Celebrating Nurses’ Monumental Impact
There is a myriad of ways to participate in National Nurses Week, which is celebrated May 6-12, from honoring your staff RNs with a gift or event to taking steps to let...
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By: Christina Weng
Published: 11/14/2019
Endophthalmitis, an infection involving the entire eye, is a rare complication of invasive procedures such as cataract surgery and intravitreal injections. Post-cataract surgery endophthalmitis rates vary, depending on the source, but are estimated to approximate 0.1%. However, because more than 3.5 million cataract surgeries are performed annually in the United States, a sizeable number of patients are at risk. The same holds true for intravitreal injections, of which over 7 million are performed in the United States each year for conditions such as wet macular degeneration, diabetic macular edema and diabetic retinopathy. Although the risk of post-injection endophthalmitis is low — estimated to be between 1 in 2,000 and 1 in 5,000 — a significant number of patients have the potential to be affected.
Post-cataract surgery or post-injection endophthalmitis can happen no matter how careful physicians are during procedures, but there are ways to minimize the risks.
Generously apply 10% povidone-iodine to the periorbital area. I also like to "paint" individual eyelashes as if applying mascara. It's important to clean the lid margins well, especially if the patient has severe blepharitis. But take care not to scrub too vigorously, which could cause microscopic wounds to form. Use 5% povidone-iodine to irrigate the ocular surface.
When draping the eye, make sure the eyelashes are fully covered. A speculum will help move the lashes and eyelids away from the ocular working surface. If patients declare an allergy to povidone-iodine, I generally inquire further and emphasize the importance of its use, because true allergies to povidone-iodine are extremely rare. While chlorhexidine gluconate can be used in its place, it is definitely a second-line agent, and is not quite as effective in reducing the bacterial load in and around the eye.
Surgeons should always discuss the symptoms of endophthalmitis with their patients, especially those who are high-risk.
Intracameral moxifloxacin also appears to be effective in reducing the rate of endophthalmitis, according to a 2017 retrospective study of more than 600,000 surgeries that was published in Ophthalmology (osmag.net/ TFngS7). Moxifloxacin is preferred by some surgeons given its accessibility and due to the concern for hemorrhagic occlusive retinal vasculitis (HORV), a severe vision-threatening inflammatory reaction associated with use of intracameral vancomycin.
There are still no FDA-approved intracameral antibiotics on the market, so surgeons who choose to use these drugs must either compound the medication on site or purchase compounded formulations from an outside pharmacy. To ensure that your intracameral antibiotics are safely and properly prepared, partner with an accredited compounding pharmacy that is compliant with current Good Manufacturing Practices (cGMP) and has a track record of safety.
Ask 10 retina specialists about their protocol for administering injections and you will get 10 different responses. One thing we all agree upon, however, is that applying 5% povidone-iodine on the ocular surface before administering an intravitreal injection is the most effective way to prevent post-injection endophthalmitis.
I like to wear non-sterile gloves, use a speculum to keep the eyelashes and eyelids clear of the injection space, and apply 10% povidone-iodine on the eyelashes, lids, and periorbital skin. However, there is mixed evidence that any of these practices decrease infection risk.
Pre-filled syringes are becoming more prevalent, and while their effect on minimizing post-injection endophthalmitis has yet to be proven, they do eliminate additional steps where cross-contamination can occur. However, most of us still play an active role in preparing the syringe, and I exercise caution when drawing up medications and transferring needles.
Like many retina specialists, I do not wear a mask while administering injections, but I do adhere to a strict no-talking policy — for myself and my patients — because oral flora is a common isolate in culture-positive, post-injection endophthalmitis. I also always place a drop of 5% povidone-iodine on the conjunctival surface over the penetration site before I give the injection. There is no evidence that post-injection topical antibiotics prevent endophthalmitis. In fact, some data suggest that they can contribute to antibiotic resistance of the ocular surface, so prescribing antibiotic drops after an injection is not recommended. OSM
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