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Pascual Carrasco Á, Espadas García I, Ramírez López A, Selva Otaolaurruchi J. [Translated article] Syringes for intraocular administration: A systematic review. FARMACIA HOSPITALARIA 2024; 48:T133-T140. [PMID: 38705829 DOI: 10.1016/j.farma.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 01/31/2024] [Indexed: 05/07/2024] Open
Abstract
OBJECTIVE The off-label use in clinical practice of non-approved syringes for intravitreal drug administration has resulted in the detection of silicone oil drops in the vitreous of some patients. This situation derives from the lack of approved syringes for intraocular use in the Spanish market. The aim of this work is to review the use of syringes for intraocular administration, as well as to search for alternatives that meet the legal requirements for these unmet needs. METHOD A systematic review was performed following the PRISMA 2020 guidelines by searching PubMed with the descriptors: (silicone) AND (syringes) AND ((intraocular) OR (intravitreal)) and filtering all existing publications from January 2006 to December 2023, including all those articles dealing with silicone oil release in intravitreal injections and analysing the possible consequences. RESULTS Sixty-eight results were found, 23 of which were excluded because they did not deal with the subject under study, leaving a total of 45 articles for the systematic review. These were classified according to the conclusions obtained in 4 groups: the adverse reactions produced by silicone; the administration technique; the physicochemical aspects of silicone release; and the characteristics of the medical device. After reviewing the current manufacturers and technical data sheets of commercialised syringes, the existing syringes for this use have been collected, finding 2 that will probably be commercialised in Spain at the beginning of 2024: Zero Residual™ 0.2 ml SiO-free and VitreJect® Ophthalmic. CONCLUSIONS From the results obtained, it can be interpreted that the use of syringes and needles with silicone for intravitreal use is a concern for health professionals due to the implications and consequences that may arise in patients, the most important being adverse reactions, so it is necessary to have silicone-free syringes on the market that are specific for intraocular use. Safety and legality in the use of intraocular syringes and needles is essential to guarantee ocular integrity and patient health.
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Affiliation(s)
| | | | - Ana Ramírez López
- Servicio de Farmacia, Hospital General Universitario Doctor Balmis, Alicante, Spain
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Pascual Carrasco Á, Espadas García I, Ramírez López A, Selva Otaolaurruchi J. Syringes for intraocular administration: Systematic review. FARMACIA HOSPITALARIA 2024; 48:133-140. [PMID: 38556370 DOI: 10.1016/j.farma.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 01/31/2024] [Indexed: 04/02/2024] Open
Abstract
OBJECTIVE The off-label use in clinical practice of non-approved syringes for intravitreal drug administration has resulted in the detection of silicone oil drops in the vitreous of some patients. This situation derives from the lack of approved syringes for intraocular use in the Spanish market. The aim of this work is to review the use of syringes for intraocular administration, as well as to search for alternatives that meet the legal requirements for these unmet needs. METHOD A systematic review was performed following the PRISMA 2020 Guidelines by searching PubMed with the descriptors: "silicone" AND "syringes" AND ("intraocular" OR "intravitreal") and filtering all existing publications from January 2006 to December 2023, including all those articles dealing with silicone oil release in intravitreal injections and analysing the possible consequences. RESULTS Sixty-eight results were found, 23 of which were excluded because they did not deal with the subject under study, leaving a total of 45 articles for the systematic review. These were classified according to the conclusions obtained in 4 groups: the adverse reactions produced by silicone, the administration technique, the physicochemical aspects of silicone release, and the characteristics of the medical device. After reviewing the current manufacturers and technical data sheets of commercialized syringes, the existing syringes for this use have been collected, finding two that will probably be commercialized in Spain at the beginning of 2024: Zero Residual™ 0.2 ml SiO-free and VitreJect® Ophthalmic. CONCLUSIONS From the results obtained, it can be interpreted that the use of syringes and needles with silicone for intravitreal use is a concern for health professionals due to the implications and consequences that may arise in patients, the most important being adverse reactions, so it is necessary to have silicone-free syringes on the market that are specific for intraocular use. Safety and legality in the use of intraocular syringes and needles is essential to guarantee ocular integrity and patient health.
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Affiliation(s)
| | - Isabel Espadas García
- Servicio de Farmacia, Hospital General Universitario Doctor Balmis, Alicante, España
| | - Ana Ramírez López
- Servicio de Farmacia, Hospital General Universitario Doctor Balmis, Alicante, España
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Singh RP, Avery RL, Barakat MR, Kim JE, Kiss S. Evidence-Based Use of Bevacizumab in the Management of Neovascular Age-Related Macular Degeneration. Ophthalmic Surg Lasers Imaging Retina 2024; 55:156-162. [PMID: 38466965 DOI: 10.3928/23258160-20240108-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
Indicated for colorectal cancer for decades, bevacizumab has been widely used off label to treat retinal diseases, and the benefits of its use, specifically in neovascular age-related macular degeneration, have been demonstrated in multiple clinical trials. The intravitreal delivery of bevacizumab requires it to be aseptically repackaged into individual syringes by compounding pharmacies for use in the eye. Although the repackaging process is permitted by the US Food and Drug Administration, the resultant product does not meet the specific standards of products approved for use as ophthalmic injectables nor is the parenteral innovator solution compliant with ophthalmic standards. Studies have also demonstrated variability in the quality and quantity of repackaged bevacizumab. This narrative review summarizes the evidence and discusses the role of off-label bevacizumab in the treatment and management of retinal diseases, its mechanism of action, current challenges and provides a critical appraisal of current evidence, clinical implications, and future directions. [Ophthalmic Surg Lasers Imaging Retina 2024;55:155-162.].
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Vitharana S, Stillahn JM, Katayama DS, Henry CS, Manning MC. Application of Formulation Principles to Stability Issues Encountered During Processing, Manufacturing, and Storage of Drug Substance and Drug Product Protein Therapeutics. J Pharm Sci 2023; 112:2724-2751. [PMID: 37572779 DOI: 10.1016/j.xphs.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 07/24/2023] [Accepted: 08/07/2023] [Indexed: 08/14/2023]
Abstract
The field of formulation and stabilization of protein therapeutics has become rather extensive. However, most of the focus has been on stabilization of the final drug product. Yet, proteins experience stress and degradation through the manufacturing process, starting with fermentaition. This review describes how formulation principles can be applied to stabilize biopharmaceutical proteins during bioprocessing and manufacturing, considering each unit operation involved in prepration of the drug substance. In addition, the impact of the container on stabilty is discussed as well.
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Affiliation(s)
| | - Joshua M Stillahn
- Legacy BioDesign LLC, Johnstown, CO 80534, USA; Department of Chemistry, Colorado State University, Fort Collins, CO 80523, USA
| | | | - Charles S Henry
- Department of Chemistry, Colorado State University, Fort Collins, CO 80523, USA
| | - Mark Cornell Manning
- Legacy BioDesign LLC, Johnstown, CO 80534, USA; Department of Chemistry, Colorado State University, Fort Collins, CO 80523, USA.
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Dessouki A, He L, Park K, Chen H, Chow CC. Presumed Silicone Oil Droplets After Intravitreal Pegcetacoplan Injections. JAMA Ophthalmol 2023; 141:1062-1065. [PMID: 37796497 PMCID: PMC10557030 DOI: 10.1001/jamaophthalmol.2023.4326] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 08/03/2023] [Indexed: 10/06/2023]
Abstract
Importance Recently, intravitreal pegcetacoplan became the first drug to gain US Food and Drug Administration approval for the treatment of geographic atrophy associated with nonexudative age-related macular degeneration, but the administration of this medication may be associated with unanticipated posttreatment complications. Objective To assess the prevalence of presumed silicone oil droplets in the vitreous cavity after intravitreal injection of pegcetacoplan. Design, Setting, and Participants This case series study involved a retrospective record review of all 55 patients treated with intravitreal pegcetacoplan, 0.1 mL in 150-mg/mL solution, between March 24 and June 5, 2023, at a single specialty retina practice. All injections were done using needles from the kit supplied by Apellis Pharmaceuticals on a 1-mL McKesson Luer lock syringe. Main Outcomes and Measures The presence or absence of presumed silicone bubbles detected during dilated biomicroscopic fundus examination and/or on color fundus photographs, the presence or absence of symptoms, change in visual acuity, and/or increase in intraocular pressure. Results A total of 62 intravitreal pegcetacoplan injections were given to 55 patients (mean [SD] age, 83.8 [7.8] years; 33 women [60%]) from March 24 to June 5, 2023. Of the 55 patients, 16 (29%; mean [SD] age, 83.8 [7.4] years; 9 women [56%]) had presumed intravitreal silicone droplets discovered 2 to 4 weeks after treatment, 3 of which were documented on color fundus photographs. Of the 16 patients, 14 (88%) were symptomatic for new floaters that they described as persistent, while 2 (13%) were asymptomatic. There were no signs of inflammation or infection, no increases in intraocular pressure, and no changes in visual acuity for all 16 patients. Conclusions and Relevance A substantial percentage of patients had symptomatic floaters from presumed intravitreal silicone oil droplets after injections of pegcetacoplan using a McKesson 1-mL Luer lock syringe. These findings support consideration of informing patients of this potential adverse effect, avoiding use of the McKesson syringe, and considering use of silicone-free syringes for pegcetacoplan injections.
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Affiliation(s)
| | - Lingmin He
- Retinal Diagnostic Center, Campbell, California
| | | | - Howard Chen
- Retinal Diagnostic Center, Campbell, California
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Weatherby T, Makris L. Silicone Oil Droplet Over the Optic Nerve Head After Intravitreal Injections. JAMA Ophthalmol 2023; 141:e225550. [PMID: 36795106 DOI: 10.1001/jamaophthalmol.2022.5550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
This case report discusses the finding of a silicone oil droplet over the optic nerve head of a patient with a history of multiple intravitreal injections.
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da Cruz NFS, Polizelli MU, Muralha FP, de Morais CNL, Junior OMS, Maia M, Melo GB, Farah ME. Ocular inflammation after agitation of siliconized and silicone oil-free syringes: a randomized, double-blind, controlled clinical trial. Int J Retina Vitreous 2022; 8:41. [PMID: 35715871 PMCID: PMC9205077 DOI: 10.1186/s40942-022-00387-z] [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: 03/31/2022] [Accepted: 05/12/2022] [Indexed: 11/19/2022] Open
Abstract
Background Noninfectious endophthalmitis may be misdiagnosed, leading to serious clinical implications. So far, its causative factors remain unknown. Therefore, this study assessed the role of silicone oil and syringe agitation in the development of inflammation after intravitreal injection of aflibercept. Methods A randomized, double-blind, controlled clinical trial included subjects with an indication of intravitreal antiangiogenic therapy prior to vitrectomy for proliferative diabetic retinopathy. Aflibercept was injected 48 h before surgery. The control group received the injection without agitation, while the intervention group was injected with a previously agitated syringe by flicking with either a siliconized or silicone oil-free syringe. The primary endpoint was the presence of anterior chamber reaction (ACR) at 48 h. Aqueous samples were collected and underwent cytometric bead array analysis for quantification of interleukins and chemokines. Results Forty-one individuals were included (21 in the agitation group and 20 in the no-agitation group). None of the included eyes showed baseline signs of AC cells, hyperemia or pain complaint, while 10% of control group and 80% of agitation group showed AC cells 48 h after injection of aflibercept with SR syringe. There were no differences in the mean variations of all cytokines and chemokines by agitation status. However, there was a marginally significant increase between the mean variations of IP-10 (p = 0.057) and IL-8 (p = 0.058) in the siliconized one. Conclusion This clinical trial discloses a potential role of agitation and siliconized syringes in the development of inflammation after an intravitreal injection of aflibercept. These findings have important clinical implications for all healthcare practitioners who perform intravitreal injections. Trial Registration: Brazilian Registry of Clinical Trials, RBR-95ddhp. Registered 12 May 2019, http://www.ensaiosclinicos.gov.br/rg/RBR-95ddhp/
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Affiliation(s)
| | | | | | | | | | - Mauricio Maia
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Gustavo Barreto Melo
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, SP, Brazil. .,Hospital de Olhos de Sergipe, Rua Campo do Brito, 995, São José, Aracaju, SE, 49020-380, Brazil.
| | - Michel Eid Farah
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, SP, Brazil
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Miller CW, Wilneff MA, Wuller AL, Platt SM, Schartman JP, Lewis SA, Rao LJ, Wuller SL, Miller DG. Frequency and Symptoms of Intravitreal Silicone Oil Droplets Following Becton Dickinson and Norm-Ject Bevacizumab Injections. Ophthalmic Surg Lasers Imaging Retina 2022; 53:108-112. [PMID: 35148214 DOI: 10.3928/23258160-20220124-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE To determine silicone oil droplet frequency and symptomatic impact in patients injected with Norm-Ject (NJ) and/or Becton Dickinson (BD) intravitreal bevacizumab. PATIENTS AND METHODS This was a retrospective cohort study of 426 patients with prior bevacizumab injection(s). Symptomatic floaters questionnaire responses were compiled and statistical analysis was performed using Fisher's exact t test with 95% CI calculated via the modified Wald method. RESULTS Patients who received BD intravitreal bevacizumab showed more droplets (67.2%) than those who received NJ intravitreal bevacizumab (7.8%), and droplets increased with injection quantity. However, the symptomatic patients reporting new floaters were similar (NJ: 39.22%, BD: 39.47%). [Ophthalmic Surg Lasers Imaging Retina. 2022;53:108-112.].
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Melo GB, Cruz NFS, Monte Agra LL, Emerson GG, Lima LH, Linkuviene V, Maia M, Farah ME, Carpenter JF, Rodrigues EB, Probst C. Silicone oil-free syringes, siliconized syringes and needles: quantitative assessment of silicone oil release with drugs used for intravitreal injection. Acta Ophthalmol 2021; 99:e1366-e1374. [PMID: 33890418 DOI: 10.1111/aos.14838] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/17/2021] [Accepted: 02/23/2021] [Indexed: 01/04/2023]
Abstract
PURPOSE This study aimed to quantify the amount of silicone oil (SO) released across a variety of syringe and needle models routinely used for intravitreal injection. METHODS The release of SO was assessed in eight models of syringes, two of which were reported to be 'SO-free', and eleven models of needles with unknown SO content. To evaluate SO release within the context of anti-VEGF therapeutics, syringes were evaluated using aflibercept, bevacizumab, buffer, ziv-aflibercept and formulation buffer. All syringe tests were performed with or without agitation by flicking for syringes. Needles were evaluated without agitation only. Samples were fluorescently labelled to identify SO, and triplicate measurements were collected using imaging flow cytometry. RESULTS Seven out of 8 syringe models showed a statistically significant increase in the SO particle count after agitation. The two SO-free syringe models (HSW Norm-Ject, Daikyo Crystal Zenith) released the least SO particles, with or without agitation, whereas the BD Ultra-Fine and Saldanha-Rodrigues syringes released the most. More SO was released when the syringes were prefilled with formulation buffer than with ziv-aflibercept. Syringes filled with aflibercept and bevacizumab had intermediate levels. Agitation increased the release of SO into each of the drug solutions. Silicone oil (SO) was detected in all needles. CONCLUSIONS Agitation of the syringe by flicking leads to a substantial increase in the number of SO particles. Silicone oil (SO)-free syringes had the best performance, but physicians must also be aware that needles are siliconized and also contribute to the injection of SO into the vitreous.
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Affiliation(s)
- Gustavo Barreto Melo
- Department of Ophthalmology Federal University of São Paulo São Paulo Brazil
- Hospital de Olhos de Sergipe Aracaju Brazil
| | | | - Lydianne Lumack Monte Agra
- Department of Ophthalmology Federal University of São Paulo São Paulo Brazil
- Hospital de Olhos de Sergipe Aracaju Brazil
| | | | - Luiz H. Lima
- Department of Ophthalmology Federal University of São Paulo São Paulo Brazil
| | - Vaida Linkuviene
- Department of Pharmaceutical Sciences University of Colorado Denver CO USA
| | - Maurício Maia
- Department of Ophthalmology Federal University of São Paulo São Paulo Brazil
| | - Michel Eid Farah
- Department of Ophthalmology Federal University of São Paulo São Paulo Brazil
| | - John F. Carpenter
- Department of Pharmaceutical Sciences University of Colorado Denver CO USA
| | - Eduardo Büchele Rodrigues
- Department of Ophthalmology Federal University of São Paulo São Paulo Brazil
- Department of Ophthalmology Saint Louis University School of Medicine Saint Louis MO USA
| | - Christine Probst
- Department of Research and Development Sciences Luminex Corporation Seattle WA USA
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Sanabria MR, Alonso‐Tarancón AM, Calles‐Monar PS, Ibañez P, García de Arriba S, Alvarez N, Piñuel JA, Coco RM, Fernández I. Silicone microbubbles after anti-vascular endothelial growth factor injections in patients with wet age-related macular degeneration: incidence, quantification and secondary optical coherence tomography artfacts. Acta Ophthalmol 2021; 99:e1051-e1055. [PMID: 33421336 DOI: 10.1111/aos.14743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 12/05/2020] [Accepted: 12/07/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE To report the incidence and quantity of silicone oil microbubbles and the relationship with the number of intravitreal anti-vascular endothelial growth factor (VEGF) injections and evaluate if microbubbles induce artefacts on optical coherence tomography (OCT) images. METHODS Observational, descriptive, cross-sectional study. Patients with wet age-related macular degeneration were included who had been treated for 1 year minimally with anti-VEGF injections repackaged in the hospital pharmacy. Detection and quantification of silicone microbubbles by mydriatic biomicroscopic examination were conducted 1 month after the last injection. The numbers of microbubbles were quantified on a scale of 0-3: 0, none; 1 scarce (1-10 microbubbles); 2 moderate (10-30); or 3 numerous (>30). Shadowing on OCT images was classified as 0-3: 0, none; 1 obscuring some retinal layers; 2 obscuring all retinal layers; or 3 obscuring the retinal thickness. RESULTS The study included 142 eyes of 98 patients (mean age, 82.4 years + 7.3; range, 65-97) treated with 2377 injections. Microbubbles were detected in 127 (89.4%) eyes, 62 (43.6%) with numerous microbubbles and 36 (25.4%) and 29 (20.4%), respectively, with scarce and moderate numbers. A positive correlation was found between the numbers of injections and intravitreal silicone (rho, 0.7). Optical coherence tomography (OCT) artefacts were detected in 11 eyes; the artefacts obscured all retinal layers in three eyes. No significant relationship could be established between the appearance of floaters and the microbubbles. CONCLUSION The presence and number of silicone microbubbles were correlated with the number of intravitreal injections. Microbubbles can produce OCT artefacts, which can hinder the treatment decision.
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Affiliation(s)
- Maria R. Sanabria
- Palencia University Hospital Complex Palencia Spain
- Institute of Applied Ophthalmobiology University of Valladolid Valladolid Spain
| | | | | | | | | | | | | | - Rosa M. Coco
- Institute of Applied Ophthalmobiology University of Valladolid Valladolid Spain
- OFTARED Health Research Thematic Network Carlos III Health Institute Madrid Spain
| | - Itziar Fernández
- Institute of Applied Ophthalmobiology University of Valladolid Valladolid Spain
- Department of Statistics University of Valladolid Valladolid Spain
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Lam LA, Mehta S, Lad EM, Emerson GG, Jumper JM, Awh CC. Intravitreal Injection Therapy: Current Techniques and Supplemental Services. JOURNAL OF VITREORETINAL DISEASES 2021; 5:438-447. [PMID: 37008713 PMCID: PMC9976140 DOI: 10.1177/24741264211028441] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: Intravitreal injection is the most frequently performed eye procedure in the world and is an essential component in the management of sight-threating retinal diseases and conditions. Given the seriousness and range of diseases treated and the risks of the procedure, retina specialists must weigh the pros and cons of each individual treatment. Complexities guiding injection treatment are multifaceted and involve patient-history review, careful examination, diagnostic testing selection and interpretation, customized medical decision-making, and follow-up considerations. Methods: This article by the Intravitreal Injection Task Force Committee of the American Society of Retina Specialists documents the intricacies and necessary components of the intravitreal injection procedure. Results: By expert consensus, the task force further recommends ancillary services and decision-making that may accompany intravitreal injection visits, when appropriate, to monitor response to treatment, adjust treatment, and manage additional considerations in the same or fellow eye. Conclusions: Retina specialists can optimize safety and therapeutic outcomes with individualized consideration and customization of intravitreal injection treatment for each patient.
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Affiliation(s)
- Linda A. Lam
- University of Southern California Roski Eye Institute, Keck School of Medicine, Los Angeles, CA, USA
| | - Sonia Mehta
- Wills Eye Hospital/Mid-Atlantic Retina, Philadelphia, PA, USA
| | - Eleonora M. Lad
- Duke Eye Center, Duke University Medical School, Durham, NC, USA
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da Cruz NFS, Agra LLDM, Probst C, Lima LH, Carpenter JF, Maia M, Farah ME, Melo GB. In-vitro assessment of release of silicone oil droplets with the use of variety of syringes and needles used in intravitreal injections. Eur J Ophthalmol 2021; 32:11206721211019580. [PMID: 34024140 DOI: 10.1177/11206721211019580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To assess the variability of silicone oil (SO) particles released across syringes from the same lot and the role of different needle gauges. MATERIALS AND METHODS Four syringe models and six needle models were assessed for SO release. About 50 microliters of a buffer solution were loaded into the syringe, needle or syringe/needle setup. The data were analyzed by imaging flow cytometry with fluorescently labeling for SO. RESULTS All syringe models had a high coefficient of variation in SO release across syringes from the same lot. The amount of SO was significantly greater in the syringe when the needle was attached. SO particles with the BD 30G needle attached to the syringe were statistically greater than the 27G counterpart (p = 0.005). None of the other comparisons was statistically different. Finally, the number of SO particles was higher in the syringe/needle setup than in needles only (p = 0.0024). CONCLUSION We found a high variability in SO content across syringes from the same lot. Additionally, there was no clear association between needle gauge and the number of SO particles, as well as their coefficient of variation. Finally, the needles accounted for a small number of SO particles in comparison to the combined syringe-needle setup.
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Affiliation(s)
| | - Lydianne Lumack do Monte Agra
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, SP, Brazil
- Hospital de Olhos de Sergipe, Aracaju, SE, Brazil
| | - Christine Probst
- Department of Research and Development Sciences, Luminex Corporation, Seattle, WA, USA
| | - Luiz Henrique Lima
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, SP, Brazil
| | - John F Carpenter
- Department of Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - Mauricio Maia
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Michel Eid Farah
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Gustavo Barreto Melo
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, SP, Brazil
- Hospital de Olhos de Sergipe, Aracaju, SE, Brazil
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Iyer PG, Albini TA. Drug-related adverse effects of antivascular endothelial growth factor agents. Curr Opin Ophthalmol 2021; 32:191-197. [PMID: 33770015 DOI: 10.1097/icu.0000000000000757] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Antivascular endothelial growth factor (VEGF) agents have provided historic therapeutic breakthroughs in the treatment of retinal disease. New anti-VEGF agents are emerging for the treatment of retinal vascular diseases. Both systemic and ocular adverse effect need to be understood in managing patients. This review aims to highlight the adverse effects seen with routine use of bevacizumab, ranibizumab and aflibercept, as well as with new medications such as brolucizumab and abicipar. RECENT FINDINGS We review the recent findings of intraocular inflammation (IOI) of brolucizumab and abicipar in the context of the efficacy and safety reported with the routine anti-VEGF agents. Specifically, brolucizumab has been reported to cause occlusive retinal vasculitis in the setting of IOI, which has not been seen in other anti-VEGF medications. In addition, abicipar appears to cause IOI at a higher rate of patients than other anti-VEGF agents have previously. SUMMARY Newer anti-VEGF agents pose a significant risk of adverse events not seen with routine anti-VEGF agents.
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Affiliation(s)
- Prashanth G Iyer
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
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Prospective Study of Silicone Oil Microdroplets in Eyes Receiving Intravitreal Anti-Vascular Endothelial Growth Factor Therapy in 3 Different Syringes. ACTA ACUST UNITED AC 2021; 5:234-240. [DOI: 10.1016/j.oret.2020.07.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/03/2020] [Accepted: 07/23/2020] [Indexed: 11/23/2022]
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Huet F, Miller J, Miller PE, Hayden C, Glick JJ, Bentley A, De Benedetto C, McPherson LE, Turner OC. Observation of Silicone Oil Within the Vitreous and Sclera Following Intravitreal Administration of Biotherapeutics Using Insulin Syringes in Cynomolgus Monkeys. Toxicol Pathol 2020; 49:590-597. [PMID: 33272095 DOI: 10.1177/0192623320966543] [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: 11/17/2022]
Abstract
Silicone oil droplets have been reported in the eyes of human patients following intravitreous (IVT) injections with several marketed biotherapeutic products. Intravitreous administration of a novel biotherapeutic in a 14-week cynomolgus monkey study using insulin syringes was associated with 2, non-test-article-related phenomena: "vitreous floater/clear sphere" on indirect ophthalmoscopy and intrascleral "foreign material near injection track" on histopathology. Retrospective analysis of 81 other preclinical studies of IVT administration of novel biotherapeutics found a greater frequency of clear spheres in monkey IVT studies using insulin syringes and formulations containing polysorbate. We were able to correlate microscopic findings of clear circular to oval areas in the sclera near the injection track with an energy-dispersive X-ray spectroscopy (EDS) signal for silicon at the same location in the sclera. These observations provide further evidence that silicone lubricant in insulin syringes/needles is the source of clear spheres noted in the vitreous and foreign material noted near the injection track in the sclera. Although considered inert and toxicologically insignificant, silicone deposition within the eye should form part of the risk-benefit equation in a clinical setting.
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Affiliation(s)
- François Huet
- Novartis, 33413Novartis Institutes for BioMedical Research, Preclinical Safety, Cambridge, MA, USA
| | | | - Paul E Miller
- 70738School of Veterinary Medicine, University of Wisconsin-Madison, WI, USA.,OSOD LLC, Madison, WI, USA
| | - Chris Hayden
- Novartis, 98557Novartis Institutes for BioMedical Research, Preclinical Safety, East Hanover, NJ, USA
| | - James J Glick
- Novartis, 98557Novartis Institutes for BioMedical Research, PK Sciences, East Hanover, NJ, USA
| | - Adam Bentley
- Novartis, 98557Novartis Institutes for BioMedical Research, PK Sciences, East Hanover, NJ, USA
| | - Chris De Benedetto
- Novartis, 98557Novartis Institutes for BioMedical Research, Preclinical Safety, East Hanover, NJ, USA
| | | | - Oliver C Turner
- Novartis, 98557Novartis Institutes for BioMedical Research, Preclinical Safety, East Hanover, NJ, USA
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16
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Gómez-Mariscal M, Díez-Álvarez L. Silicone oil droplets after intravitreal injections: An uncomfortable adverse effect in our consultations. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2020; 95:261-262. [PMID: 32001031 DOI: 10.1016/j.oftal.2020.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/03/2020] [Indexed: 06/10/2023]
Affiliation(s)
- M Gómez-Mariscal
- Servicio de Oftalmología, Hospital Universitario Ramón y Cajal (Irycis), Madrid, España.
| | - L Díez-Álvarez
- Servicio de Oftalmología, Hospital Universitario Ramón y Cajal (Irycis), Madrid, España
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17
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RETAINED, NONDISSOLVING, TUBULAR FOREIGN BODIES IN THE VITREOUS CAVITY AFTER INTRAVITREAL DEXAMETHASONE (OZURDEX) IMPLANTATION. Retina 2020; 40:2221-2225. [PMID: 32379167 PMCID: PMC9206819 DOI: 10.1097/iae.0000000000002824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe the retention of large, tubular, nondissolving foreign bodies because of a complication of the intravitreal dexamethasone implant (Ozurdex). METHODS This is a single-center, retrospective chart review of patients who were found to have retained, nondissolvable tubular foreign bodies in the vitreous cavity for more than 6 months (the expected dissolution time of the implants) after Ozurdex injections. Ocular symptomatology and multimodal imaging were reviewed. RESULTS Five patients had retained, nondissolvable tubular foreign bodies in the vitreous that persisted for months (mean 28.2 months, range 9-67 months) after intravitreal injection of Ozurdex. Two patients were symptomatic due to the foreign bodies and chose alternate local therapy, but none of the patients opted for surgical explantation. CONCLUSION Persistent, nondissolving, tubular foreign bodies can be seen in the vitreous cavity for years after injection of the Ozurdex implant. Clinicians should be aware of this complication that has the potential to cause visual symptoms and ocular morbidity.
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18
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Melo GB, Cruz NFSD, Emerson GG, Rezende FA, Meyer CH, Uchiyama S, Carpenter J, Shiroma HF, Farah ME, Maia M, Rodrigues EB. Critical analysis of techniques and materials used in devices, syringes, and needles used for intravitreal injections. Prog Retin Eye Res 2020; 80:100862. [PMID: 32311476 DOI: 10.1016/j.preteyeres.2020.100862] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/23/2020] [Accepted: 04/02/2020] [Indexed: 12/26/2022]
Abstract
Intravitreal injections have become the most commonly performed intraocular treatments worldwide. Because intravitreal injections may induce severe adverse events, such as infectious and noninfectious endophthalmitis, cataract, ocular hypertension, vitreous hemorrhage, or retinal detachment, appropriate awareness of the materials and techniques used are essential to reduce these sight-threatening complications. This review provides insights into the needles, syringes, silicone oil coating, sterilization methods, devices to assist intravitreal injections, scleral piercing techniques using needles, syringe handling, anesthesia, and safety issues related to materials and techniques. It is paramount that physicians be aware of every step involved in intravitreal injections and consider the roles and implications of all materials and techniques used. The ability to understand the theoretical and practical circumstances may definitely lead to state-of-the-art treatments delivered to patients. The most important practical recommendations are: choosing syringes with as little silicone oil as possible, or, preferably, none; avoiding agitation of syringes; awareness that most biologics (e.g., antiangiogenic proteins) are susceptible to changes in molecular properties under some conditions, such as agitation and temperature variation; understanding that improper materials and techniques may lead to complications after intravitreal injections, e.g., inflammation; and recognizing that some devices may contribute to an enhanced, safer, and faster intravitreal injection technique.
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Affiliation(s)
- Gustavo Barreto Melo
- Hospital de Olhos de Sergipe, Rua Campo do Brito, 995, Aracaju, SE, Brazil; Department of Ophthalmology, Federal University of São Paulo, Rua Botucatu, 806, São Paulo, SP, Brazil.
| | | | | | | | - Carsten H Meyer
- Department of Ophthalmology, Federal University of São Paulo, Rua Botucatu, 806, São Paulo, SP, Brazil; Department of Ophthalmology, Philipps University of Marburg, Robert-Koch-Strasse 4, Marburg, Germany
| | - Susumu Uchiyama
- Department of Biotechnology, Graduate School of Engineering, Osaka University, 2-1 Yamadaoka, Osaka, Japan
| | - John Carpenter
- Department of Pharmaceutical Sciences, University of Colorado, Denver/Aurora, CO, USA
| | - Hélio Francisco Shiroma
- Department of Ophthalmology, Federal University of São Paulo, Rua Botucatu, 806, São Paulo, SP, Brazil
| | - Michel Eid Farah
- Department of Ophthalmology, Federal University of São Paulo, Rua Botucatu, 806, São Paulo, SP, Brazil
| | - Maurício Maia
- Department of Ophthalmology, Federal University of São Paulo, Rua Botucatu, 806, São Paulo, SP, Brazil
| | - Eduardo Büchele Rodrigues
- Department of Ophthalmology, Federal University of São Paulo, Rua Botucatu, 806, São Paulo, SP, Brazil; Department of Ophthalmology, SSM Health Saint Louis University Hospital, Saint Louis University, 1755, S. Grand Boulevard, Saint Louis, MO, USA
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19
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Agitation of the syringe and release of silicone oil. Eye (Lond) 2020; 34:2242-2248. [PMID: 32127655 DOI: 10.1038/s41433-020-0800-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 12/03/2019] [Accepted: 12/10/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND/OBJECTIVES To investigate whether agitation promotes the release of silicone oil by different models of syringe used for intravitreal injection. METHODS This lab study analyzed eight syringe models by light microscopy for the release of silicone oil under agitation (flick), without agitation, and positive controls. Fourier-Transform Infrared Spectroscopy (FTIR) was performed to identify the molecular compounds inside the syringes. RESULTS A total of 240 syringes were analyzed. The presence of silicone oil droplets was observed in all positive controls. When agitated by flicking, 100% of the samples of the syringes disclosed silicone oil, except the BD Plastipak syringe, which presented 40% of positivity. Without agitation, a smaller percentage of samples with silicone oil was observed. Agitation by flicking had a 265-fold greater chance of presenting oil droplets when compared with the syringes without agitation. There was a statistically significant difference between the three conditions (P < 0.05). Analysis of the tip of the plunger rubber by FTIR indicated the presence of polysiloxane (silicone oil) in all models of syringe. CONCLUSIONS Agitation of the syringe promotes the release of silicone oil. It is recommended to improve the technique of injection and the manufacture of specific syringes for ophthalmological use.
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20
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A new method for pharmaceutical compounding and storage of anti-VEGF biologics for intravitreal use in silicone oil-free prefilled plastic syringes. Sci Rep 2019; 9:18021. [PMID: 31792234 PMCID: PMC6888834 DOI: 10.1038/s41598-019-54226-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 11/06/2019] [Indexed: 12/27/2022] Open
Abstract
Intravitreal injections of antibody-based biologics targeting vascular endothelial growth factor (VEGF) are highly effective and have markedly decreased the risk of visual impairment associated with prevalent retinal diseases, such as neovascular age-related macular degeneration and diabetes macular oedema. The diseases are chronic in their nature, and most patients need long-term therapy to suppress disease activity. We previously reported a compounding method for repackaging and storage of aflibercept (Eylea), a commonly used anti-VEGF biologic, in silicone oil-coated plastic syringes without compromising drug stability or activity. In addition to improving safety and time spent per patient, compounding of anti-VEGF biologics enables single-dose vials to be split into multiple syringes, thereby considerably reducing waste and drug expenses. However, symptomatic silicone oil droplets may deposit in the eye’s vitreous body after repetitive injections. To fully avoid this complication, we here report on a novel pharmaceutical compounding method using silicone oil-free syringes and a 33 G × 9 mm Low Dead Space Needle hub injection needle. We evaluate the method for three anti-VEGF biologics commonly used in ophthalmology: aflibercept, ranibizumab (Lucentis) and bevacizumab (Avastin). Our results show that compounding and storage for one week does not compromise the functional activity of the biologics and allows for safe and cost-effective compounding of anti-VEGF biologics for intravitreal injections in prefilled silicone oil-free syringes.
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21
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Melo GB, Dias Junior CDS, Morais FB, Cardoso AL, Figueiredo AGA, Lima Filho AAS, Rodrigues EB, Emerson GG, Maia M. Prevalence of silicone oil droplets in eyes treated with intravitreal injection. Int J Retina Vitreous 2019; 5:34. [PMID: 31528356 PMCID: PMC6737593 DOI: 10.1186/s40942-019-0184-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 08/05/2019] [Indexed: 11/10/2022] Open
Abstract
Objective To assess the number of eyes with silicone oil in the vitreous after intravitreal injection. Methods This cross-sectional, comparative study was divided into 2 groups: (1) treatment—eyes subjected to antiangiogenic therapy; (2) control—no history of intravitreal injection. Subjects were assessed regarding age, gender, clinical diagnosis, lens status, visual acuity and number of previous intravitreal injections. All eyes underwent a meticulous slit-lamp and ultrasound examination for the identification of silicone oil. ImageJ software was used to quantify the index of silicone oil (IOS) by ultrasonography. Results Sixty-seven eyes (30 controls, 37 treated) were included. Slit-lamp examination found silicone oil droplets in 25 out of 37 (67.57%) treated eyes and in none of the control group. Ultrasonography identified silicone oil in 28 out of 37 (75.68%) treated eyes and in 1 out of 30 (3.33%) controls. An observed agreement of 85.07% and a Cohen’s Kappa coefficient of 69.10% (p < 0.0001) between ultrasonography and biomicroscopy were found. Wilcoxon test showed a statistically significant difference (p = 0.0006) in IOS between controls (0.41 ± 0.43%) and treated eyes (2.69 ± 2.55%). Spearman’s correlation test (0.61; p < 0.0001) showed that the greater the number of injections, the higher the IOS. Conclusions Silicone oil droplets were found in the majority of the eyes previously treated with antiangiogenic intravitreal injection. The greater the number of injections, the higher the likelihood of finding silicone oil. An improvement in the technique of injection and better-quality syringes post-injection silicone oil droplets.
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23
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Melo GB, Emerson GG, Dias CS, Morais FB, Lima Filho ADS, Ota S, Farah ME, Rodrigues EB, Maia M, Belfort R. Release of silicone oil and the off-label use of syringes in ophthalmology. Br J Ophthalmol 2019; 104:291-296. [PMID: 30910872 DOI: 10.1136/bjophthalmol-2019-313823] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 02/14/2019] [Accepted: 02/26/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND/AIMS To assess silicone oil (SO) release by different brands of syringes used for intravitreal injection under different handling conditions. METHODS Eight syringes were analysed: from the USA, Terumo 0.5 mL, Becton-Dickinson (BD) Tuberculin 1 mL, BD Luer-lok 1 mL, BD Ultra-Fine 0.3 mL and Exel Insulin 0.3 mL; from Germany, Braun Omnifix-F 1 mL and Braun Injekt-F 1 mL and from Spain, BD Plastipak 1 mL. The impact of air, priming the plunger, agitation by flicking and fluid temperature on SO release were assessed by light microscopy. Fourier transform infrared spectroscopy (FTIR) was performed to identify the molecular compound in each syringe. RESULTS Five hundred and sixty syringes were analysed. Terumo 0.5 mL and BD Ultra-Fine 0.3 mL released more SO than all others. BD Luer-lok 1 mL, BD Plastipak and Braun Omnifix-F 1 mL released little SO; BD Tuberculin 1 mL, Exel 0.3 mL and Braun Injekt-F 1 mL released the least SO. Priming the syringe and different temperatures did not significantly affect SO release. Agitation by flicking caused a significantly higher proportion of samples to have SO droplets and an increased number of oil droplets. Air had an additive effect on the release of oil in the agitation groups. FTIR identified polysiloxane in all syringes but Injekt-F. CONCLUSION Syringes commonly used for intravitreal injections frequently release SO droplets, especially when agitated by flicking. To avoid unnecessary ocular risks, syringes should not be agitated before intravitreal injection. It is desirable that syringes be manufactured specifically for ophthalmic use.
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Affiliation(s)
- Gustavo Barreto Melo
- Hospital de Olhos de Sergipe, Aracaju, Brazil .,Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
| | | | | | - Fábio Barreto Morais
- Hospital de Olhos de Sergipe, Aracaju, Brazil.,Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
| | - Acacio de Souza Lima Filho
- Ophthalmology, Federal University of São Paulo, São Paulo, Brazil.,Vision Institute, IPEPO, São Paulo, Brazil
| | - Shoko Ota
- Chemical Analysis Laboratory, Center for Chemistry and Manufactured Goods, Institute for Technological Research, São Paulo, Brazil
| | - Michel Eid Farah
- Ophthalmology, Federal University of São Paulo, São Paulo, Brazil.,Vision Institute, IPEPO, São Paulo, Brazil
| | - Eduardo Büchele Rodrigues
- Ophthalmology, Federal University of São Paulo, São Paulo, Brazil.,Vision Institute, IPEPO, São Paulo, Brazil
| | - Maurício Maia
- Ophthalmology, Federal University of São Paulo, São Paulo, Brazil.,Vision Institute, IPEPO, São Paulo, Brazil
| | - Rubens Belfort
- Ophthalmology, Federal University of São Paulo, São Paulo, Brazil.,Vision Institute, IPEPO, São Paulo, Brazil
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24
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Olea JL, Gómez-Resa M, Cervera-Peris MM, Aragón JA. Silicone oil droplets in repackaged anti–vascular endothelial growth factors for intravitreal injections: In search of the main source of contamination. Eur J Ophthalmol 2019; 30:774-779. [DOI: 10.1177/1120672118823133] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Repackaging of anti–vascular endothelial growth factors in polypropylene syringes lubricated with silicone oil for intravitreal use is associated with the presence of intravitreal silicone oil droplets. The objective of this study is to assess how the use of silicone-free syringes (for storage and/or administration) would reduce the amount of silicone oil droplets in the product to be administered. Methods: Two 16 mL vials of bevacizumab were repackaged at the compounding pharmacy to obtain four sets of product, each consisting of three 1.2 mL tubes of the drug repackaged in different ways. Set A was repackaged according to routine practice, that is, the drug was placed into 1 mL siliconized syringes and 60 µL aliquots were extracted with 0.5 mL insulin siliconized syringes until reaching 1.2 mL. In set B, a 1-mL silicone-free syringe was used, followed by a 0.5 mL siliconized syringe. In set C, only 0.5 mL siliconized syringes were used. In set D, only the 1-mL silicone-free syringe was used. Micro-Flow Imaging technology was used for quantifying silicone oil droplet–like particles below 25 µm. Results: Silicone oil droplet–like particles were absent in set D. Set C had the highest average frequency of these particles, which was much lower in sets A and B. Set B had the lowest frequency. Conclusion: 0.5 mL insulin syringes with staked-in needles used for supplying the product seem to be the main source of silicone oil contamination in repackaged anti–vascular endothelial growth factors. Silicone-free insulin syringes with staked-in needles would be strongly recommended for supplying anti–vascular endothelial growth factor intravitreal injections from compounding pharmacies.
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Affiliation(s)
- José Luis Olea
- Department of Ophthalmology, Son Espases University Hospital, Palma de Mallorca, Spain
| | - María Gómez-Resa
- Department of Ophthalmology, Son Espases University Hospital, Palma de Mallorca, Spain
| | | | - Juan Antonio Aragón
- Department of Ophthalmology, Son Espases University Hospital, Palma de Mallorca, Spain
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25
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Melo GB, Dias Junior CDS, Carvalho MR, Cardoso AL, Morais FB, Figueira ACM, Lima Filho AAS, Emerson GG, Maia M. Release of silicone oil droplets from syringes. Int J Retina Vitreous 2019; 5:1. [PMID: 30788149 PMCID: PMC6318836 DOI: 10.1186/s40942-018-0153-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 12/24/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Intravitreal silicone oil droplets have been found in the vitreous. The aim of this study is to compare the rates of silicone oil released by different brands of commonly used syringes for intravitreal injection after agitation by flicking. METHODS Three models of two brands of syringes were analyzed for their rates of silicone oil release: Saldanha Rodrigues (SR) 1 mL insulin syringe (SR, Brazil, syringe 1), Becton-Dickinson (BD) Plastipak 1 mL insulin syringe (Brazil, syringe 2), and BD Safety-Glide 1 mL insulin syringe (USA, syringe 3). All syringes were tested under four different conditions: positive control (fluid with addition of silicone oil) without agitation (group 1, n = 5); positive control with agitation (group 2, n = 3); fluid only without agitation (group 3, n = 5); and fluid only with agitation (group 4, n = 5). Masked graders performed all analyses using light microscopy. RESULTS All syringes (1, 2, and 3) released silicone oil droplets in the positive control group regardless of the agitation status (groups 1 and 2). When no oil was added and the syringes were not agitated, only syringe 1 released silicone oil droplets (40% of samples). After agitation, syringes 1 and 3 released silicone oil droplets in all samples. Quantitative analysis showed a significantly (P = 0.011; 11.2 ± 2.9 vs. 0.6 ± 0.9, respectively) higher mean number of silicone oil droplets released by syringe 1 after agitation compared to no agitation. Syringe 1 also had significantly (P = 0.002, 11.2 ± 2.9 vs. 0.0 ± 0.0 vs. 2.2 ± 0.8, respectively) more droplets than syringes 2 and 3 after agitation. CONCLUSIONS Syringes commonly used for intravitreal injections frequently release silicone oil droplets when agitated by flicking, especially the SR insulin ones. We recommend that they not be agitated at the time of intravitreal injection and that the manufacturers consider producing syringes adapted for intraocular use.
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Affiliation(s)
- Gustavo Barreto Melo
- Hospital de Olhos de Sergipe, Rua Campo do Brito, 995 São José, 49020-380 Aracaju, SE Brazil
- Federal University of São Paulo, São Paulo, SP Brazil
| | | | - Mariana Reis Carvalho
- Hospital de Olhos de Sergipe, Rua Campo do Brito, 995 São José, 49020-380 Aracaju, SE Brazil
| | - Alexandre Lima Cardoso
- Hospital de Olhos de Sergipe, Rua Campo do Brito, 995 São José, 49020-380 Aracaju, SE Brazil
| | - Fábio Barreto Morais
- Hospital de Olhos de Sergipe, Rua Campo do Brito, 995 São José, 49020-380 Aracaju, SE Brazil
- Federal University of São Paulo, São Paulo, SP Brazil
| | | | | | | | - Maurício Maia
- Federal University of São Paulo, São Paulo, SP Brazil
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26
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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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