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Mirghorbani M, Bazvand F, Riazi-Esfahani H, Bahar MM, Yaseri M, Zarei M. Post-intravitreal injection endophthalmitis pattern during the COVID-19 pandemic with implementation of patients' masking. Graefes Arch Clin Exp Ophthalmol 2022; 260:3657-3664. [PMID: 35678839 PMCID: PMC9178317 DOI: 10.1007/s00417-022-05726-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/25/2022] [Accepted: 05/31/2022] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Masoud Mirghorbani
- Farabi Eye Hospital, Tehran University of Medical Sciences, South Karegar Street, Tehran, Iran
| | - Fatemeh Bazvand
- Farabi Eye Hospital, Tehran University of Medical Sciences, South Karegar Street, Tehran, Iran
| | - Hamid Riazi-Esfahani
- Farabi Eye Hospital, Tehran University of Medical Sciences, South Karegar Street, Tehran, Iran
| | | | - Mehdi Yaseri
- Farabi Eye Hospital, Tehran University of Medical Sciences, South Karegar Street, Tehran, Iran
| | - Mohammad Zarei
- Farabi Eye Hospital, Tehran University of Medical Sciences, South Karegar Street, Tehran, Iran.
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2
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Discovering the Potential of Natural Antioxidants in Age-Related Macular Degeneration: A Review. Pharmaceuticals (Basel) 2022; 15:ph15010101. [PMID: 35056157 PMCID: PMC8777838 DOI: 10.3390/ph15010101] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 01/27/2023] Open
Abstract
Age-related macular degeneration (AMD) is a multifactorial disease associated with anatomical changes in the inner retina. Despite tremendous advances in clinical care, there is currently no cure for AMD. This review aims to evaluate the published literature on the therapeutic roles of natural antioxidants in AMD. A literature search of PubMed, Web of Science and Google Scholar for peer-reviewed articles published between 1 January 2011 and 31 October 2021 was undertaken. A total of 82 preclinical and 18 clinical studies were eligible for inclusion in this review. We identified active compounds, carotenoids, extracts and polysaccharides, flavonoids, formulations, vitamins and whole foods with potential therapeutic roles in AMD. We evaluated the integral cellular signaling pathways including the activation of antioxidant pathways and angiogenesis pathways orchestrating their mode of action. In conclusion, we examined the therapeutic roles of natural antioxidants in AMD which warrant further study for application in clinical practice. Our current understanding is that natural antioxidants have the potential to improve or halt the progression of AMD, and tailoring therapeutics to the specific disease stages may be the key to preventing irreversible vision loss.
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3
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Brar AS, Wani VB, Tenagi AL. Outcomes of three intravitreal injections of bevacizumab given monthly for diabetic macular oedema is a viable treatment for an economically disadvantaged population. AFRICAN VISION AND EYE HEALTH 2021. [DOI: 10.4102/aveh.v80i1.618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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4
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Cox JT, Eliott D, Sobrin L. Inflammatory Complications of Intravitreal Anti-VEGF Injections. J Clin Med 2021; 10:981. [PMID: 33801185 PMCID: PMC7957879 DOI: 10.3390/jcm10050981] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/15/2021] [Accepted: 02/18/2021] [Indexed: 12/20/2022] Open
Abstract
Intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents is a commonly used therapy for numerous retinal diseases. The most commonly used of these medications are bevacizumab, ranibizumab, aflibercept, and brolucizumab. However, intravitreal administration of these agents is also associated with several inflammatory and non-inflammatory adverse events. The three inflammatory adverse events are sterile intraocular inflammation, brolucizumab-associated retinal vasculitis, and post-injection endophthalmitis. This narrative review summarizes the current literature regarding these conditions, including their epidemiology, presentation, management, outcomes, and pathogenesis. The inflammatory adverse events also share a number of overlapping features, which can make them difficult to discern from one another in a clinical context. This review discusses certain distinguishing features of these conditions that may aid providers in discerning between them and establishing the correct diagnosis.
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Affiliation(s)
| | | | - Lucia Sobrin
- Retina Service, Department of Ophthalmology, Massachusetts Eye and Ear, Boston, MA 02114, USA; (J.T.C.); (D.E.)
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5
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Day HR, Law JC, Lindsey JL. Risk of Infectious Endophthalmitis From a Resident-Performed Intravitreal Injection. ACTA ACUST UNITED AC 2020; 5:321-325. [PMID: 34396031 DOI: 10.1177/2474126420972562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose This work assesses the safety of resident-performed intravitreal injections by comparing the incidence of postinjection endophthalmitis associated with residents vs surgical retina attendings. Methods In this retrospective noninferiority cohort study, the Current Procedural Technology code for an intravitreal injection was used to identify patients from July 1, 2015, to October 31, 2018, at a single-center Veterans Affairs hospital where patients receive intravitreal injections from attending vitreoretinal surgeons and residents. The medical record for each injection was reviewed for the training level of the proceduralist, indication, medication, and laterality. The main outcome was the incidence of postinjection endophthalmitis occurring within 30 days of an intravitreal injection, which was confirmed by at least 2 medical-record reviewers. Results In this cohort of 593 patients, most were male (97.0%), and the average age was 70.3 years (±10.8 years). Of the 6934 injections given, 3877 (55.9%) were performed by residents and 3057 (44.1%) by attendings. Of the 5 cases of endophthalmitis identified, 3 were associated with a resident-performed injection in his or her fourth year of postgraduate training. The difference (0.012%; 95% CI, -0.168% to 0.169%) in the incidence of postinjection endophthalmitis between residents (0.077%) and attendings (0.065%) did not cross the predetermined noninferiority limit (0.200%). Conclusions At our teaching clinic, resident-performed injections were not associated with an elevated risk of endophthalmitis when compared with attending-performed injections. Under varying levels of supervision, residents appeared to demonstrate appropriate sterile injection technique.
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Affiliation(s)
- H Russell Day
- Department of Ophthalmology & Visual Sciences, Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Janice C Law
- Department of Ophthalmology & Visual Sciences, Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Ophthalmology, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Jennifer L Lindsey
- Department of Ophthalmology & Visual Sciences, Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Ophthalmology, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA
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6
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Patel SN, Gangaputra S, Sternberg P, Kim SJ. Prophylaxis measures for postinjection endophthalmitis. Surv Ophthalmol 2020; 65:408-420. [PMID: 31923477 DOI: 10.1016/j.survophthal.2019.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 12/24/2019] [Accepted: 12/30/2019] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Shriji N Patel
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
| | - Sapna Gangaputra
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Paul Sternberg
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Stephen J Kim
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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7
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Endophthalmitis Following Intravitreal Injections Performed in the Office Versus Operating Room Setting. CURRENT OPHTHALMOLOGY REPORTS 2019. [DOI: 10.1007/s40135-019-00208-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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8
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Busch C, Iglicki M, Okada M, Gabrielle PH, Cohen S, Mariussi M, Amphornphruet A, Cebeci Z, Chaikitmongkol V, Couturier A, Fraser-Bell S, Fung A, Iannetta D, Radecka L, Laíns I, Rodrigues T, Lupidi M, Ozimek M, Sala-Puigdollers A, Rehak M, Loewenstein A, Zur D. Causative Pathogens of Endophthalmitis after Intravitreal Anti-VEGF Injection: An International Multicenter Study. Ophthalmologica 2019; 241:211-219. [DOI: 10.1159/000496942] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 01/14/2019] [Indexed: 11/19/2022]
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9
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Zarei M, Karkhaneh R, Mahmoudzadeh R, Salabati M, Nabavi A, Yaseri M, Najibzadeh E, Roohipoor R, Riazi Esfahani M, Khodabande A, Ghassemi F, Ebrahimiadib N, Khojasteh H, Modjtahedi BS. Incidence and Risk Factors for Post-Intravitreal Injection Endophthalmitis in a Modified Operating Room Setting. Ocul Immunol Inflamm 2018; 27:1314-1321. [PMID: 30303423 DOI: 10.1080/09273948.2018.1526306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Purpose: To evaluate the incidence and risk factors of post-intravitreal injection (IVI) endophthalmitis in a single center modified operating room (OR) setting.Methods: In a retrospective chart review study, patients who underwent IVI in a modified OR between September 2014 and November 2016 were included. Cases of post-IVI endophthalmitis were identified from the Hospital Infection Control Committee records, which tracks all post-procedure infections.Results: 51 472 IVIs (37 814 patients) including 13 658 bilateral simultaneous injections were performed during the study period. There were 17 cases of endophthalmitis (0.033%, 95% CI 0.019%-0.052%). There were no cases of bilateral endophthalmitis. Age, sex, indication for IVI, simultaneous bilateral injections, number of previous injections, and type of injected drug were not significantly associated with incidence of endophthalmitis.Conclusion: Post-IVI endophthalmitis is rare in this modified OR setting. Simultaneous bilateral IVIs and on-site preparation of injections are safe under these conditions.
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Affiliation(s)
- Mohammad Zarei
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Karkhaneh
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Razieh Mahmoudzadeh
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mirataollah Salabati
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amin Nabavi
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Yaseri
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Najibzadeh
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ramak Roohipoor
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Riazi Esfahani
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Khodabande
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fariba Ghassemi
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Nazanin Ebrahimiadib
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hasan Khojasteh
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Bobeck S Modjtahedi
- Department of Ophthalmology, Southern California Permanente Medical Group, Baldwin Park, California, USA.,Eye Monitoring Center, Kaiser Permanente Southern California, Baldwin Park, California, USA
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10
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Hunyor AP, Merani R, Darbar A, Korobelnik JF, Lanzetta P, Okada AA. Topical antibiotics and intravitreal injections. Acta Ophthalmol 2018; 96:435-441. [PMID: 28440583 DOI: 10.1111/aos.13417] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 01/13/2017] [Indexed: 12/28/2022]
Abstract
There is increasing evidence that topical antibiotics, given before and/or after intravitreal injections, are ineffective in preventing endophthalmitis and are possibly harmful. In addition to the lack of efficacy and increased development of resistant organisms, the use of topical antibiotics adds significantly to the cost of delivering intravitreal therapy. Despite this, in many countries, it is still common practice to use pre- and/or postinjection topical antibiotics. This review outlines the general principles of effective antibiotic prophylaxis, and the evidence regarding topical antibiotic use as a prophylactic measure for endophthalmitis following intravitreal injections. A key distinguishing feature of intravitreal injections from most other invasive procedures is the fact that they are often repeated on multiple occasions to the same eye. Given the lack of evidence to support topical antibiotics as an effective method of prophylaxis for postinjection endophthalmitis, it appears that more widespread education of ophthalmologists is required to avoid continued inappropriate use. Revision of drug labels in some jurisdictions, and amendment of local/professional society guidelines, may be required to assist in achieving this goal. Emphasis should be placed on antisepsis and aseptic technique, which are the major proven methods of endophthalmitis prevention, rather than antibiotics.
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Affiliation(s)
- Alex P. Hunyor
- University of Sydney; Sydney New South Wales Australia
- Sydney Eye Hospital; Sydney New South Wales Australia
| | - Rohan Merani
- Sydney and Macquarie Universities; Sydney New South Wales Australia
- Concord Repatriation General Hospital; Concord New South Wales Australia
| | - Archie Darbar
- Royal North Shore Hospital; St Leonards New South Wales Australia
| | - Jean-François Korobelnik
- Service d'ophtalmologie; CHU de Bordeaux; Bordeaux France
- Univ. Bordeaux; ISPED; Bordeaux France
- Inserm; U1219 - Bordeaux Population Health Research Center; Bordeaux France
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11
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Antibiotic prophylaxis for preventing endophthalmitis after intravitreal injection: a systematic review. Eye (Lond) 2018; 32:1423-1431. [PMID: 29891901 DOI: 10.1038/s41433-018-0138-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 12/26/2017] [Accepted: 02/19/2018] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To assess the effect of topical antibiotic prophylaxis on the rate of post-operative endophthalmitis after intravitreal injection (IVI). METHODS We conducted a systematic review of studies comparing the rates of endophthalmitis in eyes receiving IVI of different drugs with and without topical antibiotic prophylaxis, by searching MEDLINE and EMBASE up to June 2016. The methodological quality of the included studies was assessed using the Cochrane Risk of Bias tool and the Risk Of Bias in Non-randomized Studies of Interventions (ROBINS-I) for randomized clinical trials (RCTs) and non-randomized studies, respectively. We used a random-effects meta-analysis to compute the odds ratio (OR) of endophthalmitis with antibiotic prophylaxis compared with no prophylaxis and conducted subgroup analyses to compare the efficacy of different regimens and classes of antibiotics on endophthalmitis rates. RESULTS We identified 1 randomized and 12 non-randomized studies that reported 74 cases of endophthalmitis in 147,203 IVIs using antibiotic prophylaxis compared with 55 cases in 211,418 IVIs with no prophylaxis. The overall OR of endophthalmitis for antibiotic prophylaxis vs. no prophylaxis was 1.33 (95% CI 0.75-2.38). Leave-one-out sensitivity analyses showed that the exclusion of the only study with a serious risk of bias significantly increased the risk of endophthalmitis in the antibiotic prophylaxis group compared with control (OR: 1.62, 95% CI: 1.17, 2.34). There was no difference in the endophthalmitis rate associated with any other factor analyzed, including type of antibiotic, type of drug injected, or antibiotic prophylaxis regimen. CONCLUSIONS Antibiotic prophylaxis does not reduce the rate of endophthalmitis following IVI and might potentially be associated with an increased risk of post-operative infection.
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12
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Abstract
Intravitreous injections are presently the second most frequently performed ophthalmic procedure and the most common vitreoretinal procedure. In diabetic patients, intravitreous injections are frequently performed for the treatment of center-involved diabetic macular edema, proliferative diabetic retinopathy, or other co-existing retinal vascular disease. Diabetic patients may be at higher risk of adverse events compared to non-diabetic individuals, given frequent systemic comorbidities, such as cardiovascular and renal disease and increased susceptibility to infection. This review highlights the potential complications and safety considerations in intravitreous injections in patients with diabetes.
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Affiliation(s)
- Aditi Gupta
- a Beetham Eye Institute, Joslin Diabetes Center , Boston , MA , USA
| | - Jennifer K Sun
- a Beetham Eye Institute, Joslin Diabetes Center , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
| | - Paolo S Silva
- a Beetham Eye Institute, Joslin Diabetes Center , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
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13
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Bande MF, Mansilla R, Pata MP, Fernández M, Blanco-Teijeiro MJ, Piñeiro A, Gómez-Ulla F. Intravitreal injections of anti-VEGF agents and antibiotic prophylaxis for endophthalmitis: A systematic review and meta-analysis. Sci Rep 2017; 7:18088. [PMID: 29273773 PMCID: PMC5741717 DOI: 10.1038/s41598-017-18412-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 12/11/2017] [Indexed: 01/16/2023] Open
Abstract
We performed a systematic review and meta-analysis to determine whether the use of local antibiotics is a beneficial prophylactic treatment for endophthalmitis in patients treated with anti-VEGF agents. We searched the MEDLINE and EMBASE databases, and the Cochrane Library over the period January 2007 to December 2016. The search terms used included “Endophthalmitis”, “Antibiotic” and “Intravitreal injection”. Studies in which the patients were treated exclusively with intravitreal injections of anti-VEGF were selected. Eight studies fit the inclusion criteria, which included a total of 276,774 injections; 109,178 (39.45%) were associated with the use of antibiotics and 114,821 (60.55%) were not associated with the use of antibiotics. Our meta-analysis indicated a significant risk for endophthalmitis that was 1.70 times greater with the use of antibiotics than that without antibiotics, with a confidence interval of 1.08 to 2.66 (p = 0.02). A meta-regression indicated that the location (operating rooms versus outpatient clinics) of injection did not have a significant effect on the incidence of endophthalmitis. The prophylactic use of antibiotics when administering anti-VEGF intravitreal injections may contribute to a greater incidence of endophthalmitis. This finding, in addition to reducing costs, would eliminate a treatment that has been shown to be unnecessary and even harmful to patients.
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Affiliation(s)
- Manuel F Bande
- Department of Ophthalmology, University Hospital of Santiago de Compostela, Ramon Baltar S/N, 15706, Santiago de Compostela, Spain.
| | - Raquel Mansilla
- Department of Ophthalmology, University Hospital of Santiago de Compostela, Ramon Baltar S/N, 15706, Santiago de Compostela, Spain
| | - María P Pata
- Biostatech, Advice, Training and Innovation in Biostatistics, Edificio Emprendia, Campus Vida, s/n, 15782, Santiago de Compostela, Spain
| | - Maribel Fernández
- Department of Ophthalmology, University Hospital of Santiago de Compostela, Ramon Baltar S/N, 15706, Santiago de Compostela, Spain
| | - María José Blanco-Teijeiro
- Department of Ophthalmology, University Hospital of Santiago de Compostela, Ramon Baltar S/N, 15706, Santiago de Compostela, Spain
| | - Antonio Piñeiro
- Department of Ophthalmology, University Hospital of Santiago de Compostela, Ramon Baltar S/N, 15706, Santiago de Compostela, Spain
| | - Francisco Gómez-Ulla
- Department of Ophthalmology, University Hospital of Santiago de Compostela, Ramon Baltar S/N, 15706, Santiago de Compostela, Spain
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14
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Postoperative endophthalmitis incidence after intravitreal therapy: a comparison of two different preoperative antibiotic prophylaxis. Int Ophthalmol 2016; 37:787-794. [DOI: 10.1007/s10792-016-0307-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 07/25/2016] [Indexed: 11/30/2022]
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15
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Wani VB, Al-Kandari J, Sabti K, Aljassar F, Qali H, Kumar N, Uboweja A, Al-Sabah K, Diab FA, Al-Rashidi S. Incidence of Endophthalmitis after Intravitreal Bevacizumab using Aliquots Prepared On-site in 2 Operating Rooms in Kuwait. Middle East Afr J Ophthalmol 2016; 23:64-70. [PMID: 26957841 PMCID: PMC4759906 DOI: 10.4103/0974-9233.171784] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Purpose: To report the incidence of endophthalmitis after intravitreal injection of bevacizumab and the outcomes of treatment of endophthalmitis at two centers in Kuwait. Subjects and Methods: The aliquots of bevacizumab were prepared under aseptic precautions and administered in the operating theater on the same day at both centers. All patients received antibiotic drops after injection of bevacizumab. Data were collected on the number of cases that received intravitreal bevacizumab (IVB) and those that developed endophthalmitis were identified at the two centers. All cases of endophthalmitis received an intravitreal antibiotic injection and additional treatments as warranted. Data were collected on the outcomes of endophthalmitis treatment. Results: There were 5 cases of endophthalmitis among a total of 5429 injections (0.09%: Confidence interval: 0.084–0.1). The incidence was 3 cases among 4690 (0.06%) and 2 cases among 739 injections (0.027%) at each center, respectively (P = 0.08). Four cases of endophthalmitis were culture-positive and organisms isolated were, coagulase negative Staphylococcus in 2 cases, Staphylococcus lugdunensis and Streptococcus pneumoniae in 1 case each. The final visual acuity was better than pre-IVB in 3 cases, same as pre-IVB in 1 case and worse in 1 case with streptococcal infection. No eyes developed phthisis bulbi or required enucleation. Conclusions: The incidence of endophthalmitis after intravitreal injection of bevacizumab using aliquots prepared in the operating room is comparable to other studies. There were no clusters of endophthalmitis cases.
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Affiliation(s)
- Vivek B Wani
- Department of Ophthalmology, Al-Adan Hospital, Hadiya, Kuwait; Al-Bahar Ophthalmology Center, Shuwaikh, Kuwait
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16
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[Extemporaneous withdrawal with a mini-spike filter: A low infection risk technique for drawing up bevacizumab for intravitreal injection]. J Fr Ophtalmol 2016; 39:415-20. [PMID: 27155911 DOI: 10.1016/j.jfo.2016.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 01/05/2016] [Accepted: 01/25/2016] [Indexed: 11/21/2022]
Abstract
PURPOSE To describe a technique for extemporaneously drawing up bevacizumab for intravitreal injection (IVT) and report the rate of post-injection endophthtalmitis. PATIENTS AND METHODS Retrospective monocentric analysis (January 2010-December 2014) of all IVT of bevacizumab drawn up with the following technique: in the operating room (class ISO 7) through a mini-spike with an integrated bacteria retentive air filter. The surgeon was wearing sterile gloves and a mask. The assisting nurse wore a mask. The bevacizumab vial was discarded at the end of each session. RESULTS Six thousand two hundred and thirty-six bevacizumab injections were performed. One case of endophthalmitis was noted (0.016%). During the same period, 4 cases of endophthalmitis were found after IVT of other drugs (4/32,992; 0.012%. P=0.8). CONCLUSION Intravitreal injection of bevacizumab after extemporaneous withdrawal through a mini-spike filter is a simple and safe technique. The risk of postoperative endophthalmitis is very low. This simple technique facilitates access to compounded bevacizumab.
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Schwartz SG, Grzybowski A, Flynn HW. Antibiotic prophylaxis: different practice patterns within and outside the United States. Clin Ophthalmol 2016; 10:251-6. [PMID: 26869761 PMCID: PMC4734782 DOI: 10.2147/opth.s100429] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Endophthalmitis remains a rare but important cause of visual loss. Prophylaxis strategies are important to reduce rates of endophthalmitis after cataract surgery, intravitreal injection, and other procedures. There is substantial variability between the US and the rest of the world. During cataract surgery, intracameral antibiotics are commonly used in many nations, especially in Europe, but are less commonly used in the US. A randomized clinical trial from the European Society of Cataract and Refractive Surgeons reported an approximately fivefold reduction in endophthalmitis rates associated with intracameral cefuroxime but these results are controversial. There are no randomized clinical trials regarding endophthalmitis associated with intravitreal injection. Topical antibiotics are commonly used in many nations, but are less commonly used in the US. At this time, there is no global consensus and it appears unlikely that additional major clinical trials will conclusively define the optimal endophthalmitis prophylaxis techniques.
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Affiliation(s)
- Stephen G Schwartz
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Harry W Flynn
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
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18
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A review of preoperative manoeuvres for prophylaxis of endophthalmitis in intraocular surgery. Curr Opin Ophthalmol 2016; 27:9-23. [DOI: 10.1097/icu.0000000000000216] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Eliminating antibiotic prophylaxis for intravitreal injections: a consecutive series of 18,839 injections by a single surgeon. Retina 2015; 35:783-8. [PMID: 25526099 DOI: 10.1097/iae.0000000000000392] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE By optimizing the protocol for intravitreal injections, the risk of endophthalmitis can be minimized. This study assesses the incidence of endophthalmitis and other complications after a consecutive series of intravitreal injections where all antibiotics were excluded. METHODS Injections were performed from August 1, 1997 to October 31, 2012 in outpatient examination rooms at the Retina Center of Minnesota by a single retinal surgeon, the lead author. Most injections were performed to treat exudative age-related macular degeneration. Other reasons included diabetic macular edema, cystoid macular edema because of retinal vein occlusions, cytomegalovirus retinitis, and severe uveitis. Injections were given with topical povidone-iodine, proparacaine, and tetracaine, a sterile eyelid speculum, and clean nonsterile gloves, but without any antibiotics. Data were retrospectively analyzed using billing codes from a computer database system. RESULTS A total of 18,839 injections were given. Of these, the following injections were administered: bevacizumab, 15,479 (82.16%); ranibizumab, 1,669 (8.86%); triamcinolone acetonide (Kenalog-40), 1,014 (5.38%); pegaptanib sodium, 370 (1.96%); aflibercept, 148 (0.79%); dexamethasone implant, 88 (0.47%); triamcinolone acetonide (Triesence), 32 (0.17%); dexamethasone, 29 (0.15%); and ganciclovir, 10 (0.05%). There was one case of postinjection endophthalmitis. The incidence of endophthalmitis per injection was 0.0053%. CONCLUSION A low incidence of endophthalmitis can be achieved when topical antibiotics are omitted.
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20
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Edison LS, Dishman HO, Tobin-D'Angelo MJ, Allen CR, Guh AY, Drenzek CL. Endophthalmitis outbreak associated with repackaged bevacizumab. Emerg Infect Dis 2015; 21:171-3. [PMID: 25531168 PMCID: PMC4285274 DOI: 10.3201/eid2101.141040] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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21
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Yu Y, Chen H, Su SB. Neuroinflammatory responses in diabetic retinopathy. J Neuroinflammation 2015; 12:141. [PMID: 26245868 PMCID: PMC4527131 DOI: 10.1186/s12974-015-0368-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 07/27/2015] [Indexed: 01/14/2023] Open
Abstract
Diabetic retinopathy (DR) is a common complication of diabetes and has been recognized as a vascular dysfunction leading to blindness in working-age adults. It becomes increasingly clear that neural cells in retina play an important role in the pathogenesis of DR. Neural retina located at the back of the eye is part of the brain and a representative of the central nervous system. The neurosensory deficits seen in DR are related to inflammation and occur prior to the clinically identifiable vascular complications. The neural deficits are associated with abnormal reactions of retina glial cells and neurons in response to hyperglycemia. Improper activation of the innate immune system may also be an important contributor to the pathophysiology of DR. Therefore, DR manifests characteristics of both vasculopathy and chronic neuroinflammatory diseases. In this article, we attempt to provide an overview of the current understanding of inflammation in neural retina abnormalities in diabetes. Inhibition of neuroinflammation may represent a novel therapeutic strategy to the prevention of the progression of DR.
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Affiliation(s)
- Ying Yu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, 54 S Xianlie Road, Guangzhou, 510060, China.
| | - Hui Chen
- Eye Institute, Affiliated Hospital of Nantong University, Nantong, 226001, China.
| | - Shao Bo Su
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, 54 S Xianlie Road, Guangzhou, 510060, China.
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22
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Merani R, Hunyor AP. Endophthalmitis following intravitreal anti-vascular endothelial growth factor (VEGF) injection: a comprehensive review. Int J Retina Vitreous 2015; 1:9. [PMID: 27847602 PMCID: PMC5088471 DOI: 10.1186/s40942-015-0010-y] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 06/30/2015] [Indexed: 02/03/2023] Open
Abstract
The purpose of this review is to report and summarize previously reported studies and assess many of the individual steps of the intravitreal injection procedure's possible effect on the prevention of endophthalmitis. The pooled endophthalmitis rate from 20 large retrospective case series of anti-VEGF injections was 144/510,396 (0.028%; 1/3,544). Injections may be performed in an office-based location or in an operating room (OR) and low rates of endophthalmitis can be achieved in either location with careful attention to asepsis. Pre- or post-injection topical antibiotics have not been shown to be effective, and could select for more virulent microorganisms. Povidone-iodine prior to injection is accepted as the gold-standard antiseptic agent, but aqueous chlorhexidine may be an alternative. Antisepsis before and after gel or subconjunctival anesthetic is suggested. The preponderance of Streptococcal infections after intravitreal injection is discussed, including the possible role of aerosolization, which can be minimized by using face masks or maintaining silence. As with other invasive procedures in medicine, the use of sterile gloves, following adequate hand antisepsis, may be considered. Control of the eyelashes and lid margin is required to avoid contamination of the needle, but this can be achieved with or without a speculum. Techniques to minimize vitreous reflux have not been shown to reduce the risk of endophthalmitis. Same day bilateral injections should be performed as two separate procedures, preferably using drug from different lots, especially when using compounded drugs.
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Affiliation(s)
- Rohan Merani
- Retina Associates, Level 4, 8 Thomas St, Chatswood, NSW 2067 Australia
- Save Sight Institute, University of Sydney, Sydney, NSW Australia
- Australian School of Advanced Medicine, Macquarie University, Sydney, NSW Australia
- Concord Repatriation General Hospital, Concord, NSW Australia
| | - Alex P Hunyor
- Retina Associates, Level 4, 8 Thomas St, Chatswood, NSW 2067 Australia
- Save Sight Institute, University of Sydney, Sydney, NSW Australia
- Australian School of Advanced Medicine, Macquarie University, Sydney, NSW Australia
- Sydney Eye Hospital, Sydney, NSW Australia
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23
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Abstract
Intravitreal injections for the treatment of retinal disorders and intraocular infection have become a common ophthalmic procedure, and injections of anti-vascular endothelial growth factor agents or steroids are frequently performed for the treatment of diabetic macular edema or other diabetic vascular pathology. Diabetic patients may be at higher risk of adverse events than non-diabetic individuals given frequent systemic co-morbidities, such as cardiovascular and renal disease, susceptibility to infection, and unique ocular pathology that includes fibrovascular proliferation. Fortunately, many associated complications, including endophthalmitis, are related to the injection procedure and can therefore be circumvented by careful attention to injection techniques. This review highlights the safety profile of intravitreal injections in patients with diabetes. Although diabetic patients may theoretically be at higher risk than non-diabetic patients for complications, a comprehensive review of the literature does not demonstrate substantial increased risk of intravitreal injections in patients with diabetes.
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Affiliation(s)
- Hasanain Shikari
- Beetham Eye Institute, Joslin Diabetes Center , Boston, Massachusetts , USA and
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24
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Cheema RA, Alshihry AM, Cheema HR. Incidence of endophthalmitis following intravitreal Bevacizumab injection at a tertiary care hospital in Eastern Province of Saudi Arabia. Saudi J Ophthalmol 2015; 29:135-6. [PMID: 25892933 PMCID: PMC4398804 DOI: 10.1016/j.sjopt.2014.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 09/29/2014] [Accepted: 11/09/2014] [Indexed: 11/16/2022] Open
Abstract
The aim of this communication is to report the incidence of endophthalmitis following the use of intravitreal Bevacizumab (IVB) at a tertiary care hospital in the Eastern province of Saudi Arabia. A total of 2769 intravitreal Bevacizumab injections were carried out between January 2009 and April 2014. During this period, one case of endophthalmitis following IVB injection occurred. The overall incidence of clinical endophthalmitis was 0.036% (1/2769; 95% confidence interval: 0.0001–0.002%). This compares favorably with studies reported from other parts of the world.
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Affiliation(s)
- Rizwan A Cheema
- Vitreo-Retinal Service, Dhahran Eye Specialist Hospital, Dhahran, Saudi Arabia
| | - Ahmad M Alshihry
- Epidemiology and Infection Control Department, Dhahran Eye Specialist Hospital, Dhahran, Saudi Arabia
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25
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Dashti-Khavidaki S, Abdollahi M. Intravitreal administration of bevacizumab: pros and cons. ACTA ACUST UNITED AC 2015; 23:27. [PMID: 25896903 PMCID: PMC4406161 DOI: 10.1186/s40199-015-0110-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 04/11/2015] [Indexed: 11/30/2022]
Affiliation(s)
| | - Mohammad Abdollahi
- Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences, Tehran, 1417614411, Iran.
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26
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Falavarjani KG, Aghamirsalim M, Modarres M, Hadavandkhani A, Hashemi M, Parvaresh MM, Naseripour M, Samiy N. Endophthalmitis after resident-performed intravitreal bevacizumab injection. Can J Ophthalmol 2015; 50:33-6. [DOI: 10.1016/j.jcjo.2014.09.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 08/28/2014] [Accepted: 09/04/2014] [Indexed: 12/26/2022]
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27
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Chao DL, Gregori NZ, Khandji J, Goldhardt R. Safety of bilateral intravitreal injections delivered in a teaching institution. Expert Opin Drug Deliv 2014; 11:991-3. [DOI: 10.1517/17425247.2014.909806] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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28
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Schwartz SG, Flynn HW. Endophthalmitis Associated with Intravitreal Anti-Vascular Endothelial Growth Factor Injections. CURRENT OPHTHALMOLOGY REPORTS 2013; 2:1-5. [PMID: 24579059 DOI: 10.1007/s40135-013-0033-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The use of anti-vascular endothelial growth factor (VEGF) agents has led to a dramatic increase in the number of intravitreal injections. Endophthalmitis remains a rare but potentially vision-threatening complication of intravitreal injections. Recent large series have estimated this risk to be about one in 3,000 injections or less. Bevacizumab, which is generally prepared by a compounding pharmacy, is associated with additional risks of contamination. Although endophthalmitis cannot be prevented in all cases, certain risk reduction strategies have been proposed, including the use of an eyelid speculum, povidone iodine, avoidance of needle contact with the eyelid margin or eyelashes, and avoidance of routine post-injection antibiotics. Despite these precautions, some patients will develop endophthalmitis following intravitreal anti-VEGF injections, and outcomes may be poor despite prompt and appropriate therapy.
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Affiliation(s)
- Stephen G Schwartz
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 311 9th Street North, #100, Naples, FL 34102, USA,
| | - Harry W Flynn
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL 33136, USA
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29
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Adverse events and complications associated with intravitreal injection of anti-VEGF agents: a review of literature. Eye (Lond) 2013; 27:787-94. [PMID: 23722722 DOI: 10.1038/eye.2013.107] [Citation(s) in RCA: 586] [Impact Index Per Article: 53.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 04/23/2013] [Indexed: 12/18/2022] Open
Abstract
Intravitreal injection of anti-vascular endothelial growth factor (VEGF) agents is increasingly used for the treatment of a wide variety of retinal diseases, including age-related macular degeneration, diabetic retinopathy and retinal vascular occlusions, and retinopathy of prematurity. Despite encouraging results in halting the disease and improving the vision, intravitreal injection of anti-VEGF agents may be associated with systemic adverse events and devastating ocular complications. In this review, we provide an overview of safety data for intravitreal injection of common anti-VEGF agents.
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