biostatistics and Bioinformatics (DIM), University Hospital, Bourgogne Franche-Comté University, BP 77908, 21079 Dijon, France
| | - Anne-Sophie Mariet
- Biostatistics and Bioinformatics (DIM), University Hospital, 21079 Dijon, France
- Biostatistics and Bioinformatics (DIM), University Hospital, Bourgogne Franche-Comté University, BP 77908, 21079 Dijon, France
- INSERM, CIC 1432, 21000 Dijon, France
- Clinical Epidemiology, Clinical Trials Unit, Clinical Investigation Center, Dijon University Hospital, 21000 Dijon, France
- Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases (B2PHI), INSERM, UVSQ, Institut Pasteur, Université Paris-Saclay, 94807 Paris, France
| | - Inès Ben Ghezala
- Department of Ophthalmology, University Hospital, 21000 Dijon, France
- EA7460, PEC2, Cerebral and Cardiovascular Epidemiology, and Physiopathology, 21000 Dijon, France
| | - Alain M. Bron
- Department of Ophthalmology, University Hospital, 21000 Dijon, France
- Eye and Nutrition Research Group, Bourgogne Franche-Comté University, 21000 Dijon, France
| | - Vincent Daien
- Department of Ophthalmology, University Hospital, 34295 Montpellier, France
- Inserm U1061, University of Montpellier, 34000 Montpellier, France
| | - Pierre-Henry Gabrielle
- Department of Ophthalmology, University Hospital, 21000 Dijon, France
- Eye and Nutrition Research Group, Bourgogne Franche-Comté University, 21000 Dijon, France
| | - Catherine Quantin
- Biostatistics and Bioinformatics (DIM), University Hospital, 21079 Dijon, France
- Biostatistics and Bioinformatics (DIM), University Hospital, Bourgogne Franche-Comté University, BP 77908, 21079 Dijon, France
- INSERM, CIC 1432, 21000 Dijon, France
- Clinical Epidemiology, Clinical Trials Unit, Clinical Investigation Center, Dijon University Hospital, 21000 Dijon, France
- Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases (B2PHI), INSERM, UVSQ, Institut Pasteur, Université Paris-Saclay, 94807 Paris, France
| | - Catherine Creuzot-Garcher
- Department of Ophthalmology, University Hospital, 21000 Dijon, France
- Eye and Nutrition Research Group, Bourgogne Franche-Comté University, 21000 Dijon, France
- Correspondence: ; Tel.: +33-(0)-380293277
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Design, construction and in vivo functional assessment of a hinge truncated sFLT01. Gene Ther 2022; 30:347-361. [PMID: 36114375 DOI: 10.1038/s41434-022-00362-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 08/05/2022] [Accepted: 08/26/2022] [Indexed: 11/08/2022]
Abstract
Gene therapy for the treatment of ocular neovascularization has reached clinical trial phases. The AAV2-sFLT01 construct was already evaluated in a phase 1 open-label trial administered intravitreally to patients with advanced neovascular age-related macular degeneration. SFLT01 protein functions by binding to VEGF and PlGF molecules and inhibiting their activities simultaneously. It consists of human VEGFR1/Flt-1 (hVEGFR1), a polyglycine linker, and the Fc region of human IgG1. The IgG1 upper hinge region of the sFLT01 molecule makes it vulnerable to radical attacks and prone to causing immune reactions. This study pursued two goals: (i) minimizing the immunogenicity and vulnerability of the molecule by designing a truncated molecule called htsFLT01 (hinge truncated sFLT01) that lacked the IgG1 upper hinge and lacked 2 amino acids from the core hinge region; and (ii) investigating the structural and functional properties of the aforesaid chimeric molecule at different levels (in silico, in vitro, and in vivo). Molecular dynamics simulations and molecular mechanics energies combined with Poisson-Boltzmann and surface area continuum solvation calculations revealed comparable free energy of binding and binding affinity for sFLT01 and htsFLT01 to their cognate ligands. Conditioned media from human retinal pigment epithelial (hRPE) cells that expressed htsFLT01 significantly reduced tube formation in HUVECs. The AAV2-htsFLT01 virus suppressed vascular development in the eyes of newborn mice. The htsFLT01 gene construct is a novel anti-angiogenic tool with promising improvements compared to existing treatments.
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Singh R, Davoudi S, Ness S. Preventive factors, diagnosis, and management of injection-related endophthalmitis: a literature review. Graefes Arch Clin Exp Ophthalmol 2022; 260:2399-2416. [PMID: 35278125 PMCID: PMC8917335 DOI: 10.1007/s00417-022-05607-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/14/2022] [Accepted: 02/21/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Intravitreal medication injections represent the gold standard treatment for a variety of potentially blinding chorioretinal vascular diseases. Despite their excellent safety profile, they are associated with the feared complication of injection-related endophthalmitis (IRE). Though the overall incidence of IRE is low, due to the ever-increasing number of injections being performed, it is a complication that all retina specialists are likely to encounter. This article reviews various factors that could potentially influence the risk of IRE and discusses evidence-based strategies for management. METHOD PubMed was searched for keywords "intravitreal injection" and "endophthalmitis" from the period of 1995-2021. Relevant articles were reviewed and selected articles were analyzed with respect to the incidence, potential preventive factors, clinical presentation, microbial profile, management, and outcomes for IRE. RESULTS There is strong consensus supporting the use of povidone iodine topical antiseptic, eyelid retraction away from the injection site, and avoiding treatment of eyes with active surface or eyelid disease, but there is less agreement on the use of face masks versus "no-talking" policies and optimal anesthetic technique. Current evidence comparing tap and inject or early vitrectomy for treatment of IRE is inadequate to determine an optimal treatment strategy. CONCLUSION Intravitreal injections are sight saving, but even using established prophylactic measures there remains a small but real risk of infectious injection-related complications. Further investigations comparing tap and inject versus vitrectomy may help to establish optimal treatment, although the rarity of IRE makes designing adequately powered prospective trials a difficult task.
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Affiliation(s)
| | - Samaneh Davoudi
- Boston Medical Center, 85 East Concord Street, 8th Floor, Boston, MA, 02118, USA
| | - Steven Ness
- Boston Medical Center, 85 East Concord Street, 8th Floor, Boston, MA, 02118, USA.
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6
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Mirghorbani M, Bazvand F, Riazi-Esfahani H, Bahar MM, Yaseri M, Zarei M. Post-intravitreal injection endophthalmitis pattern during the COVID-19 pandemic with implementation of patients' masking. Graefes Arch Clin Exp Ophthalmol 2022; 260:3657-3664. [PMID: 35678839 PMCID: PMC9178317 DOI: 10.1007/s00417-022-05726-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/25/2022] [Accepted: 05/31/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose To evaluate the role of patient facial masks on the occurrence of post-intravitreal injection (IVI) endophthalmitis in a real-word setting. Methods In this retrospective cohort, patients receiving IVIs between 20 February 2019 and 20 February 2021; a 12-month period before the official beginning of COVID-19 epidemic in Iran and a 12-month period thereafter were included. In the pre-COVID era, patients underwent IVI without a facial mask while in the COVID era patients wore an untaped facial mask. Physicians and staff had facial mask in both periods. IVIs were administered in a dedicated operating room without a strict no talk-policy. The main outcome measure was the rate of post-IVI endophthalmitis. Results A total number of 53,927 injections was performed during the study period: 34,277 in pre-COVID and 19,650 in COVID periods; with a 42.7% decrease in the number of injections. Endophthalmitis occurred in 7 eyes (0.020%) in pre-COVID and 7 eyes (0.036%) in COVID era (p = 0.40). In multivariate analysis, after adjustment for intercorrelations between the eyes and multiple injections in one patient, there was no statistically significant association between wearing facial masks by the patients and risk of endophthalmitis (relative risk = 1.47, 95% confidence interval of 0.97–2.22; p = 0.071). Conclusion Patients’ facial masking is not associated with an increased risk of post-injection endophthalmitis.
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Affiliation(s)
- Masoud Mirghorbani
- Farabi Eye Hospital, Tehran University of Medical Sciences, South Karegar Street, Tehran, Iran
| | - Fatemeh Bazvand
- Farabi Eye Hospital, Tehran University of Medical Sciences, South Karegar Street, Tehran, Iran
| | - Hamid Riazi-Esfahani
- Farabi Eye Hospital, Tehran University of Medical Sciences, South Karegar Street, Tehran, Iran
| | | | - Mehdi Yaseri
- Farabi Eye Hospital, Tehran University of Medical Sciences, South Karegar Street, Tehran, Iran
| | - Mohammad Zarei
- Farabi Eye Hospital, Tehran University of Medical Sciences, South Karegar Street, Tehran, Iran.
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Zhao X, Seah I, Xue K, Wong W, Tan QSW, Ma X, Lin Q, Lim JYC, Liu Z, Parikh BH, Mehta KN, Lai JW, Yang B, Tran KC, Barathi VA, Cheong KH, Hunziker W, Su X, Loh XJ. Antiangiogenic Nanomicelles for the Topical Delivery of Aflibercept to Treat Retinal Neovascular Disease. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2022; 34:e2108360. [PMID: 34726299 DOI: 10.1002/adma.202108360] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Indexed: 06/13/2023]
Abstract
The traditional intravitreal injection delivery of antivascular endothelial growth factor (anti-VEGF) to the posterior segment of the eye for treatment of retinal diseases is invasive and associated with sight-threatening complications. To avoid such complications, there has been significant interest in developing polymers for topical drug delivery to the retina. This study reports a nanomicelle drug delivery system made of a copolymer EPC (nEPCs), which is capable of delivering aflibercept to the posterior segment topically through corneal-scleral routes. EPC is composed of poly(ethylene glycol) (PEG), poly(propylene glycol) (PPG), and polycaprolactone (PCL) segments. In this study, aflibercept-loaded nEPCs (nEPCs + A) are capable of penetrating the cornea in ex vivo porcine eye models and deliver a clinically significant amount of aflibercept to the retina in laser-induced choroidal neovascularization (CNV) murine models, causing CNV regression. nEPCs + A also demonstrate biocompatibility in vitro and in vivo. Interestingly, this study also suggests that nEPCs have intrinsic antiangiogenic properties. The ability to deliver anti-VEGF drugs and the intrinsic antiangiogenic properties of nEPCs may result in synergistic effects, which can be harnessed for effective therapeutics. nEPCs may be a promising topical anti-VEGF delivery platform for the treatment of retinal diseases.
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Affiliation(s)
- Xinxin Zhao
- Institute of Molecular and Cell Biology (IMCB), Agency for Science, Technology and Research (A*STAR), 61 Biopolis Drive, Singapore, 138 673, Singapore
| | - Ivan Seah
- Department of Ophthalmology, National University Hospital, 1E Kent Ridge Road, NUHS Tower Block Level 7, Singapore, 119 228, Singapore
| | - Kun Xue
- Institute of Materials Research and Engineering (IMRE), Agency for Science, Technology and Research (A*STAR), 2 Fusionopolis Way, Singapore, 138 634, Singapore
| | - Wendy Wong
- Department of Ophthalmology, National University Hospital, 1E Kent Ridge Road, NUHS Tower Block Level 7, Singapore, 119 228, Singapore
| | - Queenie Shu Woon Tan
- Institute of Molecular and Cell Biology (IMCB), Agency for Science, Technology and Research (A*STAR), 61 Biopolis Drive, Singapore, 138 673, Singapore
| | - Xiaoxiao Ma
- Institute of Molecular and Cell Biology (IMCB), Agency for Science, Technology and Research (A*STAR), 61 Biopolis Drive, Singapore, 138 673, Singapore
| | - Qianyu Lin
- Institute of Materials Research and Engineering (IMRE), Agency for Science, Technology and Research (A*STAR), 2 Fusionopolis Way, Singapore, 138 634, Singapore
| | - Jason Y C Lim
- Institute of Materials Research and Engineering (IMRE), Agency for Science, Technology and Research (A*STAR), 2 Fusionopolis Way, Singapore, 138 634, Singapore
| | - Zengping Liu
- Institute of Molecular and Cell Biology (IMCB), Agency for Science, Technology and Research (A*STAR), 61 Biopolis Drive, Singapore, 138 673, Singapore
- Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 7, Singapore, 119 228, Singapore
| | - Bhav Harshad Parikh
- Institute of Molecular and Cell Biology (IMCB), Agency for Science, Technology and Research (A*STAR), 61 Biopolis Drive, Singapore, 138 673, Singapore
- Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 7, Singapore, 119 228, Singapore
| | - Karishma N Mehta
- Institute of Molecular and Cell Biology (IMCB), Agency for Science, Technology and Research (A*STAR), 61 Biopolis Drive, Singapore, 138 673, Singapore
- Singapore Institute of Technology (SIT), SIT@Dover, 10 Dover Drive, Singapore, 138 683, Singapore
| | - Joel Weijia Lai
- Science, Mathematics and Technology Cluster, Singapore University of Technology and Design (SUTD), 8 Somapah Road, Singapore, 487 372, Singapore
| | - Binxia Yang
- Institute of Molecular and Cell Biology (IMCB), Agency for Science, Technology and Research (A*STAR), 61 Biopolis Drive, Singapore, 138 673, Singapore
| | - Kim Chi Tran
- Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 7, Singapore, 119 228, Singapore
| | - Veluchamy Amutha Barathi
- Singapore Eye Research Institute (SERI), The Academia, 20 College Road, Level 6 Discovery Tower, Singapore, 169856, Singapore
- Academic Clinical Program in Ophthalmology, Duke-NUS Medical School, 8 College Road, Singapore, 169 857, Singapore
| | - Kang Hao Cheong
- Science, Mathematics and Technology Cluster, Singapore University of Technology and Design (SUTD), 8 Somapah Road, Singapore, 487 372, Singapore
- SUTD-Massachusetts Institute of Technology International Design Centre, 8 Somapah Road, Singapore, 487 372, Singapore
| | - Walter Hunziker
- Institute of Molecular and Cell Biology (IMCB), Agency for Science, Technology and Research (A*STAR), 61 Biopolis Drive, Singapore, 138 673, Singapore
| | - Xinyi Su
- Institute of Molecular and Cell Biology (IMCB), Agency for Science, Technology and Research (A*STAR), 61 Biopolis Drive, Singapore, 138 673, Singapore
- Department of Ophthalmology, National University Hospital, 1E Kent Ridge Road, NUHS Tower Block Level 7, Singapore, 119 228, Singapore
- Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 7, Singapore, 119 228, Singapore
- Singapore Eye Research Institute (SERI), The Academia, 20 College Road, Level 6 Discovery Tower, Singapore, 169856, Singapore
| | - Xian Jun Loh
- Institute of Materials Research and Engineering (IMRE), Agency for Science, Technology and Research (A*STAR), 2 Fusionopolis Way, Singapore, 138 634, Singapore
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Incidence and management of acute endophthalmitis after intravitreal injection of bevacizumab. Int Ophthalmol 2022; 42:1827-1833. [DOI: 10.1007/s10792-021-02180-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 12/18/2021] [Indexed: 10/19/2022]
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Kumar S, Quach J, Cook N, Gum G, Naageshwaran V. Characterization and validation of a chronic retinal neovascularization rabbit model by evaluating the efficacy of anti-angiogenic and anti-inflammatory drugs. Int J Ophthalmol 2022; 15:15-22. [PMID: 35047351 DOI: 10.18240/ijo.2022.01.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 08/11/2021] [Indexed: 11/23/2022] Open
Abstract
AIM To establish a rabbit model with chronic condition of retinal neovascularization (RNV) induced by intravitreal (IVT) injection of DL-2-aminoadipic acid (DL-AAA), a retinal glial (Müller) cell toxin, extensive characterization of DL-AAA induced angiographic features and the suitability of the model to evaluate anti-angiogenic and anti-inflammatory therapies for ocular vascular diseases. METHODS DL-AAA (80 mmol/L) was administered IVT into both eyes of Dutch Belted rabbit. Post DL-AAA delivery, clinical ophthalmic examinations were performed weekly following modified McDonald-Shadduck Scoring System. Color fundus photography, fluorescein angiography (FA), and optical coherence tomography (OCT) procedures were performed every 2 or 4wk until stable retinal vascular leakage was observed. Once stable retinal leakage (12wk post DL-AAA administration) was established, anti-vascular endothelial growth factor (VEGF) (bevacizumab, ranibizumab and aflibercept) and anti-inflammatory (triamcinolone, TAA) drugs were tested for their efficacy after IVT administration. Fluorescein angiograms were scored before and after treatment following a novel grading system, developed for the DL-AAA rabbit model. RESULTS Post DL-AAA administration, eyes were presented with moderate to severe retinal/choroidal inflammation which was accompanied by intense vitreous flare and presence of inflammatory cells in the vitreous humor. Retinal hemorrhage was restricted to the tips of neo-retinal vessels. FA revealed maximum retinal vascular leakage at 2wk after DL-AAA injection and then persisted as evidenced by stable mean FA scores in weeks 8 and 12. Retinal vascular angiographic and tomographic features were stable and consistent up to 36mo among two different staggers induced for RNV at two different occasions. Day 7, mean FA scores showed that 1 µg/eye of bevacizumab, ranibizumab, aflibercept and 2 µg/eye of TAA suppress 65%, 90%, 100% and 50% retinal vascular leakage, respectively. Day 30, bevacizumab and TAA continued to show 66% and 44% suppression while ranibizumab effect was becoming less effective (68%). In contrast, aflibercept was still able to fully (100%) suppress vascular leakage on day 30. On day 60, bevacizumab, ranibizumab and TAA showed suppression of 7%, 12%, and 9% retinal vascular leakage, respectively, however, aflibercept continued to be more effective showing 50% suppression of vascular leakage. CONCLUSION The DL-AAA rabbit model mimics RNV angiographic features like RNV and chronic retinal leakage. Based on these features the DL-AAA rabbit model provides an invaluable tool that could be used to test the therapeutic efficacy and duration of action of novel anti-angiogenic formulations, alone or in combination with anti-inflammatory compounds.
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Affiliation(s)
- Sandeep Kumar
- Department of Ophthalmology, Absorption Systems: a Pharmaron company, 7901 Vickers St, San Diego, CA 92111, USA
| | - John Quach
- Department of Ophthalmology, Absorption Systems: a Pharmaron company, 7901 Vickers St, San Diego, CA 92111, USA
| | - Nicholas Cook
- Department of Ophthalmology, Absorption Systems: a Pharmaron company, 7901 Vickers St, San Diego, CA 92111, USA
| | - Glenwood Gum
- Department of Ophthalmology, Absorption Systems: a Pharmaron company, 7901 Vickers St, San Diego, CA 92111, USA
| | - Vatsala Naageshwaran
- Department of Ophthalmology, Absorption Systems: a Pharmaron company, 7901 Vickers St, San Diego, CA 92111, USA
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Ying Z, Maria C, Spyridon D, Karl-Ulrich BS, Stephan SM, Christos S. Analysis of retinal detachment resulted from post-operative endophthalmitis treated with 23G pars Plana Vitrectomy. BMC Ophthalmol 2021; 21:414. [PMID: 34852777 PMCID: PMC8638527 DOI: 10.1186/s12886-021-02175-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 10/13/2021] [Indexed: 11/21/2022] Open
Abstract
Background To evaluate the rate, risk factors, functional outcome and prognosis in eyes with retinal detachment after post-operative endophthalmitis treated with 23G Pars Plana Vitrectomy. Methods Electronic patient files from 2009 until 2018 were screened for the presence of an endophthalmitis. Included were 116 eyes of 116 patients. This population was evaluated for the rate of retinal detachment after 23G Pars Plana Vitrectomy for endophthalmitis following cataract surgery or intravitreal injection. The main outcome measures were retinal detachment and visual acuity. Results The reasons for endophthalmitis were previous cataract surgery in 78 patients and following intravitreal injection in 38 patients. The first clinical evidence of endophthalmitis was present in median 5 days after the triggering intervention. Twenty-five eyes (21.55%) developed a retinal detachment an average of 25 days after endophthalmitis. RD is significantly associated with preoperative visual acuity (p = 0.001). Conclusions We emphasize the prognostic role of preoperative visual acuity in RD development of the endophthalmitis treated with 23G Pars Plana Vitrectomy.
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Affiliation(s)
- Zheng Ying
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. .,Department of Ophthalmology, Shanghai General Hospital Affiliated to Shanghai Jiaotong University, 100 Haining Road, Shanghai, 200080, China.
| | - Casagrande Maria
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dimopoulos Spyridon
- Department of Ophthalmology, Eberhard Karls University Medical Center, Tübingen, Germany
| | | | - Spitzer Matin Stephan
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Skevas Christos
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Angaramo S, Law JC, Maris AS, Schmitz JE, Liu Y, Chen Q, Chomsky A. Potential impact of oral flora dispersal on patients wearing face masks when undergoing ophthalmologic procedures. BMJ Open Ophthalmol 2021; 6:e000804. [PMID: 34660909 PMCID: PMC8493904 DOI: 10.1136/bmjophth-2021-000804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 09/22/2021] [Indexed: 11/04/2022] Open
Abstract
Objective The purpose of this study is to investigate the amount of oral flora dispersion towards the ocular surface in relation to various face mask scenarios. Methods and analysis Thirty participants were recruited for this prospective cross-sectional study. Each participant was seated and instructed to hold a blood agar plate perpendicular to the bridge of their nose and facing downward. Participants then partook in three unique face mask scenarios: no face mask, surgical face mask and surgical face mask with tape securing the superior edge. During each scenario, participants were instructed to forcefully exhale for 5 s three times. The primary outcome measure was the number of colony-forming units (CFUs) grown on each face mask scenario-specific plate. Results Thirty participants were recruited for the study, and a total of 90 chocolate agar plates were successfully incubated. The proportion of detecting any CFU was 6.67% (95% CI: 0.818% to 22.1%) for no mask scenario, 0% (95% CI: 0% to 11.6%) for mask scenario and 3.33% (95% CI: 0.0844% to 17.2%) for mask-taped scenario. The mean differences in proportion of detecting any CFU were 3.33% (95% CI: 0% to 10%, p=0.309) for no mask versus mask taped, 3.35% (95% CI: 0% to 10%, p=0.307) for mask taped versus mask and 6.68% (95% CI: 0% to 16.7%, p=0.142) for no mask versus mask. Conclusion This study showed no difference in bacterial dispersion towards the ocular surface when comparing no face mask, a surgical face mask without tape or a surgical face mask with tape.
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Affiliation(s)
| | - Janice C Law
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,Department of Ophthalmology and Visual Sciences, Vanderbilt Eye Institute, Nashville, Tennessee, USA
| | - Alexander Spyros Maris
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan Edward Schmitz
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Yuhan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Qingxia Chen
- Department of Ophthalmology and Visual Sciences, Vanderbilt Eye Institute, Nashville, Tennessee, USA.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amy Chomsky
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,Department of Ophthalmology and Visual Sciences, Vanderbilt Eye Institute, Nashville, Tennessee, USA
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12
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Vagge A, Ferro Desideri L, Carnevali A, Del Noce C, Camposampiero D, Agrusta M, Ponzin D, Pellegrini M, Vaccaro S, Nicolò M, Scorcia V, Traverso CE, Giannaccare G. Efficacy of a New Commercial Ocular Spray Containing Oftasecur Citrus Extract for Reducing Microbial Load in the Conjunctiva of Patients Receiving Intravitreal Injections. Ophthalmol Ther 2021; 10:1025-1032. [PMID: 34495493 PMCID: PMC8589878 DOI: 10.1007/s40123-021-00384-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/06/2021] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION The control of conjunctival microbial load is crucial for patients receiving intravitreal injections (IVTs) in order to reduce the risk of endophthalmitis. The purpose of this work was to assess the antimicrobial activity of a new commercial ocular spray containing Biosecur citrus extract (Oftasecur®, Off Health, Florence, Italy). METHODS This prospective cross-sectional pilot study included patients receiving IVTs who were instructed to apply Oftasecur spray onto the eye to be injected four times daily starting 4 days before surgery. The contralateral eye was considered the control. A conjunctival swab for microbiological analysis was performed in both eyes before starting study treatment and at the time of the injection. The Brief Ocular Discomfort Inventory (BODI) questionnaire was administered to patients based on an 11-point scale (0 for no discomfort and 10 for maximum discomfort). RESULTS Thirty patients (15 male, 15 female; mean age 64.7 ± 11.6 [standard deviation, SD] years) were included. Before starting treatment, 53.3% of the total eyes tested positive during the microbiological analysis. After the treatment period, only 20% of the eyes tested positive at the time of injection, showing a significant reduction in the microbial load (p < 0.01). Moreover, in the treated arm, the positive swabs before and after the prophylactic treatment with Oftasecur ocular spray showed a significant reduction (from 70.4% to 29.6%; p = 0.003, McNemar's test). Oftasecur ocular spray was well tolerated, with an average BODI score of 1.2 (± 0.70 SD). CONCLUSION Oftasecur ocular spray showed antimicrobial activity that significantly reduced the microbial load in patients receiving intravitreal injections. Therefore, it may have a role in the prophylaxis of infection in the setting of IVTs.
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Affiliation(s)
- Aldo Vagge
- University Eye Clinic of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Lorenzo Ferro Desideri
- University Eye Clinic of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Adriano Carnevali
- Department of Ophthalmology, University Magna Græcia of Catanzaro, Viale Europa, Germaneto, 88100, Catanzaro, Italy.
| | - Chiara Del Noce
- University Eye Clinic of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | | | - Marina Agrusta
- University Eye Clinic of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Diego Ponzin
- Fondazione Banca degli Occhi del Veneto, Venice, Italy
| | - Marco Pellegrini
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", Forlì, Italy.,Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy.,Department of Morphology Surgery, and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Sabrina Vaccaro
- Department of Ophthalmology, University Magna Græcia of Catanzaro, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Massimo Nicolò
- University Eye Clinic of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Vincenzo Scorcia
- Department of Ophthalmology, University Magna Græcia of Catanzaro, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Carlo E Traverso
- University Eye Clinic of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Giuseppe Giannaccare
- Department of Ophthalmology, University Magna Græcia of Catanzaro, Viale Europa, Germaneto, 88100, Catanzaro, Italy
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13
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The effect of topical ocular moxifloxacin on conjunctival and nasal mucosal flora. Sci Rep 2021; 11:13782. [PMID: 34215812 PMCID: PMC8253760 DOI: 10.1038/s41598-021-93233-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 06/22/2021] [Indexed: 11/16/2022] Open
Abstract
To determine the short-term effect of topically administered ocular moxifloxacin on conjunctival and nasal bacterial mucosal flora. The study included 20 patients with newly diagnosed age-related macular degeneration. Each patient’s diseased eye was selected as the treatment eye and the fellow eye was selected as the control eye. All treatment eyes constituted the treatment group and all controls eyes constituted the control group. All patients received intravitreal injection of ranibizumab. Cultures were obtained from the inferior conjunctival fornix and the nostrils in all patients. Patients were instructed to administer moxifloxacin eye drops to the treatment eye 4 times daily for 1 week. The patients were instructed to come for a follow-up exam 1 week post intravitreal injection. The bacterial culture positivity rate and the bacteria isolated from the conjunctiva and nostrils were recorded in the 2 groups before and after use of topical ocular moxifloxacin. Mean age of the patients (12 female and 8 male) was 64.9 years. Before use of topical ocular moxifloxacin the conjunctival and nasal culture positivity rates in the treatment group were both 100%, versus 90% and 95%, respectively, in the control group. At the follow-up exam the conjunctival and nasal mucosa culture positivity rates in the treatment group decreased to 20% (4/20) and 30% (6/20), respectively (P < 0.001), versus 85% (17/20) and 80% (16/20), respectively, in the control group (P = 0.68 and P = 0.72 for conjunctival and nasal). This is the first study to show that moxifloxacin applied to the ocular surface topically has a significant effect on nasal flora. Daily administration of topical ocular moxifloxacin for 1 week significantly reduces the nasal bacterial flora in addition to conjunctival flora.
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14
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Nikoi ND, Berwick M, Bryant JA, Riordan L, Slope L, Peacock AFA, de Cogan F. Stability of Cell-Penetrating Peptide anti-VEGF Formulations for the Treatment of Age-Related Macular Degeneration. Curr Eye Res 2021; 46:751-757. [PMID: 33896277 DOI: 10.1080/02713683.2020.1830117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM The development of a polyarginine cell-penetrating peptide (CPP) could enable the treatment of age-related macular degeneration, with drugs like bevacizumab, to be administered using eye drops instead of intravitreal injections. Topical formulations have a vast potential impact on healthcare by increasing patient compliance while reducing the financial burden. However, as the ocular preparations may contain several doses, it is essential to understand the stability of the bevacizumab+CPP conjugate produced. MATERIALS AND METHODS In this work, we examine the stability of a bevacizumab solution with and without cell-penetrating peptide using dynamic light scattering and circular dichroism to assess the physical stability. We use HPLC to assess the chemical stability and ELISA to assess its biological activity. We also examine the potential of the CPP to be used as an antimicrobial agent in place of preservatives in the eye drop. RESULTS The structural stability of bevacizumab with and without the CPP was found not to be affected by temperature: samples stored at either 20°C or 4°C were identical in behavior. However, physical instability was observed after five weeks, leading to aggregation and precipitation. Further investigation revealed that the addition of the polypeptide led to increased aggregation, as revealed through dynamic light scattering and concentration analysis of the peptide through HPLC. Complexing the bevacizumab with CPP had no effect on biological stability or degradation. CONCLUSIONS Our findings suggest that the shelf life of CPP+bevacizumab complexes is at least 38 days from its initial formulation. Currently, the mechanism for aggregation is not fully understood but does not appear to occur through chemical degradation.
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Affiliation(s)
- Naa-Dei Nikoi
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK.,Pharmacy Department, University Hospitals Coventry and Warwickshire Trust, Coventry, UK
| | - Matthew Berwick
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK.,School of Chemistry, University of Birmingham, Birmingham, UK
| | - Jack A Bryant
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - Lily Riordan
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - Louise Slope
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | | | - Felicity de Cogan
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
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15
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Statement of the German Ophthalmological Society, the German Retina Society, and the Professional Association of Ophthalmologists in Germany on treatment of diabetic macular edema : Dated August 2019. Ophthalmologe 2021; 118:40-67. [PMID: 33033871 DOI: 10.1007/s00347-020-01244-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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16
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Bisorca-Gassendorf L, Boden KT, Szurman P, Al-Nawaiseh S, Rickmann A, Januschowski K. [Postoperative endophthalmitis-a review of literature]. Ophthalmologe 2021; 118:210-218. [PMID: 33270146 DOI: 10.1007/s00347-020-01271-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Postoperative endophthalmitis is one of the most feared complications for ophthalmologists, and the number of infections after intraocular procedures have been increasing. Nonetheless, a prompt intervention can result in the recovery of vision. In the past, endophthalmitis after cataract surgery was accountable for the majority of cases but is becoming less frequent due to the progress of surgical techniques and demographic developments with a steadily increasing number of intravitreal injections. In this article, the different forms of postoperative endophthalmitis are assessed in terms of pathophysiology and their specific characteristics depending on their etiology.
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Affiliation(s)
- L Bisorca-Gassendorf
- Augenklinik Sulzbach, Knappschaftsklinikum Saar GmbH, An der Klinik 10, 66280, Sulzbach, Deutschland.
| | - K T Boden
- Augenklinik Sulzbach, Knappschaftsklinikum Saar GmbH, An der Klinik 10, 66280, Sulzbach, Deutschland
| | - P Szurman
- Augenklinik Sulzbach, Knappschaftsklinikum Saar GmbH, An der Klinik 10, 66280, Sulzbach, Deutschland
| | - S Al-Nawaiseh
- Augenklinik Sulzbach, Knappschaftsklinikum Saar GmbH, An der Klinik 10, 66280, Sulzbach, Deutschland
| | - A Rickmann
- Augenklinik Sulzbach, Knappschaftsklinikum Saar GmbH, An der Klinik 10, 66280, Sulzbach, Deutschland
| | - K Januschowski
- Augenklinik Sulzbach, Knappschaftsklinikum Saar GmbH, An der Klinik 10, 66280, Sulzbach, Deutschland
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17
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Pancholy M, Storey PP, Levin HJ, Obeid A, Patel SN, Kuley B, Hsu J, Spirn MJ, Fineman M, Klufas MA, Gupta O, Ho AC, Garg SJ. Endophthalmitis following Intravitreal Anti-Vascular Endothelial Growth Factor Therapy: Changes in Incidence and Outcomes over a 9-Year Period. Curr Eye Res 2021; 46:1370-1377. [PMID: 33522314 DOI: 10.1080/02713683.2021.1874023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Aims: To evaluate whether the incidence, microbial spectrum, and visual outcomes of endophthalmitis following intravitreal injections have changed over time.Methods: Retrospective cohort study of endophthalmitis in eyes receiving intravitreal injection of anti-vascular endothelial growth factor between 2009-2012 and 2016-2017 at a single, large retina practice.Results: A total of 283,315 injections resulted in 96 suspected infectious endophthalmitis cases. Comparing 2009-2012 and 2016-2017, the rate of suspected endophthalmitis changed from 1 in 2,663 injections to 1 in 3,195 injections (p = .37). Visual outcomes 6 months after endophthalmitis were significantly better during the latter period (p = .04), with an average loss of 6.3 lines of VA in 2009-2012 compared to a loss of 3.6 lines in 2016-2017. In multivariate analysis, a "no-talking" policy during injections resulted in a trend towards a decrease in endophthalmitis incidence (p = .08). Cessation of post-injection topical antibiotic use did not independently decrease endophthalmitis incidence (p = .24) when the effect of a "no-talking" policy was taken into account. A lower rate of endophthalmitis was seen after prefilled vs. conventionally prepared ranibizumab syringe use for injection (0.014% vs. 0.035%, respectively), though this difference did not meet statistical significance (p = .16).Conclusion: The incidence of endophthalmitis after intravitreal injection decreased and visual outcomes improved between the periods of 2009-2012 and 2016-2017. A "no-talking" policy during injections was associated with a trend toward a decrease in endophthalmitis rate.
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Affiliation(s)
- Maitri Pancholy
- Mid Atlantic Retina, The Retina Service of Wills Eye Hospital, Philadelphia, Pennsylvania, USA.,Department of Ophthalmology, Emory University, Atlanta, Georgia, USA
| | - Philip P Storey
- Austin Retina Associates, University of Texas Dell Medical School, Austin, Texas, USA
| | - Hannah J Levin
- Mid Atlantic Retina, The Retina Service of Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Anthony Obeid
- Mid Atlantic Retina, The Retina Service of Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Samir N Patel
- Mid Atlantic Retina, The Retina Service of Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Brandon Kuley
- Mid Atlantic Retina, The Retina Service of Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Jason Hsu
- Mid Atlantic Retina, The Retina Service of Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Marc J Spirn
- Mid Atlantic Retina, The Retina Service of Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Mitchell Fineman
- Mid Atlantic Retina, The Retina Service of Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Michael A Klufas
- Mid Atlantic Retina, The Retina Service of Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Omesh Gupta
- Mid Atlantic Retina, The Retina Service of Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Allen C Ho
- Mid Atlantic Retina, The Retina Service of Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Sunir J Garg
- Mid Atlantic Retina, The Retina Service of Wills Eye Hospital, Philadelphia, Pennsylvania, USA
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18
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Henaine-Berra A, Flores-Peredo V, Lopezcarasa-Hernandez G, Martinez-Castellanos MA, Mira-Lorenzo X, Solis-Vivanco A, Garcia-Aguirre G. Survey of Intravitreal Injection Techniques Among Retina Specialists in Mexico. Clin Ophthalmol 2020; 14:4089-4098. [PMID: 33273805 PMCID: PMC7705264 DOI: 10.2147/opth.s285955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 11/04/2020] [Indexed: 12/04/2022] Open
Abstract
Purpose To report technique preferences for intravitreal injections among retina specialists in Mexico. Methods Cross-sectional survey. Ophthalmologists with a two-year retina training, active members of the Mexican Retina Association, were contacted through email to answer a survey consisting of 37 items regarding their IVI application technique. Results A total of 133 retina specialists participated, with a response rate of 78%. Forty-five percent applied the intravitreal injections in an operating room designated for the procedure. Sixty-three percent reported never injecting both eyes on the same day. Ninety-six percent wore a face mask during the procedure and 91% wore gloves. Eighty-two percent used a lid speculum. Tetracaine drops were the anesthetic method employed by 97% of participants. All participants utilized povidone-iodine for antisepsis. Eighty percent measured the puncture site with a caliper. Superotemporal quadrant was the one chosen to place the injection by 63% of participants. Fifty-nine percent indicated post-injection antibiotic drops for several days. Post-injection counting fingers visual acuity was verified by 53% of the participants. Fifty-six percent of the participants placed an eye-patch after the procedure. Conclusion There are different practices regarding the application of intravitreal injections among retina specialists in Mexico. Performing this type of survey periodically could show changes in preferences, as new evidence is incorporated into clinical practice.
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Affiliation(s)
| | - Vanesa Flores-Peredo
- Retina Department, Hospital Regional "Lic. Adolfo Lopez Mateos" ISSSTE, Mexico City, Mexico
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19
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Jemni-Damer N, Guedan-Duran A, Fuentes-Andion M, Serrano-Bengoechea N, Alfageme-Lopez N, Armada-Maresca F, Guinea GV, Pérez-Rigueiro J, Rojo F, Gonzalez-Nieto D, Kaplan DL, Panetsos F. Biotechnology and Biomaterial-Based Therapeutic Strategies for Age-Related Macular Degeneration. Part I: Biomaterials-Based Drug Delivery Devices. Front Bioeng Biotechnol 2020; 8:549089. [PMID: 33224926 PMCID: PMC7670958 DOI: 10.3389/fbioe.2020.549089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 10/06/2020] [Indexed: 12/22/2022] Open
Abstract
Age-related Macular Degeneration (AMD) is an up-to-date untreatable chronic neurodegenerative eye disease of multifactorial origin, and the main causes of blindness in over 65 years old people. It is characterized by a slow progression and the presence of a multitude of factors, highlighting those related to diet, genetic heritage and environmental conditions, present throughout each of the stages of the illness. Current therapeutic approaches, mainly consisting of intraocular drug delivery, are only used for symptoms relief and/or to decelerate the progression of the disease. Furthermore, they are overly simplistic and ignore the complexity of the disease and the enormous differences in the symptomatology between patients. Due to the wide impact of the AMD and the up-to-date absence of clinical solutions, the development of biomaterials-based approaches for a personalized and controlled delivery of therapeutic drugs and biomolecules represents the main challenge for the defeat of this neurodegenerative disease. Here we present a critical review of the available and under development AMD therapeutic approaches, from a biomaterials and biotechnological point of view. We highlight benefits and limitations and we forecast forthcoming alternatives based on novel biomaterials and biotechnology methods. In the first part we expose the physiological and clinical aspects of the disease, focusing on the multiple factors that give origin to the disorder and highlighting the contribution of these factors to the triggering of each step of the disease. Then we analyze available and under development biomaterials-based drug-delivery devices (DDD), taking into account the anatomical and functional characteristics of the healthy and ill retinal tissue.
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Affiliation(s)
- Nahla Jemni-Damer
- Neuro-Computing and Neuro-Robotics Research Group, Complutense University of Madrid, Madrid, Spain.,Innovation Group, Institute for Health Research San Carlos Clinical Hospital (IdISSC), Madrid, Spain
| | - Atocha Guedan-Duran
- Neuro-Computing and Neuro-Robotics Research Group, Complutense University of Madrid, Madrid, Spain.,Innovation Group, Institute for Health Research San Carlos Clinical Hospital (IdISSC), Madrid, Spain.,Department of Biomedical Engineering, Tufts University, Medford, MA, United States
| | - María Fuentes-Andion
- Neuro-Computing and Neuro-Robotics Research Group, Complutense University of Madrid, Madrid, Spain.,Innovation Group, Institute for Health Research San Carlos Clinical Hospital (IdISSC), Madrid, Spain
| | - Nora Serrano-Bengoechea
- Neuro-Computing and Neuro-Robotics Research Group, Complutense University of Madrid, Madrid, Spain.,Innovation Group, Institute for Health Research San Carlos Clinical Hospital (IdISSC), Madrid, Spain.,Silk Biomed SL, Madrid, Spain
| | - Nuria Alfageme-Lopez
- Neuro-Computing and Neuro-Robotics Research Group, Complutense University of Madrid, Madrid, Spain.,Innovation Group, Institute for Health Research San Carlos Clinical Hospital (IdISSC), Madrid, Spain.,Silk Biomed SL, Madrid, Spain
| | | | - Gustavo V Guinea
- Silk Biomed SL, Madrid, Spain.,Center for Biomedical Technology, Universidad Politécnica de Madrid, Madrid, Spain.,Department of Material Science, Civil Engineering Superior School, Universidad Politécnica de Madrid, Madrid, Spain.,Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Madrid, Spain
| | - José Pérez-Rigueiro
- Silk Biomed SL, Madrid, Spain.,Center for Biomedical Technology, Universidad Politécnica de Madrid, Madrid, Spain.,Department of Material Science, Civil Engineering Superior School, Universidad Politécnica de Madrid, Madrid, Spain.,Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Madrid, Spain
| | - Francisco Rojo
- Silk Biomed SL, Madrid, Spain.,Center for Biomedical Technology, Universidad Politécnica de Madrid, Madrid, Spain.,Department of Material Science, Civil Engineering Superior School, Universidad Politécnica de Madrid, Madrid, Spain.,Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Madrid, Spain
| | - Daniel Gonzalez-Nieto
- Silk Biomed SL, Madrid, Spain.,Center for Biomedical Technology, Universidad Politécnica de Madrid, Madrid, Spain.,Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Madrid, Spain
| | - David L Kaplan
- Department of Biomedical Engineering, Tufts University, Medford, MA, United States
| | - Fivos Panetsos
- Neuro-Computing and Neuro-Robotics Research Group, Complutense University of Madrid, Madrid, Spain.,Innovation Group, Institute for Health Research San Carlos Clinical Hospital (IdISSC), Madrid, Spain.,Silk Biomed SL, Madrid, Spain
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20
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Abstract
BACKGROUND Diabetic macular edema (DME) is secondary to leakage from diseased retinal capillaries with thickening of central retina, and is an important cause of poor central visual acuity in people with diabetic retinopathy. Intravitreal steroids have been used to reduce retinal thickness and improve vision in people with DME. OBJECTIVES To assess the effectiveness and safety of intravitreal steroid therapy compared with other treatments for DME. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase on 15 May, 2019. We also searched reference lists, Science Citation Index, conference proceedings, and relevant trial registers. We conducted a top up search on 21 October, 2020. SELECTION CRITERIA We included randomized controlled trials that evaluated any type of intravitreal steroids as monotherapy against any other intervention (e.g. observation, laser photocoagulation, anti-vascular endothelial growth factor (antiVEGF) for DME. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility and risk of bias and extracted data. Where appropriate, we performed meta-analyses. MAIN RESULTS We included 10 trials (4348 participants, 4505 eyes). These trials compared intravitreal steroid therapies versus other treatments, including intravitreal antiVEGF therapy, laser photocoagulation, and sham injection. Most trials had an overall unclear or high risk of bias. One trial (701 eyes ) compared intravitreal dexamethasone implant 0.7mg with sham. We found moderate-certainty evidence that dexamethasone leads to slightly more improvement of visual acuity than sham at 12 months (mean difference [MD] -0.08 logMAR, 95% confidence interval [CI] -0.12 to -0.05 logMAR). Regarding improvement of three or more lines of visual acuity, there was moderate-certainty evidence in favor of dexamethasone at 12 months, but the CI covered the null value (risk ratio (RR) 1.39, 95% CI 0.91 to 2.12). Regarding adverse events, dexamethasone increased by about four times the risk of cataract progression and the risk of using intraocular pressure (IOP)-lowering medications compared to sham (RR 3.89, 95% CI 2.75 to 5.50 and RR 4.54, 95% CI 3.19 to 6.46, respectively; moderate-certainty evidence); about 4 in 10 participants treated with dexamethasone needed IOP-lowering medications. Two trials (451 eyes) compared intravitreal dexamethasone implant 0.7mg with intravitreal antiVEGF (bevacizumab and ranibizumab). There was moderate-certainty evidence that visual acuity improved slightly less with dexamethasone compared with antiVEGF at 12 months (MD 0.07 logMAR, 95% CI 0.04 to 0.09 logMAR; 2 trials; 451 participants/eyes; I2 = 0%). The RR of gain of three or more lines of visual acuity was inconsistent between trials, with one trial finding no evidence of a difference between dexamethasone and bevacizumab at 12 months (RR 0.99, 95% CI 0.70 to 1.40; 1 trial; 88 eyes), and the other, larger trial finding the chances of vision gain were half with dexamethasone compared with ranibizumab (RR 0.50, 95% CI 0.32 to 0.79; 1 trial; 432 participants). The certainty of evidence was low. Cataract progression and the need for IOP-lowering medications increased more than 4 times with dexamethasone implant compared to antiVEGF (moderate-certainty evidence). One trial (560 eyes) compared intravitreal fluocinolone implant 0.19mg with sham. There was moderate-certainty evidence that visual acuity improved slightly more with fluocinolone at 12 months (MD -0.04 logMAR, 95% CI -0.06 to -0.01 logMAR). There was moderate-certainty evidence that an improvement in visual acuity of three or more lines was more common with fluocinolone than with sham at 12 months (RR 1.79, 95% CI 1.16 to 2.78). Fluocinolone also increased the risk of cataract progression (RR 1.63, 95% CI 1.35 to 1.97; participants = 335; moderate-certainty evidence), which occurred in about 8 in 10 participants, and the use of IOP-lowering medications (RR 2.72, 95% CI 1.87 to 3.98; participants = 558; moderate-certainty evidence), which were needed in 2 to 3 out of 10 participants. One small trial with 43 participants (69 eyes) compared intravitreal triamcinolone acetonide injection 4 mg with sham. There may be a benefit in visual acuity at 24 months (MD -0.11 logMAR, 95% CI -0.20 to -0.03 logMAR), but the certainty of evidence is low. Differences in adverse effects were poorly reported in this trial. Two trials (615 eyes) compared intravitreal triamcinolone acetonide injection 4mg with laser photocoagulation and reached discordant results. The smaller trial (31 eyes followed up to 9 months) found more visual acuity improvement with triamcinolone (MD -0.18 logMAR, 95% CI -0.29 to -0.07 logMAR), but a larger, multicenter trial (584 eyes, 12-month follow-up) found no evidence of a difference regarding change in visual acuity (MD 0.02 logMAR, 95% CI -0.03 to 0.07 logMAR) or gain of three or more lines of visual acuity (RR 0.85, 95% CI 0.55 to 1.30) (overall low-certainty evidence). Cataract progression was about three times more likely (RR 2.68, 95% CI 2.21 to 3.24; moderate-certainty evidence) and the use of IOP-lowering medications was about four times more likely (RR 3.92, 95% CI 2.59 to 5.96; participants = 627; studies = 2; I2 = 0%; moderate-certainty evidence) with triamcinolone. About 1 in 3 participants needed IOP-lowering medication. One small trial (30 eyes) compared intravitreal triamcinolone acetonide injection 4mg with intravitreal antiVEGF (bevacizumab or ranibizumab). Visual acuity may be worse with triamcinolone at 12 months (MD 0.18 logMAR, 95% CI 0.10 to 0.26 logMAR); the certainty of evidence is low. Adverse effects were poorly reported in this trial. Four trials reported data on pseudophakic participants, for whom cataract is not a concern. These trials found no decrease in visual acuity in the second treatment year due to cataract progression. AUTHORS' CONCLUSIONS Intravitreal steroids may improve vision in people with DME compared to sham or control. Effects were small, about one line of vision or less in most comparisons. More evidence is available for dexamethasone or fluocinolone implants when compared to sham, and the evidence is limited and inconsistent for the comparison of dexamethasone with antiVEGF treatment. Any benefits should be weighed against IOP elevation, the use of IOP-lowering medication and, in phakic patients, the progression of cataract. The need for glaucoma surgery is also increased, but remains rare.
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Affiliation(s)
- Thanitsara Rittiphairoj
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Tahreem A Mir
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tianjing Li
- Department of Ophthalmology, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- Centre for Public Health, Queen's University Belfast, Belfast, UK
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PATIENTS WEARING FACE MASKS DURING INTRAVITREAL INJECTIONS MAY BE AT A HIGHER RISK OF ENDOPHTHALMITIS. Retina 2020; 40:1651-1656. [DOI: 10.1097/iae.0000000000002919] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kaldirim H, Yazgan S, Kirgiz A, Ozdemir B, Yilmaz A. Effect of Topical Antibiotic Prophylaxis on Conjunctival Flora and Antibiotic Resistance Following Intravitreal Injections in Patients with Type 2 Diabetes. KOREAN JOURNAL OF OPHTHALMOLOGY 2020; 34:265-273. [PMID: 32783418 PMCID: PMC7419237 DOI: 10.3341/kjo.2019.0144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 02/16/2020] [Accepted: 03/17/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose We sought to determine changes in the conjunctival bacterial flora and antibiotic resistance after topical antibiotic drops for infection prophylaxis were administered following intravitreal injections in patients with type 2 diabetes. Methods This prospective and nonrandomized cohort study included 116 eyes of 116 treatment-naive patients with type 2 diabetes who received six serial intravitreal anti-vascular endothelial growth factor injections for macular edema. Three conjunctival cultures were obtained from each eye over the course of the study (Culture 1, baseline; Culture 2, 1 month after the third injection; and Culture 3, 1 month after the sixth injection). The study subjects were given topical moxifloxacin hydrochloride for 4 days after each monthly intravitreal injection. The growth patterns of conjunctival bacterial flora and the antibiotic resistance to several commonly used antibiotics were examined. Results The rate of culture positivity increased significantly during the observation period (Culture 1, n = 47, 40.5%; Culture 2, n = 58, 50%; Culture 3, n = 76, 65.5%, p < 0.001). The bacterium with the highest baseline culture positivity was Staphylococcus epidermidis (n = 45, 38.8%), which increased significantly during the observation period (p < 0.001). No significant increase was noted in the culture positivity of the other bacteria with baseline culture positivity (p > 0.05). Regarding antibiotic susceptibility, significant increases in resistance to the fluoroquinolone group of drugs were noted (p < 0.001). No significant changes in sensitivity were detected in the other 11 investigated antibiotics that are commonly used in clinical practice (p > 0.05). Conclusions The use of topical moxifloxacin after each intravitreal injection significantly increases the fluoroquinolone resistance of the ocular surface flora and the culture-positivity rate of S. epidermidis in patients with type 2 diabetes.
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Affiliation(s)
- Havva Kaldirim
- Department of Ophthalmology, Bagcilar Training and Research Hospital, Health Sciences University, Istanbul, Turkey.
| | - Serpil Yazgan
- Department of Ophthalmology, Medical Faculty, Inonu University, Malatya, Turkey
| | - Ahmet Kirgiz
- Department of Ophthalmology, Beyoglu Eye Training and Research Hospital, Health Sciences University, Istanbul, Turkey
| | - Bilge Ozdemir
- Department of Microbiology, Bagcilar Training and Research Hospital, Health Sciences University, Istanbul, Turkey
| | - Ahu Yilmaz
- Department of Ophthalmology, Bagcilar Training and Research Hospital, Health Sciences University, Istanbul, Turkey
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Endophthalmitis following intravitreal injection of anti-vascular endothelial growth factor agents. Can J Ophthalmol 2020; 55:286-292. [DOI: 10.1016/j.jcjo.2020.01.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 01/27/2020] [Indexed: 11/17/2022]
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Cicinelli MV, Cavalleri M, Lattanzio R, Bandello F. The current role of steroids in diabetic macular edema. EXPERT REVIEW OF OPHTHALMOLOGY 2020. [DOI: 10.1080/17469899.2020.1729743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Maria Vittoria Cicinelli
- Department of Ophthalmology, Scientific Institute San Raffaele, Vita-Salute University, Milan, Italy
| | - Michele Cavalleri
- Department of Ophthalmology, Scientific Institute San Raffaele, Vita-Salute University, Milan, Italy
| | - Rosangela Lattanzio
- Department of Ophthalmology, Scientific Institute San Raffaele, Vita-Salute University, Milan, Italy
| | - Francesco Bandello
- Department of Ophthalmology, Scientific Institute San Raffaele, Vita-Salute University, Milan, Italy
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25
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Loukovaara S, Järventausta P, Anttila V. Pathogenic causes and outcomes of endophthalmitis after vitreoretinal surgeries in Finland from 2009 to 2018. Acta Ophthalmol 2020; 98:e128-e130. [PMID: 31352683 DOI: 10.1111/aos.14187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Sirpa Loukovaara
- Unit of Vitreoretinal Surgery Ophthalmology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Petri Järventausta
- Unit of Anterior Segment Surgery Ophthalmology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Veli‐Jukka Anttila
- Inflammation Center University of Helsinki and Helsinki University Hospital Helsinki Finland
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Use of biomaterials for sustained delivery of anti-VEGF to treat retinal diseases. Eye (Lond) 2020; 34:1341-1356. [PMID: 32001821 PMCID: PMC7376230 DOI: 10.1038/s41433-020-0770-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 12/27/2019] [Accepted: 01/13/2020] [Indexed: 12/11/2022] Open
Abstract
Anti-vascular endothelial growth factors (anti-VEGF) have become the most common treatment modality for many retinal diseases. These include neovascular age-related macular degeneration (n-AMD), proliferative diabetic retinopathy (PDR) and retinal vein occlusions (RVO). However, these drugs are administered via intravitreal injections that are associated with sight-threatening complications. The most feared of these complications is endophthalmitis, a severe infection of the eye with extremely poor visual outcomes. Patients with retinal diseases typically have to undergo multiple injections before achieving the desired therapeutic effect. Each injection incurs the risk of the sight-threatening complications. As such, there has been great interest in developing sustained delivery platforms for anti-VEGF agents to the posterior segment of the eye. In recent years, there have been various strategies that have been conceptualised. These include non-biodegradable implants, nano-formulations and hydrogels. In this review, the barriers of drug delivery to the posterior segment of the eye will be explained. The characteristics of an ideal sustained delivery platform will then be discussed. Finally, the current available strategies will be analysed with the above-mentioned characteristics in mind to determine the advantages and disadvantages of each sustained drug delivery modality. Through the above, this review attempts to provide an overview of the sustained delivery platforms in their various phases of development.
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Stellungnahme der DOG, der RG und des BVA zur Therapie des diabetischen Makulaödems. Ophthalmologe 2020; 117:218-247. [DOI: 10.1007/s00347-019-01015-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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28
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Patel SN, Gangaputra S, Sternberg P, Kim SJ. Prophylaxis measures for postinjection endophthalmitis. Surv Ophthalmol 2020; 65:408-420. [PMID: 31923477 DOI: 10.1016/j.survophthal.2019.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 12/24/2019] [Accepted: 12/30/2019] [Indexed: 12/23/2022]
Abstract
Intravitreal injections have become the most commonly performed ophthalmic procedure, transforming modern retina practice. Postinjection endophthalmitis, while rare, remains the most feared potential complication. Prophylaxis measures including topical antisepsis, hand hygiene, gloves, masks, and drapes have all been proposed to help prevent postinjection endophthalmitis; however, there remains significant variation in protocol, given the lack of agreement among retina specialists on which steps are crucial to prevent endophthalmitis. With millions of injections performed annually, collating data have helped us better understand risk factors for endophthalmitis after intravitreal injection. We summarize the consensus guidelines for intravitreal injection technique and comprehensively review the literature on prevention of postinjection endophthalmitis.
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Affiliation(s)
- Shriji N Patel
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
| | - Sapna Gangaputra
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Paul Sternberg
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Stephen J Kim
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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29
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Hsu J. Reply. Ophthalmol Retina 2019; 3:e4-e5. [PMID: 31174682 DOI: 10.1016/j.oret.2019.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 03/12/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Jason Hsu
- The Retina Service of Wills Eye Hospital, Mid Atlantic Retina, Philadelphia, Pennsylvania.
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30
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Ren YB, Su XJ, Qi YX, Luan HQ, Sun Q. Efficacy of ranibizumab for the treatment of diabetic retinopathy: A protocol for systematic review of randomized controlled trial. Medicine (Baltimore) 2019; 98:e15409. [PMID: 31027141 PMCID: PMC6831126 DOI: 10.1097/md.0000000000015409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Previous clinical trials have reported that ranibizumab can be used to treat diabetic retinopathy (DR) effectively. However, no study has been conducted to evaluate its efficacy for patients with DR systematically. Thus, this study will specifically and systematically assess the efficacy and safety of ranibizumab for DR. METHODS Cochrane Library, EMBASE, PUBMED, Web of Science, Google Scholar, Cumulative Index to Nursing and Allied Health Literature, China National Knowledge Infrastructure, and Chinese Biomedical Literature Database will be searched from inceptions to the March 20, 2019 for studies related to the topic. This study will only consider publicly released randomized controlled trials for evaluating the effect and safety of ranibizumab for DR. No language restrictions will be imposed for all databases search. Methodological quality of each included trial will be assessed by Cochrane risk of bias tool. Statistical analysis will be performed by Stata 12.0 software. RESULTS This study will provide recent summary evidence of ranibizumab for DR. Primary outcomes include percentages with retinopathy improvement, and cumulative probabilities for retinopathy worsening. Secondary outcome consist of visual function, best-corrected visual acuities, central subfield thickness, total macular volume, peripheral visual field loss, retinal neovascularization, and adverse events. CONCLUSION The findings of this study may provide theoretical basis for clinical practice refer and may benefit more patients with DR.
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31
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Hsu J. Minimizing the Risk of Endophthalmitis after Injection. ACTA ACUST UNITED AC 2019; 3:1-2. [DOI: 10.1016/j.oret.2018.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 10/18/2018] [Accepted: 10/19/2018] [Indexed: 10/28/2022]
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Asghar A, Ellhai I, Obaid N, Sughra U. Role of topical antibiotics in prophylaxis against endophthalmitis following intravitreal antibiotics. Pak J Med Sci 2018; 34:1283-1287. [PMID: 30344592 PMCID: PMC6191804 DOI: 10.12669/pjms.345.14817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective: To compare the prophylactic use of antibiotic with placebo to prevent post intra-vitreal endophthalmitis and other complications. Methods: A prospective, cohort study was conducted at Ophthalmology Department, Fauji Foundation Hospital (FFH), from June 2016 to July 2017. A total of 1082 eyes of 673 patients were enrolled in this study. Patients were selected at non-random and divided into two groups. In Group-I, non – exposed, placebo eye drops were given after intravitreal bevacizumab injections and in Group-II, exposed, ofloxacin eye drops were given after intravitreal bevacizumab injections. Results: Total 1082 eyes were given intravitreal bevacizumab injection in 673 patients. No patients in Group-I, non – exposed, receiving placebo eye drops developed post intra vitreal endophthalmitis, whereas only 01 (0.1%) patient developed post intravitreal endophthalmitis in Group-II, exposed, receiving ofloxacin eye drops. In inferential statistics the P- value was also statistically insignificant [x2 (1, N=1082) =0.95, P>0.05] Conclusion: This study showed that topical antibiotic, as a prophylaxis after intravitreal injections has no role in the prevention of post intravitreal endophthalmitis and other complications.
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Affiliation(s)
- Asfandyar Asghar
- Dr. Asfandyar Asghar, FCPS, FCPS (Vitreo Retina). Department of Ophthalmology, Foundation University Medical College/Fauji Foundation Hospital, Rawalpindi, Pakistan
| | - Imran Ellhai
- Dr. Imran Ellhai, FCPS. Department of Ophthalmology, Foundation University Medical College/Fauji Foundation Hospital, Rawalpindi, Pakistan
| | - Naila Obaid
- Dr. Naila Obaid, FCPS. Department of Ophthalmology, Foundation University Medical College/Fauji Foundation Hospital, Rawalpindi, Pakistan
| | - Ume Sughra
- Dr. Ume Sughra, FCPS, MPH. Assistant Professor, Research Associate, Al-Shifa School of Public Health, Al-Shifa Trust Eye Hospital, Rawalpindi, Pakistan
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Labardini CP, Blumenthal EZ. Causative Pathogens in Endophthalmitis after Intravitreal Injection of Anti-vascular Endothelial Growth Factor Agents. Rambam Maimonides Med J 2018; 9:1-6. [PMID: 30180932 PMCID: PMC6185999 DOI: 10.5041/rmmj.10348] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Intravitreal injection of anti-vascular endothelial growth factor is currently the preferred treatment for several posterior segment diseases, including age-related macular degeneration and diabetic retinopathy, as well as macular edema and retinal vein occlusion. As an invasive procedure it involves risks. The most significant risk is infectious endophthalmitis, a sight-threatening and even a globe-threatening acute fulminant condition. Most common pathogens include Streptococcus and Staphylococcus species, surprisingly originating from the patient's, surgeon's, or nurse's mouth. Infectious endophthalmitis may have devastating and irreversible effect, with Streptococcus-induced cases having the worst visual outcome. It is therefore crucial for clinicians to promptly recognize and treat such conditions, and, far more important, to put in place protective and preventive measures against this rare, but sight-threatening complication. To that end, this paper describes the most common pathogens causing endophthalmitis after IVI of anti-VEGF, and defines their source, to aid the physician in developing strategies to prevent this catastrophic infection.
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Affiliation(s)
| | - Eytan Z. Blumenthal
- Department of Ophthalmology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
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Hunyor AP, Merani R, Darbar A, Korobelnik JF, Lanzetta P, Okada AA. Topical antibiotics and intravitreal injections. Acta Ophthalmol 2018; 96:435-441. [PMID: 28440583 DOI: 10.1111/aos.13417] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 01/13/2017] [Indexed: 12/28/2022]
Abstract
There is increasing evidence that topical antibiotics, given before and/or after intravitreal injections, are ineffective in preventing endophthalmitis and are possibly harmful. In addition to the lack of efficacy and increased development of resistant organisms, the use of topical antibiotics adds significantly to the cost of delivering intravitreal therapy. Despite this, in many countries, it is still common practice to use pre- and/or postinjection topical antibiotics. This review outlines the general principles of effective antibiotic prophylaxis, and the evidence regarding topical antibiotic use as a prophylactic measure for endophthalmitis following intravitreal injections. A key distinguishing feature of intravitreal injections from most other invasive procedures is the fact that they are often repeated on multiple occasions to the same eye. Given the lack of evidence to support topical antibiotics as an effective method of prophylaxis for postinjection endophthalmitis, it appears that more widespread education of ophthalmologists is required to avoid continued inappropriate use. Revision of drug labels in some jurisdictions, and amendment of local/professional society guidelines, may be required to assist in achieving this goal. Emphasis should be placed on antisepsis and aseptic technique, which are the major proven methods of endophthalmitis prevention, rather than antibiotics.
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Affiliation(s)
- Alex P. Hunyor
- University of Sydney; Sydney New South Wales Australia
- Sydney Eye Hospital; Sydney New South Wales Australia
| | - Rohan Merani
- Sydney and Macquarie Universities; Sydney New South Wales Australia
- Concord Repatriation General Hospital; Concord New South Wales Australia
| | - Archie Darbar
- Royal North Shore Hospital; St Leonards New South Wales Australia
| | - Jean-François Korobelnik
- Service d'ophtalmologie; CHU de Bordeaux; Bordeaux France
- Univ. Bordeaux; ISPED; Bordeaux France
- Inserm; U1219 - Bordeaux Population Health Research Center; Bordeaux France
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Current Evidence for the Prevention of Endophthalmitis in Anti-VEGF Intravitreal Injections. J Ophthalmol 2018; 2018:8567912. [PMID: 30174946 PMCID: PMC6098904 DOI: 10.1155/2018/8567912] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 05/31/2018] [Indexed: 11/24/2022] Open
Abstract
Intravitreal injection of a therapeutic substance is the most common procedure performed in ophthalmology. It has a low incidence of serious complications but is associated with a small chance of endophthalmitis. Although the rate of endophthalmitis is between 0.019% and 0.09%, the associated visual morbidity is often devastating. Procedural changes have evolved over the years to improve patient comfort and reduce injection-related injury and infection. Despite the availability of published evidence, there remains considerable variations and lack of consensus in practical clinical settings. In addition, emerging literature concerning the use of speculums, the use of prophylactic topical antibiotics, and the setting of injections continues to impact the ophthalmologist's injection practice. This article provides an up to date assessment of various aspects of the procedure such as the setting, ventilation, type of anaesthetic, and control of sterility during the procedure; including discussions on performing bilateral eye same-day injections and the use of antibiotics.
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Antibiotic prophylaxis for preventing endophthalmitis after intravitreal injection: a systematic review. Eye (Lond) 2018; 32:1423-1431. [PMID: 29891901 DOI: 10.1038/s41433-018-0138-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 12/26/2017] [Accepted: 02/19/2018] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To assess the effect of topical antibiotic prophylaxis on the rate of post-operative endophthalmitis after intravitreal injection (IVI). METHODS We conducted a systematic review of studies comparing the rates of endophthalmitis in eyes receiving IVI of different drugs with and without topical antibiotic prophylaxis, by searching MEDLINE and EMBASE up to June 2016. The methodological quality of the included studies was assessed using the Cochrane Risk of Bias tool and the Risk Of Bias in Non-randomized Studies of Interventions (ROBINS-I) for randomized clinical trials (RCTs) and non-randomized studies, respectively. We used a random-effects meta-analysis to compute the odds ratio (OR) of endophthalmitis with antibiotic prophylaxis compared with no prophylaxis and conducted subgroup analyses to compare the efficacy of different regimens and classes of antibiotics on endophthalmitis rates. RESULTS We identified 1 randomized and 12 non-randomized studies that reported 74 cases of endophthalmitis in 147,203 IVIs using antibiotic prophylaxis compared with 55 cases in 211,418 IVIs with no prophylaxis. The overall OR of endophthalmitis for antibiotic prophylaxis vs. no prophylaxis was 1.33 (95% CI 0.75-2.38). Leave-one-out sensitivity analyses showed that the exclusion of the only study with a serious risk of bias significantly increased the risk of endophthalmitis in the antibiotic prophylaxis group compared with control (OR: 1.62, 95% CI: 1.17, 2.34). There was no difference in the endophthalmitis rate associated with any other factor analyzed, including type of antibiotic, type of drug injected, or antibiotic prophylaxis regimen. CONCLUSIONS Antibiotic prophylaxis does not reduce the rate of endophthalmitis following IVI and might potentially be associated with an increased risk of post-operative infection.
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POOLED ESTIMATES OF INCIDENCE OF ENDOPHTHALMITIS AFTER INTRAVITREAL INJECTION OF ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR AGENTS WITH AND WITHOUT TOPICAL ANTIBIOTIC PROPHYLAXIS. Retina 2018; 38:1-11. [PMID: 28267115 DOI: 10.1097/iae.0000000000001583] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE To assess the effect of topical antibiotic prophylaxis on postoperative endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents. METHODS A systematic literature search was performed from inception to March 2016 using PubMed, Medline, Web of Science, Embase, and the Cochrane Library, to identify articles that reported cases of endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents. We used a pooled analysis to estimate the incidence of cases of endophthalmitis who developed after injections performed with and without topical antibiotic prophylaxis. We used regression analysis to explore the effects of study characteristics on heterogeneity. RESULTS From our search of electronic databases, we identified and screened 4,561 unique records. We judged 60 articles to have reported findings for cohorts of patients who met our inclusion criteria, (12 arms of randomized clinical trials, 11 prospective cohort studies, and 37 retrospective cohort studies), which included 244 cases of endophthalmitis and 639,391 intravitreal injections of anti-vascular endothelial growth factor agents. The final pooled estimate endophthalmitis proportions were 9/10,000 (95% confidence interval, 7/10,000-12/10,000) in the antibiotic-treated group and 3/10,000 (95% confidence interval, 2/10,000-5/10,000) in the untreated group. The estimated incidence of endophthalmitis with topical antibiotic prophylaxis was approximated three times the incidence without prophylaxis. Random effects regression showed that none of the study characteristics significantly affected the effect size in either group. CONCLUSION Topical antibiotic after intravitreal injection of anti-vascular endothelial growth factor agents is associated with a higher risk of endophthalmitis.
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Grzybowski A, Told R, Sacu S, Bandello F, Moisseiev E, Loewenstein A, Schmidt-Erfurth U. 2018 Update on Intravitreal Injections: Euretina Expert Consensus Recommendations. Ophthalmologica 2018; 239:181-193. [PMID: 29393226 DOI: 10.1159/000486145] [Citation(s) in RCA: 180] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 12/05/2017] [Indexed: 01/24/2023]
Abstract
Intravitreal injections (IVI) have become the most common intraocular procedure worldwide with increasing numbers every year. The article presents the most up-to-date review on IVI epidemiology and techniques. Unfortunately, important issues related to pre-, peri- and postinjection management lack randomized clinical trials for a final conclusion. Also, a great diversity of approaches exists worldwide. Therefore, expert consensus recommendations on IVI techniques are provided.
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Affiliation(s)
- Andrzej Grzybowski
- Department of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland.,Institute for Research in Ophthalmology, Foundation for Ophthalmology Development, Poznan, Poland
| | - Reinhard Told
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Stefan Sacu
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Francesco Bandello
- Department of Ophthalmology, Vita-Salute University, San Raffaele Hospital, Milan, Italy
| | - Elad Moisseiev
- Department of Ophthalmology, Sackler Faculty of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Loewenstein
- Department of Ophthalmology, Sackler Faculty of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Ophthalmology, Sackler Faculty of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ursula Schmidt-Erfurth
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
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Intravitreal Injection of Bevacizumab: Review of our previous Experience. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2018; 17:1093-1098. [PMID: 30127831 PMCID: PMC6094424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Several ocular and systemic complications have been reported after the bevacizumab intravitreal injection. This study aims at reporting the main indications for the bevacizumab intravitreal injection in our center, the intravitreal injection method in this study, and the incidence of the post-injection complication, such as endophthalmitis.This study is a retrospective review of the consecutive intravitreal bevacizumab (Avastin®) injections for 359 patients between 2011 and 2013 at a single institute (Poostchi Clinic of Ophthalmology). Before the injection, a drop containing 5 mLCiprofloxacin and 5 mL Betadine 10% was applied 3 times at the intervals of 10 min. The eye lashes, upper and lower eyelids, and caruncle were swabbed with Betadine 10% but the lid speculum, drape, and conjunctival washing were not conducted.The patients were followed up 8 weeks after the injection for the evaluation of any complications.In this study, 1376 intravitreal injection of bevacizumab in 479 eyes of 359 patients were enrolled. Among them, 141patients (39.3%) were men and 218 (60.7%) were women. The mean age ( ± SD) of the patients was 61.48 (± 11.21) years. On average, each patient received 3.83 (the range 1-13) injections. The most common indications for the bevacizumab intravitreal injection were diabetic retinopathy, choroidal neovascularization, and central retinal vein occlusion. None of the patients developed endophthalmitis, retinal detachment, or other adverse effects. This study showed that the above-mentioned method of the intravitreal bevacizumab injection is easy and safe. The future studies involving more participants are required for the evaluation of rare complications.
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Hartman RR, Kompella UB. Intravitreal, Subretinal, and Suprachoroidal Injections: Evolution of Microneedles for Drug Delivery. J Ocul Pharmacol Ther 2017; 34:141-153. [PMID: 29206556 PMCID: PMC5963636 DOI: 10.1089/jop.2017.0121] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 01/04/2023] Open
Abstract
Even though the very thought of an injection into the eye may be frightening, an estimated 6 million intravitreal (IVT) injections were made in the USA during 2016. With the introduction of new therapeutic agents, this number is expected to increase. In addition, drug products that are injectable in ocular compartments other than the vitreous humor are expected to enter the back of the eye market in the not so distant future. Besides the IVT route, some of the most actively investigated routes of invasive administration to the eye include periocular, subretinal, and suprachoroidal (SC) routes. While clinical efficacy is the driving force behind new injectable drug product development for the eye, safety is also being improved with time. In the case of IVT injections, the procedural guidelines have evolved over the years to improve patient comfort and reduce injection-related injury and infection. Similar advances are anticipated for other routes of administration of injectable products to the eye. In addition to procedural improvements, the design of needles, particularly those with smaller diameters, length, and controlled bevel angles are expected to improve overall safety and acceptance of injected ophthalmic drug products. A key development in this area is the introduction of microneedles of a length less than a millimeter that can target the SC space. In the future, needles with smaller diameters and lengths, potentially approaching nanodimensions, are expected to revolutionize ophthalmic disease management.
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Affiliation(s)
- Rachel R. Hartman
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Uday B. Kompella
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Ophthalmology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Postoperative endophthalmitis incidence after intravitreal therapy: a comparison of two different preoperative antibiotic prophylaxis. Int Ophthalmol 2016; 37:787-794. [DOI: 10.1007/s10792-016-0307-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 07/25/2016] [Indexed: 11/30/2022]
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Assaad D, Wong D, Mikhail M, Tawfik S, Altomare F, Berger A, Chow D, Giavedoni L. Bacterial endophthalmitis: 10-year review of the culture and sensitivity patterns of bacterial isolates. Can J Ophthalmol 2016; 50:433-7. [PMID: 26651302 DOI: 10.1016/j.jcjo.2015.07.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 07/08/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine the spectrum and sensitivity patterns of bacterial isolates derived from all culture-positive aqueous and vitreous samples submitted for culture and sensitivity analysis at our institution over a 10-year period. DESIGN Retrospective cohort study. PARTICIPANTS A total of 368 culture-positive aqueous and vitreous samples from 265 patients were reviewed. METHODS Over a decade extending from January 2000 through December 2009, all culture-positive aqueous and vitreous specimens at our institution were identified. Isolated bacterial pathogens and their in vitro antibiotic sensitivities were analyzed. RESULTS Approximately 86.4% of patients had positive cultures for either staphylococci (Staphylococcus aureus and coagulase-negative staphylococci [CNS]) or streptococci. Gram-negative bacteria were isolated in only 9.8% of patients. From 2000 to 2004, 81.2% and 55.9% of CNS isolates were sensitive to ciprofloxacin and cefazolin, respectively, compared with 41.2% and 23.5% of isolates in the last 5 years. Over the study period, ceftazidime retained 100% efficacy against the gram-negative isolates tested. Vancomycin was 99.6% effective against the gram-positive isolates tested. CONCLUSIONS The microbiology of pathogens in endophthalmitis is evolving, with an increase in streptococcal isolates and a decrease in CNS. The apparent lack of efficacy of conventionally used antibiotics and the emergence of increasingly resistant strains of bacteria may have significant implications in the management of bacterial endophthalmitis.
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Affiliation(s)
- David Assaad
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont.,.
| | - David Wong
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont
| | - Mikel Mikhail
- Department of Ophthalmology, McGill University, Montreal, Que
| | - Sherri Tawfik
- Department of Pharmacy, University of Toronto, Ontario, Canada
| | - Filiberto Altomare
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont
| | - Alan Berger
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont
| | - David Chow
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont
| | - Louis Giavedoni
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont
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Benoist d’Azy C, Pereira B, Naughton G, Chiambaretta F, Dutheil F. Antibioprophylaxis in Prevention of Endophthalmitis in Intravitreal Injection: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0156431. [PMID: 27257676 PMCID: PMC4892688 DOI: 10.1371/journal.pone.0156431] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 05/13/2016] [Indexed: 12/13/2022] Open
Abstract
Despite endophthalmitis being the most feared complication, antibioprophylaxis remains controversial in intravitreal injections. Therefore, we conducted a systematic review and meta-analysis on the effects of antibioprophylaxis in intravitreal injections in the prevention of endophthalmitis. The PubMed, Cochrane Library, Embase and Science Direct databases were searched for studies comparing groups with and without antibiotics in intravitreal injection, with the use of the following keywords: "antibiotic*", "endophthalmitis" and “intravitreal injection*”. To be included, studies needed to specify number of participants and number of endophthalmitis within each group (with and without antibiotics). We conducted meta-analysis on the prevalence of clinical endophthalmitis including both culture-proven and culture negative samples. Nine studies were included. A total of 88 incidences of endophthalmitis were reported from 174,159 injections (0.051% i.e., one incidence of endophthalmitis for 1979 injections). Specifically, 59 incidences of endophthalmitis were reported from 113,530 injections in the group with antibiotics (0.052% or one incidence of endophthalmitis for 1924 injections) and 29 incidences of endophthalmitis from 60,633 injections in the group without antibiotics (0.048% or one endophthalmitis for 2091 injections). Our meta-analysis did not report a significant difference in the prevalence of clinical endophthalimitis between the two groups with and without topical antibiotics: the odds ratio of clinical endophthalimitis was 0.804 (CI95% 0.384–1.682, p = 0.56) for the antibiotic group compared with the group without antibiotics. In conclusion, we performed the first large meta-analysis demonstrating that antibioprophylaxis is not required in intravitreal injections. Strict rules of asepsis remain the only evidence-based prophylaxis of endophthalmitis. The results support initiatives to reduce the global threat of resistance to antibiotics.
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Affiliation(s)
- Cédric Benoist d’Azy
- University Hospital of Clermont-Ferrand (CHU), Ophthalmology, Clermont-Ferrand, France
- University Hospital of Clermont-Ferrand (CHU), Preventive and Occupational Medicine, Clermont-Ferrand, France
| | - Bruno Pereira
- University Hospital of Clermont-Ferrand (CHU), Clinical Research Direction, Clermont-Ferrand, France
| | - Geraldine Naughton
- Australian Catholic University, Faculty of Health, Melbourne, Victoria, Australia
| | - Frédéric Chiambaretta
- University Hospital of Clermont-Ferrand (CHU), Ophthalmology, Clermont-Ferrand, France
| | - Frédéric Dutheil
- University Hospital of Clermont-Ferrand (CHU), Preventive and Occupational Medicine, Clermont-Ferrand, France
- Australian Catholic University, Faculty of Health, Melbourne, Victoria, Australia
- Clermont Auvergne University, Blaise Pascal University, Laboratory of Metabolic Adaptations to Exercise in Physiological and Pathological conditions EA3533, Clermont-Ferrand, France
- Research Centre in Human Nutrition (CRNH) Auvergne, Clermont-Ferrand, France
- CNRS, UMR 6024, Physiological and Psychosocial Stress, LAPSCO, University Clermont Auvergne, Clermont-Ferrand, France
- * E-mail:
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45
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Current Perspectives of Prophylaxis and Management of Acute Infective Endophthalmitis. Adv Ther 2016; 33:727-46. [PMID: 26935830 DOI: 10.1007/s12325-016-0307-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Indexed: 12/23/2022]
Abstract
Endophthalmitis is an intraocular inflammatory condition which may or may not be caused by infective agents. Noninfectious (sterile) endophthalmitis may be attributable to various causes including postoperative retained soft lens matter or toxicity following introduction of other agents into the eye. Infectious endophthalmitis is further subdivided into endogenous and exogenous. In endogenous endophthalmitis there is hematogenous spread of organisms from a distant source of infection whereas in exogenous endophthalmitis direct microbial inoculation may occur usually following ocular surgery or penetrating eye injury with or without intraocular foreign bodies. Acute infective endophthalmitis is usually exogenous induced by inoculation of pathogens following ocular surgery, open-globe injury and intravitreal injections. More infrequently the infective source is internal and septicemia spreads to the eye resulting in endogenous endophthalmitis. Several risk factors have been implicated including immunosuppression, ocular surface abnormalities, poor surgical wound construction, complicated cataract surgery with vitreous loss and certain types of intraocular lens. Comprehensive guidelines and recommendations on prophylaxis and monitoring of surgical cases have been proposed to minimize the risk of acute endophthalmitis. Early diagnosis and prompt management of infective endophthalmitis employing appropriately selected intravitreal antibiotics are essential to optimize visual outcome.
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Mehta H, Gillies MC, Fraser-Bell S. Combination of vascular endothelial growth factor inhibitors and laser therapy for diabetic macular oedema: a review. Clin Exp Ophthalmol 2016; 44:335-9. [PMID: 27061760 DOI: 10.1111/ceo.12757] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 03/28/2016] [Accepted: 03/31/2016] [Indexed: 01/07/2023]
Abstract
This review provides a perspective on published and ongoing clinical trials of vascular endothelial growth factor inhibitors (anti-VEGF agents) combined with laser therapy for diabetic macular oedema (DMO). Although there was little short-term benefit in combining prompt macular laser with anti-VEGF therapy for centre-involving DMO in the Diabetic Retinopathy Clinical Research Network (DRCRnet) Protocol I study, deferred macular laser was still required in over 40% of study eyes in DRCRnet Protocol T. Macular laser was applied in more than 30% of eyes with centre-involving DMO receiving ranibizumab in the RISE and RIDE studies. For non centre-involving DMO the evidence-base still supports use of focal macular laser alone, although clinicians should be cautious about applying laser too close to the foveal avascular zone with the availability of pharmacotherapy. Ongoing clinical trials are assessing whether selectively targeting areas of peripheral retinal ischaemia with laser reduces the number of anti-VEGF injections to stabilise DMO and whether combining macular micropulse laser with anti-VEGF therapy is beneficial in DMO.
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Affiliation(s)
- Hemal Mehta
- Save Sight Institute, Sydney University, Sydney, New South Wales, Australia.,Moorfields Eye Hospital, London, UK.,Royal Free Hospital, London, UK
| | - Mark C Gillies
- Save Sight Institute, Sydney University, Sydney, New South Wales, Australia
| | - Samantha Fraser-Bell
- Save Sight Institute, Sydney University, Sydney, New South Wales, Australia.,Sydney Adventist Hospital Clinical School, Sydney University, Sydney, New South Wales, Australia
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Lim LT, Chia SN, Ah-Kee EY, Chew N, Gupta M. Advances in the management of diabetic macular oedema based on evidence from the Diabetic Retinopathy Clinical Research Network. Singapore Med J 2016; 56:237-47. [PMID: 26034315 DOI: 10.11622/smedj.2015071] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The Diabetic Retinopathy Clinical Research Network (DRCR.net) performs studies on new treatments for diabetic retinopathy. This review aims to summarise recent findings from DRCR.net studies on the treatment of diabetic macular oedema. We performed a PubMed search of articles from the DRCR.net, which included all studies pertaining to the treatment of diabetic maculopathy. The main outcome measures were retinal thickening as assessed by central subfield thickness on optical coherence tomography and improvement of visual acuity on the Early Treatment Diabetic Retinopathy Study (ETDRS) chart. Findings from each study were divided into modalities of treatment, namely photocoagulation, bevacizumab, triamcinolone, ranibizumab and vitrectomy. While modified ETDRS focal/grid laser remains the standard of care, intravitreal corticosteroids or anti-vascular endothelial growth factor agents have also proven to be effective, although they come with associated side effects. The choice of treatment modality for diabetic macular oedema is a clinical judgement call, and depends on the patient's clinical history and assessment.
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Affiliation(s)
- Lik Thai Lim
- Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, Scotland, United Kingdom
| | - Seen Nee Chia
- Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, Scotland, United Kingdom
| | | | - Nejia Chew
- Eye Department, Royal Victoria Infirmary, Newcastle upon Tyne, Tyne and Wear, England, United Kingdom
| | - Manish Gupta
- Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, Scotland, United Kingdom
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Gregori NZ, Flynn HW, Schwartz SG, Rosenfeld PJ, Vaziri K, Moshfeghi AA, Fortun JA, Kovach JL, Dubovy SR, Albini TA, Davis JL, Berrocal AM, Smiddy WE. Current Infectious Endophthalmitis Rates After Intravitreal Injections of Anti-Vascular Endothelial Growth Factor Agents and Outcomes of Treatment. Ophthalmic Surg Lasers Imaging Retina 2016; 46:643-8. [PMID: 26114845 DOI: 10.3928/23258160-20150610-08] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 05/05/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE To assess the incidence and outcomes of infectious endophthalmitis after intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) agents. PATIENTS AND METHODS Patient records at the Bascom Palmer Eye Institute (BPEI) from January 1, 2005, through December 31, 2014, were reviewed. The largest commercial claims and encounters database in the U.S. (MarketScan) was utilized to calculate the population-based endophthalmitis rate for 2011 to 2013. RESULTS The population-based rate of endophthalmitis after anti-VEGF injections for 2011 to 2013 was 391/740,757 (0.053%). BPEI's rate was 20/121,285 (0.016%) during the study period: eight after bevacizumab (0.012%), six after ranibizumab (0.018%), and six after aflibercept (0.031%) injection. Nine BPEI cases (45%) were culture-positive: Streptococcus species (5), coagulase-negative Staphylococcus (3), and non-anthracis Bacillus (1). Final visual acuity varied from 20/25 to no light perception. CONCLUSION Endophthalmitis after anti-VEGF injection was uncommon in our institution and in the population-based database. Treatment outcomes were variable but generally fared better in the culture-negative cases.
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Souied EH, Dugel PU, Ferreira A, Hashmonay R, Lu J, Kelly SP. Severe Ocular Inflammation Following Ranibizumab or Aflibercept Injections for Age-Related Macular Degeneration: A Retrospective Claims Database Analysis. Ophthalmic Epidemiol 2016; 23:71-9. [PMID: 26855278 PMCID: PMC4819836 DOI: 10.3109/09286586.2015.1090004] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Purpose: Intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents including ranibizumab and aflibercept are used to treat patients with ocular disorders such as neovascular age-related macular degeneration (nAMD); however, the injections are associated with rare instances of severe ocular inflammation. This study compared severe ocular inflammation rates in patients treated with ranibizumab versus aflibercept.
Methods: United States physician-level claims data covering an 18-month period for each therapy were analyzed. The primary analysis compared severe ocular inflammation event rates per 1000 injections. Sensitivity and subgroup analyses evaluated the impact of factors including intraocular surgery, intravitreal antibiotic administration, and previous intravitreal injections.
Results: The analysis included 432,794 injection claims (ranibizumab n = 253,647, aflibercept n = 179,147); significantly, more unique severe ocular inflammation events occurred in patients receiving aflibercept than ranibizumab (1.06/1000 injections, 95% confidence interval [CI], 0.91–1.21, vs. 0.64/1000 injections, 95% CI 0.54–0.74; p < 0.0001). Comparable results were observed for analyses of patients who had undergone glaucoma or cataract surgeries, had antibiotic-associated endophthalmitis, had non-antibiotic-associated endophthalmitis, and were non-treatment-naive. In contrast, no significant differences in severe ocular inflammation claims were recorded in treatment-naive patients who had no record of anti-VEGF treatment in the 6 months preceding the index claim. No significant change occurred in the rate of severe ocular inflammation claims over time following ranibizumab treatment.
Conclusions: Severe ocular inflammation was more frequent following intravitreal injection with aflibercept than with ranibizumab during routine clinical use in patients with nAMD. This highlights the importance of real-world, post-approval, observational monitoring of novel medicines, and may aid clinical decision-making, including choice of anti-VEGF agent.
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Affiliation(s)
- Eric H Souied
- a Centre Hospitalier Intercommunal Créteil , Université Paris-Est , Créteil , France
| | - Pravin U Dugel
- b Retinal Consultants of Arizona, Phoenix, AZ, USA and USC Eye Institute, Keck School of Medicine , University of Southern California , Los Angeles , CA , USA
| | | | | | | | - Simon P Kelly
- e Royal Bolton Hospitals NHS Foundation Trust , Bolton , UK
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de ANDRADE FL, LOPES FS, de ANDRADE GC, PRATA TS, MAIA A. Simultaneous Therapy with Intravitreal Dexamethasone Implant and Bevacizumab for the Treatment of Macular Edema. MEDICAL HYPOTHESIS, DISCOVERY & INNOVATION OPHTHALMOLOGY JOURNAL 2016; 5:4-9. [PMID: 28289686 PMCID: PMC5342876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To investigate the safety profile and benefits of a short-term simultaneous treatment regimen combining two drugs-an intravitreal implant of dexamethasone with an intravitreal injection of bevacizumab-in patients with macular edema. This was a retrospective, non-randomized, open-label case series study. Patients were treated between April 2014 and July 2015 and were diagnosed with recurrent macular edema secondary to diabetic retinopathy and retinal vein occlusion. They underwent simultaneous treatment with an intravitreal injection of bevacizumab (1.25 mg) and an intravitreal implant of dexamethasone (0.7 mg). Patients were evaluated at baseline and at each subsequent visit with a complete ophthalmological examination and spectral-domain optical coherence tomography (OCT) scans. They were examined 24 hours after the treatment, and then followed up after 30 days and 60 days. Twenty patients (representing 20 eyes) were included in the study. At the time of injection (i.e., baseline), the best-corrected visual acuity (BCVA) was 0.758 ± 0.42 logarithm of the minimum angle of resolution (logMAR). It improved significantly to 0.51 ± 0.33 logMAR at 1 month and to 0.5 ± 0.34 logMAR at 2 months (P ≤ 0.03). The median baseline central macular thickness (CMT) was 542 µm (interquartile range, 466 - 751 µm). The median CMT decreased significantly to 321 µm (interquartile range, 288-381 µm) at 1 month and 310 µm (interquartile range, 286 - 354 µm) at 2 months (P ≤ 0.0002). The mean intraocular pressure (IOP) increased from 14.9 ± 2.29 mmHg (at baseline) to 16.5 ± 2.99 mmHg (P = 0.04) after 2 months. Two (10%) eyes showed cataract progression. There were no other ocular or systemic complications for the duration of this study. Simultaneous therapy combining a dexamethasone implant plus bevacizumab for macular edema may be an attractive treatment regimen with an acceptable safety profile.
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Affiliation(s)
- Felipe L. de ANDRADE
- Retina Clinic, Rua Eloi Cândido Lopes, 291 Centro, Osasco - SP, 06010-130, Brazil
| | - Flavio S. LOPES
- Retina Clinic, Rua Eloi Cândido Lopes, 291 Centro, Osasco - SP, 06010-130, Brazil
| | | | - Tiago S. PRATA
- Federal University of São Paulo, Rua Sena Madureira, 1500 - Vila Mariana, São Paulo - SP, 04021-001, Brazil
| | - André MAIA
- Retina Clinic, Rua Eloi Cândido Lopes, 291 Centro, Osasco - SP, 06010-130, Brazil,Federal University of São Paulo, Rua Sena Madureira, 1500 - Vila Mariana, São Paulo - SP, 04021-001, Brazil
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