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

Endophthalmitis: a bibliometric study and visualization analysis from 1993 to 2023

Aims

This study is designed to generalize and depict the research hotspots of endophthalmitis through bibliometric methods and software and analyze the evolutive tendency of the work on this severe disease over the past 30 years.

Methods

This study employed a rigorous bibliometric approach. We identified all endophthalmitis-related literature by conducting a comprehensive search of the Science Citation Index Expanded database under the Web of Science Core Collection. The data was then analyzed and visualized using CiteSpace and VOSviewer, two widely recognized software tools in the field of bibliometrics. CiteSpace was used to analyze the country distributions, dual map overlay of journals, keyword bursts, and co-cited references. VOSviewer was employed to describe the authors and co-cited authors, the journals, the co-cited journals, and the keywords co-occurrence network. This robust methodology ensures the reliability and validity of the study's findings.

Results

A total of 2960 publications, including 2695 articles and 265 reviews, were included in this bibliometric study. There has been no shortage of endophthalmitis-related publications since 1993, with an apparent upward trend during recent years. Possible correlations with the COVID-19 pandemic are also analyzed. These studies were finished by 11,048 authors from 75 countries worldwide, with the United States in the lead. In the keyword co-occurrence network, except for the endophthalmitis term, cataract surgery becomes the keyword with the highest frequency. Different categories of endophthalmitis, including postoperative, post-injection, post-traumatic, and endogenous endophthalmitis, and antibacterial and anti-inflammatory therapies of infectious endophthalmitis, are discussed by categories. From the perspective of the timeline, postoperative and post-injection endophthalmitis were the dominant forms before and after the year 2000, respectively. Co-citation analyses reveal that the Endophthalmitis Vitrectomy Study (EVS) conducted in 1995 provides pivotal guidance for later research. Diverse pathogenic bacteria (e.g., Coagulase-negative Staphylococci, Propionibacterium acnes, Viridians Streptococci, and Bacillus cereus) or fungi (e.g., Candida, Aspergillus, and Fusarium) contribute to varying treatment principles and clinical prognosis, which should be taken seriously. In addition, intravitreal and intracameral antibiotics are the mainstay for treating and preventing infectious endophthalmitis, respectively.

Conclusion

Our bibliometric analysis provides an overview of dynamic evolution and structural relationships in the research field of endophthalmitis. The displayed hotspots and developmental directions have reference values for future investigation.

PATIENT-PHYSICIAN FACE MASKING'S INFLUENCE ON THE POST-INTRAVITREAL INJECTION ENDOPHTHALMITIS

PURPOSE

The authors sought to determine if universal face mask guidelines implemented during the coronavirus disease 2019 pandemic significantly influenced the incidence of endophthalmitis following intravitreal injections (IVI).

METHODS

This retrospective cohort study reviewed the electronic health records from a retina-only practice located in Michigan. This study evaluated patients receiving IVIs over two distinct time periods of April 2019 to March 2020 and April 2020 to March 2021, which comprised our unmasked and masked groups, respectively. The authors then calculated the incidence of endophthalmitis following IVI and evaluated the cases of post-injection endophthalmitis for both time periods.

RESULTS

A total of 121,384 IVIs performed over the 2-year period of interest. Of these, 63,114 were unmasked and 58,270 were masked patient encounters. A total of 46 post-injection endophthalmitis cases were identified. Of these, 29 cases were from the unmasked period and 17 were from the masked period. This resulted in an incidence of endophthalmitis of 0.046% and 0.038% in the masked and unmasked groups, respectively. This difference did not rise to the level of statistical significance ( P = 0.1336).

CONCLUSION

This study suggests that the incidence of post-injection endophthalmitis was not influenced by the implementation of ophthalmologist-patient face masking after IVI during the coronavirus disease 2019 pandemic.

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.

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.

COVID-19 pandemic and impact of universal face mask wear on ocular surface health and risk of infection

Universal mask wear is an effective public health intervention to reduce SARS-Cov-2 transmission, especially in enclosed public spaces and healthcare environments. Concerns have been raised about possible transmission of the SARS-Cov-2 through ocular secretions, leading to enhanced protective measures during ophthalmic procedures. However, there is some evidence for air jets from the upper edge of the surgical mask to the ocular surface, especially when the mask is not well fit. Prolonged airflow towards the ocular surface during expiration may alter tear-film stability, leading to hyperosmolarity and ocular surface inflammation. This also raises the question of whether the ocular surface is contaminated with oral flora from airflow directed toward the eyes, thus increasing the risk of ocular infection. Herein we review the impact of patient face mask wear on the ocular surface, eyelids and risk of ocular infection, particularly during ocular surgery. There is some evidence for increased incidence of dry eye or eyelid disease during periods of mandatory face mask wear. While high daily exposure is consistent with a direct association, this should be mitigated by various cofounding factors which could also affect the ocular health during the COVID-19 pandemic. An increased risk of post-intravitreal injection endophthalmitis, possibly due to face mask wear by the patient, including culture-positive endophthalmitis, has been reported in one retrospective study. Several measures have been shown to prevent or limit the risk of developing dry eye disease or exacerbation, eyelid cyst, and ocular infection during intravitreal injections.

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.

Comparison of Endophthalmitis Rates after Alcohol-Based Chlorhexidine and Povidone-Iodine Antisepsis for Intravitreal Injections

OBJECTIVE

Intravitreal injections (IVIs) are the most frequently performed intraocular procedure in Canada. Povidone-iodine (PI) is the current gold standard for antisepsis for IVI and is widely used; chlorhexidine (CH) is a possible alternative antiseptic agent. This study aims to compare rates of endophthalmitis after IVI with 0.05% chlorhexidine with a 4% alcohol base antisepsis to rates of endophthalmitis after IVI with 10% PI antisepsis.

DESIGN

Retrospective cohort study.

SUBJECTS

Eyes that received IVI between May 2019 and October 2022 at a group retina practice in Edmonton, Canada.

METHODS

Eyes at a single center received focal conjunctival application of either 10% PI antisepsis or 0.05% CH in 4% alcohol antisepsis for 30 seconds before each IVI.

MAIN OUTCOME MEASURE

Rates of endophthalmitis between the PI and CH groups.

RESULTS

A total of 170 952 IVIs were performed during the study period. A total of 31 135 were performed using CH prophylaxis compared with 139 817 with PI prophylaxis. Among all IVIs there were 49 total cases of endophthalmitis, 29 in the PI group (0.021%) and 20 in the CH group (0.064%). There was a statistically significant difference in the rates of endophthalmitis between the 2 groups (P < 0.001). The odds ratio for developing endophthalmitis with CH antisepsis was 3.1 (95% confidence interval, 1.9-5.2) compared with PI antisepsis. There were increased odds of developing endophthalmitis with aflibercept injection compared with bevacizumab (odds ratio, 3.48; 95% confidence interval, 2.09-7.24).

CONCLUSIONS

There is a statistically significant difference in rates of endophthalmitis between alcohol-based CH and PI antisepsis for IVI in our patient population utilizing the methods discussed. In our center, alcohol-based CH is now considered a second-line antiseptic agent. Further studies are warranted to further assess the endophthalmitis rate utilizing these 2 antiseptic agents.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Increased incidence of endophthalmitis after vitrectomy relative to face mask wearing during COVID-19 pandemic

BACKGROUND/AIMS

To determine the incidence and causative pathogens of endophthalmitis after vitrectomy during strict face mask wearing in the COVID-19 period.

METHODS

This was a retrospective multicentre study including 31 ophthalmological institutions of the Japanese Retina and Vitreous Society or Japan-Clinical Retina Study group. Patients who had undergone vitrectomy during 2019, the pre-COVID-19 period, and from July 2020 to June 2021, the COVID-mask period, were studied. The results of cataract surgery were used as a control. The total number of vitrectomies and the total number of postoperative endophthalmitis were determined. Then, the differences in the incidence of postoperative endophthalmitis between the pre-COVID-19 period and the COVID-mask period, and the type of pathogens causing the endophthalmitis were studied.

RESULTS

The incidence of postvitrectomy endophthalmitis was significantly lower in the pre-COVID-19 period with 16 568 surgeries and 18 endophthalmitis cases (0.11%) than in the COVID-mask period of 14 929 surgeries and 31 endophthalmitis cases (0.21%; p=0.031, OR=1.913, 95% CI 1.078 to 3.394). In the pre-COVID-19 period, 4 of the 18 eyes were culture positive, and all were of the Staphylococcus family. In the COVID-mask period, 9 of the 31 eyes were culture positive, and 4 cases were related to oral commensals including Streptococcus spp, which are reportedly very rare in endophthalmitis after vitrectomy.

CONCLUSIONS

It is necessary for physicians to be aware of the higher incidence of postvitrectomy endophthalmitis during the COVID-mask period, and to treat their patients appropriately.

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.

Intravitreal Injections and Face Masks: Endophthalmitis Risk Before and During the COVID-19 Pandemic

Purpose

To assess the added risk of acute endophthalmitis after intravitreal injections associated with the widespread use of face masks during the COVID-19 pandemic.

Methods

In this retrospective, single-center study, records of patients with acute endophthalmitis following intravitreal bevacizumab (IVB) injections during the pre-COVID era-that is, March 1st , 2013 to October 31st , 2019 -and the COVID-19 era-that is, March 1st , 2020 to April 1st , 2021 -were reviewed and compared.

Results

A total of 28,085 IVB injections were performed during the pre-COVID era; nine eyes of nine patients developed acute post-IVB endophthalmitis in this era, giving an overall incidence of 0.032% (3.2 in 10,000 injections). In the COVID era, 10,717 IVB injections were performed; four eyes of four patients developed acute post-IVB endophthalmitis in this era, giving an overall incidence of 0.037% (3.7 in 10,000 injections). The incidences of post-IVB endophthalmitis during these two eras were not statistically significantly different (P = 0.779).

Conclusion

Face masking protocols seem unlikely to impose any additional risk of post-IVB endophthalmitis.

Intravitreal injections as a leading cause of acute postoperative endophthalmitis-a regional survey in England

BACKGROUND

To evaluate the characteristics, treatment patterns and outcomes of acute postoperative endophthalmitis.

METHODS

Patients presenting with acute postoperative endophthalmitis between January 2017 to December 2019 were identified from hospital records in this multicentre retrospective cohort study. Clinical records were reviewed for visual acuity (VA) at various timepoints, cause of endophthalmitis, microbiological results, treatments and complications.

RESULTS

Forty-six eyes of 46 patients were included. Intravitreal injections were the leading cause of acute postoperative endophthalmitis (n = 29; 63%), followed by cataract surgery (n = 8; 17%), vitreoretinal surgery (n = 7; 15%), and secondary intraocular lens insertion (n = 2, 4%). The absolute risk of endophthalmitis was 0.024% (1:4132) for intravitreal injections, 0.016% (1:6096) for cataract surgery, and 0.072% (1:1385) for vitreoretinal surgery. The majority of patients (n = 38; 83%) had better VA at 6 months compared to presentation, although fewer (n = 13; 28%) maintained similar or better VA compared to before the precipitating surgery. Twenty-four cases yielded positive culture results, of which staphylococcus epidermidis was the most commonly isolated organism. Microbiological yield was not associated with better final visual outcomes. Patients who underwent therapeutic vitrectomy (n = 15; 33%) had poorer VA at presentation, but subsequently achieved visual outcomes comparable to those who received medical treatment alone. There was no difference in time to presentation, visual outcome and retinal detachment rates among the different causative procedures.

CONCLUSION

Intravitreal injections were the most common cause of endophthalmitis in our region, primarily because of their higher frequency compared to other intraocular procedures. In this cohort, the primary procedure had no effect on presentation, management or visual outcomes.

The effect of COVID-19 pandemic and wearing face masks on ophthalmology practice: What is known so far? A narrative review

Face masks, along with other preventive measures, can help slow the spread of COVID-19. Despite the positive effect of the mask in combating the virus, it has some negative effects on the human body that must be followed up on and reduced. In this study, we discuss the impact of wearing face masks on the eye and the common issues associated with using them. The literature search was conducted using electronic databases such as PubMed and Google Scholar. Only articles published in English were included. A total of 39 relevant articles were deemed eligible. After the duplicate articles were removed, the titles and abstracts of 20 papers underwent full-text screening. The review comprised both prospective and retrospective investigations, case reports, and a series of reporting ocular symptoms following the use of face masks. The COVID-19 pandemic affected ophthalmology practices in managing patients. New factors must be considered, especially when dealing with anti-VEGF injections, such as the risk of endophthalmitis, tests and symptoms of patients with glaucoma, and the emerging symptoms associated with the COVID-19 vaccination. The use of face masks and breathing aids seemed to influence the tear film.

Clinical Practice Update: Management of Infectious Endophthalmitis After Intravitreal Anti-VEGF Injection

Although infectious endophthalmitis after intravitreal antivascular endothelial growth factor injections is rare, it is the most feared and potentially devastating complication of this procedure. There is no high-level evidence to provide definitive guidance on the management of endophthalmitis occurring after intravitreal injection (IVI). This clinical practice update reviews the published literature regarding post-IVI endophthalmitis and highlights areas in which further research is needed to better guide its management.

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.

Post-intravitreal injection endophthalmitis pattern during the COVID-19 pandemic with implementation of patients' masking

Purpose

To evaluate the role of patient facial masks on the occurrence of post-intravitreal injection (IVI) endophthalmitis in a real-word setting.

Methods

In this retrospective cohort, patients receiving IVIs between 20 February 2019 and 20 February 2021; a 12-month period before the official beginning of COVID-19 epidemic in Iran and a 12-month period thereafter were included. In the pre-COVID era, patients underwent IVI without a facial mask while in the COVID era patients wore an untaped facial mask. Physicians and staff had facial mask in both periods. IVIs were administered in a dedicated operating room without a strict no talk-policy. The main outcome measure was the rate of post-IVI endophthalmitis.

Results

A total number of 53,927 injections was performed during the study period: 34,277 in pre-COVID and 19,650 in COVID periods; with a 42.7% decrease in the number of injections. Endophthalmitis occurred in 7 eyes (0.020%) in pre-COVID and 7 eyes (0.036%) in COVID era (p = 0.40). In multivariate analysis, after adjustment for intercorrelations between the eyes and multiple injections in one patient, there was no statistically significant association between wearing facial masks by the patients and risk of endophthalmitis (relative risk = 1.47, 95% confidence interval of 0.97–2.22; p = 0.071).

Conclusion

Patients’ facial masking is not associated with an increased risk of post-injection endophthalmitis.

Management Patterns and Outcomes for Intravitreal Injection–Related Endophthalmitis

Purpose:

This work describes the clinical management and outcomes in cases of presumed infectious endophthalmitis following intravitreal injection at a tertiary academic medical center.

Methods:

A retrospective review took place of eyes that presented to the Duke Eye Center over a 9-year period and were diagnosed with intravitreal injection–related endophthalmitis. Clinical presentation, management, microbiologic yield, visual outcomes, and complications were abstracted from medical records.

Results:

Of 23 eyes diagnosed with postinjection endophthalmitis, 52.2% underwent anterior chamber tap (33.3% of which first underwent dry needle vitreous tap), 47.8% underwent needle vitreous tap, 17.4% underwent neither, and none underwent pars plana vitrectomy (PPV) for initial management. Subsequent PPV was performed in 6 eyes (26.1%). Mean visual acuity (VA) improved by 50 Early Treatment Diabetic Retinopathy Study letters at 6 months. Eyes that underwent initial anterior chamber tap had worse presenting VA than those that did not ( P = .01). Eyes undergoing subsequent PPV had worse VA at presentation ( P = .02) and at 6 months ( P < .001). Eyes presenting with VA of hand motion (20/8000) or worse were more likely to undergo subsequent PPV ( P = .02).

Conclusions:

Eyes with intravitreal injection–related endophthalmitis presenting with VA of hand motion or worse were more likely to undergo subsequent PPV. Future studies with larger cohorts may reveal whether earlier vitrectomy should be considered in these patients.

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.

Short-term Safety Evaluation of Resident-performed Intravitreal Injection

Purpose: This study evaluated the short-term safety of resident-performed intravitreal injections.Methods: We retrospectively reviewed the medical records of 503 patients (503 eyes) treated for the first time in our hospital from January 2018 to October 2020 via intravitreal bevacizumab, ranibizumab, aflibercept, or triamcinolone acetonide injections by residents or retina specialists. In terms of short-term ophthalmic complications, patients were followed-up 1 day, 1 week, and 1 month after injection.Results: A total of 503 eyes of 503 patients were included. Intravitreal injections were given to 211 and 292 eyes by residents (the resident group) and retina specialists (the retina specialist group), respectively. There were no between-group differences in baseline characteristics except in terms of the indications for injection. Intraocular pressure elevation >5 mmHg occurred in two eyes (0.95%) in the resident group and five (1.71%) in the retina specialist group, but the difference was not statistically significant. Subconjunctival hemorrhage occurred in 29 eyes (13.74%) of the resident group and 32 eyes (10.96%) of the retina specialist group; again, the difference was not statistically significant. No case of noninfectious endophthalmitis occurred in the resident group but two (0.68%) cases occurred in the retina specialist group; again, the difference was not significant. There were two (0.95%) cases of infectious endophthalmitis in the resident group and one (0.34%) case in the retina specialist group; again, the difference was not significant. No corneal erosion, traumatic lens damage, vitreous hemorrhage, or retinal tearing or detachment were noted in either group.Conclusions: Resident-performed intravitreal injections appear to be safe.

ENDOPHTHALMITIS AFTER INTRAVITREAL INJECTIONS DURING THE COVID-19 PANDEMIC WITH IMPLEMENTATION OF UNIVERSAL MASKING

PURPOSE

To evaluate the rates of postintravitreal injection-related endophthalmitis during the COVID-19 pandemic with institution of both physician and patient face masking.

METHODS

All eyes receiving intravitreal injections of any kind from a single large tertiary retina practice in Houston, TX before (August 2017-March 22, 2020) and after (March 23, 2020-September 2020) COVID-19 pandemic universal masking protocols. The total number of injections and cases of acute injection-related endophthalmitis were determined from billing records and subsequent retrospective chart review. The primary outcome was the rate of endophthalmitis after intravitreal injection. Secondary outcomes included visual acuity, time until initial presentation, patient age, and differences in the overall number of injections performed monthly pre-COVID-19 and post-COVID-19.

RESULTS

A total of 134, 097 intravitreal injections were performed during the study period (111,679 pre-COVID-19 and 22,418 post-COVID-19 masking protocols). A total of 41 cases of acute endophthalmitis occurred in the pre-COVID group (0.04%, one in 2,500) and 7 cases in the post-COVID group (0.03%, one in 3,333) P = 0.85.

CONCLUSION

In this single center, retrospective study, the implementation of universal patient and physician masking as practiced during the COVID-19 pandemic did not significantly affect the rate of postintravitreal injection endophthalmitis.

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.

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.

Effect of Taping Face Masks on Quantitative Particle Counts Near the Eye: Implications for Intravitreal Injections in the COVID-19 Era

Purpose

To determine the effect of taping the top of face masks on air particle counts directed toward the eye during simulated intravitreal injections.

Design

Prospective observational crossover study.

Methods

Thirteen healthy subjects were recruited. Each wore a cloth, surgical, or N95 mask in randomized order. The number of air particles were quantified by using a particle counter suspended over the right eye while each subject breathed normally, deeply, or spoke using a standardized script. Particle counts were obtained with the top of each mask taped and not taped. The main outcome measurements were particle counts of 0.3, 0.5, 1, 3, 5, and 10 μm and total particle counts.

Results

Taping cloth masks while subjects were speaking significantly reduced particle counts for the 0.3- (P = .03), 0.5- (P = .01), and 1-μm (P = .03) particles and total particle counts (P = .008) compared to no taping. Taping the top of cloth masks during normal or deep breathing did not significantly affect particle counts compared to no taping. Taping the top of surgical or N95 masks did not significantly alter particle counts for any breathing condition tested.

Conclusions

Taping the top of cloth masks prior to simulated intravitreal injections significantly reduced air particle counts directed toward the eye when subjects were speaking compared to no taping. This may have implications for decreasing air particles reaching the eye during intravitreal injections, including aerosolized droplets from a patient's mouth that may carry oral pathogens.