Endophthalmitis following intravitreal anti-VEGF injections in ambulatory surgical centre facility: incidence, management and outcome

Mithal, Kopal; Mathai, Annie; Pathengay, Avinash; Jalali, Subhadra; Relhan, Nidhi; Motukupally, Swapna Reddy; Sharma, Savitri; Das, Taraprasad

doi:10.1136/bjophthalmol-2013-303222

Cited by 21 publications

(15 citation statements)

References 5 publications

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“…There are numerous large retrospective studies in which topical antibiotics have been used postinjection, but not preinjection, without any evidence of benefit in preventing endophthalmitis (Fintak et al 2008;Pilli et al 2008;Moshfeghi et al 2011;Fineman et al 2013;Mithal et al 2013;Casparis et al 2014;Nentwich et al 2014;Li et al 2016). In fact, a higher rate of endophthalmitis has been found in patients receiving postinjection antibiotics (versus those who did not) in a number of studies, although this was not statistically significant in most of these studies (Bhavsar et al 2009(Bhavsar et al , 2012Bhatt et al 2011;Cheung et al 2012;Falavarjani et al 2013;Storey et al 2014;Dossarps et al 2015).…”

Section: Postinjection Antibiotic Prophylaxismentioning

confidence: 99%

Topical antibiotics and intravitreal injections

Hunyor

Merani

Darbar

et al. 2017

Acta Ophthalmologica

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There is increasing evidence that topical antibiotics, given before and/or after intravitreal injections, are ineffective in preventing endophthalmitis and are possibly harmful. In addition to the lack of efficacy and increased development of resistant organisms, the use of topical antibiotics adds significantly to the cost of delivering intravitreal therapy. Despite this, in many countries, it is still common practice to use pre- and/or postinjection topical antibiotics. This review outlines the general principles of effective antibiotic prophylaxis, and the evidence regarding topical antibiotic use as a prophylactic measure for endophthalmitis following intravitreal injections. A key distinguishing feature of intravitreal injections from most other invasive procedures is the fact that they are often repeated on multiple occasions to the same eye. Given the lack of evidence to support topical antibiotics as an effective method of prophylaxis for postinjection endophthalmitis, it appears that more widespread education of ophthalmologists is required to avoid continued inappropriate use. Revision of drug labels in some jurisdictions, and amendment of local/professional society guidelines, may be required to assist in achieving this goal. Emphasis should be placed on antisepsis and aseptic technique, which are the major proven methods of endophthalmitis prevention, rather than antibiotics.

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Section: Postinjection Antibiotic Prophylaxismentioning

confidence: 99%

Topical antibiotics and intravitreal injections

Hunyor

Merani

Darbar

et al. 2017

Acta Ophthalmologica

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“…Antibiotics have been used post-injection, but not pre-injection, in several series without the prevention of endophthalmitis (see Table 1) [17, 19, 22, 25, 26, 31, 32]. In fact, a non-statistically significant higher rate of endophthalmitis has been found in patients receiving post-injection antibiotics in a number of studies [16, 28, 148–150].…”

Section: Reviewmentioning

confidence: 99%

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

Merani

Hunyor

2015

Int J Retin Vitr

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The purpose of this review is to report and summarize previously reported studies and assess many of the individual steps of the intravitreal injection procedure’s possible effect on the prevention of endophthalmitis. The pooled endophthalmitis rate from 20 large retrospective case series of anti-VEGF injections was 144/510,396 (0.028%; 1/3,544). Injections may be performed in an office-based location or in an operating room (OR) and low rates of endophthalmitis can be achieved in either location with careful attention to asepsis. Pre- or post-injection topical antibiotics have not been shown to be effective, and could select for more virulent microorganisms. Povidone-iodine prior to injection is accepted as the gold-standard antiseptic agent, but aqueous chlorhexidine may be an alternative. Antisepsis before and after gel or subconjunctival anesthetic is suggested. The preponderance of Streptococcal infections after intravitreal injection is discussed, including the possible role of aerosolization, which can be minimized by using face masks or maintaining silence. As with other invasive procedures in medicine, the use of sterile gloves, following adequate hand antisepsis, may be considered. Control of the eyelashes and lid margin is required to avoid contamination of the needle, but this can be achieved with or without a speculum. Techniques to minimize vitreous reflux have not been shown to reduce the risk of endophthalmitis. Same day bilateral injections should be performed as two separate procedures, preferably using drug from different lots, especially when using compounded drugs.

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“…Although a rare complication of cataract surgery or intravitreal injection, with an incidence of 0.05% to 0.3%, 1–7 endophthalmitis often leads to poor visual outcomes. 3, 8, 9 Because of the high volume of current and anticipated cataract surgery worldwide (with VISION2020 goals of 32 million cataract surgeries per year), and the large and increasing number of intravitreal injections performed, endophthalmitis will continue to affect tens of thousands of individuals annually worldwide.…”

Section: Introductionmentioning

confidence: 99%

Identification of Torque Teno Virus in Culture-Negative Endophthalmitis by Representational Deep DNA Sequencing

et al. 2015

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Purpose To test the hypothesis that uncultured organisms may be present in cases of culture-negative endophthalmitis, by use of deep DNA sequencing of vitreous biopsies. Design Single center consecutive prospective observational study. Participants and Controls Aqueous or vitreous biopsies from 21 consecutive patients presenting with presumed infectious endophthalmitis, and seven vitreous samples from patients undergoing surgery for non-infectious retinal disorders. Methods Traditional bacterial and fungal culture, 16S quantitative polymerase chain reaction (qPCR) and a representational deep-sequencing method (Biome Representational in Silico Karyotyping [BRiSK]) were applied in parallel to samples to identify DNA sequences corresponding to potential pathogens. Main Outcome Measures Presence of potential pathogen DNA in ocular samples. Results None of 7 control eyes undergoing routine vitreous surgery yielded positive results for bacteria or virus by culture or 16S PCR. Fourteen of the 21 samples (66.7%) from eyes harboring suspected infectious endophthalmitis were culture-positive, the most common being Staphylococcal and Streptococcal species. There was good agreement among culture, 16S bacterial PCR, and BRiSK methodologies for culture-positive cases (Fleiss’ kappa of 0.621). 16S PCR did not yield a recognizable pathogen sequence in any culture-negative sample, while BRiSK suggested presence of Steptococcus in one culture-negative sample. Surprisingly, using BRiSK, 57.1% of culture-positive and 100% of culture-negative samples demonstrated presence of Torque Teno Virus (TTV) sequences, compared to none in the controls (Fisher exact, p = 0.0005). Presence of TTV viral DNA was confirmed in seven cases by qPCR. No other known viruses or potential pathogens were identified in these samples. Conclusion Culture, 16S qPCR, and BRiSK provide complementary information in presumed infectious endophthalmitis. The majority of culture-negative endophthalmitis samples did not contain significant levels of bacterial DNA. ‘culture-negativity’ does not appear to be due to failure of growth of fastidious bacteria. The small DNA virus TTV was unexpectedly found in all culture-negative samples and some culture-positive samples. The current study cannot distinguish whether TTV is a direct intraocular pathogen, an adjuvant for inflammation, a general marker of inflammation, or a commensal virus, but provides a testable hypothesis for a pathogenic mechanism in culture-negative endophthalmitis.

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Endophthalmitis following intravitreal anti-VEGF injections in ambulatory surgical centre facility: incidence, management and outcome

Cited by 21 publications

References 5 publications

Topical antibiotics and intravitreal injections

Topical antibiotics and intravitreal injections

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

Identification of Torque Teno Virus in Culture-Negative Endophthalmitis by Representational Deep DNA Sequencing

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