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Endophthalmitis rates similarly low in operating room, office settings
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Rates of endophthalmitis after intravitreal injections were similarly low whether the injections were given in the operating room or office, according to a study.
Only five patients were reported to be treated for endophthalmitis in the retrospective review of 11,710 intravitreal injections given in both settings. Three cases occurred in patients who were treated in the office, and two cases occurred in patients who were treated in the operating room.
While multiple, often mandated precautions taken during intravitreal injections in operating rooms are believed to reduce the risk for endophthalmitis, no concrete data show such safeguards lower the risk for infection in operating rooms or other settings, lead author Homayoun Tabandeh, MD, told Ocular Surgery News.
“The use of certain precautions — wearing sterile gloves, drape and mask — probably does not lead to major reductions in endophthalmitis,” Tabandeh said.
Study design, methods
The consecutive case series included 8,647 injections given in office settings and 3,063 injections given in operating rooms in a 3-year period.
In all patients, neovascular age-related macular degeneration, diabetic macular edema or retinal vein occlusion, among other conditions, was diagnosed and treated with Lucentis (ranibizumab, Genentech), Avastin (bevacizumab, Genentech) or triamcinolone acetonide.
“Our group wanted to look into whether there is a major difference in doing the procedure where all the precautions are taken — the operating room — from those done in the office,” Tabandeh said.
In the operating room group, physicians used sterile gloves, surgical masks, sterile drapes and eyelid speculums. Patients were prescribed topical antibiotic drops for 4 days after the injection. Conversation was restricted during the procedure.
In the office-based group, physicians used nonsterile disposable gloves, applied antibiotic drops after the procedure and prescribed topical antibiotic drops for 4 days after injection. Physicians conversed with patients during the procedure.
Tabandeh said that he talks to patients during the procedure to alleviate their anxiety as well as to give them instruction.
Convenience, cost
Internationally, where operating rooms remain one of the primary settings for intravitreal injections, an analysis of the impact that operating room protocol has on convenience and cost could lead to payoffs for patients and their health care systems, Tabandeh said.
“If you can do the procedure with the same efficacy, but more efficiently, more cost-effective and with more convenience for the patient, then obviously that is something to consider,” Tabandeh said.
In operating rooms settings, separate visits are often required for the evaluation and procedure, resulting in added inconvenience for patients and caregivers. In office settings, however, the evaluation and procedure often occur the same day.
“That is a recurring situation because every month is a treatment,” Tabandeh said.
Performing intravitreal injections in operating rooms drives up the cost of the procedure and strains the health care system, Tabandeh said. With more than a million intravitreal injections performed annually, the cost of those precautions and the expense of running the operating room add up quickly.
“The surgical mask may seem to be a small issue,” Tabandeh said. “But when you are using three masks per injection, and there are millions of procedures per year, we are talking about millions of masks being worn. Or, for that matter, sterile gloves.”
In the study, the operating room group received preoperative antibiotic drugs, whereas the office group did not, suggesting that the use of preinjection prophylaxis has no apparent preventive impact, Tabandeh said, adding that use of preoperative antibiotics has significant costs and potential safety issues.
“There is a suggestion that giving prophylaxis antibiotics may encourage resistant bacteria,” Tabandeh said.
Dousing the eye with povidone-iodine solution to decrease the presence of conjunctival bacteria, injecting the needle far enough from adnexal tissue and the eyelid margin, and preparing the drug just before the procedure to avoid contamination are precautions that must be taken during intravitreal procedures, Tabandeh said.
“Most important is patient safety,” Tabandeh said. “Given that the patient’s safety seems to be similar in both groups, the next concerns are patient convenience and the socioeconomic impact, considering how common the procedure is.”– by Steve Ahern