Outcomes of intravitreal injections performed with a lid splinting eyelid retraction technique: A minimized sterile approach

Session Details

Session Title: Free Paper Session 5: Anterior/Posterior Segment Surgery

Session Date/Time: Thursday 07/09/2017 | 11:00-12:30

Paper Time: 11:00

Venue: Room 117

First Author: : M.Munro CANADA

Co Author(s): :    G. Williams   A. Ells   M. Fielden   A. Kherani   P. Mitchell   F. Adatia              

Abstract Details

Purpose:

To describe an alternative technique for avoiding contact with the lids and lashes, without the use of a lid speculum, during intravitral injections. The main outcome measures were the incidence of suspected and culture-positive proven infectious endophthalmitis.

Setting:

A retrospective office-based study located in Calgary, Alberta, Canada.

Methods:

A retrospective review of the medical records of all patients undergoing intravitreal injections of bevacizumab and ranibizumab with the lid splinting retraction technique between January 2010 to October 2015. Bevacizumab and Ranibizumab intravitral injections performed by 6 vitreo-retinal specialists were included. A search of the electronic medical records identified patients diagnosed with post-injection endophthalmitis. Prior to injection, patients received topical anesthetic drops (0.5% alcaine). This was followed by 5% povidone-iodine topical drops then a subconjunctival injection of 2% lidocaine with epinephrine. Pre-injection antibiotics, sterile drapes, lid speculum, surgical attire and gloves were not used. Following preparation of the ocular surface prior to injection, to remove the lids and lashes from the injection field, the physicians use their own hand to lift the lid and stabilize it against the patient’s brow. Care is taken to avoid direct globe pressure. The fingers are placed several millimeters away from the lid margin to avoid the meibomian glands and inadvertent expression. Placement of the fingers can be adjusted depending on the quadrant for maximal scleral exposure. With this technique, the upper lid becomes splinted, removing the lashes from the injection site.

Results:

A total of 78,009 consecutive intravitreal injections were performed, of which 22,207 were bevacizumab and 55,802 were ranibizumab. In this cohort of patients, 12 cases of endophthalmitis developed, corresponding to a rate of 0.015%. 10 cases were ranibizumab and 2 cases were bevacizumab. The time to onset occurred after a mean 4 ± 2 days post-injection (median 3.5, range 2-7). Patients were being treated for age-related macular degeneration-related choroidal neovascular membranes (n=9), diabetic macular edema (n=2) and radiation retinopathy (n=1). 7 cases were culture negative, 4 cases grew coagulase negative staphlococci and 1 case grew staphlococcus epidermidis. Treatment involved vitreous tap and injection of antibiotics in 8 cases (7 went on to have pars plana vitrectomy) and total of 11 patients underwent pars plana vitrectomy with intravitreal antibiotic and steroid injection.

Conclusions:

The technique of eyelid retraction for intravitreal injection has a low rate of endophthalmitis, similar to the reported rates using a metal lid speculum. This technique can safely be performed in a clean, office setting. This is beneficial for both the physician and the patient as it minimizes patient discomfort as well as the duration of the procedure.

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