["Iodine allergy" : A medical myth with risks for the ophthalmological patient]

Endophthalmitis after Anti-VEGF Intravitreal Injections with Aqueous Chlorhexidine versus Povidone-Iodine as Ocular Antiseptics

PURPOSE

To compare the rates and outcomes of endophthalmitis after intravitreal injections (IVIs) for patients pretreated with 5% povidone-iodine (PI) and 0.05% chlorhexidine (CHX).

DESIGN

A retrospective, single-center, comparative cohort study.

PARTICIPANTS

A total of 8686 patients were included in the study, and a total of 67 695 anti-VEGF injections were performed from January 1, 2019, to November 30, 2021.

SETTING

A private retina practice of 13 retina specialists in Colorado.

METHODS

Using electronic health records, patients with preinjection preparation with PI or CHX were compiled retrospectively. Use of prefilled versus nonprefilled syringes was also tabulated. Patients with postinjection endophthalmitis (PIE) were identified among the 2 groups. Postinjection endophthalmitis is defined as an inflammation of the eye from infectious agents after an IVI. Logarithm of the minimum angle of resolution (logMAR) visual acuity (VA) was determined at the time of causative anti-VEGF injection, endophthalmitis presentation, and 3-month follow-up.

RESULTS

A total of 67 695 IVIs were administered by 13 retina specialists during the study period. A total of 13 of 32 802 (0.0396%; 1 in 2523 injections) cases of presumed endophthalmitis occurred in the PI group, and 9 of 34 893 (0.0258%; 1 in 3877 injections) cases in the CHX group (P = 0.395). For the PI group, there were 2 culture-positive endophthalmitis cases (0.0061%, 1 in 16 401), compared with 2 cases in the CHX group (0.00573%, 1 in 17 447) (P = 1.000). No significant difference was observed in the average logMAR VA of PI and CHX at causative injection (P = 0.3851), endophthalmitis encounter (P = 0.7718), and 3-month follow-up (P = 0.6152). A significant reduction in presumed endophthalmitis (P = 0.0445) and culture-positive cases (P = 0.0130) was present for prefilled IVI compared with nonprefilled injections.

CONCLUSIONS

No significant difference in the rate of endophthalmitis or visual outcomes were found in the CHX group compared with the PI group. Prefilled syringes were associated with a significant reduction in endophthalmitis rate. Further multicenter studies are needed to validate the efficacy and safety of CHX compared with PI for IVI preparation.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

METHOD OF POVIDONE-IODINE APPLICATION AND ENDOPHTHALMITIS RISK

PURPOSE

To evaluate the proportion of patients developing endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents according to the mode of povidone-iodine (PI) antisepsis.

METHODS

A retrospective review of the anti-vascular endothelial growth factor injections given in a 7-year period at a community-based retinal practice. Endophthalmitis was diagnosed to have occurred if an eye developed intraocular inflammation and was given antibiotics with or without supportive culture identification of an organism. As part of their habitual clinical practice, component physicians used 5% PI as two drops, one drop, or just a dot of PI administered with a cotton-tipped applicator to the site before injection.

RESULTS

There were 113,610 intravitreal injections administered and 23 cases were diagnosed with endophthalmitis over the 7-year period, for a rate of 1 case per 4,940 injections. The mode of PI antisepsis showed no significant relation to the rate of endophthalmitis ( P = 0.55, chi-square test). The proportion of endophthalmitis by physician demonstrated no significant difference ( P = 0.39, chi-square test).

CONCLUSION

The use of PI has been associated with decreased incidence of endophthalmitis, but the mode of application has not been standardized. The results of this study suggest that "more is not better" in PI antisepsis in endophthalmitis. Moreover, the toxicity of PI on the ocular surface is known to be dose-related.

The Use of Iodophor-Impregnated Drapes in Patients With Iodine-Related Allergies: A Case Series and Review of the Literature

Background

The use of iodophor-impregnated adhesive drapes have become almost universally incorporated into standard practice of arthroplasty draping technique. Iodine-related allergies in patients planned for joint replacement present a challenge in terms of the best course of action to minimize complications and optimize outcomes.

Methods

This is a retrospective case series of patients that received an iodophor-impregnated drape as part of draping for a total hip or knee arthroplasty at a single orthopaedic-specific hospital with documented iodine-related allergies. From 2015 to 2023, 9816 total hip arthroplasty and total knee arthroplasty cases were reviewed, and 135 were documented to have an iodine-related allergy for a prevalence of 1.38%. Intraoperative and postoperative records were reviewed to screen for an allergic reaction or wound healing issues that may have been related to an adverse reaction to the use of the iodophor-impregnated drape.

Results

Of the 135 patients, 43 had iodine listed as an allergy, 85 had shellfish, 20 had iodinated contrast media, and 3 had povidone iodine. Sixteen patients had a cluster of iodine-related allergies. There were no intraoperative reports of an allergic reaction to this drape. There were four superficial wound problems, none of which were documented to relate to an allergic dermatitis reaction, and none required further surgery.

Conclusions

Patients reporting iodine-related allergies were present in 1.38% of patients undergoing hip or knee arthroplasty in our series. We encountered no allergic reactions or adverse outcomes that could be attributed to the use of iodiphor impregnated drapes in these patients.

Povidone-Iodine Adverse Effects and Alternatives for Ocular Procedures

Purpose: Povidone-iodine (PVI), also known as Betadine, is a widely used antiseptic agent used in several fields of medicine. In ophthalmology, it is applied as a preoperative antiseptic to prevent infectious complications that can result from surgical procedures. PVI's safety and efficacy have been extensively studied and represented in the literature; however, the incidence of adverse effects has been reported in conjunction. The aim of this paper is to compile information regarding PVIs use, safety profile, adverse effects, and possible alternatives through a review of the existing literature. Methods: Literature was compiled utilizing the database PubMed and Google Scholar using specified keywords with a total of 86 reviewed articles, after excluding search results that did not meet the inclusion criteria. Results: While the allergic potential to PVI is a highly contested topic, there are several nonallergic adverse effects of PVI that should not be overlooked. These effects include chemical burn, cytotoxic effects, and general patient discomfort. In light of these adverse effects, alternatives to PVI may be considered. However, there has been little research identifying feasible alternatives in preoperative intraocular procedures. Alternatives including chlorhexidine, polyhexamethylene biguanide (polyhexanide), and octenidine were identified as potential substitutes for PVI. Conclusions: Further study is needed to provide robust evidence regarding the efficacy profiles of these alternatives in comparison with PVI and to demonstrate comparable tolerance to PVI in intraocular procedures.

Ocular signs and symptoms of orthokeratology patients associated with povidone iodine-based disinfecting solution

PURPOSE

To determine the frequency and severity of ocular symptoms and signs in new orthokeratology (ortho-k) subjects using a povidone iodine (PI) disinfecting system compared to those present before lens wear, and whether these were associated with cleaning regimes.

METHODS

This study recruited 80 subjects from two myopia control studies, who used a PI disinfecting solution for routine use. Ocular symptoms and signs at baseline, one- and six-month after lens wear were reported via questionnaires and ocular examination, respectively. To determine if rates of occurrence were attributable to differences in cleaning regime, subjects were randomly assigned into four groups with respect to routine care procedures, which involved various combinations of rubbing and use of a daily and/or enzymatic cleaner.

RESULTS

Sixty-eight subjects completed all aspects of the study. As there were no significant differences in incidence of signs and symptoms between the four groups before and after lens wear (Friedman tests, p > 0.07), data were combined for further analysis. Prior to lens wear, itchiness (69 %) and dryness (53 %) were the most commonly reported symptoms. The frequency and severity of all symptoms remained similar after lens wear (p > 0.10). Presence of follicles in the lower tarsal conjunctiva (22 %) and conjunctival injection (15 %) was frequently observed, but reduced significantly after lens wear (p < 0.01). Mild corneal staining, noted in 13 % of subjects at baseline, did not change significantly over time (p = 0.17). Ocular signs were not necessarily reflected in symptoms and vice versa.

CONCLUSION

Use of a PI-based solution did not increase the frequency or severity of ocular signs and symptoms observed before lens wear. Absence of a difference in occurrence of ocular discomfort with respect to cleaning regimes indicated that the use of the PI-based solution may adequately clean the lenses over a 6-month period.

Indocyanine Green Is a Safe and Effective Alternative to Radioisotope in Breast Cancer Sentinel Lymph Node Biopsy regardless of Patient Body Mass Index

INTRODUCTION

A recent meta-analysis [Lancet Oncol. 2010;11:908-909] has confirmed high sensitivity of indocyanine green (ICG) fluorescence mapping for sentinel node detection in early breast cancer. Concerns have previously been raised regarding the efficacy in patients with high body mass index (BMI).

MATERIALS AND METHODS

All consecutive patients undergoing sentinel lymph node biopsies (SLNBs) for early breast cancer in NHS Tayside were included in a prospective audit of surgical and pathology findings. All patients included in the study received dual injection of patent blue dye and ICG. Approval was obtained from the local Caldicott guardian for collection and use of personal data.

RESULTS

Of 239 cases, all were female patients of mean age 62 years (range 27-93). In 4.2% (10/239) of cases, neither blue dye nor ICG was present in the axilla. Of the remaining 229 SLNB cases in this series, surgeons documented retrieval of 451 nodes, with a mean surgical nodal count per case of 1.97 (range 1-5) and pathological nodal count of 2.15 (range 0-7). Eighty three cases were performed in patients with BMI 30-39.9 and 21 cases with BMI ≥40, with nodal detection rates of 96.4% (80/83) and 95.2% (20/21), respectively, in these groups of patients. Twenty percent (48/229) of cases had nodal metastases on histopathology.

CONCLUSIONS

This is a large single-center study which demonstrates the safety and accuracy of the combined ICG and blue dye technique for SLNB in breast cancer. This is represented by nodal detection rates and node positivity rates which are comparable to previous multicenter studies of standard SLNB regardless of BMI.

Akute Schwellung im Halsbereich nach iodhaltigem Kontrastmittel – der oft unerkannte Iodmumps anhand von drei Fallbeispielen

Es werden drei Patientinnen vorgestellt, die zur Abklärung einer akuten Halsschwellung nach einer Untersuchung mit iodierten Kontrastmitteln zugewiesen wurden. Bei allen drei war ein akutes Angioödem vermutet worden, das allerdings nicht ausreichend auf Antihistaminika und Kortikosteroide ansprach. Es wurde schließlich ein sog. „Iodmumps“ oder Iod-assoziierte Sialoadenopathie diagnostiziert. Sonografisch und histologisch finden sich lediglich ein Ödem der Speicheldrüsen, hingegen keine Hinweise für eine ausgeprägte entzündliche Reaktion. Diese Komplikation ist nicht so selten und wird von Iod selbst ausgelöst, wie mit einer Provokation mit Iod-Kaliumiodid (Lugolʼscher Lösung) nachgewiesen werden konnte. Die pathophysiologisch ungeklärte Iod-assoziierte Sialoadenopathie wird somit als idiosynkratische Reaktion klassifiziert.

Successful prolonged cardiopulmonary resuscitation after intraoperative cardiac arrest due to povidone-iodine allergy: A case report

BACKGROUND

Iodophor (povidone-iodine) is widely used clinically because of its broad-spectrum antibacterial effects. Although extremely rare, it may cause anaphylactic shock, which itself carries the life-threatening risk of cardiac arrest.

CASE SUMMARY

We present a case in which a patient with postoperative infection went into anaphylactic shock and cardiac arrest caused by povidone-iodine during secondary surgery. The patient was successfully resuscitated by 2 h of cardiopulmonary resuscitation.

CONCLUSION

This is the first known case of cardiac arrest caused by povidone-iodine allergy.

[Adherence to anti-VEGF treatment-Considerations and practical recommendations]

BACKGROUND

Numerous studies have identified a lack of treatment adherence as an important factor that often conflicts with the necessary number of anti-VEGF injections and therefore a better functional result.

OBJECTIVE

This article discusses approaches and possible measures to reduce the risk of late and infrequent intravitreal injections leading to the major issue of undertreatment.

MATERIAL AND METHOD

In the course of an expert dialogue, relevant parameters of treatment adherence and variables were identified. Meaningful processes were structured and assigned to organizational areas.

RESULTS

The compilation of meaningful measures enables practitioners to optimize their own implementation in different areas. Regular monitoring measures can identify the extent of treatment interruption and discontinuation. For specific indicators (treatments per time interval, longest pause interval, minimum coverage per unit time, delay) an effect on the development of visual function was demonstrated. Organizational measures, training of teams and referring physicians, redundant and iterative information transfer to patients have been proven in the experience of experts. The firm integration of these processes into the structures is facilitated by working with checklists.

CONCLUSION

An optimization of the processes is possible to improve the adherence and the functional results; however, interventional studies showing how adherence and persistence can be increased in the German treatment setting are still lacking.

Prophylaxis measures for postinjection endophthalmitis

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.

Low Efficacy of Hypochlorous Acid Solution Compared to Povidone-iodine in Cataract Surgery Antisepsis

Background:

Hypochlorous Acid Solution (HAS) is a non-irritating, odorless and transparent, pH-neutral substance having antimicrobial activity.

Objective:

The study aimed to compare the efficacy of HAS with a 10% povidone-iodine (PVI) solution for antisepsis in Phacoemulsification Cataract Surgery (PCS).

Methods:

Consecutive patients undergoing PCS in the Elbląg City Hospital, Poland, were enrolled in this prospective trial. In the morning just before surgery a swab was taken from the inferior conjunctival fornix of the eye that was to be operated. Patients were assigned to receive conjunctival irrigation with PVI or HAS in the operating room. Three minutes after lavage with PVI or HAS, conjunctival swabs were taken. During surgery the cornea and conjunctival sac were irrigated with Ringer’s lactate. The last swab was taken before removing the eye speculum.

Results:

Overall, 110 patients completed the study; there were 59 patients in the PVI group and 51 patients in the HAS group. Conjunctival lavage with 10% PVI resulted in a decrease in bacterial load, while HAS application did not. In the HAS group a reduction in bacterial load was found after surgery. Patients after HAS irrigation reported significantly less discomfort associated with conjunctival lavage than with PVI. None of the patients developed postoperative endophthalmitis or any type of eye inflammation within the follow-up period.

Conclusions:

This study confirms the excellent antibacterial activity of a 10% povidone-iodine solution used for three minutes before cataract surgery. Conjunctival irrigation with Ringer lactate during PCS decreased the bacterial load of the conjunctival sac.

Retrospective validation of the laparoscopic ICG SLN mapping in patients with grade 3 endometrial cancer

PURPOSE

To evaluate the sensitivity, negative predictive value (NPV) and false-negative (FN) rate of the near infrared (NIR) indocyanine green (ICG) sentinel lymph node (SLN) mapping in patients with poorly differentiated endometrial cancer who have undergone a full pelvic and para-aortic lymphadenectomy after SLN mapping.

METHODS

We performed a retrospective analysis of patients with endometrial cancer undergoing a laparoscopic NIR-ICG SLN mapping followed by a systematic pelvic and para-aortic lymphadenectomy. Inclusion criteria were a grade 3 endometrial cancer or a high-risk histology (papillary serous, clear cell carcinoma, carcinosarcoma, and neuroendocrine carcinoma) and a completion pelvic and para-aortic lymphadenectomy to the renal vessels after SLN mapping. Overall and bilateral detection rates, sensitivity, NPV, and FN rates were calculated.

RESULTS

From December 2012 until January 2017, 42 patients fulfilled inclusion criteria. Overall and bilateral detection rates were 100 and 90.5%, respectively. Overall, 23.8% of the patients had lymph node metastases. In one patient, despite negative bilateral pelvic SLNs, a metastatic non-SLN-isolated para-aortic metastasis was detected. This NSLN was clinically suspicious and sent to frozen section analysis during the surgery. FN rate, sensitivity, and NPV were 10, 90, and 97.1%, respectively. For the SLN mapping algorithm, FN rate, sensitivity, and NPV were 0, 100, and 100%, respectively.

CONCLUSIONS

Laparoscopic NIR-ICG SLN mapping in high-risk endometrial cancer patients has acceptable sensitivity, FN rate, and NPV.

2018 Update on Intravitreal Injections: Euretina Expert Consensus Recommendations

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.

Sentinel lymph node mapping in endometrial cancer: comparison of fluorescence dye with traditional radiocolloid and blue

Sentinel lymph node (SLN) mapping in endometrial cancer (EMCA) is rapidly gaining acceptance in the clinical community. As compared to a full lymphadenectomy in every patient, to a selective lymphadenectomy after frozen section of uterus in selected patients with intrauterine risk factors or to a strategy in which a lymphadenectomy is always omitted, SLN mapping seems to be a reasonable and oncologically safe middle ground. Various protocols can be used when applying an SLN mapping. In this manuscript we review the characteristics, toxicity and clinical impact of technetium-99m radiocolloid (Tc-99m), of the blue dyes (methylene blue, isosulfan blue and patent blue) and of indocyanine green (ICG). ICG has an excellent toxicity profile, has higher overall and bilateral detection rates as compared to blue dyes and higher bilateral detection rates as compared to a combination of Tc-99m and blue dye. The detrimental effect of BMI on the detection rates is attenuated when ICG is used as a tracer. The ease of use of the ICG SLN mapping is perceived by the patients as a better quality of care delivered. Whenever possible, ICG should be favored over the other tracers for SLN mapping in EMCA patients.