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Endophthalmitis as related to use of bevacizumab or ranibizumab
MEDICAL ABSTRACTS Marc D. Myers, O.D.
Endophthalmitis as related to use of bevacizumab or ranibizumab Fintak DR, Shah GV, Blinder KJ, et al. Incidence of endophthalmitis related to intravitreal injection of bevacizumab and ranibizumab. Retina 2008;28(10):1395-9. Intravitreal injections have expanded from their initial use of air injection for retinal tamponade to delivery of antibiotics, antivirals, antifungals, and steroids, to most recent antivascular endothelial growth factor therapies, including pegaptanib, bevacizumab, and ranibizumab for the treatment of age-related macular degeneration (AMD). Protocols for treatment of AMD dictate near-monthly injections of antivascular endothelial growth factor therapies, making the risk of endophthalmitis an even greater concern. This study considers a large sample size to better quantify the incidence of endophthalmitis related to current use of bevacizumab or ranibizumab. Patients receiving at least 1 intravitreal injection of bevacizumab or ranibizumab were included in this retrospective, consecutive, multicenter case series. A total of 12,585 injections of bevacizumab and 14,320 of
ranibizumab were given during the study period. Standard dosage of medications and the customary injection procedure was used in eyes prepared with routine topical or injectable anesthetics. Ocular surface disinfection included several drops of either 5% or 10% povidone-iodine-solution, with some surgeons using an additional 10% povidone-iodine-soaked cotton tip applicator for cleansing the eyelid skin, eyelashes, and lid margin. At the conclusion of the procedure, topical antibiotic drops, usually a fourth-generation fluoroquinolone, were instilled and subsequently used 4 times daily for 3 to 5 days. Patients were educated regarding the symptoms of endophthalmitis and the need for acute consultation. Follow-up appointments were scheduled based on the need for additional therapy. Three patients had infectious endophthalmitis after administration of intravitreal bevacizumab and 3 patients after ranibizumab. All patients presented for re-examination within 1 to 5 days of the injection with symptoms typical for endophthalmitis. Four of the 6 cases had culture-proven bacterial endophthalmitis. Therefore, rates of endophthalmitis were 0.02% (95% confidence interval [CI]: 0.00% to 0.07%) per injection in the bevacizumab group and 0.02% (95% CI: 0.00% to 0.05%) in the ranibizumab group.
1529-1839/09/$ -see front matter Ó 2009 American Optometric Association. All rights reserved.
Marc D. Myers, O.D.
The theoretical risk that the rate of endophthalmitis will be higher when the same vial is used for multiple injections was not supported in this study. Endophthalmitis rates in this study were similar between bevacizumab (multiuse vial) and ranibizumab (single-use vial). Also shown was the reliable and safe practice of the preparation of the medications for intravitreal use. Improved sterile technique and patient education regarding symptoms may minimize the occurrence and morbidity of endophthalmitis. Marc D. Myers, O.D. doi:10.1016/j.optm.2009.05.005
Endophthalmitis as related to use of bevacizumab or ranibizumab Fintak DR, Shah GV, Blinder KJ, et al. Incidence of endophthalmitis related to intravitreal injection of bevacizumab and ranibizumab. Retina 2008;28(10):1395-9. Intravitreal injections have expanded from their initial use of air injection for retinal tamponade to delivery of antibiotics, antivirals, antifungals, and steroids, to most recent antivascular endothelial growth factor therapies, including pegaptanib, bevacizumab, and ranibizumab for the treatment of age-related macular degeneration (AMD). Protocols for treatment of AMD dictate near-monthly injections of antivascular endothelial growth factor therapies, making the risk of endophthalmitis an even greater concern. This study considers a large sample size to better quantify the incidence of endophthalmitis related to current use of bevacizumab or ranibizumab. Patients receiving at least 1 intravitreal injection of bevacizumab or ranibizumab were included in this retrospective, consecutive, multicenter case series. A total of 12,585 injections of bevacizumab and 14,320 of
ranibizumab were given during the study period. Standard dosage of medications and the customary injection procedure was used in eyes prepared with routine topical or injectable anesthetics. Ocular surface disinfection included several drops of either 5% or 10% povidone-iodine-solution, with some surgeons using an additional 10% povidone-iodine-soaked cotton tip applicator for cleansing the eyelid skin, eyelashes, and lid margin. At the conclusion of the procedure, topical antibiotic drops, usually a fourth-generation fluoroquinolone, were instilled and subsequently used 4 times daily for 3 to 5 days. Patients were educated regarding the symptoms of endophthalmitis and the need for acute consultation. Follow-up appointments were scheduled based on the need for additional therapy. Three patients had infectious endophthalmitis after administration of intravitreal bevacizumab and 3 patients after ranibizumab. All patients presented for re-examination within 1 to 5 days of the injection with symptoms typical for endophthalmitis. Four of the 6 cases had culture-proven bacterial endophthalmitis. Therefore, rates of endophthalmitis were 0.02% (95% confidence interval [CI]: 0.00% to 0.07%) per injection in the bevacizumab group and 0.02% (95% CI: 0.00% to 0.05%) in the ranibizumab group.
1529-1839/09/$ -see front matter Ó 2009 American Optometric Association. All rights reserved.
Marc D. Myers, O.D.
The theoretical risk that the rate of endophthalmitis will be higher when the same vial is used for multiple injections was not supported in this study. Endophthalmitis rates in this study were similar between bevacizumab (multiuse vial) and ranibizumab (single-use vial). Also shown was the reliable and safe practice of the preparation of the medications for intravitreal use. Improved sterile technique and patient education regarding symptoms may minimize the occurrence and morbidity of endophthalmitis. Marc D. Myers, O.D. doi:10.1016/j.optm.2009.05.005