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Jung JH, Kim SS, Chung H, Hejri A, Prausnitz MR. Six-month sustained delivery of anti-VEGF from in-situ forming hydrogel in the suprachoroidal space. J Control Release 2022; 352:472-484. [PMID: 36309098 DOI: 10.1016/j.jconrel.2022.10.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/11/2022] [Accepted: 10/19/2022] [Indexed: 11/08/2022]
Abstract
Patients with wet age-related macular degeneration (AMD) require intravitreal injections of bevacizumab (Bev) or other drugs, often on a monthly basis, which is a burden on the healthcare system. Here, we developed an in-situ forming hydrogel comprised of Bev and hyaluronic acid (HA) crosslinked with poly(ethylene glycol) diacrylate for slow release of Bev after injection into the suprachoroidal space (SCS) of the eye using a microneedle. Liquid Bev formulations were cleared from SCS within 5 days, even when formulated with high viscosity, unless Bev was conjugated to a high molecular-weight HA (2.6 MDa), which delayed clearance until 1 month. To extend release to 6 months, we synthesized in-situ forming Bev-HA hydrogel initially as a low-viscosity mixture suitable for injection and flow in the SCS to cover a large area extending to the posterior pole of the eye where the macula is located in humans. Within 1 h after injection, Bev and HA were crosslinked, which retained Bev for slow release as the hydrogel biodegraded. In vivo studies in the rabbit eye reported Bev release for >6 months, depending on gel formulation and Bev assay. The in-situ forming Bev-HA hydrogel was well tolerated, as assessed by clinical exam, fundus imaging, histological analysis, and intraocular pressure measurement. We conclude that Bev released from an in-situ forming hydrogel may enable long-acting treatments of AMD and other posterior ocular indications.
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Affiliation(s)
- Jae Hwan Jung
- School of Chemical & Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA, USA; Dankook University, Department of Pharmaceutical Engineering, Republic of Korea
| | - Seong Shik Kim
- School of Chemical & Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Hyunwoo Chung
- School of Chemical & Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Amir Hejri
- School of Chemical & Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Mark R Prausnitz
- School of Chemical & Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA, USA.
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PATEL SAMIRN, CAI LOUISZ, MAHMOUDZADEH RAZIYEH, SALABATI MIRATAOLLAH, MAGAN TEJAL, OBEID ANTHONY, SOARES REBECCAR, HINKLE JOHNW, HSU JASON, DUNN JAMESP, VANDER JAMESF, GARG SUNIRJ. Endophthalmitis After Intravitreal Anti-Vascular Endothelial Factor Injections: Outcomes of Eyes Managed Without Microbiologic Cultures. Am J Ophthalmol 2022; 235:1-6. [PMID: 34461083 DOI: 10.1016/j.ajo.2021.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE To evaluate outcomes of eyes that developed endophthalmitis after intravitreal anti-vascular endothelial growth factor injections that were managed without microbiologic cultures. DESIGN Retrospective, single-center, comparative cohort study. METHODS We included all eyes with postinjection endophthalmitis from July 1, 2013, to September 1, 2019. Endophthalmitis cases were divided into the culture group if treated with intravitreal antibiotics and a vitreous or aqueous tap sent for microbiologic sampling or into the no culture group if treated with immediate injection of intravitreal antibiotics with an anterior chamber paracentesis that was not sent for microbiologic sampling. The main outcome measures were visual acuity, the incidence of retinal detachment, and the need for additional procedures. RESULTS Of 165 endophthalmitis cases identified, 119 (72%) were in the culture group and 46 (28%) were in the no culture group. At endophthalmitis presentation, eyes in the culture group had a mean logMAR VA of 1.98 (∼20/1900) compared with 1.90 (∼20/1600) for eyes in the no culture group (P = .589). At the 6-month follow-up, the mean vision loss was 5.5 lines lost from baseline for the culture group compared with 2.5 lines lost for the no culture group (P = .017). Eyes in the culture group required a subsequent pars plana vitrectomy in 29 of 119 cases (24%) compared with 7 of 46 cases (15%) in the no culture group (P = .29). Six of 119 eyes (5%) in the culture group developed secondary retinal detachments compared with none in the no culture group (P = .143). CONCLUSIONS When access to microbiologic facility is not available, the management of postinjection endophthalmitis using intravitreal antibiotics without microbiologic cultures may be an acceptable treatment strategy.
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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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Bacterial Dispersion Associated With Various Patient Face Mask Designs During Simulated Intravitreal Injections. Am J Ophthalmol 2021; 223:178-183. [PMID: 33129809 PMCID: PMC7598764 DOI: 10.1016/j.ajo.2020.10.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 10/21/2020] [Accepted: 10/24/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE We sought to investigate bacterial dispersion with patient face mask use during simulated intravitreal injections. DESIGN Prospective cross-sectional study. METHODS Fifteen healthy subjects were recruited for this single-center study. Each participant was instructed not to speak for 2 minutes, simulating a "no-talking" policy, while in an ophthalmic examination chair with an blood agar plate secured to the forehead and wearing various face masks (no mask, loose fitting surgical mask, tight-fitting surgical mask without tape, tight-fitting surgical mask with adhesive tape securing the superior portion of the mask, N95 mask, and cloth mask). Each scenario was then repeated while reading a 2-minute script, simulating a talking patient. The primary outcome measures were the number of colony-forming units (CFUs) and microbial species. RESULTS During the "no-talking" scenario, subjects wearing a tight-fitting surgical mask with tape developed fewer CFUs compared with subjects wearing the same mask without tape (difference 0.93 CFUs [95% confidence interval 0.32-1.55]; P = .003). During the speech scenarios, subjects wearing a tight-fitting surgical mask with tape had significantly fewer CFUs compared with subjects without a face mask (difference 1.07 CFUs; P = .001), subjects with a loose face mask (difference 0.67 CFUs; P = .034), and subjects with a tight face mask without tape (difference 1.13 CFUs; P < .001). There was no difference between those with a tight-fitting surgical mask with tape and an N95 mask in the "no-talking" (P > .99) and "speech" (P = .831) scenarios. No oral flora were isolated in "no-talking" scenarios but were isolated in 8 of 75 (11%) cultures in speech scenarios (P = .02). CONCLUSION The addition of tape to the superior portion of a patient's face mask reduced bacterial dispersion during simulated intravitreal injections and had no difference in bacterial dispersion compared with wearing N95 masks.
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Patel SN, Hsu J, Sivalingam MD, Chiang A, Kaiser RS, Mehta S, Park CH, Regillo CD, Sivalingam A, Vander JF, Ho AC, Garg SJ. The Impact of Physician Face Mask Use on Endophthalmitis After Intravitreal Anti-Vascular Endothelial Growth Factor Injections. Am J Ophthalmol 2021; 222:194-201. [PMID: 32888902 PMCID: PMC7462768 DOI: 10.1016/j.ajo.2020.08.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/05/2020] [Accepted: 08/05/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the effect of physician face mask use on rates and outcomes of postinjection endophthalmitis. DESIGN Retrospective, comparative cohort study. METHODS Setting: Single-center. StudyPopulation: Eyes receiving intravitreal anti-vascular endothelial growth factor injections from July 1, 2013, to September 1, 2019. INTERVENTION Cases were divided into "Face Mask" group if face masks were worn by the physician during intravitreal injections or "No Talking" group if no face mask was worn but a no-talking policy was observed during intravitreal injections. MainOutcomeMeasures: Rate of endophthalmitis, visual acuity, and microbial spectrum. RESULTS Of 483,622 intravitreal injections administered, 168 out of 453,460 (0.0371%) cases of endophthalmitis occurred in the No Talking group, and 9 out of 30,162 (0.0298%) cases occurred in the Face Mask group (odds ratio, 0.81; 95% confidence interval, 0.41-1.57; P = .527). Sixteen cases of oral flora-associated endophthalmitis were found in the No Talking group (1 in 28,341 injections), compared to none in the Face Mask group (P = .302). Mean logMAR visual acuity at presentation in cases that developed culture-positive endophthalmitis was significantly worse in the No Talking group compared to the Face Mask group (17.1 lines lost from baseline acuity vs 13.4 lines lost; P = .031), though no difference was observed at 6 months after treatment (P = .479). CONCLUSION Physician face mask use did not influence the risk of postinjection endophthalmitis compared to a no-talking policy. However, no cases of oral flora-associated endophthalmitis occurred in the Face Mask group. Future studies are warranted to assess the role of face mask use to reduce endophthalmitis risk, particularly attributable to oral flora.
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Affiliation(s)
- Samir N Patel
- Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jason Hsu
- Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Meera D Sivalingam
- Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Allen Chiang
- Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Richard S Kaiser
- Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sonia Mehta
- Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Carl H Park
- Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Carl D Regillo
- Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Arunan Sivalingam
- Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - James F Vander
- Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Allen C Ho
- Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sunir J Garg
- Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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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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Storey PP, Pancholy M, Wibbelsman TD, Obeid A, Su D, Borkar D, Garg S, Gupta O. Rhegmatogenous Retinal Detachment after Intravitreal Injection of Anti–Vascular Endothelial Growth Factor. Ophthalmology 2019; 126:1424-1431. [DOI: 10.1016/j.ophtha.2019.04.037] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 04/14/2019] [Accepted: 04/23/2019] [Indexed: 11/28/2022] Open
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