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Acute Endophthalmitis Incidence
Intravitreal Triamcinolone
Andrew C. Westfall, MD;
Alexander Osborn, PhD;
Derek Kuhl, PhD, MD;
Matthew S. Benz, MD;
William F. Mieler, MD;
Eric R. Holz, MD
Arch Ophthalmol. 2005;123:1075-1077.
ABSTRACT
Objective To report the incidence of acute postinjection endophthalmitis following intravitreal injection of triamcinolone acetonide (IVTA) as an office procedure.
Methods Retrospective, noncomparative, consecutive, interventional case series of all patients who had received IVTA at 2 clinical centers between January 1, 2000, and January 30, 2004.
Results A total of 1006 eyes received IVTA. None of the eyes developed acute, culture-positive, postoperative endophthalmitis in the 6 weeks following the procedure. One patient developed acute, culture-negative, postoperative endophthalmitis 4 days after receiving IVTA, resulting in an incidence of 0.10%. In this case, the presenting symptoms were decreased vision and acute conjunctival erythema. The case was notable for the absence of pain or hypopyon.
Conclusion Although acute postoperative endophthalmitis may follow IVTA, our experience suggests that this is a relatively uncommon event.
INTRODUCTION
The intravitreal use of triamcinolone acetonide (IVTA) has become increasingly popular. Indications for injection either alone or in combination with photodynamic therapy include macular edema due to diabetes mellitus, retinal vein occlusion, and uveitis, as well as exudative age-related maculopathy.1-11 The procedure has several well-recognized risks including elevated intraocular pressure, cataract progression, and endophthalmitis.12-20 One recent report suggests that the incidence of culture-positive endophthalmitis following IVTA may be higher (0.87%)17 than is reported for other intraocular procedures.21-26 This issue becomes more important in the context of the need for repetitive injections required to treat chronic retinal conditions. This study reports the incidence rates of culture-negative and culture-positive endophthalmitis for patients receiving IVTA at 2 centers.
METHODS
The Baylor College of Medicine institutional review board approved the study protocol. This is a retrospective, interventional, consecutive case series including all eyes (n = 1006) receiving IVTA injection between January 1, 2000, and January 30, 2004, at 2 centers (Baylor College of Medicine, Houston, Tex, and Austin Retina Associates, College Station, Tex). The indications for injection included diabetic macular edema, pseudophakic macular edema, edema due to retinal vein occlusion, uveitic macular edema, and exudative age-related maculopathy. Eyes undergoing combination treatment with photodynamic therapy were included in the study. Eyes were excluded if another intraocular procedure was performed during the 6-week study period. In particular, eyes undergoing vitrectomy with IVTA were excluded.
The IVTA procedure was similar for all of the patients. All of the patients underwent an informed consent discussion and then signed an operative permit. Topical 0.5% proparacaine hydrochloride drops (Alcain; Alcon Laboratories, Fort Worth, Tex) were placed on the ocular surface. Either a 4% lidocaine hydrochloride–soaked cotton pledget was placed on the temporal bulbar conjunctiva and held in place for approximately 1 minute or a subconjunctival injection of approximately 0.1 mL of 2% lidocaine over the temporal pars plana via a 30-gauge needle on a 1-mL syringe was used for anesthesia. Some investigators used both the pledget and subconjunctival injection. The eye was disinfected by instilling several drops of 5% povidone-iodine solution onto the ocular surface and then cleansing the lid margins, lashes, and periocular skin with 10% povidone-iodine solution–soaked cotton tip applicators. Approximately 5 minutes were allowed to elapse after preparation prior to injection. Triamcinolone acetonide (Kenalog; Bristol Myers Squibb Co, Princeton, NJ) in single-use, 40-mg/mL, 1-mL bottles was used exclusively. The top of the container was cleansed with an alcohol wipe and approximately 0.5 mL of the drug vehicle mixture was drawn into a 1-mL syringe. The syringe was allowed to sit in an upright position and the excess corticosteroid was expressed, leaving approximately 0.1 mL of the drug within the syringe. Injections were performed using either a 30-gauge needle or a 27-gauge needle. However, owing to clogging in the 30-gauge needle, the vast majority of these injections were given with the larger-bored 27-gauge needle. A wire eyelid speculum was then placed into the eye. Plastic drapes were not used. Either 3.5 mm (in pseudophakic patients) or 4 mm (in phakic patients) was measured from the limbus with a caliper in the inferotemporal quadrant. The 27-gauge needle was then introduced into the anterior vitreous cavity with the needle tip aimed at the inferior retina. The drug was injected with a slow, continuous push. As the needle was removed from the eye, a sterile cotton tip applicator was applied over the injection site to limit egress of drug or vitreous. The eye was inspected with indirect ophthalmoscopy to ensure adequate perfusion of the retinal arteries and veins at the optic nerve head and to assess drug location. The intraocular pressure was checked immediately following the injection and, in most cases, was found to be quite elevated initially with intraocular pressure readings of 40 to 60 mm Hg by applanation tonometry. In most cases, the patient was monitored using serial intraocular pressure measurements, and over the ensuing half hour following injection, the intraocular pressure normalized. In rare cases where the intraocular pressure failed to decrease substantially, an anterior chamber paracentesis was performed using a 30-gauge needle on a 1-mL syringe with the plunger removed. Following the injection, the patient was educated about the symptoms of endophthalmitis and instructed to report immediately should symptoms arise. Postoperative examinations were scheduled between 2 and 7 days, 4 weeks, and 6 weeks.
The primary outcome was the occurrence of endophthalmitis within the observation period of 6 weeks, which was thus considered acute.
RESULTS
In total, 1006 IVTA injections were performed at the 2 centers during this time period. One patient was identified with signs and symptoms of endophthalmitis. The time to presentation was 4 days. The clinical findings were conjunctival erythema, mild anterior chamber cellular reaction, trace flare, mild vitritis with several strands of fibrin, and decreased vision. Pain, keratoprecipitates, anterior chamber fibrin, and hypopyon were absent. Owing to the mild findings we found at examination, the patient was placed on oral gatifloxacin (Tequin; Bristol Myers Squibb Co) at a dose of 400 mg once per day and topical gatifloxacin (Zymar; Allergan Inc, Irvine, Calif) at a dose of 1 drop 4 times per day.
By the following day, the vitreous fibrin and number of cells increased, so the patient was taken to the operating room for vitreous biopsy and intravitreal antibiotics (vancomycin hydrochloride, 1 mg/0.1 mL, and ceftazidime, 2.25 mg/0.1 mL). Postoperatively, the patient continued to receive topical gatifloxacin (1 drop 4 times/d) and oral gatifloxacin (400 mg/d) for 10 days. Gram stain, acid-fast stain, acridine orange, calcofluor white, and silver stain were negative for organisms. The fungal, aerobic, and anaerobic cultures were all negative for growth. After 6 weeks, the patient’s visual acuity was 20/40, an improvement over his preinjection visual acuity of 20/100.
In the 6 weeks following IVTA, there was an incidence of 1 case of acute, culture-negative endophthalmitis per 1006 eyes, or 0.10%.
COMMENT
In our study, the incidence of culture-positive endophthalmitis was 0.00% for patients in the 6 weeks following IVTA injection. It is possible that the single patient in our study who had culture-negative endophthalmitis (for an incidence of 0.10%) had no laboratory growth because of an aggressive antibiotic regimen prior to the culture. This rate is considerably lower than the rate of 0.87% of culture-positive cases reported by Moshfeghi et al.17 Our rate is also lower than those reported following intravitreal ganciclovir injection for cytomegalovirus retinitis (0.29% in 1372 injections,21 0.14% in 2890 injections,22 and 0.64% in 156 injections23).24 The low incidence of endophthalmitis in our study may be owing to our sterile approach that was prompted by previous reports associating corticosteroid injections with endophthalmitis.17 We feel that preparation with povidone-iodine, use of an eyelid speculum, and single-use medication containers were significant.27-29 Many studies have shown that 5% povidone-iodine is a safe and effective agent in reducing endophthalmitis at the time of surgery.27, 30-37 Thorough preparation with povidone-iodine on the ocular surface and eyelids is the only agent that has been shown to reduce the risk of endophthalmitis in a prospective study.31 Given that the source of causative bacteria is often the patient’s own ocular surface or adnexa, it is reasonable to try to reduce the exposure to the injection site and injection needle.38-39 Thus, retracting the eyelids with an eyelid speculum seems reasonable. In addition, none of the patients received an injection from a multiple-use vial of triamcinolone since a previous study38 showed that multiple-use medication bottles were more likely to be colonized by bacteria.40-41
The incidence of endophthalmitis following IVTA injection in our study reflects the heightened interest in minimizing risks associated with this increasingly common procedure. The significance lies in counseling the patient accurately on the risk-benefit ratio for IVTA. In addition, treatment of chronic conditions with IVTA needs to be repeated frequently after 3 to 4 months. While the previously reported risk of 0.87% may seem unacceptably high in this context, we feel that the incidence in our study of 1 case of acute postoperative endophthalmitis in 1006 eyes significantly alters the risk-benefit ratio for IVTA.
AUTHOR INFORMATION
Correspondence: Eric R. Holz, MD, Cullen Eye Institute, Baylor College of Medicine, 6565 Fannin St, NC-205, Houston, TX 77030 (eholz{at}bcm.tmc.edu).
Submitted for Publication: November 16, 2004; accepted November 29, 2004.
Funding/Support: This research was supported in part by an unrestricted grant from Research to Prevent Blindness, New York, NY.
Financial Disclosure: None.
Author Affiliations: Department of Ophthalmology, Baylor College of Medicine, Houston, Tex (Drs Westfall, Osborn, Benz, Mieler, and Holz); and Austin Retina Associates, College Station, Tex (Dr Kuhl). Dr Mieler is now with the Department of Ophthalmology, University of Chicago, Chicago, Ill.
REFERENCES
| |
1. Antcliff RJ, Spalton DJ, Stanford MR, Graham EM, Ffytche TJ, Marshall J. Intravitreal triamcinolone for uveitic cystoid macular edema: an optical coherence tomography study. Ophthalmology. 2001;108:765-772.
FULL TEXT
|
ISI
| PUBMED
2. Greenberg PB, Martidis A, Rogers AH, Duker JS, Reichel E. Intravitreal triamcinolone acetonide for macular oedema due to central retinal vein occlusion. Br J Ophthalmol. 2002;86:247-248.
FREE FULL TEXT
3. Martidis A, Duker JS, Greenberg PB, et al. Intravitreal triamcinolone for refractory diabetic macular edema. Ophthalmology. 2002;109:920-927.
FULL TEXT
|
ISI
| PUBMED
4. Martidis A, Duker JS, Puliafito CA. Intravitreal triamcinolone for refractory cystoid macular edema secondary to birdshot retinochoroidopathy. Arch Ophthalmol. 2001;119:1380-1383.
FREE FULL TEXT
5. Young S, Larkin G, Branley M, Lightman S. Safety and efficacy of intravitreal triamcinolone for cystoid macular oedema in uveitis. Clin Experiment Ophthalmol. 2001;29:2-6.
FULL TEXT
|
ISI
| PUBMED
6. Jonas JB, Kreissig I, Degenring RF. Intravitreal triamcinolone acetonide for pseudophakic cystoid macular edema. Am J Ophthalmol. 2003;136:384-386.
FULL TEXT
|
ISI
| PUBMED
7. Jonas JB, Kreissig I, Hugger P, Sauder G, Panda-Jonas S, Degenring R. Intravitreal triamcinolone acetonide for exudative age related macular degeneration. Br J Ophthalmol. 2003;87:462-468.
FREE FULL TEXT
8. Jonas JB, Kreissig I, Sofker A, Degenring RF. Intravitreal injection of triamcinolone for diffuse diabetic macular edema. Arch Ophthalmol. 2003;121:57-61.
FREE FULL TEXT
9. Jonas JB, Sofker A. Intraocular injection of crystalline cortisone as adjunctive treatment of diabetic macular edema. Am J Ophthalmol. 2001;132:425-427.
FULL TEXT
|
ISI
| PUBMED
10. Jonas JB, Hayler JK, Sofker A, Panda-Jonas S. Intravitreal injection of crystalline cortisone as adjunctive treatment of proliferative diabetic retinopathy. Am J Ophthalmol. 2001;131:468-471.
FULL TEXT
|
ISI
| PUBMED
11. Danis RP, Ciulla TA, Pratt LM, Anliker W. Intravitreal triamcinolone acetonide in exudative age-related macular degeneration. Retina. 2000;20:244-250.
FULL TEXT
|
ISI
| PUBMED
12. Wingate RJ, Beaumont PE. Intravitreal triamcinolone and elevated intraocular pressure. Aust N Z J Ophthalmol. 1999;27:431-432.
FULL TEXT
|
ISI
| PUBMED
13. Jonas JB, Kreissig I, Degenring R. Intraocular pressure after intravitreal injection of triamcinolone acetonide. Br J Ophthalmol. 2003;87:24-27.
FREE FULL TEXT
14. Jonas JB, Kreissig I, Degenring RF. Endophthalmitis after intravitreal injection of triamcinolone acetonide. Arch Ophthalmol. 2003;121:1663-1664.
FREE FULL TEXT
15. Jager RD, Aiello LP, Patel SC, Cunningham ET Jr. Risks of intravitreous injection: a comprehensive review. Retina. 2004;24:676-698.
FULL TEXT
|
ISI
| PUBMED
16. Moshfeghi AA, Scott IU, Flynn HW Jr, Puliafito CA. Pseudohypopyon after intravitreal triamcinolone acetonide injection for cystoid macular edema. Am J Ophthalmol. 2004;138:489-492.
FULL TEXT
|
ISI
| PUBMED
17. Moshfeghi DM, Kaiser PK, Scott IU, et al. Acute endophthalmitis following intravitreal triamcinolone acetonide injection. Am J Ophthalmol. 2003;136:791-796.
FULL TEXT
|
ISI
| PUBMED
18. Nelson ML, Tennant MT, Sivalingam A, Regillo CD, Belmont JB, Martidis A. Infectious and presumed noninfectious endophthalmitis after intravitreal triamcinolone acetonide injection. Retina. 2003;23:686-691.
FULL TEXT
|
ISI
| PUBMED
19. Roth DB, Chieh J, Spirn MJ, Green SN, Yarian DL, Chaudhry NA. Noninfectious endophthalmitis associated with intravitreal triamcinolone injection. Arch Ophthalmol. 2003;121:1279-1282.
FREE FULL TEXT
20. Sutter FK, Gillies MC. Pseudo-endophthalmitis after intravitreal injection of triamcinolone. Br J Ophthalmol. 2003;87:972-974.
FREE FULL TEXT
21. Engstrom RE Jr, Holland GN. Local therapy for cytomegalovirus retinopathy. Am J Ophthalmol. 1995;120:376-385.
ISI
| PUBMED
22. Baudouin C, Chassain C, Caujolle C, Gastaud P. Treatment of cytomegalovirus retinitis in AIDS patients using intravitreal injections of highly concentrated ganciclovir. Ophthalmologica. 1996;210:329-335.
ISI
| PUBMED
23. Heinemann MH. Long-term intravitreal ganciclovir therapy for cytomegalovirus retinopathy. Arch Ophthalmol. 1989;107:1767-1772.
FREE FULL TEXT
24. Young S, Morlet N, Besen G, et al. High-dose (2000-µg) intravitreous ganciclovir in the treatment of cytomegalovirus retinitis. Ophthalmology. 1998;105:1404-1410.
FULL TEXT
|
ISI
| PUBMED
25. Aaberg TM Jr, Flynn HW Jr, Schiffman J, Newton J. Nosocomial acute-onset postoperative endophthalmitis survey: a 10-year review of incidence and outcomes. Ophthalmology. 1998;105:1004-1010.
FULL TEXT
|
ISI
| PUBMED
26. Sakamoto T, Enaida H, Kubota T, et al. Incidence of acute endophthalmitis after triamcinolone-assisted pars plana vitrectomy. Am J Ophthalmol. 2004;138:137-138.
FULL TEXT
|
ISI
| PUBMED
27. Alp BN, Elibol O, Sargon MF, et al. The effect of povidone iodine on the corneal endothelium. Cornea. 2000;19:546-550.
FULL TEXT
|
ISI
| PUBMED
28. Zamora JL. Iodine toxicity. Ann Thorac Surg. 1986;41:462-463.
ISI
| PUBMED
29. Zamora JL. Chemical and microbiologic characteristics and toxicity of povidone-iodine solutions. Am J Surg. 1986;151:400-406.
FULL TEXT
|
ISI
| PUBMED
30. Menikoff JA, Speaker MG, Marmor M, Raskin EM. A case-control study of risk factors for postoperative endophthalmitis. Ophthalmology. 1991;98:1761-1768.
ISI
| PUBMED
31. Speaker MG, Menikoff JA. Prophylaxis of endophthalmitis with topical povidone-iodine. Ophthalmology. 1991;98:1769-1775.
ISI
| PUBMED
32. Apt L, Isenberg S, Yoshimori R, Paez JH. Chemical preparation of the eye in ophthalmic surgery, III: effect of povidone-iodine on the conjunctiva. Arch Ophthalmol. 1984;102:728-729.
FREE FULL TEXT
33. Apt L, Isenberg SJ, Yoshimori R, Spierer A. Outpatient topical use of povidone-iodine in preparing the eye for surgery. Ophthalmology. 1989;96:289-292.
ISI
| PUBMED
34. Caldwell DR, Kastl PR, Cook J, Simon J. Povidone-iodine: its efficacy as a preoperative conjunctival and periocular preparation. Ann Ophthalmol. 1984;16:577-580.
ISI
| PUBMED
35. Dereklis DL, Bufidis TA, Tsiakiri EP, Palassopoulos SI. Preoperative ocular disinfection by the use of povidone-iodine 5%. Acta Ophthalmol (Copenh). 1994;72:627-630.
36. Binder C, de Kaspar HM, Engelbert M, Klauss V, Kampik A. Colonization of conjunctiva with Propionibacterium acnes before and after application of polyvidone iodine before intraocular surgery [in German]. Ophthalmologe. 1998;95:438-441.
FULL TEXT
|
ISI
| PUBMED
37. Rodeheaver G, Bellamy W, Kody M, et al. Bactericidal activity and toxicity of iodine-containing solutions in wounds. Arch Surg. 1982;117:181-186.
FREE FULL TEXT
38. Høvding G, Sjursen H. Bacterial contamination of drops and dropper tips of in-use multidose eye drop bottles. Acta Ophthalmol (Copenh). 1982;60:213-222.
39. Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol. 1995;113:1479-1496.
FREE FULL TEXT
40. Aiello LP, Brucker AJ, Chang S, et al. Evolving guidelines for intravitreous injections. Retina. 2004;24(suppl 5):S3-S19.
FULL TEXT
|
ISI
| PUBMED
41. Ta CN. Minimizing the risk of endophthalmitis following intravitreous injections. Retina. 2004;24:699-705.
FULL TEXT
|
ISI
| PUBMED
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