Complications of subspecialty ophthalmic care: endophthalmitis after intravitreal injections of anti-vascular endothelial growth factor medications

Adverse event reporting of faricimab: a disproportionality analysis of FDA adverse event reporting system (FAERS) database

Background

Faricimab is the first and only bispecific antibody approved by the U.S. Food and Drug Administration (FDA) for intravitreal injection. Given its increasingly widespread use in retinal vascular diseases, understanding its adverse events (AEs) in real-world settings is crucial. This study employed the FDA Adverse Event Reporting System (FAERS) database to investigate potential safety concerns, with the aim of providing new insights for clinical practice.

Methods

This study conducted a disproportionality analysis of adverse event data from the FAERS database, in which faricimab was identified as the primary suspect, covering the period from the first quarter of 2022 to the second quarter of 2024. To ensure the accuracy and reliability of the study, we employed four types of disproportionality analyses: the reporting odds ratio (ROR), proportional reporting ratio (PRR), multi-item gamma Poisson shrinker (MGPS), and Bayesian confidence propagation neural network (BCPNN). Additionally, the Weibull distribution was utilized to model the risk of adverse events over time.

Results

A total of 2,735 adverse reaction reports, in which faricimab was identified as the primary suspect, were retrieved from the FAERS database. The analysis showed that faricimab-induced AEs occurred across 25 system organ classes (SOCs), with eye disorders meeting the positive threshold for all four algorithms. Significant AEs were mapped to preferred terms (PT), identifying the adverse reactions listed on the drug label: endophthalmitis, elevated intraocular pressure, cataract, retinal pigment epithelial tear, vitreous floaters, retinal vasculitis, retinal artery occlusion, and retinal vein occlusion. In addition to the AEs listed on the drug label, several previously unreported AEs were identified, including blindness, cerebral infarction, retinal hemorrhage, retinal occlusive vasculitis, glaucoma, dry eye, metamorphopsia, and unilateral blindness.

Conclusion

This study provided valuable evidence on the real-world safety of faricimab, suggesting that clinicians should place greater emphasis on monitoring its adverse effects during use.

Topical Solution for Retinal Delivery: Bevacizumab and Ranibizumab Eye Drops in Anti-Aggregation Formula (AAF) in Rabbits

PURPOSE

Wet age-related macular degeneration (AMD) is a blinding retinal disease. Monthly intravitreal anti-VEGF antibody injections of bevacizumab (off-label) and ranibizumab (FDA approved) are the standard of care. Antibody aggregation may interfere with ocular absorption/distribution. This study assessed topical delivery of dilute antibodies to the posterior segment of rabbit eyes using a novel anti-aggregation formula (AAF).

METHODS

Bevacizumab, or biosimilar ranibizumab was diluted to 5 mg/ml in AAF. All rabbits were dosed twice daily. Substudy 1 rabbits (bevacizumab, 100 µl eye drops): Group 1 (bevacizumab/AAF, n = 6); Group 2 (bevacizumab/PBS, n = 7) and Vehicle control (AAF, n = 1). Substudy 2 rabbits (ranibizumab biosimilar/AAF, 50 µl eye drops): (ranibizumab biosimilar/AAF, n = 8). At 14.5 days, serum was drawn from rabbits. Aqueous, vitreous and retina samples were recovered from eyes and placed into AAF aliquots. Tissue analyzed using AAF as diluent.

RESULTS

Bevacizumab in AAF permeated/accumulated in rabbit aqueous, vitreous and retina 10 times more, than when diluted in PBS. AAF/0.1% hyaluronic acid eye drops, dosed twice daily, provided mean tissue concentrations (ng/g) in retina (29.50), aqueous (12.34), vitreous (3.46), and serum (0.28 ng/ml). Additionally, the highest concentration (ng/g) of ranibizumab biosimilar was present in the retina (18.0), followed by aqueous (7.82) and vitreous (1.47). Serum concentration was negligible (< 0.04 ng/ml). No irritation was observed throughout the studies.

CONCLUSIONS

Bevacizumab and ranibizumab, in an AAF diluent eye drop, can be delivered to the retina, by the twice daily dosing of a low concentration mAb formulation. This may prove to be an adjunct to intravitreal injections.

Early Vitrectomy with Silicone Oil Tamponade in the Management of Postoperative Endophthalmitis

Background: Early vitrectomy for postsurgical endophthalmitis may improve visual acuity outcomes. Silicone oil as a tamponade has some potential benefits in the management of endophthalmitis. This study aims to evaluate the use of a silicone oil tamponade in the surgical management of endophthalmitis. Material and Methods: All patients with a pars plana vitrectomy with silicone oil tamponade for postsurgical endophthalmitis at the Department of Ophthalmology, University of Bonn, Germany, between 2017 and 2021 were retrospectively reviewed. We included all preoperative data, including BCVA at diagnosis, clinical findings, and symptoms. For every follow-up visit, we looked at BCVA and complications. Results: In total, 82 patients were included in this study. The mean follow-up was 13.1 months (range 1-58 months). An intravitreal injection was the cause in 42 patients (51.2%) and cataract surgery in 29 patients (35.4%). The mean interval between the causing event and the date of onset was 8.8 days (range, 1-59 days). The most prevalent pathogen was Staphylococcus epidermidis in 16 patients (19.5%). In 47 patients (57.3%), no pathogen was found. The initial best-corrected visual acuity was 2.1 logMAR and improved significantly to 1.0 logMAR after six months (p < 0.001) and 1.1 logMAR after 1 year (p < 0.001). In a multivariate analysis, a low BCVA at diagnosis (p = 0.041) was a significant predictor for poor visual acuity outcomes. A total of 17 patients (20.1%) developed postoperative complications. Five patients (6.1%) needed an anterior chamber washout with repeated injections of antibiotics. Two patients (2.4%) had persistent fibrin and were treated with YAG-laser treatment. Three patients (6.7%) developed a retinal detachment. Two patients (2.4%) had persistent corneal decompensation with endothelial cell loss and received perforating keratoplasty. We performed a matched-pair analysis (n = 30, each group n = 15) to compare a silicone oil tamponade with BSS at the end of surgery. The visual acuity outcome showed no significant differences (BCVA after one year: 1.17 logMAR in eyes with silicone oil and 0.90 logMAR in eyes with BSS; p = 0.684). Conclusions: In our study, a vitrectomy with silicone oil tamponade in the surgical management of postoperative endophthalmitis led to a significant improvement in visual acuity and had a low complication rate. Low BCVA at diagnosis was significantly associated with poor visual acuity outcomes. A comparison of silicone oil and BSS at the end of surgery showed similar results.

Ocular adverse events associated with anti-VEGF therapy: A pharmacovigilance study of the FDA adverse event reporting system (FAERS)

Background: The purpose of this study is to identify and characterize ocular adverse events (AEs) that are significantly associated with anti-VEGF drugs for treatment of neovascular age-related macular degeneration and compare the differences between each drug, and provide clinical reference. Methods: Ocular AEs submitted to the US Food and Drug Administration were analyzed to map the safety profile of anti-VEGF drugs. The Pharmacovigilance tools used for the quantitative detection of signals were reporting odds ratio and bayesian confidence propagation neural network. Results: A total of 10,608,503 AE reports were retrieved from FAERS, with 20,836 for ranibizumab, 19,107 for aflibercept, and 2,442 for brolucizumab between the reporting period of Q1, 2004 and Q3, 2021. We found and analyzed the different AEs with the strongest signal in each drug-ranibizumab-macular ischaemia (ROR = 205.27, IC-2SD = 3.70), retinal pigment epithelial tear (ROR = 836.54, IC-2SD = 7.19); aflibercept-intraocular pressure increased (ROR = 31.09, IC-2SD = 4.61), endophthalmitis (ROR = 178.27, IC-2SD = 6.70); brolucizumab-retinal vasculitis (ROR = 2930.41, IC-2SD = 7.47) and/or retinal artery occlusion (ROR = 391.11, IC-2SD = 6.10), dry eye (ROR = 12.48, IC-2SD = 2.88). Conclusion: The presence of AEs should bring clinical attention. The use of anti-VEGF drugs should be based on the patient's underlying or present medical condition to reduce any adverse event associated with the treatment.

Intraocular pressure decreases in eyes with glaucoma-related diagnoses after conversion to aflibercept for treatment-resistant age-related macular degeneration

OBJECTIVE

To understand intraocular pressure (IOP) response after switching from intravitreal bevacizumab (IVB) and/or ranibizumab (IVR) to intravitreal aflibercept (IVA) for treatment-resistant neovascular age-related macular degeneration (nAMD) in patients with and without coexisting glaucoma-related diagnoses.

METHODS

Retrospective, cross-sectional comparative case series of 62 eyes of 58 patients treated with intravitreal injection for nAMD from March 2010 to April 2018. Patients with glaucoma-related diagnoses, defined here as open-angle glaucoma or suspicion of open-angle glaucoma, ocular hypertension, and/or narrow-angle glaucoma, were compared to those without glaucoma. IOP data were collected at baseline, at the three visits where patients received loading doses of IVB/IVR, and at all of the visits following the switch to IVA through the end of follow-up.

RESULTS

19 eyes with pre-existing glaucoma-related diagnoses were compared to 43 eyes without such diagnoses. Baseline IOP was similar for glaucoma and non-glaucoma patients. The loading doses of IVB/IVR did not impact IOP; however, a small, sustained rise in IOP was noted among patients with glaucoma-related diagnoses by the final IVB/IVR injections before the switch to IVA (∆IOP 1.61 ± 0.52 mmHg, P < 0.002). After conversion to IVA, pre-injection IOP declined in eyes both with (-1.59 ± 0.54 mmHg, P < 0.001) and without (-0.99 ± 0.28 mmHg, P < 0.001) glaucoma-related diagnoses.

CONCLUSIONS

IOP in patients with glaucoma-related diagnoses appears to be more sensitive to intravitreal injections than it is in patients without glaucoma-related diagnoses. It rises with IVB/IVR and declines after the switch to IVA. Switching patients with nAMD to IVA may present an opportunity to lower IOP in patients with glaucoma.

Reducing Injection-Related Safety Events in Retina Clinics

Purpose

At the Kellogg Eye Center, we identified a series of injection-related patient safety events that led to a systematic review and redesign of our intravitreal injection protocol. The objective was to reduce injection-related patient safety events to zero.

Methods

A retroactive review, using the Healthcare Failure Mode and Effect Analysis model as a guide, was performed on our process for delivering intravitreal injections to identify potential failure modes and their impact.

Results

The total number of injection-related safety events was 1 in 2017 and 16 in 2018 at baseline. Potential vulnerabilities identified included errors in communication, patient identification, clinical documentation, and medication orders. The injection protocol was redesigned. After implementation, there were zero injection-related safety events in all Kellogg Eye Center Retina clinics for the subsequent 18-month follow-up period.

Conclusion

It is possible to redesign and implement an intravitreal injection protocol to reduce the rate of safety events in a large academic eye center.

Underdiagnosis of glaucoma in patients with exudative age-related macular degeneration

OBJECTIVE

To compare the rate of glaucoma-related diagnoses in patients with exudative or non-exudative age-related macular degeneration (AMD).

METHODS

Patients above the age of 55 with a diagnosis of AMD were identified from billing records from 2015 to 2018. Out of the 3991 patients with AMD, two cohorts with 990 patients in each were formed by randomly age-matching patients with exudative AMD with those with non-exudative AMD; patients within each group were further classified by subtype and severity of glaucoma. Charts of AMD patients without glaucoma-related diagnoses were reviewed to determine potential underdiagnosis. We applied a set of broad clinical criteria that comprised an intraocular pressure ≥22 mmHg, a cup-to-disc ratio (CDR) ≥ 0.6, and/or CDR difference between eyes of ≥0.2.

RESULTS

The rate of diagnosed, open-angle glaucoma was significantly lower in patients with exudative AMD (6.06%) compared to patients with non-exudative AMD (8.99%, P = 0.04). Similarly, the rate of suspected glaucoma was significantly lower in the first group compared to the second (12.12% versus 18.48%, respectively, P < 0.001). A greater number of patients with exudative AMD (13.94%, n = 138) met clinical risk criteria compared with those having non-exudative AMD (6.97%, n = 69, P < 0.001). When these at-risk patients were added to their respective groups, the rate of glaucoma, or its suspicion, became similar (χ2 = 1.24, P = 0.539).

CONCLUSIONS

A significantly lower rate of diagnosed glaucoma, or its suspicion, was identified in patients with exudative compared to non-exudative AMD. This apparent underdiagnosis was resolved by the retrospective application of clinical criteria that may represent a risk of glaucoma.

Safety of Receiving Anti-Vascular Endothelial Growth Factor Intravitreal Injection in Office-Based vs Operating Room Settings: A Meta-analysis

Importance

Compared with the operating room (OR), office-based intravitreal injection (IVI) is considered a more cost-effective and convenient approach, yet clinical outcomes of IVIs with anti-vascular endothelial growth factor (VEGF) agents in different settings (office-based vs OR) have not been systematically evaluated.

Objective

To evaluate the safety outcomes of IVI with anti-VEGF agents in the OR vs office-based setting.

Data Sources

PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov were searched from inception to July 2020.

Study Selection

Eligible studies reporting on patients who received IVIs with anti-VEGF drugs with a clearly stated injection setting of the office or OR.

Data Extraction and Synthesis

Two reviewers independently screened studies, extracted data, and assessed risk of bias. A meta-analysis was conducted to determine the rates of endophthalmitis (EO) and culture-positive EO.

Main Outcomes and Measures

Rates of EO and culture-positive EO following anti-VEGF IVIs in the OR and office-based setting.

Results

Thirty-one studies with a total of 1 275 815 injections were included. Comparative analysis suggested no difference between rates of EO after IVIs performed in the office and OR settings (odds ratio, 3.06; 95% CI, 0.07-139.75; P = .57; I2 = 80%) were identified, yet a higher rate of culture-positive EO was found in the office setting (odds ratio, 21.52; 95% CI, 2.39-193.55; P = .006; I2 = 0%). The pooled rates of EO following anti-VEGF IVIs were 0.03% (95% CI, 0.03-0.04) and 0.02% (95% CI, 0.01-0.04) in office and OR settings, respectively, and the pooled rates of culture-positive EO were 0.01% (95% CI, 0.01-0.02) and 0.01% (95% CI, 0-0.02). The pooled rates of other ocular and systemic adverse events were low.

Conclusions and Relevance

The rate of clinically suspected or culture-positive EO following anti-VEGF IVIs was low whether the procedure was performed in the office or OR setting. Bacterial spectrum could differ between the 2 settings. This meta-analysis could not determine if it is more appropriate to give treatment in the OR for safety reasons in low-income compared with higher-income regions in the world.

Comparison of Two Different Intravitreal Injection Techniques

Objective

To compare the effectiveness, procedure time and safety outcomes of two different intravitreal injections (IVI) techniques.

Methods

This was a prospective, single-center, randomized clinical trial of 200 adult eyes receiving intravitreal medications for various indications. Eyes were assigned (1:1) to undergo IVI using either an intravitreal injection guide (IIG) (n= 100) or conventional dual blade speculum plus surgical caliper (DBS) (n=100). All IVI were administered using a 30-gauge needle placed 4 mm posterior to the inferior limbus. The main outcome measures were rate of successful IVI administration, procedure time (seconds) as measured by a stopwatch from application to removal of IIG or DBS, patient preference for IVI technique and adverse events.

Results

The two groups were similar in terms of mean age (P=0.398), laterality (P=0.671), indication for treatment (P=0.175) and medication type (P=0.489). All IVI procedures were successfully completed in both groups. The mean procedure time was shorter using the IIG (9.94 ± 2.87 seconds) versus DBS (21.85 ± 7.25 seconds) technique (P ≤ 0.01). The incidence of post-injection subconjunctival hemorrhage was higher when the DBS was applied (OR = 2.35, 95% CI = 1.22-4.53). Patients with previous history of IVI preferred the IIG over the DBS. No other injection-related adverse events were observed in both groups.

Conclusion

DBS and IIG techniques are similarly effective and safe for the administration of intravitreal medications. The IIG appears to significantly reduce procedure time, be associated with a lower incidence of subconjunctival hemorrhage and engender better patient acceptance.

Clinical Trial Registration

ClinicalTrials.gov (NCT04455399).

Hypochlorous acid antiseptic washout improves patient comfort after intravitreal injection: A patient reported outcomes study

Purpose:

Current ocular antiseptic practice for intravitreal injection (IVI) employs 5% povidone–iodine (Betadine^®) drops which frequently cause ocular discomfort and prolonged irritation. In an effort to improve comfort while maintaining efficacy, we studied a hypochlorous acid (HOCL 0.01%) spray washout prior to injection.

Methods:

Patients had received a minimum of 3 IVIs prepared with Betadine^® antisepsis prior to entry in this study. Their subsequent IVIs were prepared with Betadine^® followed by HOCL 0.01% washout. Facets of comfort were measured by a Likert-scaled questionnaire to compare their experiences after IVI.

Results:

Thirty-seven participants were enrolled. Addition of HOCL 0.01% spray after Betadine^® reduced the duration of discomfort (P = 0.001) and need for artificial tears postinjection (P = 0.003). It improved their reported quality of life (P = 0.04) and sleep (P = 0.01). There were neither HOCL-related side effects nor endophthalmitis during this study.

Conclusion:

Topical HOCL 0.01% spray after topical Betadine^® antisepsis significantly improved patient comfort following IVIs.

Antivascular Endothelial Growth Factor Treatment Might Be Continued Even After Vitrectomy for Endophthalmitis in Neovascular Age-Related Macular Degeneration

Purpose:

This article studies visual outcome and frequency of antivascular endothelial growth factor (anti-VEGF) injections continued in patients with neovascular age-related macular degeneration (AMD) who had an earlier vitrectomy for postinjection endophthalmitis.

Methods:

A retrospective interventional study was conducted reviewing our database for patients with a diagnosis of endophthalmitis in the course of anti-VEGF injections. Endophthalmitis diagnosis was made on clinical examination of pain, rapid decrease in visual acuity (VA), conjunctival hyperemia, hypopyon, and vitritis. In all eyes, core vitrectomy with intravitreal antibiotics was performed. Spectral-domain optical coherence tomography was performed monthly before and after surgery during follow-up. Anti-VEGF injections were continued after surgery in all cases.

Results:

Eight eyes with postinjection endophthalmitis were included. Mean VA immediately before endophthalmitis was 20/50 Snellen with a mean of 19 intravitreal anti-VEGF injections ( P = .45). At time of endophthalmitis diagnosis, mean VA was 20/1000 (range, 20/2000-20/200). Mean time from injection to when the patient noted first symptoms was 4.3 days (range, 1-8 days). Mean time from first symptoms to surgery was 12 hours (range, 2.5-26 hours). Final mean VA at the end of follow-up (range, 12-84 months) did not statistically differ from VA at the visit immediately before endophthalmitis diagnosis ( P = .69). Mean frequency of injections after vitrectomy did not significantly differ from the presurgical course of treatment ( P =.97).

Conclusions:

Anti-VEGF treatment might be continued after vitrectomy for endophthalmitis and results in satisfactory anatomical and visual outcome. Surgery did not influence the frequency of anti-VEGF injections for neovascular AMD.

Lipopolysaccharide-Induced Autophagy Mediates Retinal Pigment Epithelium Cells Survival. Modulation by the Phospholipase D Pathway

Inflammation and oxidative stress are common factors involved in the pathogenesis of retinal diseases, such as aged-related macular degeneration (AMD) and diabetic retinopathy (DR). Autophagy is a catabolic process essential to cell survival in response to stress. This process is highly active in retinal pigment epithelium (RPE) cells. Our previous findings demonstrated that lipopolysaccharide (LPS) induces an inflammatory response of RPE cells that implies classical phospholipases D (PLD1 and 2) activation, cyclooxygenase-2 (COX-2) expression, prostaglandin E₂ (PGE₂) production and reduced cell viability. In this work, we studied the autophagic process and its modulation by the PLD pathway in D407 and ARPE-19 RPE cells exposed to LPS. LPS (10 μg/ml or 25 μg/ml) exposure for 24 h increased light chain 3B-II (LC3B-II) content (an autophagy marker) and LC3B-positive punctate structures in both RPE cell lines studied. Next, the drug bafilomycin A₁ (BAF, 50 nM) was used to block the autophagic flux. In cells pre-incubated with BAF, LC3B-II and sequestosome 1 (SQSTM1/p62) levels and autophagosome-like structures were increased by LPS, demonstrating that the inflammatory injury increases the autophagic process in RPE cells. To study the role of the PLD pathway, cells were pre-incubated for 1 h with selective PLD1 (VU0359595) or PLD2 (VU0285655-1) inhibitors prior to LPS addition. Under control condition, LC3B-positive punctate structures were increased in cells pre-incubated with PLD2 inhibitor while with PLD1 inhibitor were increased in cells exposed to LPS. MTT reduction assays showed that early autophagy inhibitors, 3-methyladenin (3-MA) or LY294002, enhanced the loss in cell viability induced by LPS exposure for 48 h. On the contrary, the inhibition of PLD1 and PLD2 prevented the loss in cell viability induced by LPS. In conclusion, our results show that even though LPS treatment promotes an inflammatory response in RPE cells, it also triggers the activation of the autophagic process which in turn may serve as a protective mechanism for the cells. In addition, we demonstrate that the PLD pathway modulates the autophagic process in RPE cells. Our findings contribute to the knowledge of the molecular basis of retinal inflammatory and degenerative diseases and open new avenues for potential therapeutic exploration.

Combination of bevacizumab and photodynamic therapy vs. bevacizumab monotherapy for the treatment of wet age-related macular degeneration: A meta-analysis of randomized controlled trials

The purpose of this meta-analysis was to compare the efficacy and safety of the combination of bevacizumab and photodynamic therapy (PDT) with bevacizumab monotherapy for the treatment of age-related macular degeneration (AMD). Patients with active choroidal neovascularization (CNV) secondary to AMD were included in the present study. The treatment group included patients treated with a combination of bevacizumab and PDT and patients treated with bevacizumab monotherapy. Only randomized controlled trials (RCTs) were included in the analysis. The PubMed, EMBASE and Cochrane Central Register of Controlled Trials databases were searched. Meta-analysis was performed using RevMan v.5.3 software, and best-corrected visual acuity (BCVA), central retinal thickness (CRT) and the average number of bevacizumab retreatments were assessed. A total of 5 RCTs were included in the analysis. There were no significant differences observed in the mean BCVA change between the combination treatment group and the bevacizumab monotherapy group [standard mean difference 0.20; 95% confidence interval (CI) −0.53, 0.93, P=0.59]. There were also no significant differences in the CRT increases between the two groups [weighted mean difference (WMD) −22.16, 95% CI −52.01 to 7.69, P=0.15]. No significant differences were observed in the proportions of patients gaining >15 letters between the two groups [risk ratio (RR) 0.86, 95% CI 0.64, 1.15, P=0.30]. However, the average number of the ranibizumab retreatments was significantly lower in the combination treatment group compared with the bevacizumab monotherapy group (WMD, −2.70, 95% CI −3.93 to −1.46; P<0.0001). Additionally, there were no significant differences in the rate of ocular adverse events (RR, 0.57; 95% CI, 0.27 to 1.22; P=0.15) and systemic adverse events (RR, 5.42; 95% CI, 0.29 to 101.77; P=0.26) between the two groups. In conclusion there were no significant differences in mean BCVA change, CRT increases, the proportions of patients gaining >15 letters, or the incidences of ocular adverse events and systemic adverse events. However, combination treatment may significantly reduce the average number of bevacizumab retreatments compared with monotherapy.

LOW ENDOPHTHALMITIS RATES AFTER INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR INJECTIONS IN AN OPERATION ROOM: A Retrospective Multicenter Study

PURPOSE

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

METHODS

A retrospective multicenter study between 2003 and 2016 at three European sites, City Hospital Triemli Zurich, Switzerland (CHT), Zealand University Hospital Roskilde, Denmark (ZUH) and University Clinic Bern, Switzerland (UCB). Intravitreal injection (IVI) database of each department was reviewed. All anti-vascular endothelial growth factor injections were performed using a standardized sterile technique in an operation room. Injection protocols were similar between the three sites. No preinjection antibiotics were given. Postoperative antibiotics varied among sites.

RESULTS

A total of 134,701 intravitreal injections were performed at the 3 sites between 2003 and 2016. Ten cases of presumed endophthalmitis were documented: 4 in 50,721 at CHT (95% CI: 0.0071-0.0087%), 2 in 44,666 at ZUH (95% CI: 0.0039-0.0051%), and 4 in 39,314 at UCB (95% CI: 0.0092-0.011%). This results in one case in 13,470 intravitreal injections and a combined incidence of 0.0074% per injection (95% CI: 0.0070-0.0078%). Positive cultures were found in 4 out of 10 presumed endophthalmitis cases.

CONCLUSION

The standardized sterile technique in an operation room with laminar airflow showed very low rates of endophthalmitis at three European sites.

Long-Term PEDF Release in Rat Iris and Retinal Epithelial Cells after Sleeping Beauty Transposon-Mediated Gene Delivery

Pigment epithelium derived factor (PEDF) is a potent antiangiogenic, neurotrophic, and neuroprotective molecule that is the endogenous inhibitor of vascular endothelial growth factor (VEGF) in the retina. An ex vivo gene therapy approach based on transgenic overexpression of PEDF in the eye is assumed to rebalance the angiogenic-antiangiogenic milieu of the retina, resulting in growth regression of choroidal blood vessels, the hallmark of neovascular age-related macular degeneration. Here, we show that rat pigment epithelial cells can be efficiently transfected with the PEDF-expressing non-viral hyperactive Sleeping Beauty transposon system delivered in a form free of antibiotic resistance marker miniplasmids. The engineered retinal and iris pigment epithelium cells secrete high (141 ± 13 and 222 ± 14 ng) PEDF levels in 72 hr in vitro. In vivo studies showed cell survival and insert expression during at least 4 months. Transplantation of the engineered cells to the subretinal space of a rat model of choroidal neovascularization reduces almost 50% of the development of new vessels.

Intravitreal Injection--Technique and Safety

Intravitreal (IVT) injection of therapeutic agents has become one of the most commonly performed procedures in ophthalmology. Over the past decade, a number of guidelines have been published that recommend proper techniques to increase the safety of IVT injections. Among the various complications of IVT injections, endophthalmitis can be sight threatening. The reported endophthalmitis rates after IVT injection range from 0.020% to 0.085%, which are higher than what would be expected from a simple, fast, and relatively atraumatic procedure. The 2 key issues involved in the prevention of endophthalmitis are pre-IVT injection disinfection using povidone-iodine (PVI) and the use of topical antibiotics as prophylaxis. Whereas 5% PVI for 5 minutes is most commonly used in cataract surgery for disinfection, the duration in IVT injection is much less and can be as short as 30 seconds. Further studies seem warranted to investigate whether longer duration of PVI application in IVT injection can lower the endophthalmitis rate. Recent data suggest that there is inadequate evidence to support the routine use of prophylactic pre-, peri-, or postinjection antibiotics to reduce the risk of endophthalmitis. However, as many confounding factors such as the PVI regimens were not standardized in previous studies, it is too soon to make a concrete conclusion. Despite the availability of published guidelines, considerable variations still exist in real-life clinical situations. In this article, we describe our IVT injection practice protocol and compare it with the most recent international guidelines. Finally, a summary table that shows the clinical features of true, sterile, and pseudoendophthalmitis is presented.

High Glucose-induced Retinal Pericyte Apoptosis Depends on Association of GAPDH and Siah1

Diabetic retinopathy (DR) is a leading cause of blindness worldwide, and its prevalence is growing. Current therapies for DR address only the later stages of the disease, are invasive, and have limited effectiveness. Retinal pericyte death is an early pathologic feature of DR. Although it has been observed in diabetic patients and in animal models of DR, the cause of pericyte death remains unknown. A novel pro-apoptotic pathway initiated by the interaction between glyceraldehyde-3-phosphate dehydrogenase (GAPDH) and the E3 ubiquitin ligase, seven in absentia homolog 1 (Siah1), was recently identified in ocular tissues. In this article we examined the involvement of the GAPDH/Siah1 interaction in human retinal pericyte (hRP) apoptosis. HRP were cultured in 5 mm normal glucose, 25 mm l- or d-glucose for 48 h (osmotic control and high glucose treatments, respectively). Siah1 siRNA was used to down-regulate Siah1 expression. TAT-FLAG GAPDH and/or Siah1-directed peptides were used to block GAPDH and Siah1 interaction. Co-immunoprecipitation assays were conducted to analyze the effect of high glucose on the association of GAPDH and Siah1. Apoptosis was measured by Annexin V staining and caspase-3 enzymatic activity assay. High glucose increased Siah1 total protein levels, induced the association between GAPDH and Siah1, and led to GAPDH nuclear translocation. Our findings demonstrate that dissociation of the GAPDH/Siah1 pro-apoptotic complex can block high glucose-induced pericyte apoptosis, widely considered a hallmark feature of DR. Thus, the work presented in this article can provide a foundation to identify novel targets for early treatment of DR.