Endophthalmitis following intravitreal anti-vascular endothelial growth factor (VEGF) injection: a comprehensive review

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.

Topical antibiotics and intravitreal injections

“…In a recent audit of Medicare 5% claims data, Hahn et al (2016) found an increased risk of endophthalmitis after cataract surgery in patients who were undergoing regular anti-VEGF injections. During the earlier part of the audit period, the ASRS PAT survey data suggest that pre-and/or postinjection antibiotic administration was common practice (Merani & Hunyor 2015). Due to limitations in the data set, it is not clear whether the cases of endophthalmitis in this study were related to vitreous loss during cataract surgery, or if they occurred after subsequent intravitreal injections.…”

“…Since the introduction of intravitreal antivascular endothelial growth factor (VEGF) agents, the exponential increase in the number of intravitreal injections has seen a considerable body of evidence established with regard to postinjection endophthalmitis (Merani & Hunyor 2015). The extremely low incidence of this complication means that randomized controlled trials examining the effectiveness of individual measures to prevent endophthalmitis are not feasible.…”

Modeling intraocular bacterial infections

“…Intravitreal injections are also being performed with greater frequency for the treatment of neovascular disorders and inflammation (Peyman et al, 2009). In the United States, the number of intravitreal injections has increased from 4,215 in 2001 to 2.5 million in 2011, with similar increases reported for Canada and the United Kingdom (Merani and Hunyor, 2015). The rate of injection-related complications has also increased, with endophthalmitis incidences after intravitreal injection reported to be 0.006-0.16% per injection and 0.7-1.3% per treatment period (Diago et al, 2009; Klein et al, 2009; Sampat and Garg 2010; VEGF Inhibition Study in Ocular Neovascularization (V.I.S.I.O.N.)…”

Povidone‐iodine is still a premium antiseptic measure in ocular surgery

“…While studies regarding postinjection pain scores are few and far between, we have found two suggestions for minimizing postinjection pain. Merani & Hunyor (2015) suggest using lubricant preservative-free eyedrops one day before the injection to reduce pain levels. The use of 30-gauge needles has been reported to reduce pain scores in another study (G€ uler et al 2015).…”