title: 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, butaqueouschlorhexidine 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.
authors.affiliation: Retina Associates, Level 4, 8 Thomas St, Chatswood, NSW 2067 Australia ; grid.1013.3000000041936834XSave Sight Institute, University of Sydney, Sydney, NSW Australia ; grid.1004.50000000121585405Australian School of Advanced Medicine, Macquarie University, Sydney, NSW Australia ; grid.414685.a0000000403923935Concord Repatriation General Hospital, Concord, NSW Australia.
authors.forename: Rohan
authors.initials: R
authors.lastname: Merani
authors.affiliation: Retina Associates, Level 4, 8 Thomas St, Chatswood, NSW 2067 Australia ; grid.1013.3000000041936834XSave Sight Institute, University of Sydney, Sydney, NSW Australia ; grid.1004.50000000121585405Australian School of Advanced Medicine, Macquarie University, Sydney, NSW Australia ; grid.416790.d0000000406258248Sydney Eye Hospital, Sydney, NSW Australia.
authors.forename: Alex P
authors.initials: AP
authors.lastname: Hunyor
keywords: Anti-VEGF; Antibiotics; Antisepsis; Chlorhexidine; Endophthalmitis; Intravitreal injection; Masks; Povidone-Iodine; Speculum; Streptococcus