An effective method to reduce the risk of endophthalmitis after intravitreal injection (IVI): Application of 0.25% povidone-iodine

Abdulgani Kaymaz; Fatih Ulaş; Adem Soydan; Güvenç Toprak

doi:10.28982/josam.901604

Authors

Abdulgani Kaymaz https://orcid.org/0000-0003-1018-925X
Fatih Ulaş https://orcid.org/0000-0003-4468-3985
Adem Soydan https://orcid.org/0000-0002-3053-2396
Güvenç Toprak Muş State Hospital https://orcid.org/0000-0001-8363-2983

DOI:

https://doi.org/10.28982/josam.901604

Keywords:

Anti-vascular endothelial growth factor, Endophthalmitis, Hypopion, Intravitreal injection, Povidone-iodine

Abstract

Background/Aim: The most important complication after intravitreal injection (IVI) is endophthalmitis, which can result in severe vision loss. This study aims to investigate the effect of 0.25% povidone-iodine (PI) application before IVI on the incidence of endophthalmitis in patients who received intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection. Methods: A total of 15345 intravitreal anti-VEGF injections and nine endophthalmitis cases after IVI performed at the outpatient injection room of a single university hospital between January 2017 and January 2020 were included in this retrospective cohort study. Before July 2018, after applying 10% PI around the eyes and 5% PI on the eyes, an eyelid speculum was inserted, and the injection was performed. After this date, in addition to these steps, after placing a speculum and determining the injection site with a caliper, 3-4 drops of 0.25% PI were applied just before injection. Topical antibiotics were not used before or after the injection. Results: Nine cases of endophthalmitis were detected in 3 years. The most common symptoms were vision loss (9/9) and pain in the eye (7/9). All cases had conjunctival hyperemia, cells-hypopyon in the anterior chamber, and cells in the vitreous. The time between injection and re-visiting the clinic due to endophthalmitis symptoms ranged between 2-6 days, and visual acuity varied between hand motion and 0.2. While the number of endophthalmitis cases before July 2018 was 8 (8/8330) in 1.5 years, after the addition of 0.25% PI application to the protocol, only 1 case of endophthalmitis (1/7015) was seen in the last 1.5 years. The rate of endophthalmitis had decreased significantly (P=0.037). Conclusion: Since July 2018, the addition of 0.25% PI to the standard IVI protocol just before injection has significantly reduced endophthalmitis rates. With this method, endophthalmitis rates may be decreased despite the increasing number of IVIs.

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References

Ohm J. Über die Behandlung der Netzhautablösung durch operative Entleerung der subretinalen Flüssigkeit und Einspritzung von Luft in den Glaskörper. Albrecht von Graefe's Arch. f. 0phth. 1911;79(3):442-50.

Lanzetta P, Mitchell P, Wolf S, Veritti D. Different antivascular endothelial growth factor treatments and regimens and their outcomes in neovascular age-related macular degeneration: a literature review. Br J Ophthalmol. 2013;97(12):1497-507.

Kataja M, Hujanen P, Huhtala H, Kaarniranta K, Tuulonen A, Uusitalo-Jarvinen H. Outcome of anti-vascular endothelial growth factor therapy for neovascular age-related macular degeneration in real-life setting. Br J Ophthalmol. 2018;102(7):959-65.

Sachdeva MM, Moshiri A, Leder HA, Scott AW. Endophthalmitis following intravitreal injection of anti-VEGF agents: long-term outcomes and the identification of unusual micro-organisms. J Ophthal Inflamm Infect. 2016;6(1):2.

Moshfeghi AA, Rosenfeld PJ, Flynn Jr HW, Schwartz SG, Davis JL, Murray TG, et al. Endophthalmitis after intravitreal anti–vascular endothelial growth factor antagonists: A Six-Year Experience at a University Referral Center. Retina. 2011;31(4):662-8.

Rayess N, Rahimy E, Shah CP, Wolfe JD, Chen E, DeCroos FC, et al. Incidence and clinical features of post-injection endophthalmitis according to diagnosis. Br J Ophthalmol. 2016;100(8):1058-61.

Ciulla TA, Starr MB, Masket S. Bacterial endophthalmitis prophylaxis for cataract surgery: an evidence-based update. Ophthalmology. 2002;109(1):13-24.

Speaker MG, Milch FA, Shah MK, Eisner W, Kreiswirth BN. Role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis. Ophthalmology. 1991;98(5):639-50.

Wen JC, McCannel CA, Mochon AB, Garner OB. Bacterial dispersal associated with speech in the setting of intravitreous injections. Arch Ophthalmol. 2011;129(12):1551-4.

Kim SJ, Toma HS, Midha NK, Cherney EF, Recchia FM, Doherty TJ. Antibiotic resistance of conjunctiva and nasopharynx evaluation study: a prospective study of patients undergoing intravitreal injections. Ophthalmology. 2010;117(12):2372-8.

Kim SJ, Toma HS. Antimicrobial resistance and ophthalmic antibiotics: 1-year results of a longitudinal controlled study of patients undergoing intravitreal injections. Arch Ophthalmol. 2011;129(9):1180-8.

Moss JM, Sanislo SR, Ta CN. A prospective randomized evaluation of topical gatifloxacin on conjunctival flora in patients undergoing intravitreal injections. Ophthalmology. 2009;116(8):1498-501.

Zamora JL. Chemical and microbiologic characteristics and toxicity of povidone-iodine solutions. Am J Surg. 1986;151(3):400-6.

Gottardi W. Potentiometrische Bestimmung der Gleichgewichtskonzentrationen an freiem und komplex gebundenem Iod in wÄrigen Lösungen von Polyvinylpyrrolidon-Iod (PVP-Iod). Z. Anal. Chem. 1983;314(6):582-5.

Shimada H, Nakashizuka H, Grzybowski A. Prevention and treatment of postoperative endophthalmitis using povidone-iodine. Curr Pharm Des. 2017;23(4):574-85.

Duperet Carvajal D, Audivert Hung Y, Quiala Alayo L, Duperet Cabrera E, Sánchez Boloy FA. Valoración de la endoftalmitis en la primera etapa clínica. Medisan. 2013;17(12):9057-62.

Relhan N, Forster RK, Flynn Jr HW. Endophthalmitis: then and now. Am J Ophthalmol. 2018;187:xx-xxvii.

Grzybowski A, Told R, Sacu S, Bandello F, Moisseiev E, Loewenstein A, et al. 2018 update on intravitreal injections: Euretina expert consensus recommendations. Ophthalmologica. 2018;239(4):181-93.

Hosseini H, Ashraf MJ, Saleh M, Nowroozzadeh MH, Nowroozizadeh B, Abtahi MB, et al. Effect of povidone–iodine concentration and exposure time on bacteria isolated from endophthalmitis cases. J Cataract Refract Surg. 2012;38(1):92-6.

Pinna A, Donadu MG, Usai D, Dore S, D'Amico‐Ricci G, Boscia F, et al. In vitro antimicrobial activity of a new ophthalmic solution containing povidone‐iodine 0.6% (IODIM®). Acta Ophthalmol. 2020;98(2):e178-e80.

Shimada H, Hattori T, Mori R, Nakashizuka H, Fujita K, Yuzawa M. Minimizing the endophthalmitis rate following intravitreal injections using 0.25% povidone–iodine irrigation and surgical mask. Graefes Arch Clin Exp Ophthalmol. 2013;251(8):1885-90.

Meredith TA, McCannel CA, Barr C, Doft BH, Peskin E, Maguire MG, et al. Postinjection endophthalmitis in the comparison of age-related macular degeneration treatments trials (CATT). Ophthalmology. 2015;122(4):817-21.

Forooghian F, Albiani DA, Kirker AW, Merkur AB. Comparison of endophthalmitis rates following intravitreal injection of compounded bevacizumab, ranibizumab, and aflibercept. Can J Ophthalmol. 2017;52(6):616-9.

Berkelman RL, Holland B, Anderson R. Increased bactericidal activity of dilute preparations of povidone-iodine solutions. J Clin Microbiol. 1982;15(4):635-9.

Shimada H, Arai S, Nakashizuka H, Hattori T, Yuzawa M. Reduction of anterior chamber contamination rate after cataract surgery by intraoperative surface irrigation with 0.25% povidone–iodine. Am J Ophthalmol. 2011;151(1):11-7. e1.

Van den Broek PJ, Buys LF, Van Furth R. Interaction of povidone-iodine compounds, phagocytic cells, and microorganisms. Antimicrob Agents Chemother. 1982;22(4):593-7. Epub 1982/10/01.

Uçan Gündüz G, Ulutaş HG, Yener N, Yalçınbayır Ö. Corneal endothelial alterations in patients with diabetic macular edema. J Surg Med. 2021;5(2):120-3.