The Impact of Prefilled Syringes on Endophthalmitis Following Intravitreal Injection of Ranibizumab

Risk of post-injection endophthalmitis peaks within the first three injections of anti-vascular endothelial growth factor therapy: A nationwide registry-based study

PURPOSE

To report the incidence of post-injection endophthalmitis (PIE) and the cumulative risk associated with repeated injections of intravitreal anti-vascular endothelial growth factor (anti-VEGF).

METHODS

We employed nationwide registries in Denmark to include all individuals aged ≥40 years who received at least one intravitreal anti-VEGF injection in 2007-2022. Our primary endpoint PIE was identified using specific diagnostic codes for endophthalmitis and procedure codes for vitreous biopsy within 10 days prior to and 120 days post-injection. Patients were stratified according to the underlying diagnoses for which they received the treatment. The relative risk (RR) for PIE was calculated between groups based on the number of injections received by the patients.

RESULTS

We identified 60 825 patients who received intravitreal anti-VEGF treatment during study time, with a median age of 77.2 years and females constituting 58.1%. We identified 232 cases of PIE after 1 051 549 injections during follow-up, resulting in an incidence of 0.022% [95% CI 0.019%-0.025%]. Despite a linear growth in annual anti-VEGF use, the incidence remained stable at 0.020% [95% CI 0.017%-0.023%] from 2013 to 2022. Compared to patients receiving 1-3 injections, RR for patients receiving 4-20, 21-40, and >40 injections were 0.46 [95% CI 0.34-0.63], 0.32 [95% CI 0.21-0.50], and 0.54 [95% CI 0.36-0.81], respectively. Findings were similar across the different diagnoses.

CONCLUSIONS

Based on 16 years of nationwide registry data, this study identified a low and stable incidence of PIE. Notably, the highest risk of endophthalmitis was within the first three anti-VEGF injections.

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.

Risk of Endophthalmitis Based on Cumulative Number of Anti-VEGF Intravitreal Injections

PURPOSE

To determine the risk of endophthalmitis in eyes undergoing intravitreal injections (IVIs) of anti-VEGF based on cumulative number of injections per eye.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients from a single center undergoing IVIs of ranibizumab, aflibercept, or bevacizumab.

METHODS

Eyes were divided into quartiles based on injection number causative of endophthalmitis between January 1, 2011, and June 1, 2022.

MAIN OUTCOME MEASURES

Interquartile clinical outcomes and cumulative risk of endophthalmitis per injection and per eye.

RESULTS

A total of 43 393 eyes received 652 421 anti-VEGF injections resulting in 231 endophthalmitis cases (0.035% per injection, 1 in 2857), of which 215 were included. The cumulative endophthalmitis risk increased from 0.0018% (1 in 55 556) after 1 injection to 0.013% (1 in 7692) after 11 injections (0.0012 percentage point change), versus 0.014% (1 in 7143) after 12 injections to 0.025% (1 in 4000) after 35 injections (0.00049 percentage point change), versus 0.025% (1 in 4000) after 36 injections to 0.031% (1 in 3226) after 66 injections (0.00017 percentage point change), versus 0.031% (1 in 3226) after 63 injections to 0.033% (1 in 3030) after 126 injections (0.000042 percentage point change) (P < 0.001). Likewise, the cumulative endophthalmitis risk per eye increased from 0.028% (1 in 3571) to 0.20% (1 in 500) between injections 1 and 11 (0.018 percentage point change), versus 0.21% (1 in 476) to 0.38% (1 in 263) between injections 12 and 35 (0.0075 percentage point change), versus 0.38% (1 in 263) to 0.46% (1 in 217) between injections 36 and 66 (0.0026 percentage point change), versus 0.46% (1 in 217) to 0.50% (1 in 200) between injections 67 and 126 (0.00063 percentage point change) (P < 0.001).

CONCLUSIONS

The cumulative endophthalmitis risk per injection and per eye increased with greater number of injections received but appeared to do so at a higher rate during earlier injections and at a lower rate further into the treatment course.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

NO EFFECT OF REAL-WORLD UNIVERSAL FACE MASKING ON POST-INTRAVITREAL INJECTION ENDOPHTHALMITIS RATE AT A SINGLE TERTIARY ACADEMIC CENTER

PURPOSE

To determine whether universal masking during COVID-19 altered rate and outcomes of postinjection endophthalmitis.

METHODS

Retrospective, single-site, comparative, cohort study. Eyes diagnosed with endophthalmitis within 4 weeks of intravitreal injection at the University of Michigan from August 1, 2012, to November 15, 2022, were identified. Cases were considered "masking" between March 15, 2020, and November 15, 2022. Endophthalmitis rate, visual acuity, and microbial spectrum were investigated.

RESULTS

There were 20 postinjection endophthalmitis cases out of 72,194 injections (0.028%; one in 3,571 injections) premasking and 10 of 38,962 with universal masking (0.026%; one in 3,846 injections; odds ratio 0.9; 95% [confidence interval]: 0.4-2.0). Referral from the community was unchanged with 32 cases referred premasking (0.35 cases/month) and 10 cases with masking (0.31 cases/month). Presenting mean the logarithm of the minimum angle of resolution visual acuity with masking of all postinjection endophthalmitis cases trended worse (2.35 ± 0.40) compared with premasking (2.09 ± 0.48; P = 0.05) with light perception visual acuity more common with masking (31.6% vs. 10.9%, P = 0.06). There was no delay in time from procedure to initial treatment ( P = 0.36), no difference in the rate of initial treatment with tap and inject (T/I), and similar positive-culture rates ( P = 0.77) between the cohorts. Visual acuity after 30 days of follow-up was clinically unchanged (∼20/500 vs. 20/400; P = 0.59).

CONCLUSION

Universal masking had no effect on postinjection endophthalmitis rate or on the rate of culture-positive cases. Although presenting visual acuity appeared worse with masking, this was not statistically significant, and current treatment paradigms resulted in similar visual outcomes.

Morganella morganii and Enterococcus faecalis endophthalmitis following intravitreal injection

BACKGROUND

Endophthalmitis following intravitreal injection is a potentially devastating complication of anti-VEGF injections. Post-injection endophthalmitis due to Enterococcus faecalis is rare, and no previous case of Morganella morganii endophthalmitis after intravitreal injection has been reported.

CASE PRESENTATION

We present the first reported case of Morganella morganii and Enterococcus faecalis endophthalmitis after intravitreal injection in an immunocompetent patient in the absence of recent ocular surgery. Our patient presented with hand movement visual acuity one day after anti-VEGF injection and demonstrated no clinical improvement despite repeated intravitreal ceftazidime and vancomycin injections. A decision was made to proceed with early vitrectomy given failure of intravitreal antibiotics. Visual acuity improved to 6/90 at 12 weeks after vitrectomy without any evidence of disease recurrence.

CONCLUSIONS

Post-injection endophthalmitis due to concurrent Morganella morganii and Enterococcus faecalis infections can have visually devastating consequences despite repeated empirical and targeted intravitreal antibiotics. Lack of clinical improvement following intravitreal antibiotics should warrant consideration of early vitrectomy. Our experience is a pertinent reminder of the ever-growing threat of uncommon and multi-resistant bacteria that must be considered when treating infections such as post-injection endophthalmitis.

Glycosylation differences of an anti-VEGF monoclonal antibody (PRO-169) and its extensive comparison with Bevacizumab

PRO-169 is an anti-VEGF monoclonal antibody developed by Laboratorios Sophia that shares its sequence with Bevacizumab (BVZ); though, PRO-169 is intended for intravitreal administration. In this study, analytical characterization showed that PRO-169 had glycosylation differences in comparison to BVZ reference product (RP); since it had more content of G1F, G2F, sialic acid and high mannose. Further investigation was performed to evaluate if differences between both products would affect the efficacy and safety profile of PRO-169. PRO-169 had no alteration in its in vitro biological activity; moreover, no cytotoxicity or immunogenicity concerns should be expected as demonstrated by different orthogonal methods at analytical, in vitro and in vivo assays. These results support moving to the clinical testing of PRO-169 since no major complications will be expected with its clinical use for the treatment of ophthalmic diseases.

Risk of transient vision loss after intravitreal aflibercept using vial-prepared vs. the novel prefilled syringe formulation

Purpose

To compare the risk of transient vision loss (TVL) probably attributable to a severe intraocular pressure spike after intravitreal aflibercept application using the novel prefilled syringe (PFS) vs. the established vial system (VS).

Methods

Datasets of the intravitreal injection service of the Ludwig Maximilians-University Munich and the Technical University Munich, Germany, were screened for documentation of TVL after intravitreal injection of aflibercept. The observation period included two full months prior to the introduction of the novel PFS and two months afterwards. TVL was defined as loss of perception of hand motion for a duration of >30 s.

Results

Over a period of four months, 1720 intravitreal injections of aflibercept were administered in 672 patients. There were 842 injections with the old VS, and 878 injections using the novel PFS. Using the VS, TVL was noted during two injections (0.24%) in two patients, as compared to 11 cases of TVL (1.25%) in 10 patients with the PFS (p = 0.015). Using the PFS, patients had a 5.3-fold risk of TVL as compared to the VS (OR: 5.33; 95% CI: 1.2-24.1; p = 0.0298).

Conclusion

There was a more than five-fold risk of TVL using the novel pre-filled aflibercept syringe as compared to the established vial system. During informed consent, this risk should be discussed.

Impact of Prefilled Syringes and Masking on Postintravitreal Injection Endophthalmitis

Purpose: To compare rates of endophthalmitis (1) following intravitreal injection of antivascular endothelial growth factor therapies with glass-vial preparation (GVP) vs prefilled syringes (PFS) and (2) before and after masking protocols were implemented. Methods: Medical records within a multicenter retina practice in Houston, Texas, from January 2015 to August 2021 were retrospectively reviewed. The primary outcome was rate of endophthalmitis after intravitreal injection. Results: A total of 307 349 injections were performed during the study period and 101 cases of endophthalmitis were identified (0.033%). PFS use was associated with a decreased risk of endophthalmitis (relative risk [RR], 0.320; 95% CI, 0.198-0.518, P < .001); 54 cases of endophthalmitis occurred in the GVP group of aflibercept and ranibizumab (0.052%) compared with 24 in the PFS group (0.017%). There was no difference in the endophthalmitis rates with or without universal masking (RR, 0.953; 95% CI 0.616-1.473, P = .91). Discussion: PFS use was associated with a significant reduction in the rate of endophthalmitis while the use of surgical face masks did not appear to significantly impact the rate of endophthalmitis.

Reduced Incidence of Intravitreal Injection-Related Endophthalmitis With Prefilled Syringes

Purpose: To evaluate the incidence and clinical characteristics of intravitreal injection-related endophthalmitis cases with antivascular endothelial growth factor (anti-VEGF) medications manufactured as prefilled syringes or non-prefilled preparations. Methods: This retrospective chart review comprised eyes that received intravitreal anti-VEGF at a single-specialty retina practice from January 1, 2014, to December 31, 2019. Eyes diagnosed with injection-related endophthalmitis were identified. Demographic and clinical data were abstracted from medical records, including the type of anti-VEGF agent, baseline and follow-up corrected visual acuity (VA), and microbiologic findings. Results: The review identified 88 cases of intravitreal anti-VEGF injection-related endophthalmitis and 325 990 total injections. Total injections included 32 045 (9.8%) bevacizumab (BEV), 93 073 (28.6%) ranibizumab (RAN), 122 947 (37.7%) aflibercept (AFL), and 77 925 (23.9%) ranibizumab prefilled syringe (RANPFS). Ten of the endophthalmitis cases were related to BEV, 21 to RAN, 45 to AFL, and 12 to RANPFS. The endophthalmitis rate was lowest for RANPFS (0.0154%) (BEV, 0.0312%; RAN, 0.0226%; AFL, 0.0366%) (P = .030). Thirty-four (41.5%) of 82 samples were culture positive. RANPFS had a significantly lower rate of culture-proven postinjection endophthalmitis than the other agents (P = .003). The mean VA for endophthalmitis cases related to RANPFS vs non-prefilled agents was similar at presentation (Snellen 20/2092 vs 20/2327) and at the 3-month follow-up (Snellen 20/201 vs 20/272) (both P > .05). Conclusions: Anti-VEGF medications in prefilled syringes may reduce the risk for medication contamination during injection preparation. RANPFS was associated with a lower rate of injection-related endophthalmitis than non-prefilled anti-VEGF medications.

Endophthalmitis After Intravitreal Bevacizumab (Avastin) Injections: An Outbreak Investigated

Purpose To investigate an endophthalmitis outbreak in different eye hospitals after intravitreal (IVT) bevacizumab (Avastin) injections over two days. Place and duration of the study Mughal Eye Hospital, Nov 2022 to Jan 2023. Materials and methods All cases reported with endophthalmitis in Mughal Eye Hospital after administration of anti-vascular endothelial growth factor IVT injections in different hospitals on November 8-9, 2022, were studied. In all endophthalmitis cases, one to five IVT injections of antibiotics (vancomycin, ceftazidime, and dexamethasone) were given depending on the clinical picture. Results Thirty-six eyes of 34 patients who developed endophthalmitis were included in the study. Age (mean 53 years) ranged from 44 years to 70 years. There were 18 males and 16 females. Two patients had bilateral endophthalmitis. Thirty-three patients were given two to four IVT injections of antibiotics depending on the clinical response. Five cases of vitreous tap done before injecting antibiotics were found to have Pseudomonas. Anterior chamber wash was done in 15 cases to improve visualization for doing pars plana vitrectomy (PPV). In 24 patients PPV with silicon oil was done. Eighteen patients showed improvement as their hypopyon disappeared after IVT antibiotic injections. One patient developed corneal sloughing (she refused IVT antibiotic injections). One patient developed malignant/pupil block glaucoma. In two eyes, early PPV was done. Four eyes developed no perception of light. In our series, endophthalmitis patients started reporting one day after the injection. One patient who developed bilateral endophthalmitis developed bilateral cataracts with subluxations. One patient developed retinal detachment. One eye developed choroidal detachment. Conclusion IVT bevacizumab (Avastin) may be associated with an outbreak of endophthalmitis. Pseudomonas endophthalmitis is a very grave condition associated with severe morbidity.

Ocular Injection Techniques for Retinitis Pigmentosa: Intravitreal, Subretinal, and Suprachoroidal

Ocular gene therapy represents an emerging and promising therapeutic approach for the treatment of several of the inherited retinal diseases. Currently, the focus has been to investigate monogenic inherited retinal disorders. Genetic and cellular therapies can be delivered to the eye by various injection techniques, including those that are intravitreal, subretinal, and suprachoroidal. Each of these three delivery methods are discussed with regard to their historical background, indications, surgical steps, and follow-up.

Incidence of severe rise in intraocular pressure after intravitreous injection of aflibercept with prefilled syringes

Our aim was to analyze the intraocular pressure (IOP) changes following different intravitreous injection (IVI) procedures with or without prefilled syringes (PFS) and to elaborate their possible causes. Clinical study and laboratory assessment. 173 eyes of 141 patients. The IOP was prospectively measured pre- and postoperatively in three groups of patients receiving IVI either with ranibizumab (RP), aflibercept PFS (AP) or aflibercept vials (AV). The AP emptying volume (EV) was assessed using 40 aflibercept PFS vials: the plunger was aligned precisely (normal volume, NV) or right below the indication line (high volume, HV) and the drug was ejected with (wP) or without forced pressure (nP). Primary outcome was post-treatment IOP with type of IVI and pre-treatment IOP as fixed factors. Secondary outcome was identification of possibly confounding factors (age, sex, pathology, presence of pseudophakia, spherical error, and number of injections) and IOP > 30 mmHg post-treatment. An IOP rise above 30 mmHg was observed in 8/38 (22%), 16/51 (31%) and 35/86 (41%) cases in the RP, AV and AP groups, respectively (p = 0.129). Pre-treatment IOP was the only predictive variable for IOP rise (p < 0.001). The EV values in the NVnP, NVwP, HVnP and HVwP groups were 56.06 ± 10.32, 70.69 ± 4.56, 74.22 ± 7.41 and 81.63 ± 3.67 µl, respectively (p < 0.001). We observed a marked, although not significantly higher incidence of IOP elevations with the aflibercept PFS. One possible reason may be the error-proneness of administering the correct volume with the AP. Caution should be taken when using the aflibercept PFS in order to prevent potential optic nerve damage in cases with marked elevation in IOP.

Incidence and visual outcomes of acute endophthalmitis post intravitreal injection of anti-vascular endothelial growth factors in a single referral center

BACKGROUND

To describe the incidence and factors predicting visual outcome in patients with infectious endophthalmitis following intravitreal anti-VEGF injection.

METHODS

Retrospective, single-site, cohort study. Patients with acute endophthalmitis within 6 weeks of intravitreal anti-VEGF injection who were referred to our practice after inciting injection or were injected by us between January 2010 and July 2017 were included. All patients received intravitreal antibiotics with either vitreous/anterior chamber tap (TAP) or pars plana vitrectomy. Visual outcomes pre/post treatment, baseline variables (age, gender, ocular disease) and cultures results were studied.

RESULTS

Seventy eyes of 69 patients were included. Presenting VA was the strongest factor associated with final visual outcome after adjusting for other variables including culture status and baseline VA (p = .0002). Cultures were positive in 62.8% of eyes and were associated with worse visual outcome (p = .0087). Growth of Streptococcus or microorganisms other than coagulase negative Staphylococci (CNS) was also associated with worse prognosis, regardless of baseline and presenting VA (p = .0002). The crude incidence of post-injection endophthalmitis was 0.028% in our practice (40 eyes in 143,628 injections) during the study time. No significant difference was found between pre-filled bevacizumab versus ranibizumab or aflibercept drawn from a vial.

CONCLUSIONS

In a large, single center, retrospective study, the incidence of acute endophthalmitis post anti-VEGF injection was relatively low. Worse visual acuity at presentation of endophthalmitis and growth of Streptococcus or organisms other than CNS were associated with the worst visual outcomes.

Incidence and Visual Outcomes of Endophthalmitis After Intravitreal Injection of Dexamethasone Implant vs Ranibizumab

Purpose

To compare the incidence and visual outcomes of endophthalmitis after injection of an intravitreal dexamethasone implant and injection of intravitreal ranibizumab.

Methods

This retrospective cohort study assessed endophthalmitis in eyes receiving an intravitreal injection of a 0.7 mg dexamethasone implant (DEX group), 0.5 mg ranibizumab (R5 group), or 0.3 mg ranibizumab (R3 group) between January 1, 2016, and May 31, 2018, at 2 large retina practices in the United States.

Results

Suspected endophthalmitis occurred in 5 eyes after 4973 DEX injections, 43 eyes after 163 974 R5 injections, and 6 eyes after 18 954 R3 injections. Suspected endophthalmitis was significantly more common in the DEX group (1/995) than in the R5 group (1/3813) (P = .008) but not than in the R3 group (1/3159) (P = .10). Visual acuity outcomes were similar in the 3 groups.

Conclusions

Suspected endophthalmitis might be more common after 0.7 mg dexamethasone injections than after 0.5 mg ranibizumab injections. Culture-positive endophthalmitis rates were similar across all 3 medications.

Preventive factors, diagnosis, and management of injection-related endophthalmitis: a literature review

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.

Seasonal and environmental variations in endophthalmitis after intravitreal anti-vascular endothelial growth factor injection: a six-year review

PURPOSE/AIM

To evaluate seasonal and environmental variations on the incidence and outcomes of post-injection endophthalmitis.

MATERIALS AND METHODS

A single-center, retrospective cohort study was conducted including all patients diagnosed with post-injection endophthalmitis between 2013-2018. Associations between climate variables and endophthalmitis incidence were evaluated.

RESULTS

Of 423,297 injections administered, seasonal distribution in spring, summer, autumn, and winter was 26%, 27%, 25%, and 22%, respectively. Of 171 cases of endophthalmitis identified, seasonal distribution over the spring, summer, autumn, and fall was 25%, 23%, 26%, and 26%, respectively. Endophthalmitis incidence was not correlated with monthly precipitation (p = 0.45), monthly snowfall (p = 0.49), or monthly temperature (p = 0.65). Worse visual outcomes at initial endophthalmitis presentation were correlated with increased precipitation level (p = 0.025), but were not correlated with snowfall level (p = 0.228) or mean monthly temperature (p = 0.132). Although there were no seasonal variations of visual acuity at endophthalmitis presentation (p = 0.894), odds of final visual acuity returning to within two lines of pre-endophthalmitis visual acuity were worse among patients with endophthalmitis diagnosed in the spring (OR, 0.041; p = 0.016).

CONCLUSION

In contrast to previous work on post-cataract endophthalmitis, seasonal and weather factors were not associated with post-injection endophthalmitis risk or bacterial species isolated. Visual outcomes at initial endophthalmitis presentation were correlated with precipitation, and worse visual outcomes were seen in patients who developed endophthalmitis in the spring.

Complications of intravitreal injections: 2022

PURPOSE OF REVIEW

This review highlights the complications of both intravitreal injection procedure as well as different intravitreal medications including antivascular endothelial growth factors, antibiotics, antivirals, antifungals, methotrexate, and steroids. Techniques for reducing rates of endophthalmitis will also be discussed.

RECENT FINDINGS

Intravitreal vancomycin can cause hemorrhagic occlusive retinal vasculitis resulting in severe vision loss. Intravitreal brolucizumab is associated with intraocular inflammation and retinal vasculitis resulting in significant vision loss. Face mask use by both patient and physician is not associated with increased risk of endophthalmitis and may decrease culture positive endophthalmitis.

SUMMARY

Intravitreal injections continue to be one of the most commonly performed procedures by ophthalmologists. Although the injections are generally well tolerated, sight-threatening complications can occur including endophthalmitis, retinal detachment, and/or retinal vasculitis. Adverse events associated with specific medications are outlined below. Several safety measures have been shown to reduce rates of endophthalmitis, the most concerning complication of this procedure.

Endophthalmitis After Intravitreal Anti-Vascular Endothelial Factor Injections: Outcomes of Eyes Managed Without Microbiologic Cultures

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.

Impact of the COVID-19 pandemic on patients receiving intravitreal injections

We analyzed the economic benefits versus safety risks of sharing anti-vascular endothelial growth factor (VEGF) vials during the coronavirus disease (COVID-19) pandemic. This single-center retrospective study analyzed the data of patients with neovascular age-related macular degeneration (nAMD), proliferative diabetic retinopathy (PDR) and retinal vein occlusion (RVO) who received anti- VEGF between January 2016 and July 2021 at Renmin Hospital, Wuhan University, China. Costs were compared of the two protocols of intravitreal injections (IVIs) of ranibizumab, aflibercept and conbercept after (i) splitting the vial content for use in two patients and after (ii) disposal of the remaining vial content after use in a single patient, with the COVID-19 outbreak considered as the demarcation point. The incidence rates of post-injection endophthalmitis (PIE) pre- and post-outbreak were analyzed. The mean cost of a single IVI increased by 33.3%, from 3917.67?71.69 to 5222.67?84.98 Chinese Yuan during the pandemic. The incidences of IVI-related culture-positive PIE were 0.0134% (3 in 22448) and 0.0223% (1 in 4479), respectively, before and after the pandemic (P=0.6532). We conclude that vial sharing of IVIs in a large clinical institution is not associated with increased PIE risk and can significantly reduce the cost of therapy.

THE RELATIONSHIP BETWEEN STOPPER POSITION AND INJECTION VOLUME IN RANIBIZUMAB AND AFLIBERCEPT PREFILLED SYRINGES

PURPOSE

To determine the relationship between stopper position and injection volume in aflibercept and ranibizumab prefilled syringes (PFS).

METHODS

Empty aflibercept 2.0 mg PFS and ranibizumab 0.3 mg and 0.5 mg PFS were collected and refilled with saline. The stopper was positioned relative to the preprinted mark, and resulting injection volumes were recorded. The position for double the on-label volume was confirmed with repeated testing. The quantitative relationship between position and volume was calculated.

RESULTS

In ranibizumab PFS, doubling the distance increased the volume injected by 2.6 times. Positioning the stopper 4.0, 3.0, 2.0, and 0 mm proximal to and 1.0 mm distal to the mark injected volumes of 0.13, 0.1, 0.08, 0.05, and 0.03 mL, respectively. The relationship between position (x) and volume (y) was y = 0.019x + 0.048. In aflibercept PFS, doubling the distance increased the volume injected by 3.2 times. Positioning the stopper 2.5, 2.0, 1.0, and 0 mm proximal to and 1.0 mm distal to the mark injected volumes of 0.16, 0.14, 0.11, 0.05, and 0.02 mL, respectively. The relationship between position (x) and volume (y) was y = 0.041x + 0.059.

CONCLUSION

Proper positioning of the stopper at the preprinted mark accurately delivers the on-label volume with both the ranibizumab and aflibercept PFS. However, small variations in stopper position appear to have substantial effects on the volume of drug injected.

Ocular Therapeutics and Molecular Delivery Strategies for Neovascular Age-Related Macular Degeneration (nAMD)

Age-related macular degeneration (AMD) is the leading cause of vision loss in geriatric population. Intravitreal (IVT) injections are popular clinical option. Biologics and small molecules offer efficacy but relatively shorter half-life after intravitreal injections. To address these challenges, numerous technologies and therapies are under development. Most of these strategies aim to reduce the frequency of injections, thereby increasing patient compliance and reducing patient-associated burden. Unlike IVT frequent injections, molecular therapies such as cell therapy and gene therapy offer restoration ability hence gained a lot of traction. The recent approval of ocular gene therapy for inherited disease offers new hope in this direction. However, until such breakthrough therapies are available to the majority of patients, antibody therapeutics will be on the shelf, continuing to provide therapeutic benefits. The present review aims to highlight the status of pre-clinical and clinical studies of neovascular AMD treatment modalities including Anti-VEGF therapy, upcoming bispecific antibodies, small molecules, port delivery systems, photodynamic therapy, radiation therapy, gene therapy, cell therapy, and combination therapies.

Chemical-gas Sterilization of External Surface of Polymer-based Prefilled Syringes and Its Effect on Stability of Model Therapeutic Protein

To reduce the risk of infection during intravitreal injections, the external surface of prefilled syringes (PFSs) must be sterilized. Usually, ethylene oxide (EO) gas or vaporized hydrogen peroxide (VHP) is used for sterilization. More recently, nitrogen dioxide (NO₂) gas sterilization has been developed. It is known that gas permeability is approximately zero into glass-PFSs. However, polymer-PFSs (P-PFSs) have relatively high gas permeability. Therefore, there are concerns about the potential impact of external surface sterilization on drug solutions in P-PFSs. In this study, P-PFSs [filled with water for injection (WFI) or human serum albumin (HSA) solution] were externally sterilized using EO, VHP, and NO₂ gases. For the WFI-filled syringes, the concentration of each gas that ingressed into the WFI was measured. For the HSA solution-filled syringes, the physical and chemical degradation of HSA molecules by each sterilant gas was quantified. For the EO- or VHP-sterilized syringes, the ingressed EO or hydrogen peroxide (H₂O₂) molecules were detected in the filled WFI. Additionally, EO-adducted or oxidized HSA molecules were observed in the HSA-filled syringes. In contrast, the NO₂-sterilized WFI-filled syringes exhibited essentially immeasurable ingressed NO₂, and protein degradation was not detected in HSA-filled syringes.

Treatment of Neovascular Age-Related Macular Degeneration: An Economic Cost-Risk Analysis of Anti-Vascular Endothelial Growth Factor Agents

PURPOSE

To find the best cost-effective neovascular age-related macular degeneration (nAMD) treatment to improve vision while avoiding complications. The model is based on a cost-risk tradeoff analysis from policymakers' perspective.

DESIGN

A powerful and flexible simulation modeled outcomes of 2 years of treatment with the 4 commonly used anti-vascular endothelial growth factor drugs (bevacizumab, ranibizumab, aflibercept, and brolucizumab) across 3 injection protocols, building on prior findings that these drugs are noninferior. The model incorporates blinding complications, their management, and associated costs to society. Each option and several what-if scenarios were simulated 1,000 times with 100,000 hypothetical patients.

PARTICIPANTS

One hundred thousand simulated patients using data from published clinical trials.

METHOD

Case- and eye-specific cost-risk economic analysis.

MAIN OUTCOME MEASURES

Costs of nAMD treatment per patient and number of eyes that become blind as a result of treatment over 2 years.

RESULTS

Using published prices and fees, the injection protocol that follows published clinical studies, results showed that the mean±standard deviation cost per patient were $16,859 ± $3.65, $32,949 ± $3.27, $39,831 ± $3.80, and $53,056 ± $2.99 for bevacizumab, brolucizumab, aflibercept, and ranibizumab, respectively. The numbers±standard deviations of treated eyes that became blind were 108 ± 10.18, 694 ± 26.66, 168 ± 12.83, and 108 ± 10.52, respectively. We further provide a lower bound (when all patients are maximally extended) and upper bound (when no patient is extended) to these numbers. For brolucizumab, the upper bound is the 2-month interval injection protocol.

CONCLUSIONS

Taking a policymaking perspective, this study suggested that bevacizumab is the preferred first-line therapy. Recommendation for second-line therapy depends on the extent of the policymaker's risk aversion because of the tradeoff between cost and risk of blindness as a result of treatment. If risk neutral, the least expensive option (brolucizumab) is preferred. But if policymakers are moderately to highly risk averse, then aflibercept or ranibizumab are preferred. Because medical advances and different costs may change our findings, we provide a free application (https://eye-inj.shinyapps.io/calc/) for readers who wish to use different cost structures. Simulating outcomes is an innovative approach, unique in ophthalmology, and presents a significant opportunity because it can be adapted easily to different settings (using different costs, risks, and protocols) and to other diseases (e.g., diabetic macular edema), to ultimately improve wide-scale decision-making and use of funds.

Impact of patient face mask use on endophthalmitis after intravitreal anti-VEGF injections

OBJECTIVE

To compare the incidence of endophthalmitis after intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections with and without patient face masking.

DESIGN

Two-centre retrospective cohort study PARTICIPANTS: Patients receiving a total of 28 501 injections (period 1 before masking: n = 13 863; period 2 after masking: n = 14 638) METHODS: Periods before and after implementation of patient masking were compared: period 1 (July-December 2019) and period 2 (July-December 2020). All patients requiring treatment for endophthalmitis following intravitreal anti-VEGF injections were reviewed. Endophthalmitis risks were compared. Statistical simulations were run to determine the number of injections or endophthalmitis cases required to detect a statistically significant difference between both periods.

RESULTS

Five patients (0.036%) had endophthalmitis in period 1 compared with 7 patients (0.048%) in period 2. Odds ratio, 95% confidence interval, for risk of patient masking was 1.326, 0.421-4.179 (p = 0.63). Three patients (0.022%) in period 1 had culture-positive endophthalmitis compared with 2 patients (0.014%) in period 2. Risk of patient masking for culture-positive endophthalmitis was 0.631, 0.105-3.779 (p = 0.61). Assuming similar rates of endophthalmitis, 476,806 injections in both groups would be required to detect a significant difference. Alternatively, assuming that masking would increase endophthalmitis risk in period 2, a significant difference would require twice as many cases (n = 15, 0.102%) for a risk of 2.843, 1.033-7.825 (p = 0.043).

CONCLUSIONS

The implementation of patient masking in clinical practice did not significantly alter the rate of endophthalmitis following intravitreal anti-VEGF injections.

Systemic Immunosuppression and Risk of Endophthalmitis After Intravitreal Anti-Vascular Endothelial Growth Factor Injections

BACKGROUND AND OBJECTIVE

To evaluate the impact of systemic immunosuppressive therapy on the rates and outcomes of endophthalmitis following intravitreal anti-vascular endothelial growth factor (VEGF) injections.

PATIENTS AND METHODS

A retrospective, single-center, comparative cohort study examining eyes undergoing intravitreal anti-VEGF injections from January 2016 to September 2019. Cohorts were created based on concurrent immunosuppressive therapy at time of injection.

RESULTS

Of 270,347 anti-VEGF injections administered, 1,300 injections (0.48%) were administered while on systemic immunosuppressive therapy. The odds of endophthalmitis occurring in the immunosuppression group was 9.86 (95% confidence interval [CI], 4.0-24.3; P < .001) times higher than the no-immunosuppression group. Symptom onset occurred 2.51 (95% CI, 0.15-4.870; P = .040) days earlier in the immunosuppression cohort; visual acuity at 6 months after treatment was similar in both groups.

CONCLUSIONS

Patients on systemic immunosuppressive medications undergoing intravitreal injections may be at increased risk for post-injection endophthalmitis and may have earlier symptom onset. However, visual outcomes were similar between the two groups. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:S17-S22.].

Intravitreal injection associated rhegmatogenous retinal detachment: outcomes of a European analysis

Purpose

As the number of intravitreal injections (IVI) increases annually, this study aimed to assess the anatomical and functional outcomes following rhegmatogenous retinal detachment (RRD) surgery for IVI-associated RRD (IVARD).

Methods

All non-vitrectomized eyes developing IVARD since 2007 in two European vitreoretinal centers (Department of Ophthalmology, LMU Munich, Germany, and Eye Clinic Luigi Sacco, University of Milan, Milan, Italy) were included. Main outcomes were primary and secondary retinal attachment rate after surgery, rate of proliferative vitreoretinopathy (PVR), and final functional result. Ten years of incidence rates per injection were calculated for one center.

Results

Fifty-two eyes of 52 patients comprised the study. Primary anatomic success rate was 83% (n = 43) and secondary 96% (n = 50). PVR was observed in all uveitic eyes (n = 3), in eyes with postoperative cystoid macular edema (n = 2), and in 8 of 9 eyes that received the dexamethasone implant (DEX). Age, number of prior injections, duration of symptoms, or time between last IVI and RRD did not show any statistically significant differences with regard to presence of PVR or not. Mean BCVA improved in 28 cases, remained stable in 16 cases, and worsened in 8 cases. The RRD incidence rate was statistically significant higher for DEX and ocriplasmin compared with that for anti-VEGF agents.

Conclusion

The anatomical result after one surgical intervention seems acceptable, but the final visual outcome remains rather poor, because of the underlying macular disease. In our population, injection with DEX is associated with higher IVARD rate, presence and development of PVR, and recurrent RRD in comparison with anti-VEGF agents.

Rates of Suspected Endophthalmitis Following Intravitreal Injections in Clinical Practices in the United States

BACKGROUND AND OBJECTIVE

To evaluate rates of suspected endophthalmitis following intravitreal injections of aflibercept, bevacizumab, ranibizumab (vial and pre-filled), dexamethasone implant, and triamcinolone in clinical practice.

PATIENTS AND METHODS

Retrospective study of aggregated electronic medical records from the Vestrum Health Database. Eyes with a diagnosis of suspected endophthalmitis based on billing codes between January 2013 and June 2019 were included.

RESULTS

Total number of injections, suspected endophthalmitis cases, and medication rate, respectively, were: aflibercept (1,412,699; 687; 0.049%); bevacizumab (1,467,722; 379; 0.026%); ranibizumab vial (884,061; 233; 0.026%), ranibizumab pre-filled (427,763; 96; 0.022%); dexamethasone implant (49,464; 53; 0.107%); and triamcinolone (75,038; 110; 0.147%). Rates were lower for bevacizumab and ranibizumab (vial and pre-filled) compared to aflibercept, dexamethasone implant, and triamcinolone (P < .05). Triamcinolone had a higher rate compared to all of the other medications (P < .05).

CONCLUSIONS

Suspected endophthalmitis rates following anti-vascular endothelial growth factor injections in clinical practice were similar to reported rates in clinical trials. Rates of suspected endophthalmitis following steroid injections trended higher with significantly higher rates with triamcinolone. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:312-318.].

Impurities in Drug Vials Intended for Intravitreal Medication

Sterility is an important prerequisite for minimizing the risk of severe vision loss due to endophthalmitis after intravitreal injections. We describe three cases series of incidents where an unclear contamination of the drug solution or syringe caused the injection process to stop and continue with a new preparation. During a period of 12 months with 30,502 intravitreal injections at a tertiary center, wherein 7,076 were of the drug Aflibercept drawn up from a glass vial, three cases of the critical incident reporting system relating to intravitreal injections were identified: (1) After a typical contact with the filter cannula, the glass of an Aflibercept vial was no longer intact. (2) In the course of another injection, there was a clear deposition of debris on the outer edge of the syringe when removing the attached filter cannula. (3) After inserting the syringe into the rubber top of the vial, a whitish particle of unclear origin was identified within the drug solution. Later, this contamination/particle was identified as part of the greyish rubber that was punched out with the cannula, according to the analyses of the material sent in and the manufacturer's investigations. Thus, even in busy clinics, visual inspection of the injection solution and materials used for impurities, preferably before and after pulling them out of a vial, must be an essential part of the injection process. Even when using ready-to-use prefilled syringes (PFS), vigilance must be kept high, knowing the risk of potential contamination.

The Influence of Universal Face Mask Use on Endophthalmitis Risk after Intravitreal Anti-Vascular Endothelial Growth Factor Injections

Purpose

Routine use of face masks for patients and physicians during intravitreal anti–vascular endothelial growth factor (VEGF) injections has increased with the emergence of the coronavirus disease 2019 pandemic. This study evaluates the impact of universal face mask use on rates and outcomes of post-injection endophthalmitis (PIE).

Design

Retrospective, multicenter, comparative cohort study.

Participants

Eyes receiving intravitreal anti-VEGF injections from October 1, 2019, to July 31, 2020, at 12 centers.

Methods

Cases were divided into a “no face mask” group if no face masks were worn by the physician or patient during intravitreal injections or a “universal face mask” group if face masks were worn by the physician, ancillary staff, and patient during intravitreal injections.

Main Outcome Measures

Rate of endophthalmitis, microbial spectrum, and visual acuity (VA).

Results

Of 505 968 intravitreal injections administered in 110 547 eyes, 85 of 294 514 (0.0289%; 1 in 3464 injections) cases of presumed endophthalmitis occurred in the “no face mask” group, and 45 of 211 454 (0.0213%; 1 in 4699) cases occurred in the “universal face mask” group (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.51–1.18; P = 0.097). In the “no face mask” group, there were 27 cases (0.0092%; 1 in 10 908 injections) of culture-positive endophthalmitis compared with 9 cases (0.004%; 1 in 23 494) in the “universal face mask” group (OR, 0.46; 95% CI, 0.22–0.99; P = 0.041). Three cases of oral flora–associated endophthalmitis occurred in the “no face mask” group (0.001%; 1 in 98 171 injections) compared with 1 (0.0005%; 1 in 211 454) in the “universal face mask” group (P = 0.645). Patients presented a mean (range) 4.9 (1–30) days after the causative injection, and mean logarithm of the minimum angle of resolution (logMAR) VA at endophthalmitis presentation was 2.04 (~20/2200) for “no face mask” group compared with 1.65 (~20/900) for the “universal face mask” group (P = 0.022), although no difference was observed 3 months after treatment (P = 0.764).

Conclusions

In a large, multicenter, retrospective study, physician and patient face mask use during intravitreal anti-VEGF injections did not alter the risk of presumed acute-onset bacterial endophthalmitis, but there was a reduced rate of culture-positive endophthalmitis. Three months after presentation, there was no difference in VA between the groups.

Enterococcus faecalis Endophthalmitis: Clinical Settings, Antibiotic Susceptibility, and Management Outcomes

Enterococcus faecalis is known to cause severe acute endophthalmitis and often leads to poor visual outcomes in most ophthalmic infections. This retrospective study is to report the clinical settings, antimicrobial susceptibility patterns, and visual outcome of E. faecalis endophthalmitis at a tertiary referral institution in Taoyuan, Taiwan. E. faecalis endophthalmitis was diagnosed in 37 eyes of 37 patients. Post-cataract surgery was the most common cause (n = 27, 73%), followed by bleb-associated (n = 3, 8%), endogenous (n = 2, 5%), corneal ulcer-related (n = 2, 5%), post-vitrectomy (n = 1, 3%), post-pterygium excision (n = 1, 3%), and trauma (n = 1, 3%). Visual acuities upon presentation ranged from counting fingers to no light perception. Pars plana vitrectomy with intravitreal antibiotics were performed in 23 eyes (76%) as primary or secondary treatment. All isolates (37/37, 100%) were sensitive to vancomycin, penicillin, ampicillin, and teicoplanin. Six of 22 eyes (27%) were resistant to high-level gentamicin (minimum inhibitory concentration > 500 mg/L). Final visual acuities were better than 20/400 in 11 eyes (30%), 5/200 to hand motions in 4 eyes (11%), and light perception to no light perception in 22 eyes (59%). Three eyes were treated with evisceration. Compared with non-cataract subgroups, the post-cataract subgroup showed a significant difference of better visual prognosis (p = 0.016).

Incidence of Endophthalmitis after Intravitreal Anti-Vascular Endothelial Growth Factor Injections in an Operating Room in China

Purpose

To evaluate the rate of presumed endophthalmitis (EO) after intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections performed in an operating room (OR) under sterile conditions in mainland China.

Methods

Retrospective single-center study between September 2012 and December 2017 at Beijing Tongren Eye Center, Beijing, China. Intravitreal injection database was reviewed. All anti-VEGF injections were performed using a standardized sterile technique in an OR. Injection protocols included antibiotics for 3 days pre-injection, topical 5% povidone-iodine rinsing before the procedure, and post-injection antibiotics for 3 days.

Results

A total of 37,830 intravitreal injections were performed at Beijing Tongren Eye Center. Three cases were managed as presumed EO (0.0079%). Positive cultures were documented in 2 of 3 cases. EO incidence following ranibizumab and conbercept administration was 0.0088% (3 in 33,930) and 0% (0 in 3,900), respectively. No significant difference was detected between the two drugs (P = 0.745).

Conclusions

Very low EO rates were seen in mainland China using a standardized sterile technique in an OR. However, EO could not be completely avoided.

PARTICULATE MATTER FROM SYRINGES USED FOR INTRAVITREAL INJECTIONS

BACKGROUND

Syringes containing anti-vascular endothelial growth factor drugs to treat retinal diseases are prepared in different ways by various parties with syringe selection, preparation, and storage conditions affecting the risk of injecting particles into the vitreous. This study examines particle loads from various syringes over time.

METHODS

Four syringes were studied: two plastic transfer syringes lubricated with silicone oil or oleamide, a glass syringe with baked-on silicone, and a lubricant-free polymer syringe. Syringes were rinsed with water or filled with buffer and analyzed over time; particles were quantified by flow imaging. Particle formation in a bevacizumab formulation was also characterized.

RESULTS

Insulin syringes consistently showed very high particle counts. Oleamide-lubricated syringes had substantially fewer particles, but showed appreciable increases over time (leading to visible particles). Baked-on silicone glass syringes and lubricant-free polymer syringes both showed low particle levels ≥10 μm. Lubricant-free syringes showed the lowest particle levels ≥1 μm and the lowest particle levels with bevacizumab agitation.

CONCLUSION

Syringes have different intrinsic particle loads which can contribute to particle loads in the delivered drug. Oleamide-lubricated transfer syringes, commonly used for bevacizumab repackaging, have time-dependent particle loads and are associated with the formation of visible particles beyond 30 days of storage.

Incidence and outcomes of endophthalmitis with in-house compounded intravitreal bevacizumab injections: A multicentric study

PURPOSE

To evaluate the incidence rate and outcomes of endophthalmitis after intravitreal injection of in-house compounded bevacizumab.

METHODS

In this multicentric study performed from 2014 to 2018, patients who were injected with in-house compounded and sterilized bevacizumab were observed for endophthalmitis. In-house compounded syringes were prepared in compounding pharmacy using sterile standard operating guidelines. All cases of acute endophthalmitis following intravitreal injection were recorded and followed up for final anatomical and visual outcome after management.

RESULTS

A total of 50,361 bevacizumab injections were administered. Incidence of post-injection endophthalmitis was 0.0377%. Incidence of culture-positive endophthalmitis was 0.0178%, with 55.5% culture positivity for Staphylococcus species. A significant improvement in the final visual outcome was noted (p<0.05), and overall five patients (26.3%) achieved visual acuity of 6/18 or more.

CONCLUSIONS

In-house compounded injections of bevacizumab can reduce post-injection endophthalmitis to a minimum, with maintenance of proper asepsis and strict protocols by the compounding pharmacy.

[Postoperative endophthalmitis-a review of literature]

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.

Bacterial Dispersion Associated With Various Patient Face Mask Designs During Simulated Intravitreal Injections

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.

Incidence of Acute Endophthalmitis After Intravitreal Bevacizumab Injection at a Tertiary Care Hospital in Lahore

OBJECTIVE

We aimed to assess the incidence, management, and visual outcome of acute endophthalmitis in patients following intravitreal bevacizumab injection in a tertiary care setup. It was a prospective and single-center database study.

PATIENTS AND METHODS

Patients receiving intravitreal bevacizumab injections for various retinal vascular diseases from January 2019 to September 2020. The study was carried out at the Institute of Ophthalmology, Mayo Hospital, Lahore over a period of 21 months. Preformed bevacizumab injections were administered intravitreally on patients of various retinal vascular diseases under strict aseptic measures and by following the standard guidelines. The patients were put on follow-ups for a duration of four weeks to see any signs of acute endophthalmitis.

RESULTS

A total of 3051 injections were administered in 1104 eyes of 743 patients during the above-mentioned study period. The incidence of endophthalmitis was found to be 0.0328% (1/3051). The patient, who developed endophthalmitis, was treated with topical and intravitreal antibiotics followed by vitrectomy that resulted in clinically significant improvement in vision.

CONCLUSION

Incidence of acute endophthalmitis following intravitreal bevacizumab injection was low and could be prevented by taking strict aseptic measures during administration.

The Impact of Physician Face Mask Use on Endophthalmitis After Intravitreal Anti-Vascular Endothelial Growth Factor Injections

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.

Endophthalmitis following Intravitreal Anti-Vascular Endothelial Growth Factor Therapy: Changes in Incidence and Outcomes over a 9-Year Period

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.

Incidence of endophthalmitis after intravitreal injection of an anti-VEGF agent with or without topical antibiotics

Intravitreal injection (IVI) of anti-vascular endothelial growth factor (VEGF) is the standard treatment modality in various types of retinal diseases. However, endophthalmitis remains the most serious complication. Despite the lack of evidence that antibiotics prevent endophthalmitis, topical antibiotics are still used routinely in Japan. We conducted a retrospective multicenter study by analyzing records from patients who underwent IVI of anti-VEGF agents with or without antibiotic treatment. In the analysis of a total of 147,440 eyes, the incidence of endophthalmitis was 0.007%: 0.005% with no use of antibiotics, 0.009% with antibiotic pretreatment, 0.012% with posttreatment, and 0.005% with pre- and posttreatment. There was no statistically significant difference among the four groups (chi-square test, p = 0.57). Most facilities used masks, sterilized gloves, and drapes. Nine of the 10 eyes that developed endophthalmitis received topical antibiotics, and all infected eyes underwent IVI with aflibercept, not the prefilled syringe delivery system. In four patients who received multiple IVI, the detection of causative bacteria revealed resistance to used antibiotics. Data from this large population, treated with or without antibiotics, suggests that antibiotic prophylaxis does not reduce the rate of endophthalmitis after IVI.

Treatment-Emergent Adverse Events in Gene Therapy Trials for Inherited Retinal Diseases: A Narrative Review

Patient safety is a primary priority in the conduction of retinal gene therapy trials. An understanding of risk factors and mitigation strategies for post-procedure complications is crucial for the optimization of gene therapy clinical trial protocols. In this review, we synthesize the literature on ocular delivery methods, vector platforms, and treatment-emergent adverse effects in recent gene therapy clinical trials for inherited retinal diseases.

Aqueous Chlorhexidine Compared with Povidone-Iodine as Ocular Antisepsis before Intravitreal Injection: A Randomized Clinical Trial

PURPOSE

Topical povidone-iodine (PI) is widely used as an ocular surface antiseptic for intravitreal injections (IVIs). Although PI is generally well tolerated, it can be associated with significant ocular irritation. Aqueous chlorhexidine (AqCHX) has been described as a possibly better tolerated antimicrobial for ophthalmic procedures. We compared patient pain scores, ocular surface characteristics, and antimicrobial efficacy between PI 5% and AqCHX 0.1% during IVIs.

DESIGN

Prospective single-center, randomized clinical trial.

PARTICIPANTS

Patients receiving same-day bilateral intravitreal anti-vascular endothelial growth factor (VEGF) injections.

METHODS

Each patient had 1 eye randomized to PI or AqCHX, and the second eye received the other agent. Both eyes received topical proparacaine 0.5%.

MAIN OUTCOME MEASURES

After IVIs, participants rated their pain (Wong-Baker, scale 0-10) for each eye 1 minute after PI or AqCHX instillation and 1 day after the procedure. Each eye was assessed using a standardized quantitative grading system of corneal epitheliopathy (ocular staining score). Microbial swab cultures of the conjunctiva both before instillation of topical antisepsis and 10 minutes after IVIs were given.

RESULTS

A total of 100 eyes of 50 patients were included. The mean patient age was 68 years (range, 39-92), and 30 of 50 (60%) were male. Compared with AqCHX, eyes receiving PI had a greater mean pain score immediately after injection (1.44 vs. 0.44, P < 0.001) but not on postprocedure day 1 (1.04 vs. 0.48, P = 0.06). Eyes that received PI had a higher ocular staining score indicating worse corneal epitheliopathy (4.22 vs. 3.10, P < 0.001). There was no difference in rates of positive microbial cultures between groups. There was no difference in rates of adverse events between groups (P = 0.99), and no cases of endophthalmitis occurred.

CONCLUSIONS

Povidone-iodine demonstrated greater ocular surface discomfort and corneal epitheliopathy compared with AqCHX during same-day bilateral IVIs. The 2 agents otherwise demonstrated no difference in positive microbial cultures or adverse events. Aqueous chlorhexidine may be a better tolerated alternative to PI for antimicrobial prophylaxis during IVIs for some patients.

Alcohol Pads and Nonsterile Gloves in Preparation of Aflibercept

Use of nonsterile gloves and an alcohol pad does not significantly impact the contamination of the rubber septum of the aflibercept vial. Other contamination points might instead be explored for endophthalmitis risk.

Providing a Safe and Effective Intravitreal Treatment Service: Strategies for Service Delivery

An aging population leads to increasing demand for medical retina services with chronic diseases being managed in long-term care pathways. Many hospital services struggle to deliver efficient and effective MR care due, at least in part, to infrastructure that does not expand responsively enough to meet the increased demand. A steering committee of retinal specialists from a variety of UK NHS hospital ophthalmology departments with experience of leading and managing NHS retinal services in the intravitreal era came together for the generation of this document to review and compile key aspects that should be considered when optimising intravitreal treatment capacity within MR services. This article aims to provide a useful collation and signposting of key published evidence, consensus and insights on aspects of delivering an intravitreal service, including treatment regimens, virtual clinics, staff training and governance, telemedicine and information technology, and data collection and key performance indicators. The objective is to equip ophthalmologic healthcare professionals with the necessary tools to develop and adapt their local service in the face of current and projected increased demand.

Issues with Intravitreal Administration of Anti-VEGF Drugs

Purpose

To provide an update of summary of risk factors and side effects of long-term use and contamination of intravitreal anti-VEGF injections.

Methods

We reviewed relevant publications of the topic of contamination of anti-VEGF injections and long-term side effects due to this reason.

Results

Due to the long-term use of anti-VEGF drugs and the higher number of injections worldwide, various studies have shown side effects in recent years, ranging from increased intraocular pressure to visual disturbing silicone oil vesicles in the vitreous cavity. Several studies have demonstrated that both the drug and the processing, storage, environmental factors and the material and design of the syringes have a decisive influence on these side effects.

Conclusion

The risks of deposits from syringes in the eye can be significantly reduced by various optimizations in transport, storage and syringe and cannula selection.

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.

Changes in Management Based on Vitreous Culture in Endophthalmitis After Intravitreal Anti-vascular Endothelial Growth Factor Injection

PURPOSE

To assess whether vitreous culture results affect the clinical management of patients with acute endophthalmitis after intravitreal anti-vascular endothelial growth factor (VEGF) injection.

DESIGN

Retrospective case series.

METHODS

Setting: Single-center.

STUDY POPULATION

Patients who developed endophthalmitis after intravitreal injection of aflibercept, bevacizumab, or ranibizumab between January 1, 2016, and May 31, 2018.

OBSERVATION

A change in clinical management was defined as additional intravitreal antibiotic injections or pars plana vitrectomy.

MAIN OUTCOME MEASURES

A change in clinical management within 2 weeks of initial endophthalmitis culture and treatment; visual acuity.

RESULTS

Of 204,986 intravitreal anti-VEGF injections performed, 60 cases (0.0293%) of endophthalmitis were identified, 18 of which were culture-positive. Six of 60 eyes (10%) had a change in clinical management. A change in clinical management was initiated in 3 of 18 (17%) culture-positive cases compared to 3 of 42 (7%) culture-negative cases (P = .357). Changes in management for culture-positive cases were performed based on declining vision (2 cases) and worsening clinical examination (1 case). Changes in management for culture-negative endophthalmitis cases were performed based on declining vision (1 case) and worsening clinical examination (2 cases). No additional interventions were initiated based on positive-culture results. Comparing vision loss from baseline by culture result, at final follow-up, oral flora-associated culture-positive cases lost 17.5 lines, non-oral flora-associated culture-positive cases lost 9.1 lines, and culture-negative cases lost 2.5 lines of vision (P < .001).

CONCLUSION

Following endophthalmitis from intravitreal injection of anti-VEGF agents, vitreous culture data may help prognosticate visual outcomes but appear to have a limited effect on clinical management.