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RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2014 VOLUME 34 NUMBER 9
anteriorly protrusion forces, decenteration of the IOL are not as frequent. Also, direct oil contact with the IOL might have potential risks for chemical modification of the IOL surface. Most of all, in oil tamponade cases, the posterior capsular opacity can be removed during oil removal procedures. In our technique, the precise size and location of the capsulotomy is still required. With the development of femtosecond laser-assisted cataract surgery, it is possible to make precise anterior and posterior capsulotomies easily.3,4 We expect that our technique may have more potential value in the future. We also hope for the development of specially designed IOLs for posterior optic buttonholing. Joo Youn Shin, MD Suk Ho Byeon, MD Sung Eun Kim, MD Department of Ophthalmology, Severance Hospital, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea None of the authors have any financial/conflicting interests to disclose. References 1. Shin JY, Kim SE, Byeon SH. Primary posterior capsulotomy and posterior optic buttonholing in eyes with phacovitrectomy and gas tamponade. Retina 2014;34:610–615. 2. Kim SW, Oh J, Song JS, et al. Risk factors of iris posterior synechia formation after phacovitrectomy with three-piece acrylic IOL or single-piece acrylic IOL. Ophthalmologica 2009;223:222–227. 3. Friedman NJ, Palanker DV, Schuele G, et al. Femtosecond laser capsulotomy. J Cataract Refract Surg 2011;37:1189–1198. 4. Dick HB, Schultz T. Primary posterior laser-assisted capsulotomy. J Refract Surg 2014;30:128–133.
Correspondence To the Editor: In the January issue, Tabandeh et al1 reported on the equally low rates of endophthalmitis after intravitreal injections in an office-based setting compared with an operating room in “Endophthalmitis associated with intravitreal injections: Office-based setting and operating room setting.” Although prophylactic antibiotics were used in both settings, we demonstrate that similar rates of endophthalmitis can be achieved solely using 5% povidone–iodide in a district general NHS hospital clinic-based setting in the United Kingdom. Intravitreal injections have become the mainstay of administering medications to the posterior segment in
treating conditions such as age-related macular degeneration. It is estimated that 30,458 intravitreal injections were administered in the NHS between 2008 and 2009.2 One of the most serious ocular adverse events after intravitreal injection is endophthalmitis. The most recent Royal College of Ophthalmology guidelines recommend the use of 5% povidone–iodide to the eyelids, eyelid margins, and conjunctival sac, with a contact time of 60 seconds before injection, but routine postinjection antibiotics are not recommended, although can be used at the discretion of the treating clinician.3 Topical povidone–iodide is the only substance to have been proven in a randomized control trial to reduce the risk of endophthalmitis after intraocular surgery if administered before procedure.4 Low rates of endophthalmitis (0.007%) have been reported in a study of 15,000 intravitreal injections using a protocol that includes topical povidone–iodide, sterile drape, lid speculum, and topical anesthetic but not requiring topical antibiotics.5 We conducted a retrospective study of all intravitreal injections performed at Queens Hospital BHR NHS trust between 2008 and 2013. All intravitreal injections were performed using a clean room, sterile gloves, topical anesthetic, and lid speculum. Topical 5% povidone–iodide was administered to the conjunctival sac, before speculum insertion, and over the conjunctiva displaced injection site. Povidone–iodide to the periocular skin was used at the discretion of the surgeon. No antibiotics were given before or after injection. Presumed endophthalmitis that required intravitreal biopsy and intravitreal antibiotics was determined on clinical grounds by an ophthalmologist. A total number of 6,957 intravitreal injections were performed in 870 eyes of 749 patients during this period. Ten different doctors administered the injections with an experience ranging from 20 to 551 injections. The incidence of presumed endophthalmitis was 0.04% (3 cases). All of these three cases of culture-negative endophthalmitis received amikacin and vancomycin intravitreal antibiotics. The experience of the doctor administering the injection ranged from 176 to 382 injections. Tabandeh et al discuss the risks of using a prophylactic antibiotic with suboptimal coverage for the organisms responsible for endophthalmitis after intravitreal injection in promoting colonization with more virulent pathogens. We agree that low rates of endophthalmitis can be achieved in a clinic-based setting compared with an operating room setting. In addition, we found that there is no added risk to endophthalmitis when antibiotics were not given as prophylaxis after intravitreal injection in a district general NHS clinicbased setting in the United Kingdom.
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CORRESPONDENCE
Alastair Porteous, BSc (Hons), MBBS* Roopa Vemala, MRCOphth* Judith Field, BSc* Niaz Islam, BSC (Hons), MBBS, MRCOphth, FRCOphth† *Queens Hospital, Romford, Essex, United Kingdom †Moorfields Eye Hospital, London, United Kingdom None of the authors have any financial/conflicting interests to disclose. References 1. Tabandeh H, Boscia F, Sborgia A, et al. Endophthalmitis associated with intravitreal injections: office-based setting and operating room setting. Retina 2014;34:18–23. 2. Keenan TD, Wotton CJ, Goldacre MJ. Trends over time and geographical variation in rates of intravitreal injections in England. Br J Ophthalmol 2012;96:413–418. 3. Royal college of ophthalmologists age-related macular degeneration: guidelines for management. The Royal College of Ophthalmologists 2013:76–79. 4. Speaker MG, Menikoff JA. Prophylaxis of endophthalmitis with topical povidone-iodine. Ophthalmology 1991;98:1769–1775. 5. Bhavsar AR, Googe JM Jr, Stockdale CR, et al. The risk of endophthalmitis following intravitreal injection in the DRCR. net Laser-Ranibizumab-Triamcinolone clinical trials. Arch Ophthalmol 2009;127:1581–1583.
Reply To the Editor: We thank Dr. Porteous et al for their interest in our article and their comments.1 They report 3 cases (0.04%) of presumed infectious endophthalmitis occurring in 6,957 intravitreal injections performed by 10 treating physicians over a period of 5 years. The injections were performed in a clean room, using sterile gloves, lid speculum, and povidone–iodine 5%. Prophylactic topical antibiotics were not used before or after the injections. They conclude that there is no added risk of endophthalmitis when antibiotics were not used after injection. Comments by Porteous et al are consistent with the findings of our study that performing intravitreal injection in the operating room, use of sterile gloves, wearing surgical masks, and use of sterile drapes are not essential in achieving a low rate of endophthalmitis. Preparing the ocular surface with povidone– iodine 5% immediately before cataract surgery is associated with reduced risk of postoperative endophthalmitis.2 Extrapolating these findings to the setting of intravitreal injection, it is presumed that preparing the ocular surface with povidone–iodine before intravitreal injection will likely reduce the risk of postinjection endophthalmitis.
As intravitreal injections have become the mainstay treatment for many retinal diseases and an increasing number of intravitreal injections are performed every year, the practice pattern for performing this procedure has evolved. Accumulation of data from numerous published studies, protocols used in major clinical trials, and increased personal experiences have influenced our current practice. In the early days of intravitreal drug administration, use of prophylactic topical antibiotics before and after intravitreal injection was common practice. As experience accumulated, many physicians modified their practice omitting the use of preinjection topical antibiotics. Recent studies have shown low rates of endophthalmitis without the use of postinjection topical antibiotic prophylaxis.3–6 Other studies have demonstrated increased antibiotic resistance of ocular surface flora with repeated use of topical antibiotics after intravitreal injection.7,8 Subsequently, many physicians no longer use postinjection antibiotics. Indeed, since the conclusion of our study, our practice has also evolved in that postinjection prophylactic antibiotics are not used by many of the authors. We agree with the observation of Dr. Porteous et al and those of others that use of postinjection topical antibiotics may not confer added protection against the risk of endophthalmitis. Homayoun Tabandeh, MD* Francesco Boscia, MD† Harry W. Flynn, Jr., MD‡ *Retina-Vitreous Associates Medical Group Los Angeles, California †Department of Ophthalmology University of Sassari, Sassari, Italy ‡Bascom Palmer Eye Institute, Miami, Florida None of the authors have any financial/conflicting interests to disclose. References 1. Tabandeh H, Boscia F, Sborgia A, et al. Endophthalmitis associated with intravitreal injections: office-based setting and operating room setting. Retina 2014;34:18–23. 2. Speaker MG, Menikoff JA. Prophylaxis of endophthalmitis with topical povidone-iodine. Ophthalmology 1991;98:1769–1775. 3. Bhavsar AR, Googe JM Jr, Stockdale CR, et al. The risk of endophthalmitis following intravitreal injection in the DRCR. net laser-ranibizumab-triamcinolone clinical trials. Arch Ophthalmol 2009;127:1581–1583. 4. Bhavsar AR, Stockdale CR, Ferris FL III, et al. Update on risk of endophthalmitis after intravitreal drug injections and potential impact of elimination of topical antibiotics. Arch Ophthalmol 2012;130:809–810.
RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2014 VOLUME 34 NUMBER 9
anteriorly protrusion forces, decenteration of the IOL are not as frequent. Also, direct oil contact with the IOL might have potential risks for chemical modification of the IOL surface. Most of all, in oil tamponade cases, the posterior capsular opacity can be removed during oil removal procedures. In our technique, the precise size and location of the capsulotomy is still required. With the development of femtosecond laser-assisted cataract surgery, it is possible to make precise anterior and posterior capsulotomies easily.3,4 We expect that our technique may have more potential value in the future. We also hope for the development of specially designed IOLs for posterior optic buttonholing. Joo Youn Shin, MD Suk Ho Byeon, MD Sung Eun Kim, MD Department of Ophthalmology, Severance Hospital, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea None of the authors have any financial/conflicting interests to disclose. References 1. Shin JY, Kim SE, Byeon SH. Primary posterior capsulotomy and posterior optic buttonholing in eyes with phacovitrectomy and gas tamponade. Retina 2014;34:610–615. 2. Kim SW, Oh J, Song JS, et al. Risk factors of iris posterior synechia formation after phacovitrectomy with three-piece acrylic IOL or single-piece acrylic IOL. Ophthalmologica 2009;223:222–227. 3. Friedman NJ, Palanker DV, Schuele G, et al. Femtosecond laser capsulotomy. J Cataract Refract Surg 2011;37:1189–1198. 4. Dick HB, Schultz T. Primary posterior laser-assisted capsulotomy. J Refract Surg 2014;30:128–133.
Correspondence To the Editor: In the January issue, Tabandeh et al1 reported on the equally low rates of endophthalmitis after intravitreal injections in an office-based setting compared with an operating room in “Endophthalmitis associated with intravitreal injections: Office-based setting and operating room setting.” Although prophylactic antibiotics were used in both settings, we demonstrate that similar rates of endophthalmitis can be achieved solely using 5% povidone–iodide in a district general NHS hospital clinic-based setting in the United Kingdom. Intravitreal injections have become the mainstay of administering medications to the posterior segment in
treating conditions such as age-related macular degeneration. It is estimated that 30,458 intravitreal injections were administered in the NHS between 2008 and 2009.2 One of the most serious ocular adverse events after intravitreal injection is endophthalmitis. The most recent Royal College of Ophthalmology guidelines recommend the use of 5% povidone–iodide to the eyelids, eyelid margins, and conjunctival sac, with a contact time of 60 seconds before injection, but routine postinjection antibiotics are not recommended, although can be used at the discretion of the treating clinician.3 Topical povidone–iodide is the only substance to have been proven in a randomized control trial to reduce the risk of endophthalmitis after intraocular surgery if administered before procedure.4 Low rates of endophthalmitis (0.007%) have been reported in a study of 15,000 intravitreal injections using a protocol that includes topical povidone–iodide, sterile drape, lid speculum, and topical anesthetic but not requiring topical antibiotics.5 We conducted a retrospective study of all intravitreal injections performed at Queens Hospital BHR NHS trust between 2008 and 2013. All intravitreal injections were performed using a clean room, sterile gloves, topical anesthetic, and lid speculum. Topical 5% povidone–iodide was administered to the conjunctival sac, before speculum insertion, and over the conjunctiva displaced injection site. Povidone–iodide to the periocular skin was used at the discretion of the surgeon. No antibiotics were given before or after injection. Presumed endophthalmitis that required intravitreal biopsy and intravitreal antibiotics was determined on clinical grounds by an ophthalmologist. A total number of 6,957 intravitreal injections were performed in 870 eyes of 749 patients during this period. Ten different doctors administered the injections with an experience ranging from 20 to 551 injections. The incidence of presumed endophthalmitis was 0.04% (3 cases). All of these three cases of culture-negative endophthalmitis received amikacin and vancomycin intravitreal antibiotics. The experience of the doctor administering the injection ranged from 176 to 382 injections. Tabandeh et al discuss the risks of using a prophylactic antibiotic with suboptimal coverage for the organisms responsible for endophthalmitis after intravitreal injection in promoting colonization with more virulent pathogens. We agree that low rates of endophthalmitis can be achieved in a clinic-based setting compared with an operating room setting. In addition, we found that there is no added risk to endophthalmitis when antibiotics were not given as prophylaxis after intravitreal injection in a district general NHS clinicbased setting in the United Kingdom.
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CORRESPONDENCE
Alastair Porteous, BSc (Hons), MBBS* Roopa Vemala, MRCOphth* Judith Field, BSc* Niaz Islam, BSC (Hons), MBBS, MRCOphth, FRCOphth† *Queens Hospital, Romford, Essex, United Kingdom †Moorfields Eye Hospital, London, United Kingdom None of the authors have any financial/conflicting interests to disclose. References 1. Tabandeh H, Boscia F, Sborgia A, et al. Endophthalmitis associated with intravitreal injections: office-based setting and operating room setting. Retina 2014;34:18–23. 2. Keenan TD, Wotton CJ, Goldacre MJ. Trends over time and geographical variation in rates of intravitreal injections in England. Br J Ophthalmol 2012;96:413–418. 3. Royal college of ophthalmologists age-related macular degeneration: guidelines for management. The Royal College of Ophthalmologists 2013:76–79. 4. Speaker MG, Menikoff JA. Prophylaxis of endophthalmitis with topical povidone-iodine. Ophthalmology 1991;98:1769–1775. 5. Bhavsar AR, Googe JM Jr, Stockdale CR, et al. The risk of endophthalmitis following intravitreal injection in the DRCR. net Laser-Ranibizumab-Triamcinolone clinical trials. Arch Ophthalmol 2009;127:1581–1583.
Reply To the Editor: We thank Dr. Porteous et al for their interest in our article and their comments.1 They report 3 cases (0.04%) of presumed infectious endophthalmitis occurring in 6,957 intravitreal injections performed by 10 treating physicians over a period of 5 years. The injections were performed in a clean room, using sterile gloves, lid speculum, and povidone–iodine 5%. Prophylactic topical antibiotics were not used before or after the injections. They conclude that there is no added risk of endophthalmitis when antibiotics were not used after injection. Comments by Porteous et al are consistent with the findings of our study that performing intravitreal injection in the operating room, use of sterile gloves, wearing surgical masks, and use of sterile drapes are not essential in achieving a low rate of endophthalmitis. Preparing the ocular surface with povidone– iodine 5% immediately before cataract surgery is associated with reduced risk of postoperative endophthalmitis.2 Extrapolating these findings to the setting of intravitreal injection, it is presumed that preparing the ocular surface with povidone–iodine before intravitreal injection will likely reduce the risk of postinjection endophthalmitis.
As intravitreal injections have become the mainstay treatment for many retinal diseases and an increasing number of intravitreal injections are performed every year, the practice pattern for performing this procedure has evolved. Accumulation of data from numerous published studies, protocols used in major clinical trials, and increased personal experiences have influenced our current practice. In the early days of intravitreal drug administration, use of prophylactic topical antibiotics before and after intravitreal injection was common practice. As experience accumulated, many physicians modified their practice omitting the use of preinjection topical antibiotics. Recent studies have shown low rates of endophthalmitis without the use of postinjection topical antibiotic prophylaxis.3–6 Other studies have demonstrated increased antibiotic resistance of ocular surface flora with repeated use of topical antibiotics after intravitreal injection.7,8 Subsequently, many physicians no longer use postinjection antibiotics. Indeed, since the conclusion of our study, our practice has also evolved in that postinjection prophylactic antibiotics are not used by many of the authors. We agree with the observation of Dr. Porteous et al and those of others that use of postinjection topical antibiotics may not confer added protection against the risk of endophthalmitis. Homayoun Tabandeh, MD* Francesco Boscia, MD† Harry W. Flynn, Jr., MD‡ *Retina-Vitreous Associates Medical Group Los Angeles, California †Department of Ophthalmology University of Sassari, Sassari, Italy ‡Bascom Palmer Eye Institute, Miami, Florida None of the authors have any financial/conflicting interests to disclose. References 1. Tabandeh H, Boscia F, Sborgia A, et al. Endophthalmitis associated with intravitreal injections: office-based setting and operating room setting. Retina 2014;34:18–23. 2. Speaker MG, Menikoff JA. Prophylaxis of endophthalmitis with topical povidone-iodine. Ophthalmology 1991;98:1769–1775. 3. Bhavsar AR, Googe JM Jr, Stockdale CR, et al. The risk of endophthalmitis following intravitreal injection in the DRCR. net laser-ranibizumab-triamcinolone clinical trials. Arch Ophthalmol 2009;127:1581–1583. 4. Bhavsar AR, Stockdale CR, Ferris FL III, et al. Update on risk of endophthalmitis after intravitreal drug injections and potential impact of elimination of topical antibiotics. Arch Ophthalmol 2012;130:809–810.
