Evaluation of conjunctival sac culture findings prior to intravitreal injection_Chinese Journal of Ocular Fundus Diseases

Authors：

Ren Xinjun , Ke Yifeng , Tan Liangzhang , Emmanuel Eric Pazo , Li Yongtao ,  Li Xiaorong

Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China;

Corresponding author：

Li Xiaorong, Email: xiaorli@163.com

Keywords：

Intravitreal injection; Conjunctival sac microbial culture; Povidone-iodine; Endophthalmitis

DOI：

10.3760/cma.j.cn511434-20240218-00072

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Objective To observe the differences in the positive rate of conjunctival sac microbial culture after different methods of preventing infection before intravitreal injection (IVI). Methods A prospective case-control study. A total of 1 200 participants with fundus diseases who received IVI injection at Tianjin Medical University Eye Hospital from July 2021 to December 2023 were included. Patients were randomly divided into 6 groups according to eye spot with antibiotic solution 3, 1 and 0 days before IVI and local eye disinfection with povidone-iodine (PVI) 3 min and 30 s before IVI: the first 3 days of antibiotics+3 min PVI group, the first 1 day of antibiotics+3 min PVI group, the first 0 days of antibiotics+3 min PVI group, the first 3 days of antibiotics+30 s PVI group, the first 1 day of antibiotics+30 s PVI group, the first 0 days of antibiotics+30 s PVI group, there were 200 cases in each group. Microbial sampling and cultivation of conjunctival sac were conducted before IVI to compare the differences in positive rates among different groups. Multiple group comparisons were conducted using one-way analysis of variance; The comparison of count data is conducted using χ² test. Results Among the 1 200 patients, there were 566 males and 634 females. Age (62.59±13.44) years old. There were 397 cases of diabetes and 482 cases of hypertension. IVI frequency (2.35±2.34). 64 cases were positive for conjunctival sac culture before IVI. The age (F=1.468), sex composition ratio (χ²=2.876), diabetes (χ²=10.002), hypertension (χ²=6.019), times of IVI (χ²=4.507), and positive rate of conjunctival sac bacterial culture (χ²=6.272) of patients in each group had no statistical significance (P＞0.05). Using the duration of antibiotic application before IVI as a stratified factor, there was no statistically significant difference in the positive rate of conjunctival sac culture between groups with different durations of antibiotic application before IVI [χ²=0.414, P=0.52, combined odds ratio (OR)=0.819, 95% confidence interval (CI) 0.493-1.360]. Using the duration of PVI application as a stratified factor, there was no statistically significant difference in the positive rate of conjunctival sac culture between different PVI disinfection times [χ²=0.000, P=1.00, combined OR=1.00, 95% CI 0.503-1.988]. Conclusions Pre IVI treatment with 0.5% PVI for 30 s can inhibit the growth of microbial colonies in the conjunctival sac. The application of local antibiotic eye fluid in the anterior eye of IVI cannot reduce the positive rate of conjunctival sac bacteria.

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2.	Fileta JB, Scott IU, Flynn HW Jr. Meta-analysis of infectious endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents[J]. Ophthalmic Surg Lasers Imaging Retina, 2014, 45(2): 143-149. DOI: 10.3928/23258160-20140306-08.
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10.	Miller KM, Oetting TA, Tweeten JP, et al. Cataract in the adult eye preferred practice pattern[J]. Ophthalmology, 2022, 129(1): 1-126. DOI: 10.1016/j.ophtha.2021.10.006.
11.	Sigford DK, Reddy S, Mollineaux C, et al. Global reported endophthalmitis risk following injections of anti-VEGF: a literature review and analysis[J]. Clin Ophthalmol, 2015, 9: 773-781. DOI: 10.2147/OPTH.S77067.
12.	Wykoff CC, Flynn HW Jr, Rosenfeld PJ. Prophylaxis for endophthalmitis following intravitreal injection: antisepsis and antibiotics[J]. Am J Ophthalmol, 2011, 152(5): 717-719. DOI: 10.1016/j.ajo.2011.07.002.
13.	Ta CN, Singh K, Egbert PR, et al. Prospective comparative evaluation of povidone-iodine (10% for 5 minutes versus 5% for 1 minute) as prophylaxis for ophthalmic surgery[J]. J Cataract Refract Surg, 2008, 34(1): 171-172. DOI: 10.1016/j.jcrs.2007.08.035.
14.	Li B, Nentwich MM, Hoffmann LE, et al. Povidone-iodine 1.0%, 5.0%, and 10.0% as preoperative prophylaxis before cataract surgery[J]. J Cataract Refract Surg, 2013, 39(7): 994-1001. DOI: 10.1016/j.jcrs.2013.02.039.
15.	Pinna A, Donadu MG, Usai D, et al. In vitro antimicrobial activity of a new ophthalmic solution containing povidone-iodine 0.6%(IODIM^®)[J/OL]. Acta Ophthalmol, 2020, 98(2): e178-e180[2019-09-05]. https://pubmed.ncbi.nlm.nih.gov/31486592/. DOI: 10.1111/aos.14243.
16.	Zamora JL. Chemical and microbiologic characteristics and toxicity of povidone-iodine solutions[J]. Am J Surg, 1986, 151(3): 400-406. DOI: 10.1016/0002-9610(86)90477-0.
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18.	Jiang J, Wu M, Shen T. The toxic effect of different concentrations of povidone iodine on the rabbit’s cornea[J]. Cutan Ocul Toxicol, 2009, 28(3): 119-124. DOI: 10.1080/15569520903080511.
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20.	Olson RJ, Braga-Mele R, Chen SH, et al. Cataract in the adult eye preferred practice pattern^®[J]. Ophthalmology, 2017, 124(2): P1-P119. DOI: 10.1016/j.ophtha.2016.09.027.
21.	Hunyor AP, Merani R, Darbar A, et al. Topical antibiotics and intravitreal injections[J]. Acta Ophthalmol, 2018, 96(5): 435-441. DOI: 10.1111/aos.13417.
22.	Milder E, Vander J, Shah C, et al. Changes in antibiotic resistance patterns of conjunctival fora due to repeated use of topical antibiotics afer intravitreal injection[J]. Ophthalmology, 2012, 119(7): 1420-1424. DOI: 10.1016/j.ophtha.2012.01.016.
23.	Bhavsar AR, Stockdale CR, Ferris FL 3rd, et al. Update on risk of endophthalmitis after intravitreal drug injections and potential impact of elimination of topical antibiotics[J]. Arch Ophthalmol, 2012, 130(6): 809-810. DOI: 10.1001/archophthalmol.2012.227.
24.	De Caro JJ, Ta CN, Ho HK, et al. Bacterial contamination of ocular surface and needles in patients undergoing intravitreal injections[J]. Retina, 2008, 28(6): 877-883. DOI: 10.1097/IAE.0b013e318 16b3180.

1. Reibaldi M, Pulvirenti A, Avitabile T, et al. Pooled estimates of incidence of endophthalmitis afer intravitreal injection of anti-vascular endothelial growth factor agents with and without topical antibiotic prophylaxis[J]. Retina, 2018, 38(1): 1-11. DOI: 10.1097/IAE.0000000000001583.
2. Fileta JB, Scott IU, Flynn HW Jr. Meta-analysis of infectious endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents[J]. Ophthalmic Surg Lasers Imaging Retina, 2014, 45(2): 143-149. DOI: 10.3928/23258160-20140306-08.
3. Davidov B, Ohayon A, Trivizki O, et al. Postintravitreal injection. endophthalmitis: incidence, characteristics, management, and outcome[J/OL]. J Ophthalmol, 2023, 2023: 9212524[2023-11-06]. https://pubmed.ncbi.nlm.nih.gov/37965437/. DOI: 10.1155/2023/9212524.
4. Rosenfeld PJ, Brown DM, Heier JS, et al. Ranibizumab for neovascular age-related macular degeneration[J]. N Engl J Med, 2006, 355(14): 1419-1431. DOI: 10.1056/NEJMoa054481.
5. Friedman DA, Mason JO 3rd, Emond T, et al. Povidoneiodine contact time and lid speculum use during intravitreal injection[J]. Retina, 2013, 33(5): 975-981. DOI: 10.1097/IAE.0b013e31 82877585.
6. De Kaspar HM, Chang RT, Shriver EM, et al. Three-day application of topical ofloxacin reduces the contamination rate of microsurgical knives in cataract surgery: a prospective randomized study[J]. Ophthalmology, 2004, 111(7): 1352-1355. DOI: 10.1016/j.ophtha.2003.10.032.
7. Aiello LP, Brucker AJ, Chang S, et al. Evolving guidelines for intravitreous injections[J]. Retina, 2004, 24(5 Suppl): S3-19. DOI: 10.1097/00006982-200410001-00002.
8. Jaissle GB, Szurman P, Bartz-Schmidt KU. Recommendation for the implementation of intravitreal injections–statement of the German Retina Society, the German Society of Ophthalmology (DOG) and the German Professional Association of Ophthalmologists (BVA)[J]. Klin Monbl Augenheilkd, 2005, 222(5): 390-395. DOI: 10.1055/s-2005-858231.
9. Moss JM, Sanislo SR, Ta CN. A prospective randomized evaluation of topical gatifloxacin on conjunctival flora in patients undergoing intravitreal injections[J]. Ophthalmology, 2009, 116(8): 1498-1501. DOI: 10.1016/j.ophtha.2009.02.024.
10. Miller KM, Oetting TA, Tweeten JP, et al. Cataract in the adult eye preferred practice pattern[J]. Ophthalmology, 2022, 129(1): 1-126. DOI: 10.1016/j.ophtha.2021.10.006.
11. Sigford DK, Reddy S, Mollineaux C, et al. Global reported endophthalmitis risk following injections of anti-VEGF: a literature review and analysis[J]. Clin Ophthalmol, 2015, 9: 773-781. DOI: 10.2147/OPTH.S77067.
12. Wykoff CC, Flynn HW Jr, Rosenfeld PJ. Prophylaxis for endophthalmitis following intravitreal injection: antisepsis and antibiotics[J]. Am J Ophthalmol, 2011, 152(5): 717-719. DOI: 10.1016/j.ajo.2011.07.002.
13. Ta CN, Singh K, Egbert PR, et al. Prospective comparative evaluation of povidone-iodine (10% for 5 minutes versus 5% for 1 minute) as prophylaxis for ophthalmic surgery[J]. J Cataract Refract Surg, 2008, 34(1): 171-172. DOI: 10.1016/j.jcrs.2007.08.035.
14. Li B, Nentwich MM, Hoffmann LE, et al. Povidone-iodine 1.0%, 5.0%, and 10.0% as preoperative prophylaxis before cataract surgery[J]. J Cataract Refract Surg, 2013, 39(7): 994-1001. DOI: 10.1016/j.jcrs.2013.02.039.
15. Pinna A, Donadu MG, Usai D, et al. In vitro antimicrobial activity of a new ophthalmic solution containing povidone-iodine 0.6%(IODIM^®)[J/OL]. Acta Ophthalmol, 2020, 98(2): e178-e180[2019-09-05]. https://pubmed.ncbi.nlm.nih.gov/31486592/. DOI: 10.1111/aos.14243.
16. Zamora JL. Chemical and microbiologic characteristics and toxicity of povidone-iodine solutions[J]. Am J Surg, 1986, 151(3): 400-406. DOI: 10.1016/0002-9610(86)90477-0.
17. Trost LW, Kivilcim M, Peyman GA, et al. The effect of intravitreally injected povidone-iodine on Staphylococcus epidermidis in rabbit eyes[J]. J Ocul Pharmacol Ther, 2007, 23(1): 70-77. DOI: 10.1089/jop.2006.0076.
18. Jiang J, Wu M, Shen T. The toxic effect of different concentrations of povidone iodine on the rabbit’s cornea[J]. Cutan Ocul Toxicol, 2009, 28(3): 119-124. DOI: 10.1080/15569520903080511.
19. Barry P, Cordovès L, Gardner S. European Society of Cataract and Refractive Surgeons. ESCRS Guidelines for prevention and treatment of endophthalmitis following cataract surgery: data dilemmas and conclusion[M/OL]. Blackrock, Co: Dublin, 2013: 2. https://www.escrs.org/media/uljgvpn1/english_2018_updated.pdf.
20. Olson RJ, Braga-Mele R, Chen SH, et al. Cataract in the adult eye preferred practice pattern^®[J]. Ophthalmology, 2017, 124(2): P1-P119. DOI: 10.1016/j.ophtha.2016.09.027.
21. Hunyor AP, Merani R, Darbar A, et al. Topical antibiotics and intravitreal injections[J]. Acta Ophthalmol, 2018, 96(5): 435-441. DOI: 10.1111/aos.13417.
22. Milder E, Vander J, Shah C, et al. Changes in antibiotic resistance patterns of conjunctival fora due to repeated use of topical antibiotics afer intravitreal injection[J]. Ophthalmology, 2012, 119(7): 1420-1424. DOI: 10.1016/j.ophtha.2012.01.016.
23. Bhavsar AR, Stockdale CR, Ferris FL 3rd, et al. Update on risk of endophthalmitis after intravitreal drug injections and potential impact of elimination of topical antibiotics[J]. Arch Ophthalmol, 2012, 130(6): 809-810. DOI: 10.1001/archophthalmol.2012.227.
24. De Caro JJ, Ta CN, Ho HK, et al. Bacterial contamination of ocular surface and needles in patients undergoing intravitreal injections[J]. Retina, 2008, 28(6): 877-883. DOI: 10.1097/IAE.0b013e318 16b3180.

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