Legal obligation in the general population: face mask influence on endophthalmitis after intravitreal injection

Abstract

Purpose To investigate whether compulsory face masking in public life changes the incidence or pattern of post-injection endophthalmitis (PIE). Patients and methods All injections of bevacizumab, ranibizumab, aflibercept, dexamethasone or triamcinolone between 01/01/2015 and 12/31/2021 at the University Eye Clinic of Tuebingen were included in this retrospective analysis. The injection procedure itself was unchanged since 2015 and included the use of a sterile drape covering the head up to the shoulders which prevents airflow toward the eye. Furthermore, all staff wore a face mask and gloves at all times. The two study periods were defined by the introduction of a compulsory face masking rule in public life (01/01/2015 until 04/27/2020 vs. 04/28/2020 until 12/31/2021). Results A total of 83,543 injections were performed in the tertiary eye clinic, associated with a total of 20 PIE (0.024%, 1/4177 injections). Of these, thirteen PIE were documented during the pre-pandemic period (0.021%, 1/4773 injections) and seven PIE during the pandemic period (0.033%, 1/3071 injections). No significant difference in PIE risk was observed (p = 0.49), and there was no case of oral flora associated PIE. Conclusion Although some potential confounders (wearing time, skin flora) could not be considered, there was no clear signal that the introduction of compulsory face masking in public life did alter the risk for PIE in our patient population. Three and six months after PIE, no difference in visual acuity was detectable between the two study periods.

Intravitreale Injektionen: Nachhaltigkeit durch Reduktion von Klinikabfall

“…Performing intravitreal injections without using a lid speculum does not appear to compromise safety: in two large case series of 10,164 and 78,009 intravitreal injections performed with manual eyelid opening only, endophthalmitis rates were 0.03% and 0.015% respectively 28 , 29 . This was comparable to endophthalmitis rates in a meta-analysis of 105,536 cases (0.05%) 30 , or two large case series of 60,322 31 and 83,543 injections (both 0.02%) 30 , 31 , 32 . This is reflected in the current guidelines and policies of the Royal College of Ophthalmologists and the American Academy of Ophthalmologists, which describe the use of a speculum and drape as “not essential”, instead emphasizing the importance of a standardized, controlled maneuver for eyelid retraction 26 , 27 .…”

“…Somit besteht kein relevanter Unterschied zu Endophthalmitisraten einer Metaanalyse mit 105 536 30 (0,05%) oder von großen Fallserien mit 60 322 31 bzw. 83 543 Injektionen (jeweils 0,02%) 30 , 31 , 32 . Diese Datenlage, wenngleich ohne endgültige, randomisierte, kontrollierte Evidenz, spiegelt sich sowohl in den aktuellen Richtlinien des Royal College of Ophthalmologists als auch der American Academy of Ophthalmologists wider, die ein Spekulum und Abdecktuch als „nicht essenziell“ bezeichnen, jedoch die Bedeutsamkeit eines standardisierten, kontrollierten Manövers zur Retraktion der Lider betonen 26 , 27 .…”

Face mask might increase the risk of endophthalmitis after intravitreal injection

“…Apart from this variability, some studies did report an increase in PIE, but because the incidence of endophthalmitis is very low, these findings have not reached statistical significance. 9–11,15 In addition, the average time covered in the post-COVID period by these studies is only 6.3 months. Detailed characteristics of the studies are presented in Table 1.…”

“…The majority of them indicate that there is no statistically significant increase in risk. 1,[9][10][11][12][13][14][15] However, the protocols and the way to collect data in these studies are very heterogeneous. Thus, in one of these studies, the patient's mask is removed down to the chin, 9 and an adhesive drape is placed isolating the eye before the injection 9,10 to control the possible deleterious effect of the periocular airflow because of the mask.…”

“…1,[9][10][11][12][13][14][15] However, the protocols and the way to collect data in these studies are very heterogeneous. Thus, in one of these studies, the patient's mask is removed down to the chin, 9 and an adhesive drape is placed isolating the eye before the injection 9,10 to control the possible deleterious effect of the periocular airflow because of the mask. [5][6][7] During another study, there was a transition from nonprefilled syringes to prefilled ones, 13 and in the studies performed in the United States, including the one developed by Naguib et al, 1,13,14 it was not mandatory for health care personnel to wear face masks during the pre-COVID period, a measure that might reduce the risk of endophthalmitis by itself.…”