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Safety Measures for Maintaining Low Endophthalmitis Rate after Intravitreal Anti-Vascular Endothelial Growth Factor Injection before and during the COVID-19 Pandemic. J Clin Med 2022; 11:jcm11030876. [PMID: 35160327 PMCID: PMC8837000 DOI: 10.3390/jcm11030876] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/24/2022] [Accepted: 02/03/2022] [Indexed: 02/06/2023] Open
Abstract
During the COVID-19 pandemic, intravitreal injections are performed with patients wearing masks. The risk of endophthalmitis after intravitreal injection is reported to increase due to an influx of exhaled air containing oral bacteria from the upper part of the mask onto the ocular surface. We retrospectively investigated the incidence of endophthalmitis when intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections were performed using the same infection control measures before and during the pandemic. Vitreoretinal specialists performed intravitreal injections of anti-VEGF agents in the outpatient room of a university hospital. Infection control measures before and during the pandemic included covering the patient’s eye with adhesive face drape and irrigating the ocular surface with 0.25% povidone-iodine before draping, and immediately before and after injection. Before the COVID-19 pandemic (February 2016 to December 2019), one case of endophthalmitis occurred among 31,173 injections performed (0.0032%; 95% confidence interval (CI), 0.000008–0.017872%). During the COVID-19 pandemic (January 2020 to August 2021), one case of endophthalmitis occurred among 14,725 injections performed (0.0068%; 95% CI, 0.000017–0.037832%). There was no significant difference between the two periods (Fisher’s exact test: p = 0.5387). Even during the COVID-19 pandemic, very low incidence of endophthalmitis after intravitreal injection can be maintained by implementing basic infection prophylactic measures, including face draping and 0.25% povidone-iodine irrigation, established before COVID-19 pandemic.
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Sisco E, Robinson EL, Mead R, Miller CR. Measuring changes in drug particulate on evidence packaging due to routine case analysis. Forensic Chem 2021. [DOI: 10.1016/j.forc.2021.100372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Cataract Surgery by Intraoperative Surface Irrigation with 0.25% Povidone-Iodine. J Clin Med 2021; 10:jcm10163611. [PMID: 34441906 PMCID: PMC8397035 DOI: 10.3390/jcm10163611] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/09/2021] [Accepted: 08/08/2021] [Indexed: 11/16/2022] Open
Abstract
Postoperative endophthalmitis after cataract surgery is typically caused by the patient's own conjunctival normal bacterial flora. A three-step approach is recommended to prevent endophthalmitis: (1) "border control" to prevent microorganisms from entering the eye by disinfecting the ocular surface is the most important measure; (2) bacteria that have gained access into the anterior chamber are reduced by irrigation; (3) bacteria remaining in the anterior chamber and vitreous at the end of surgery are controlled by antibacterial drugs. We have devised a method, "the Shimada technique", for irrigating the ocular surface with povidone-iodine, a disinfectant with potent microbicidal effect and established effective and safe concentrations for eye tissues. Povidone-iodine exhibits a bactericidal effect for a wide concentration range of 0.005-10%, but 0.1% povidone-iodine has the highest activity and requires the shortest time of only 15 s to achieve microbicidal effect. When used to irrigate the ocular surface every 20-30 s during cataract surgery, 0.25% povidone-iodine is conceivably diluted to around 0.1%. Irrigation with 0.25% povidone-iodine during cataract surgery significantly reduced bacteria contamination rate in the anterior chamber compared with saline (p = 0.0017) without causing corneal endothelial damage.
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Sisco E, Staymates ME, Watt LM. Net Weights: Visualizing and Quantifying their Contribution to Drug Background Levels in Forensic Laboratories. Forensic Chem 2021; 20. [PMID: 34151050 DOI: 10.1016/j.forc.2020.100259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
While the drug background in forensic laboratories has been quantified, the processes that most contribute to the background have not been extensively researched. This work presents both qualitative visualization and quantitative analysis of the spread of simulant drug particulate during the process of taking net weights. The process was modeled using three masses of powder (0.2 g, 2 g, and 100 g). The net weight process, in which the mixture was poured onto weighing paper, was mimicked and the resulting aerosolized particulate was allowed to settle. Wetted cotton swabs were then used to sample 6.45 cm2 (1 in2) squares extending up to 61 cm (24 in) away from the weigh paper. The swabs were then extracted and quantified using LC-MS/MS and two-dimensional color plots were created to visualize the magnitude of particulate spread. Qualitative flow visualization of the process, accomplished using laser light sheet videography, was also completed to support the quantitative extraction experiments and provide a visual representation of the mechanism of particulate spread. Surface concentrations were found to be highest in the area immediately surrounding the weigh paper, though transport as far as 61 cm (24 in) was observed with all mass loadings. The amount of the material aerosolized and transported on the bench surrounding the weigh paper was dependent upon the mass of material being poured. These results highlight that weighing activities encountered in forensic labs may be a primary contributor to drug background and may be a potential source of inhalation exposure for chemists.
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Machida Y, Nakashizuka H, Shoji J, Shimada H. Microincision vitrectomy surgery: experimental visualization and quantification of vitreous contamination. BMC Ophthalmol 2020; 20:441. [PMID: 33167915 PMCID: PMC7653715 DOI: 10.1186/s12886-020-01712-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/29/2020] [Indexed: 11/10/2022] Open
Abstract
Background To visualize and quantify vitreous contamination following microincision vitrectomy surgery (MIVS) using an experimental vitreous contamination model (EVCM). Methods Enucleated porcine eyes with fluoresbrite carboxylate microspheres applied to the conjunctival surface were used as a type 1 EVCM. Twenty-five- or 27-gauge (G) trocar cannulas were inserted through the conjunctiva and sclera, followed by the placing and opening of an infusion cannula. These procedures were monitored by an intraocular fiber catheter. Secondly, condensed microspheres were applied to an excised sheet of porcine sclera to serve as type 2 EVCM. Twenty-five- or 27-G trocar cannulas were inserted perpendicularly through the top of the sclera where the condensed microspheres were applied, an infusion cannula was inserted, 0.1 mL of saline solution injected through the infusion cannula, and samples collected. The fluorescence strength of samples was then measured using fluorophotometry. Results We visually detected fluorescent microspheres in 10/10 eyes with 25-G and 10/10 with 27-G MIVS. In the experimental quantification study, each MIVS gauge value was significantly higher than the control (P < 0.01). However, there was no significant difference between 25-G and 27-G MIVS. Conclusions MIVS carries the risk of introducing contamination directly into the eyes when the trocar cannula is inserted and infusion cannula is opened, even when a 27-G MIVS is used. Our study has shown it is essential that the surgeon be aware of the possibility of introducing contamination from the conjunctiva at all times during MIVS. Supplementary Information The online version contains supplementary material available at 10.1186/s12886-020-01712-6.
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Affiliation(s)
- Yumiko Machida
- Division of Ophthalmology, Department of Visual Sciences, Nihon University School of Medicine, Nihon University Hospital, 1-6 Kandasurugadai, Chiyoda-ku, Tokyo, 101-8309, Japan
| | - Hiroyuki Nakashizuka
- Division of Ophthalmology, Department of Visual Sciences, Nihon University School of Medicine, Nihon University Hospital, 1-6 Kandasurugadai, Chiyoda-ku, Tokyo, 101-8309, Japan.
| | - Jun Shoji
- Division of Ophthalmology, Department of Visual Sciences, Nihon University School of Medicine, Nihon University Hospital, 1-6 Kandasurugadai, Chiyoda-ku, Tokyo, 101-8309, Japan
| | - Hiroyuki Shimada
- Division of Ophthalmology, Department of Visual Sciences, Nihon University School of Medicine, Nihon University Hospital, 1-6 Kandasurugadai, Chiyoda-ku, Tokyo, 101-8309, Japan
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Shimada H, Kato K, Ishida K, Yamaguchi T, Shinoda K. Evaluation of Retinal Function and Pathology After Intravitreal Injection of Povidone-Iodine and Polyvinyl Alcohol-Iodine in Rabbits. Transl Vis Sci Technol 2020; 9:5. [PMID: 32821477 PMCID: PMC7401888 DOI: 10.1167/tvst.9.5.5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/11/2020] [Indexed: 01/24/2023] Open
Abstract
Purpose This study compared intraocular toxicity of intravitreally injected povidone-iodine (PI) and polyvinyl alcohol-iodine (PAI) in rabbits. Methods In each rabbit, 0.1 mL of PI or PAI solution was injected intravitreally into one eye and saline was injected into the other. PI was tested at available iodine concentrations of 0.05%, 0.1%, 0.2%, and 0.5%, and PAI at 0.05%, 0.1%, and 0.2% (n = 6 each). Electroretinograms were recorded before injection and 1, 7, and 14 days after injection. Pathological examinations of eyeballs were performed on day 15. Results Mean b-/a-wave ratios of the electroretinograms did not change in eyes injected with 0.05%, 0.1%, or 0.2% PI (PI-0.05, PI-0.1, and PI-0.2, respectively) or in eyes injected with 0.05% or 0.1% PAI (PAI-0.05 and PAI-0.1, respectively) compared to saline-injected eyes, but was transiently impaired on day 1 in PAI-0.2 eyes. Histopathologically, no retinal abnormalities were observed in PI-0.05, PAI-0.05, or PAI-0.1 eyes. One PI-0.1 eye first showed localized inflammatory cell infiltration in the inferior retinal region. Two PI-0.2 eyes and one PAI-0.2 eye had retinal degeneration and inflammatory cell infiltration. In the PI-0.5 group, extensive inflammatory cell infiltration was observed in six eyes and inferior retinal detachment in five eyes. Conclusions PI and PAI have equivalent retinal toxicity profiles, and retinal toxicity first affects the inner retinal layer in the inferior region. The highest non-retinotoxic vitreous concentration is 0.0033% available iodine from intravitreal injection of PI or PAI containing 0.05% available iodine. Translational Relevance Low concentrations of PI or PAI can be used to wash the ocular surface during surgery or intravitreal injection to prevent endophthalmitis.
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Affiliation(s)
- Hiroyuki Shimada
- Department of Ophthalmology, Nihon University Hospital, Chiyoda-ku, Tokyo, Japan
| | - Kimiko Kato
- R&D Department, Nitten Pharmaceutical Co., Ltd., Nagoya, Aichi, Japan
| | - Kazuumi Ishida
- R&D Department, Nitten Pharmaceutical Co., Ltd., Nagoya, Aichi, Japan
| | | | - Kei Shinoda
- Department of Ophthalmology, Faculty of Medicine, Saitama Medical University, Iruma, Saitama, Japan
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Tanaka K, Shimada H, Mori R, Nakashizuka H, Hattori T, Okubo Y. No increase in incidence of post-intravitreal injection endophthalmitis without topical antibiotics: a prospective study. Jpn J Ophthalmol 2019; 63:396-401. [PMID: 31446502 DOI: 10.1007/s10384-019-00684-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 06/17/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE In our previous report, intravitreal injection using 0.25% povidone-iodine to irrigate the conjunctival sac together with pre- and post-injection topical antibiotics achieved an incidence of post-injection endophthalmitis significantly lower than other reports. In this study, we examined whether similarly low incidence is achieved without using any topical antibiotics. STUDY DESIGN Prospective cohort study. METHODS We evaluated intravitreal injections of anti-vascular endothelial growth factor agents conducted by vitreoretinal specialists at the outpatient injection room of a single university hospital. This study had two protocols. First stage: We performed more than 3000 injections with pre-injection but without post-injection topical antibiotics. Final stage: After confirming no case of endophthalmitis in the first stage, we performed more than 12,500 injections without either pre- or post-injection topical antibiotics. In both protocols, we used 0.25% povidone-iodine to sterilize the conjunctival sac both before and after injection. RESULTS First stage was performed between April 2015 and January 2016. No case of suspected or proven infectious endophthalmitis occurred in 6039 injections [95% confidence interval (CI) 0-0.000497%]. Final stage was performed between February 2016 and November 2017. No case of suspected or proven infectious endophthalmitis occurred in 12,523 injections (95% CI 0-0.00024%). This result was comparable to our previous study using both pre- and post-injection topical antibiotics (0/15,144 injections, 95% CI 0-0.000198%). CONCLUSION Using conjunctival sac irrigation with 0.25% povidone-iodine before and after intravitreal injection, the incidence of endophthalmitis remains low even when the use of pre- or post-injection topical antibiotics is discontinued.
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Affiliation(s)
- Koji Tanaka
- Department of Ophthalmology, School of Medicine, Nihon University Hospital, 1-6 Surugadai, Kanda, Chiyodaku, Tokyo, 101-8309, Japan
| | - Hiroyuki Shimada
- Department of Ophthalmology, School of Medicine, Nihon University Hospital, 1-6 Surugadai, Kanda, Chiyodaku, Tokyo, 101-8309, Japan.
| | - Ryusaburo Mori
- Department of Ophthalmology, School of Medicine, Nihon University Hospital, 1-6 Surugadai, Kanda, Chiyodaku, Tokyo, 101-8309, Japan
| | - Hiroyuki Nakashizuka
- Department of Ophthalmology, School of Medicine, Nihon University Hospital, 1-6 Surugadai, Kanda, Chiyodaku, Tokyo, 101-8309, Japan
| | - Takayuki Hattori
- Department of Ophthalmology, School of Medicine, Nihon University Hospital, 1-6 Surugadai, Kanda, Chiyodaku, Tokyo, 101-8309, Japan
| | - Yuko Okubo
- Department of Ophthalmology, School of Medicine, Nihon University Hospital, 1-6 Surugadai, Kanda, Chiyodaku, Tokyo, 101-8309, Japan
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Reibaldi M, Avitabile T, Bandello F, Longo A, Bonfiglio V, Russo A, Castellino N, Rejdak R, Nowomiejska K, Toro M, Furino C, Cillino S, Fiore T, Cagini C, Grassi P, Musumeci R, Cocuzza CE, Martinelli M, Fallico M. The Effectiveness of 0.6% Povidone Iodine Eye Drops in Reducing the Conjunctival Bacterial Load and Needle Contamination in Patients Undergoing Anti-VEGF Intravitreal Injection: A Prospective, Randomized Study. J Clin Med 2019; 8:E1031. [PMID: 31337003 PMCID: PMC6678890 DOI: 10.3390/jcm8071031] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/04/2019] [Accepted: 07/06/2019] [Indexed: 02/07/2023] Open
Abstract
The study purpose was to assess the efficacy of a preservative-free 0.6% povidone iodine eye drops as perioperative prophylactic treatment for reducing conjunctival bacterial load and the rate of needle contamination in patients undergoing intravitreal anti-vascular endothelial growth factor injection. Enrolled patients were randomized to either the study group (0.6% povidone iodine, three day-prophylactic treatment before the injection) or to the control group (placebo, three day-prophylactic treatment). Conjunctival swabs were obtained before and after the prophylactic treatment in both groups. Intravitreal injections were performed in a sterile fashion. The injection needle and a control needle were collected for microbiological culture. Data from 254 and 253 eyes in the study group and control group, respectively, were analyzed. Bacterial growth from conjunctival swab cultures was significantly lower after 0.6% povidone iodine prophylaxis compared to baseline and to placebo prophylaxis (p < 0.001), showing an 82% eradication rate in the study group. No injection needle showed bacterial contamination in the study group, whereas six needles were culture-positive in the control group (p = 0.015). No serious ocular and non-ocular adverse events were recorded. The 0.6% povidone iodine solution proved an effective treatment in reducing conjunctival bacterial load and risk of needle contamination.
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Affiliation(s)
- Michele Reibaldi
- Department of Ophthalmology, University of Catania, 95123 Catania, Italy.
| | - Teresio Avitabile
- Department of Ophthalmology, University of Catania, 95123 Catania, Italy
| | - Francesco Bandello
- Department of Ophthalmology, University Vita Salute Hospital San Raffaele, 20132 Milano, Italy
| | - Antonio Longo
- Department of Ophthalmology, University of Catania, 95123 Catania, Italy
| | - Vincenza Bonfiglio
- Department of Ophthalmology, University of Catania, 95123 Catania, Italy
| | - Andrea Russo
- Department of Ophthalmology, University of Catania, 95123 Catania, Italy
| | - Niccolò Castellino
- Department of Ophthalmology, University of Catania, 95123 Catania, Italy
| | - Robert Rejdak
- Department of General Ophthalmology, Medical University of Lublin, 20079 Lublin, Poland
| | - Katarzyna Nowomiejska
- Department of General Ophthalmology, Medical University of Lublin, 20079 Lublin, Poland
| | - Mario Toro
- Department of Ophthalmology, University of Catania, 95123 Catania, Italy
| | - Claudio Furino
- Department of Ophthalmology, University of Bari, 70124 Bari, Italy
| | - Salvatore Cillino
- Department of Experimental Biomedicine and Clinical Neuroscience, Ophthalmology Section, University of Palermo, 90127 Palermo, Italy
| | - Tito Fiore
- Division of Ophthalmology, Department of Surgery and Biomedical Science, University of Perugia, S Maria della Misericordia Hospital, 06129 Perugia, Italy
| | - Carlo Cagini
- Division of Ophthalmology, Department of Surgery and Biomedical Science, University of Perugia, S Maria della Misericordia Hospital, 06129 Perugia, Italy
| | - Patrizia Grassi
- Laboratory Analysis Unit II, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania, 95123 Catania, Italy
| | - Rosario Musumeci
- Laboratory of Clinical Microbiology and Virology, Department of Medicine, University of Milano-Bicocca, 20900 Milano, Italy
| | - Clementina Elvezia Cocuzza
- Laboratory of Clinical Microbiology and Virology, Department of Medicine, University of Milano-Bicocca, 20900 Milano, Italy
| | - Marianna Martinelli
- Laboratory of Clinical Microbiology and Virology, Department of Medicine, University of Milano-Bicocca, 20900 Milano, Italy
| | - Matteo Fallico
- Department of Ophthalmology, University of Catania, 95123 Catania, Italy
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Koerner JC, George MJ, Meyer DR, Rosco MG, Habib MM. Povidone-iodine concentration and dosing in cataract surgery. Surv Ophthalmol 2018; 63:862-868. [PMID: 29778494 DOI: 10.1016/j.survophthal.2018.05.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 04/26/2018] [Accepted: 05/07/2018] [Indexed: 11/28/2022]
Abstract
Iodine has been recognized as an effective bactericide since the 1800s, and povidone-iodine (PI) solution has been applied to the ocular surface and periocular skin since the 1980s to prevent endophthalmitis in cataract surgery. In vitro, PI solution kills bacteria quickly at dilute concentrations (0.05%-1.0%). In many instances, PI kills bacteria more quickly at these dilute concentrations than more conventional (5%-10%) concentrations. This is due to greater availability of diatomic free iodine in dilute solution, the bactericidal component of PI. The toxicity of PI, both in vitro and clinically, has been shown to be related to concentration. Current American Academy of Ophthalmology and the European Society of Cataract and Refractive Surgeons recommendations regarding PI use suggest using 5% PI before surgery. An alternative dosing strategy uses dilute PI repetitively throughout cataract surgery (0.25% every 30 seconds). We review the povidone-iodine literature with attention to basic science and use of dilute PI.
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Affiliation(s)
- Jagger C Koerner
- The Lions Eye Institute, Department of Ophthalmology, Albany Medical College, Albany, New York, USA.
| | - Mary J George
- Albany Medical College, Department of Microbiology, Albany, New York, USA
| | - Dale R Meyer
- The Lions Eye Institute, Department of Ophthalmology, Albany Medical College, Albany, New York, USA
| | - Michael G Rosco
- The Lions Eye Institute, Department of Ophthalmology, Albany Medical College, Albany, New York, USA
| | - Matthew M Habib
- The Lions Eye Institute, Department of Ophthalmology, Albany Medical College, Albany, New York, USA
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