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Vitreous wick syndrome - A potential cause of endophthalmitis after intravitreal injection of triamcinolone through the pars plana
... Since repetitive intravitreal injections increase the risk of related complications, there is increased interest in these complications and their prevention 2 . Endophthalmitis can occur if bacteria enter the eye following needle passage for intravitreal injection 10 and is one of the most devastating complications in ophthalmology, leading to blindness in severe cases [11][12][13][14][15][16] . Thus, there is a need to prevent infection following intravitreal injection 2,17 . ...
... Methods used to prevent endophthalmitis include using the beveled incision technique and performing the procedure in an aseptic environment, with disinfection using a povidone iodine solution before the procedure. The beveled incision technique could reduce vitreous and drug reflux compared to a straight incision, maximizing the drug delivery and decreasing the risk of infection 2,10 . On the other hand, regurgitation after intravitreal injection has the advantage of reducing intraocular pressure (IOP) after injection. ...
... These blebs were caused by regurgitation of liquefied vitreous humor or injected drugs 24 . Vitreous regurgitation and incarceration induced at the injection site are risk factors for endophthalmitis after intravitreal injection 10 . In the present study, we found that when conventional needles were removed after intravitreal injections of ICG dye, either the dye leaked out of the eyeball or subconjunctival blebs formed in more than half of eyes. ...
Self-sealing hyaluronic acid (HA)-coated self-sealing 30-gauge needles exhibiting instant leakage prevention of intravitreal humor and injected drug were developed in this study. Ninety New Zealand rabbits were used in this study. We assessed dye regurgitation in intravitreal ICG dye injections using HA-coated needles (HA needle group) and conventional needles (control group). Vitreous humor levels of anti-vascular endothelial growth factor (VEGF) were compared between groups one, three, and seven days after intravitreal bevacizumab (0.016 mL) injections. Expression levels of inflammatory cytokines in the aqueous humor and vitreous humor, including prostaglandin E 2 (PGE 2 ), interferon-γ, tumor necrosis factor-α, interleukin (IL)-1β, IL-4, IL-6, IL-17, and IL-8, were compared between HA needle, control, and normal (in which intravitreal injection was not performed) groups following 12 intravitreal injections over a period of one week. In the HA needle group, HA remained at the injection site and blocked the hole after intravitreal injection. Dye regurgitation occurred significantly less frequently in the HA needle group (16.7%) than the control group (55.6%) after intravitreal ICG dye injection. Meanwhile, vitreous anti-VEGF levels were markedly higher in the HA needle group than the control group one and three days after intravitreal bevacizumab injections. After 12 intravitreal injections, expression levels of aqueous and vitreous IL-8 significantly increased in the control group compared to the HA needle and normal groups. Conversely, there were no significant differences in the expression of the other seven cytokines among the three groups. Intravitreal injections using HA-coated self-sealing 30-gauge needles can block the outflow of vitreous humor and drugs through the needle passage.
... Since the implementation of transconjunctival sutureless vitrectomy (TSV), 2,3 numerous studies have analyzed different aspects of sclerotomies, such as the presence of vitreous incarceration in sclerotomies. [4][5][6][7][8][9][10][11] This vitreous entrapment may work as an incisional plug, favoring postoperative sclerotomy closure; nevertheless, it has also been related to some postoperative complications, such as peripheral retinal tears, [12][13][14] acute endophthalmitis, 15 and fibrovascular proliferation. 16 Vitreous shaving around the sclerotomy sites 17 and removing the scleral cannulas over the light probe at the end of the vitrectomy 18 have been related to less postoperative vitreous incarceration. ...
... The risk of postoperative complications due to the presence of vitreous incarceration [12][13][14][15][16] has encouraged investigators to analyze the influence that sclerotomy use may have on vitreous entrapment rate after vitrectomy. In that sense, Bhende et al 26 The establishment of 23-and 25-gauge TSV 2,3 as firstchoice vitrectomy techniques for most vitreoretinal surgeons, and the differences they possess compared to conventional 20-gauge vitrectomy (oblique sclerotomies, narrower gauge, and no suture at the end of the surgery), make it necessary to deeply reassess the influence of sclerotomy use on postoperative vitreous incarceration in these microincisional sclerotomies. ...
... 9,26,27 We considered it useful to examine the sclerotomies shortly after the vitrectomy was finished, given that the vitreous incarcerated in the first days after the operation is related to postvitrectomy endophthalmitis. 15 The time gap between vitrectomy and UBM exploration may alter the presence of the early postvitrectomy incisional vitreous, making results less reliable. ...
To evaluate the influence of sclerotomy use during vitrectomy (vitreous cutter, illumination probe, or infusion-line entrance) on postoperative vitreous incarceration using an experimental model of vitrectomized eye.
Experimental, randomized, and observer-masked study in which 23-gauge transconjunctival sutureless vitrectomy was performed in cadaveric pig eyes. Postoperative incisional vitreous entrapment was evaluated by direct visualization. No vitreous incarceration was classified as grade 0 (G0), thin vitreous entrapment was classified as grade 1 (G1), and thick vitreous strands as grade 2 (G2).
A total of 46 eyes were included. Vitreous incarceration was detected in 91.3% (43.5% G1, 47.8% G2) of the sclerotomies used by the vitreous cutter probe, 95.7% (45.7% G1, 50% G2) of the illumination-pipe entrances, and 93.5% (45.7% G1, 47.8% G2) of the infusion-line incisions. No statistical differences were found when comparing incisional vitreous incarceration after vitrectomy according to sclerotomy use.
Different manipulation of the sclerotomies, depending on their use, does not seem to influence postvitrectomy vitreous entrapment in our experimental model.
... It has been reported that the factors such as volume amount, injection speed, and length and direction of the scleral incision might have influence on amount of vitreal reflux after IVT injections. However, there was no report or consensus on the site or the quadrant location that used for injection [11][12][13][14][15][16][17][18][19][20][21]. Thus, in this study we aimed to investigate the effects of injection site on the reflux following IVT injections. ...
... It has been also reported that the factors such as volume amount, injection speed, length and direction of the scleral incision, the needle size, the consequential rise in IOP, and the injection technique used might have influence on amount of vitreal reflux after IVT injections. However, there was no report or consensus on the site or the quadrant location that used for injection except the direction of the needle towards the centre of vitreous cavity [11][12][13][14][15][16][17][18][19][20][21]. ...
... The reflux after intravitreal injection can be observed in about 20% of injections [17]. The problems that could be associated with a vitreous or drug reflux are the misplacement of substantial amount of the injected drug, the vitreous wick syndrome and the increase in the risk of endophthalmitis due to the entering of the bacteria from the ocular surface through injection site [18,19]. ...
This study aimed to investigate the effects of injection site on the reflux after intravitreal injection.
One hundred and eighty eyes undergoing intravitreal injection including 0.1 ml of triamcinolone acetonide or bevacizumab or pegaptanib were divided to six groups (30 patients in each group) to compare the vitreal reflux after injection using superotemporal versus inferotemporal quadrant. The amount of intraoperative reflux was estimated by measuring the width of the subconjunctival bleb. An interventional, prospective, comparative clinical trial was applied.
The mean bleb width as the reflux amount after injection of three drugs was statistically less after the inferotemporal injection (1.50 ± 0.94 mm for triamcinolone acetonide, p < 0.001; 1.60 ± 1.07 mm for bevacizumab, p < 0.001; and 1.77 ± 0.94 mm for pegaptanib, p = 0.001) than those in eyes undergoing the superotemporal injection (3.20 ± 1.63 mm for triamcinolone acetonide; 3.07 ± 1.53 mm for bevacizumab; and 2.80 ± 1.32 mm for pegaptanib).
The injection through inferotemporal quadrant provides statistically significant less vitreal reflux for intravitreal drug injection.
Intravitreal injection; Injection site; Reflux.
... It is thought to comprise liquefied vitreous as well as some of the injected drug [170][171][172], but the presence of reflux does not lead to a subtherapeutic effect [173]. There is a theoretical risk of endophthalmitis occurring when organisms gain entry into the vitreous cavity through a "vitreous wick" [174]. Turgut et al. [175] found less vitreous reflux with injections performed through the inferotemporal quadrant compared with the superotemporal quadrant. ...
... Inoculation of the vitreous with a cotton fiber has been reported as a complication [176,177]. Applying pressure to the injection site immediately after needle withdrawal has also been advocated to help reduce the amount of vitreous reflux [174]. ...
The purpose of this review is to report and summarize previously reported studies and assess many of the individual steps of the intravitreal injection procedure’s possible effect on the prevention of endophthalmitis. The pooled endophthalmitis rate from 20 large retrospective case series of anti-VEGF injections was 144/510,396 (0.028%; 1/3,544). Injections may be performed in an office-based location or in an operating room (OR) and low rates of endophthalmitis can be achieved in either location with careful attention to asepsis. Pre- or post-injection topical antibiotics have not been shown to be effective, and could select for more virulent microorganisms. Povidone-iodine prior to injection is accepted as the gold-standard antiseptic agent, but aqueous chlorhexidine may be an alternative. Antisepsis before and after gel or subconjunctival anesthetic is suggested. The preponderance of Streptococcal infections after intravitreal injection is discussed, including the possible role of aerosolization, which can be minimized by using face masks or maintaining silence. As with other invasive procedures in medicine, the use of sterile gloves, following adequate hand antisepsis, may be considered. Control of the eyelashes and lid margin is required to avoid contamination of the needle, but this can be achieved with or without a speculum. Techniques to minimize vitreous reflux have not been shown to reduce the risk of endophthalmitis. Same day bilateral injections should be performed as two separate procedures, preferably using drug from different lots, especially when using compounded drugs.
... The one exception is the use of a straight approach to cannula insertion, which has an increased risk for endophthalmitis as compared to a beveled approach [83,84]. This probably relates to a reduction of vitreous incarceration, which will not only mitigate endophthalmitis [85,86] but also peripheral retinal tears [87][88][89] and fibrovascular proliferation in diabetic patients [90]. Regarding endophthalmitis, incisional vitreous incarceration is believed to improve postoperative sclerotomy closure, preventing the entry of bacteria into vitreous via an incisional vitreous wick [85]. ...
... This probably relates to a reduction of vitreous incarceration, which will not only mitigate endophthalmitis [85,86] but also peripheral retinal tears [87][88][89] and fibrovascular proliferation in diabetic patients [90]. Regarding endophthalmitis, incisional vitreous incarceration is believed to improve postoperative sclerotomy closure, preventing the entry of bacteria into vitreous via an incisional vitreous wick [85]. Cannula removal at the end of surgery also influences the risk of postoperative endophthalmitis. ...
Floaters most commonly occur in the middle age due to age-related changes in vitreous structure and light scattering by the posterior vitreous cortex after collapse of the vitreous body during posterior vitreous detachment (PVD). In youth, floaters are most often due to myopic vitreopathy. Vitreous floaters can have a negative impact on visual function and in turn the quality of life. Techniques to characterize floaters clinically include ultrasound imaging, optical coherence tomography, and dynamic light scattering for structural characterization. Functional impact can be assessed by straylight measurements, as well as contrast sensitivity testing. When the severity of floater symptomatology is significant, commonly used therapies include neodymium:yttrium-aluminum-garnet (YAG) laser and limited 25-gauge vitrectomy. While the former is of unproven efficacy, the latter has been shown to be a safe, effective, and definitive cure that improves patients’ quality of life and eradicates symptomatology produced by light scattering and diffraction. It is thus reasonable to offer limited vitrectomy to individuals who have attempted to cope unsuccessfully and in whom functional deficit can be objectively demonstrated by testing contrast sensitivity, an important aspect of vision.
... However, when a small needle sclerotomy is created, the hole may also allow for egress of medication or vitreous as well as act as a portal of entry for bacteria. For example, conjunctival blebs have been noted to form over sclerotomy sites (4)(5)(6)(7). ...
... Strategies for minimizing the loss of intravitreal medication include lowering intraocular pressure (IOP) prior to injection, tamponading the sclerotomy site, and angled injections (7)(8)(9)(10). However, few in vivo studies have been reported (4,11). diabetic retinopathy, central retinal vein occlusion, or radiation retinopathy. ...
Purpose:
The perfect intravitreal injection delivers an exact amount of medication with the least risk to vision and the eye. We examined 2 different methods of intravitreal injection to determine if an angled transscleral entry for intravitreal injection results in less egress of intravitreal contents, including medication.
Methods:
In a crossover controlled trial at an outpatient clinical facility within a major ophthalmology referral center, we treated 10 patients. The surgical technique involved injecting 0.05 mL of bevacizumab injected in one eye by both an orthogonal (straight in) and oblique (angled) technique. The intraocular pressure (IOP) was measured immediately before and after each monthly injection.
Results:
Orthogonal injections raised the IOP significantly less (mean 24.6 mm Hg or 126%) than oblique injections (29.6 mm Hg or 152%) (p = 0.045). There were no reported differences in injection-related pain or adverse effects between the techniques.
Conclusions:
Oblique or angled injections caused a larger IOP rise than straight or orthogonal injections. This finding suggests that oblique injections are self-sealing, deliver a higher dose of medication, or prevent vitreous reflux as well as close a potential portal of entry for pathogens.
... Furthermore, the use of nonhollow probes for cannula extraction at the end of surgery has been shown to decrease vitreous incarceration in the sclerotomies, a risk factor for endophthalmitis and retinal tears. 18,19 Regarding cataracts after vitrectomy, studies [20][21][22] have shown that the vitreous contains antioxidants and that vitrectomy as well as PVD increase intravitreal oxygen levels, postulated to be the cause of cataract formation. Thus, leaving anterior vitreous intact and not inducing PVD during vitrectomy might lower the incidence of postvitrectomy cataract formation from the previously reported levels of 50% to 76%. ...
... There were no cases of endophthalmitis, perhaps partly because of the use of beveled incisions and nonhollow probes for cannula extraction, which have been shown 18 to decrease vitreous incarceration in sclerotomies, a finding associated with postoperative endophthalmitis. 19 Vitreous incarceration also increases the risk of postoperative retinal tears, 18 but there were no cases of retinal tears and detachments in this study with an average follow-up of 17.5 months. ...
Floaters impact vision but the mechanism is unknown. We hypothesize that floaters reduce contrast sensitivity function, which can be normalized by vitrectomy, and that minimally invasive vitrectomy will have lower incidences of retinal tears (reported at 30%) and cataracts (50-76%).
Seventy-six eyes (34 phakic) with floaters were evaluated in 2 separate studies. Floater etiologies were primarily posterior vitreous detachment in 61 of 76 eyes (80%) and myopic vitreopathy in 24 of 76 eyes (32%). Minimally invasive 25G vitrectomy was performed without posterior vitreous detachment induction, leaving anterior vitreous, and using nonhollow probes for cannula extraction. Efficacy was studied prospectively (up to 9 months) in 16 floater cases with Freiburg Acuity Contrast Testing (Weber index [%W] reproducibility = 92.1%) and the National Eye Institute Visual Function Questionnaire. Safety was separately evaluated in 60 other cases followed up on an average of 17.5 months (range, 3-51 months).
Floater eyes had 67% contrast sensitivity function attenuation (4.0 ± 2.3 %W; control subjects = 2.4 ± 0.9 %W, P < 0.013). After vitrectomy, contrast sensitivity function normalized in each case at 1 week (2.0 ± 1.4 %W, P < 0.01) and remained normal at 1 month (2.0 ± 1.0 %W, P < 0.003) and 3 months to 9 months (2.2 ± 1.5 %W, P < 0.018). Visual Function Questionnaire was 28.3% lower in floater patients (73.2 ± 15.6, N = 16) than in age-matched control subjects (93.9 ± 8.0, N = 12, P < 0.001), and postoperatively improved by 29.2% (P < 0.001). In the safety study of 60 floater cases treated with vitrectomy, none developed retinal breaks, infection, or glaucoma after a mean follow-up of 17.5 months. Only 8 of 34 cases (23.5%) required cataract surgery (none younger than 53 years) at an average of 15 months postvitrectomy.
Floaters lower contrast sensitivity function, which normalizes after vitrectomy. Visual Function Questionnaire quantified improvement in satisfaction. Not inducing posterior vitreous detachment reduced retinal tear incidence from 30% to 0% (P < 0.007). Postvitrectomy cataract incidence was reduced from 50% to 23.5% (P < 0.02). This approach thus seems effective and safe in alleviating the visual dysfunction induced by floaters.
... However, the influence that the presence of incisional vitreous incarceration may exert on sclerotomy closure competency was not considered previously. This vitreous entrapment has been related to postoperative complications, such as peripheral retinal tears as a result of postoperative vitreous contraction, [21][22][23] acute endophthalmitis due to the presence of an incisional vitreous wick that may facilitate the entry of bacteria into the vitreous cavity, 24 and fibrovascular proliferation that is considered a major risk factor for recurring vitreous hemorrhage in diabetic patients. 25 However, it was important to evaluate the role that the residual vitreous may have on sclerotomy closure after vitrectomy, given that there are maneuvers with the ability to modify the presence of this vitreous entrapment. ...
... 16 With this maneuver, it is accepted a higher incidence and grade of conjunctival blebs over the sclerotomies and, therefore, a greater need of scleral suture. Postvitrectomy complications related to the presence of vitreous incarceration [21][22][23][24][25] cannot be avoided in the postoperative period; after the surgery we can only check the patient and act if any problem appears. In turn, the risk of complications associated with sclerotomy closure incompetency 5-7 can be prevented by suturing the incisions. ...
Purpose:
To evaluate the influence that the origin of incisional vitreous incarceration may have on the presence of postoperative conjunctival blebs over sclerotomies after transconjunctival sutureless vitrectomy (TSV). Blebs are formed by incisional leakage due to incompetent closure.
Methods:
Twenty-three-gauge TSV was performed in 83 cadaveric pig eyes. Once each vitrectomy was finished, ultrasound biomicroscopy (UBM) was used to assess the presence of postoperative conjunctival blebs over the sclerotomy sites, as well as the existence of vitreous incarcerated in incisions. Vitreous strands may come from the perisclerotomy area, running parallel to the sclera toward the inner hole of the sclerotomies, or may radiate from the core of the vitreous cavity.
Results:
Vitreous entrapment was found in 73.9% of the sclerotomies; 43.4% of the incisions showed vitreous strands coming parallel to the sclera (12.9% of them showed conjunctival bleb), 19.7% of the wounds presented vitreous aiming toward the core of the vitreous cavity (2% of them had conjunctival bleb) and 10.8% of the entrances presented both vitreous incarceration sources (none of them showed bleb). Incisions with vitreous entrapment parallel to the sclera were associated with a significantly greater sclerotomy leakage rate.
Conclusions:
Sclerotomies with vitreous incarceration coming from the core of the vitreous cavity showed a greater incisional closure competency than that observed in incisions with vitreous entrapment coming from the pericannular area; if these results were confirmed in humans, different postoperative suture rates may be expected on sclerotomies according to the vitrectomy degree performed in different areas of the vitreous cavity.
... VR reduces immediate IOP increase [9][10][11] . Chen et al [24] reported that VR might be a potential cause of endophthalmitis after intravitreal injection and its visual outcome is poor [25] . VR rates should be reduced as much as possible. ...
AIM: To evaluate the effect of background diseases and number of previous intravitreal aflibercept injections (IVAIs) on immediate intraocular pressure (IOP) increase and vitreous reflux (VR) rate and to evaluate the correlation of both age and axial length with immediate IOP increase and VR rate. METHODS: This study included 105 patients with cystoid macular edema secondary to retinal vein occlusion, 35 patients with diabetic macular edema, 69 patients with neovascular age-related macular degeneration (nAMD), and 12 patients with myopic choroidal neovascularization, which underwent first-time IVAI. The correlation of immediate IOP increase and VR rates with the four background diseases was investigated. Moreover, the correlation of age with immediate IOP increase and VR rate as well as correlation of axial length with immediate IOP increase and VR rate were evaluated. Further, 54 patients with nAMD were treated with IVAI>10 times (multiple IVAIs). Moreover, the correlation of immediate IOP increase and VR rates with first-time and multiple IVAIs in nAMD was determined. RESULTS: The immediate IOP increase (P=0.16) and VR rates (P=0.50) were almost similar among the four background diseases. The immediate postinjection IOP and age, VR rate and age, immediate postinjection IOP and axial length, or VR rate and axial length were not correlated in the four background diseases. The immediate IOP increase (P=0.66) and VR rates (P=0.28) did not significantly differ between first-time and multiple IVAIs in nAMD. CONCLUSION: Background diseases and number of previous IVAIs have no effect on immediate IOP increase and VR rate. Further, age and axial length have no correlation on immediate IOP increase and VR rate.
... After all eight aspirations were attempted all needles were withdrawn from the eye. Each needle was observed to watch for 'wicking' of the vitreous, forming a 'string' between the tip of the needle and the eye on withdrawal [8]. The final mass for each prototype was again measured on the precision balance. ...
Purpose
VitreoDx is an experimental device enabling push-button collection of a neat vitreous liquid biopsy incidental to an intravitreal injection. We explored the ability of the device to collect a sample usable for proteomic biomarker discovery and testing.
Design
Pilot study using ex vivo human eyes.
Methods
Non-vitrectomized, human eyes from nine donors 75–91 years of age were refrigerated in BSS and used within 5 days of death. Four VitreoDx devices fitted with 25G needles, and four staked needle insulin syringes with 30G needles, were inserted at equal intervals through the pars plana of each eye and held in place by a fixture. The sampling mode of each VitreoDx device was triggered to attempt to acquire a liquid biopsy up to 70 μL. The plunger of each insulin syringe was retracted to attempt to obtain a liquid biopsy with a maximum volume of 50 μL. Samples acquired with the VitreoDx were extracted to polypropylene cryovials, refrigerated to -80 ºC, and sent for offsite proteomic analysis by proximity extension assay with a focus on panels containing approved and pipelined drug targets for neovascular disease and inflammatory factors.
Results
Of the attempted liquid biopsies with the novel 25G VitreoDx, 92% (66 of 72) resulted in successful acquisition (>25 μL) while 89% (64 of 72) attempted by a traditional 30G needle resulted in a successful acquisition. Sample volume sufficient for proteomics array analysis was acquired by the VitreoDx for every eye. Detectable protein was found for 151 of 166 unique proteins assayed in at least 25% of eyes sampled by VitreoDx.
Conclusions
The high acquisition rate achieved by the prototype was similar to that achieved in previous clinical studies where a standard syringe was used with a 25G needle to biopsy vitreous fluid directly prior to standard intravitreal injection. Successful aspiration rates were likewise high for 30G needles. Together, these suggest that it is possible to routinely acquire liquid vitreous biopsies from patients who typically receive intravitreal injections with an injection device using a standard size needle without a vitreous cutter. Protein analysis shows that proteins of interest survive the sampling mechanism and may have potential to direct care in the future.
... Other complications include lens injury, vitreous hemorrhage, and retinal detachment. Chen et al. [2] reported that vitreous reflux, which appears as a subconjunctival bleb, is a common incident and might be a risk factor for endophthalmitis following IVI. Prior studies reported a strong relationship between the intraocular pressure (IOP) spike and vitreous reflux [3][4][5][6][7]. ...
Aim To investigate the role of pre-injection antiglaucoma medications as a noninvasive method to prevent reflux following intravitreal injection (IVI).
Patients and methods This single-center prospective randomized study included patients who were planned to receive an IVI of anti-vascular endothelial growth factor ranibizumab 0.05 ml for macular edema for diabetic macular edema, branch retinal vein occlusion, or choroidal neovascular membrane. Patients were randomized into five groups: no intervention (group 1), pre-injection topical brimonidine (group 2), pre-injection oral acetazolamide (Diamox) (group 3), pre-injection topical brimonidine and oral Diamox (group 4), and pre-injection paracentesis (group 5). The primary outcomes were the occurrence and degree of reflux following IVI. In addition, the evaluation of conjunctival bleb estimated the degree of reflux. Patient self-rated pain and early complications were secondary outcome measures.
Results A total of 150 eyes of 150 patients were included. Vitreous reflux occurred in 13 (43%), 14 (46.7%), 19 (63.3%), six (20.0%), and four (13.3%) eyes in groups 1–5, respectively (P
... Although bacterial conjunctivitis is a common ophthalmic condition that often resolves spontaneously without the help of topical antibiotics [4], we believe injection site infections should be aggressively treated and followed due to the risk of tenonitis, infectious scleritis [5], and endophthalmitis if a vitreous wick was present [6]. Conjunctivitis-causing bacteria can infect the conjunctiva via fingers carrying the bacteria, the eyelids, eyelashes, and skin surrounding the eye, the nasopharynx, or contaminated eye drops and contact lenses [7]. ...
A 73-year-old man presented 3 days after intravitreal injection (IVI) with bevacizumab for treatment of neovascular age-related macular degeneration with pain and redness around the injection site. Examination showed conjunctival edema and injection around the injection site and a central infiltrate at the injection site consistent with infection of Tenon’s capsule and the conjunctiva. Infection of a vitreous wick was considered, but vitreous inflammation was not present. Acute bacterial tenonitis and conjunctivitis were diagnosed, and the patient was prescribed topical antibiotic drops. The patient’s symptoms were resolved within 48 h following the use of topical antibiotic drops, so a culture was not performed. The patient did not develop endophthalmitis. To our knowledge, this is the first reported case of acute bacterial tenonitis and conjunctivitis of the injection site following IVI. Even with the use of betadine, infection of Tenon’s capsule and the conjunctiva may occur after IVI and must be differentiated from other causes of postinjection ocular redness such as chemical irritation of the ocular surface, corneal abrasions, and endophthalmitis.
... Bei der Auswertung autopsierter vitrektomierter Augen wurde eine Glaskörperinkarzeration an den Portstellen festgestellt [65,66]. Bei einer nahtlosen Sklerotomie kann dies dazu führen, dass Mikroorganismen entlang eines Glaskörperstrangs, der aus der undichten Sklerotomiewunde vorfällt, in den Bulbus einwandern können [52,58,67]. ...
Postoperative endophthalmitis is one of the most feared complications for ophthalmologists, and the number of infections after intraocular procedures have been increasing. Nonetheless, a prompt intervention can result in the recovery of vision. In the past, endophthalmitis after cataract surgery was accountable for the majority of cases but is becoming less frequent due to the progress of surgical techniques and demographic developments with a steadily increasing number of intravitreal injections. In this article, the different forms of postoperative endophthalmitis are assessed in terms of pathophysiology and their specific characteristics depending on their etiology.
... Chen et al reported that vitreous reflux (VR) might be a cause of endophthalmitis after intravitreal injection. 1 Occasionally, ophthalmologists encounter VR after intravitreal injection in practice. This VR resembles a subconjuctival bleb. ...
Purpose
To compare the effects of 30-gauge versus 32-gauge needles on vitreous reflux (VR) frequency and intraocular pressure (IOP) following first-time intravitreal aflibercept injections.
Materials and Methods
Overall, 116 patients (116 eyes) who received intravitreal injections using 30-gauge needles and 104 patients (104 eyes) who received the same injection using 32-gauge needles were reviewed. The medical records of 116 patients who each received an intravitreal injection using a 30-gauge needle (median age: 67.5 ± 13.9 years) and 104 patients who each received the same injection using a 32-gauge needle (median age: 66. 3 ± 10.6 years) from January 2015 to June 2019 were compared.
Results
No significant difference in the frequency of VR was observed between patients injected using 30-gauge needles (38/116) and patients injected using 32-gauge needles (31/104, P = 0.64). There were no significant differences in the VR rates of patients with phakic and pseudophakic eyes between those injected using 30-gauge (P = 0.94) or 32-gauge needles (P = 0.77). Axial length did not significantly differ between patients with and without VR when injected using 30-gauge (P = 0.89) and with 32-gauge needles (P = 0.69). IOP immediately after injection was significantly higher in patients injected using 30-gauge needles than in patients injected using 32-gauge needles (P < 0.01).
Conclusion
VR frequency was not correlated with needle size, lens status, or axial length. Patients receiving injections using 30-gauge needles had higher IOP immediately after intravitreal injection.
... This condition is reported in cataract surgery with a posterior capsular defect, corneal relaxation incisions and intravitreal injections, and is known to cause cystoid macular oedema, vitreomacular traction, retinal detachment and endophthalmitis. [5][6][7][8] This condition and prevention of associated complications can be treated medically, surgically or using ND:Yag vitreolysis. 9 10 We report a case of vitreous with AH incarceration in the limbal surgical port following an eventful cataract surgery possibly causing an increased risk of vitreoretinal interface disorders as described above. ...
... Although the conventional indirect ophthalmoscopy-guided technique requires considerable surgical skill, mastery of the skill is still important for clinicians since its long-term safety has been proven with low incidence of endophthalmitis after conventional scleral buckling. [14] The Optos Ultra-Widefield Fundus Camera (Optos, Dumfermline, UK) has proven useful in documenting the preoperative state of RRD with acquisition of 200˚panoramic images of the retina. [15] In the present study, we investigated whether the preoperative Optos image in RRD cases can facilitate estimation of scleral chord length from the limbus to the retinal tears, which might aid scleral marking during scleral buckling surgery. ...
Objective
Accurate scleral marking of retinal breaks is essential for successful scleral buckling. This study aimed to investigate the use of wide-field fundus images obtained with an Optos for preoperative estimation of the distance from the limbus to the retinal breaks.
Methods and analysis
This is a retrospective review of 29 eyes from 26 patients with rhegmatogenous retinal detachment who received scleral buckling with anatomically successful repair. They underwent wide-field fundus photography with Optos California. In the pre- and postoperative fundus images, we measured distances from the macula to the retinal tears (TM), to the center of the vortex veins (VM), to the optic disc (DM), and to the posterior edge of the scleral buckle (BM).
Results
(BM—VM) / DM was significantly correlated with the distance from the limbus to the posterior edge of the scleral buckle that had been determined intraoperatively. (r = 0.705; p<0.001) We applied a regression line derived from this correlation with the value of (TM -VM) / DM in order to calculate estimated distances between retinal breaks and the limbus. The calculated distances were all within the range of distances from the limbus to the anterior and posterior edges of the scleral buckles.
Conclusion
Preoperative analysis of Optos images may be useful for estimating the distance from the limbus to retinal breaks, which might aid scleral marking during scleral buckling surgery.
... It is well known that the vitreous that has herniated to the sclerotomy site can be a bridge for pathological organisms to enter the intraocular tissue. 22 During scleral buckling surgery, the changes of the intraocular pressure is substantial because of the scleral indentation so that vitreous herniation at the incision site can easily occur. To try to avoid the possibility of infection, we washed the surgical field with PAI solution several times intraoperatively, and the scleral sclerotomy was covered by the conjunctiva at the end of surgery. ...
Purpose: The non-contact wide-angle viewing system (WAVS) with chandelier endoillumination is being used more commonly during scleral buckling surgery for rhegmatogenous retinal detachments although its safety has not been established. We report our findings in a case of bacterial endophthalmitis that developed after scleral buckling surgery with WAVS and chandelier endoillumination.
Observations: A 42-year-old man underwent scleral buckling surgery for a rhegmatogenous retinal detachment in his right eye using a WAVS with chandelier endoillumination. Three days after the surgery, the patient noticed a marked decrease in his vision with ocular pain. Slit-lamp examination showed dense infiltration in the anterior chamber and vitreous body. Pars plana vitrectomy with antibiotic irrigation was done immediately, and Staphylococcus epidermidis was detected in the vitreous fluid. After vancomycin 6/day for 4 weeks, the inflammation gradually subsided, and the visual acuity recovered to 20/20 in 3 months.
Conclusions and importance: Acute bacterial endophthalmitis can develop after scleral buckling surgery performed with WAVS and chandelier endoillumination.
... 20 This has led to several studies evaluating factors that may influence the amount of reflux from intravitreal injections. [21][22][23][24] Though vitreous prolapse may be observed after intravitreal injection with both 27-and 30-gauge needles, 25 27-gauge needles require twice the force to penetrate the sclera than a 30/31-gauge needle, 26 potentially leading to more discomfort during intravitreal injections. 27 Though most participants in this study stated that they do not prefer a specific quadrant (21/52), the superotemporal one was the most frequent among those who did (17/52). ...
Purpose
The purpose of this study was to describe antivascular endothelial growth factor intravitreal injection techniques of retinal specialists in order to establish a cornerstone for future practice guidelines.
Methods
All members of the Israeli Retina Society were contacted by email to complete an anonymous, 19-question, Internet-based survey regarding their intravitreal injection techniques.
Results
Overall, 66% (52/79) completed the survey. Most (98%) do not instruct patients to discontinue anticoagulant therapy and 92% prescribe treatment for patients in the waiting room. Three quarters wear sterile gloves and prepare the patient in the supine position. A majority (71%) use sterile surgical draping. All respondents apply topical analgesics and a majority (69%) measure the distance from the limbus to the injection site. A minority (21%) displace the conjunctiva prior to injection. A majority of the survey participants use a 30-gauge needle and the most common quadrant for injection is superotemporal (33%). Less than half routinely assess postinjection optic nerve perfusion (44%). A majority (92%) apply prophylactic antibiotics immediately after the injection.
Conclusion
The majority of retina specialists perform intravitreal injections similarly. However, a relatively large minority performs this procedure differently. Due to the extremely low percentage of complications, it seems as though such differences do not increase the risk. However, more evidence-based medicine, a cornerstone for practice guidelines, is required in order to identify the intravitreal injection techniques that combine safety and efficacy while causing as little discomfort to the patients as possible.
... 10 Vitreus inkarserasyonu veya ilacın konjonktiva altına geri kaçışının önlenmesi için skleradan giriş açısının oblik olması ve tünel tekniği kullanılması, lens hasarından kaçınmak için de iğne ucunun göz küresinin merkezine doğru yönlendirilmesi önerilmektedir (Şekil 1). 6,11 Enjeksiyon iğnesi çapının 27 gauge veya daha küçük olması doku travması, subkonjonktival hemoraji, ilaç reflüsü ve olası kristalin lens hasarı riskini azaltmaktadır. 12 İğnenin künt uçlu olması enjeksiyon sırasında sklerada belirgin bir çöküntüye ve iğne ucu ile lens arasındaki mesafenin azalmasına sebep olmaktadır. ...
During intraocular surgery, undesired damages of various etiology may occur in adjacent tissues. One of these tissues is the crystalline lens,
which may be traumatized both in anterior segment and posterior segment surgeries, and when damaged, it usually causes marked decrease
in visual acuity. The leading causes of iatrogenic lens injuries are intravitreal injection, laser iridotomy, phakic intraocular lens implantation,
anterior chamber paracentesis, and vitreoretinal surgery. When crystalline lens damage occurs, its negative effect on visual function may be
eliminated by performing cataract surgery intraoperatively or in elective conditions. (Turk J Ophthalmol 2012; 42: Supplement 27-30)
... The use of a larger bore needle may increase the likelihood of vitreous wick and potential infection. The use of a sterile cotton -bud to tamponade the pars plana entry site immediately upon needle withdrawal may minimize the risk of vitreous prolapse [29] . The MARINA Study had a per -injection incidence of endophthalmitis of 0. 05% (5 cases / 10 443 injections) [2] . ...
AIM: To determine whether inferior injections had a higher incidence of post-injection endophthalmitis than superior injections. The incidence of endophthalmitis is higher for inferior than superior trabeculectomy filtering blebs, possibly due to bacteria pooling in the inferior tear lake. METHODS: A practice-wide database of endophthalmitis cases identified 5 occurring during the two-year study period. A retrospective review of 8 672 injections in 1 121 eyes of 909 patients treated during the same two-year study period was performed in order to assess the injection site location. RESULTS: Five eyes developed presumed infectious endophthalmitis. Eighty percent of endophthalmitis cases were injected inferiorly, even though 84.6% of the total cohort was injected superiorly. The odds ratio of infection associated with inferior injection location is 22.1 (P=0.006). CONCLUSION: Endophthalmitis after intravitreal injection is rare, occurring in only 0.025% of injections overall. Avoiding intravitreal injections in the inferior quadrants may further reduce the rate of endophthalmitis.
... Once the needle is positioned in the eye, the medication should be injected in a steady slow to moderate fashion and then the needle removed in a single motion. A sterile cotton tip applicator may be used to tamponade the site to prevent vitreous reflux and theoretically prevent a tract for bacterial entry into the eye [22]. To minimize pressure rise, it is recommended that an anterior chamber paracentesis be performed if more than 0.1 mL is injected into the eye. ...
... [4][5][6][7] It has been speculated that a trocar and cannula inserted into a sclerotomy site, which is generally done during microincision vitrectomies, reduces stress on the sclerotomy site. 8,9 Parameters [10][11][12] have been identified relating to the sclerotomy architecture and the surgery that affect the integrity of the sclerotomy closure, such as vitreous incarceration, which may function as an incisional plug, favoring postoperative sclerotomy closure; 13 however, vitreous incarceration has also been associated with postoperative complications, such as peripheral retinal tears as a result of postoperative vitreous contraction, acute endophthalmitis due to the presence of an incisional vitreous wick that may facilitate entry of bacteria into the vitreous cavity, [14][15][16][17] and fibrovascular proliferation, which is considered a major risk factor for recurrent vitreous hemorrhage in patients with diabetes. 18 Some investigators [19][20][21][22][23][24] prefer creation of oblique sclerotomy incisions rather than straight incisions to prevent leakage through the sutureless wounds. ...
Background
The purpose of this study was to determine the incidence of vitreous incarceration in sclerotomy after cannula removal during 23-gauge vitrectomy.
Methods
Thirty-seven eyes underwent 23-gauge sutureless vitrectomy. Oblique sclerotomies were made parallel to the limbus and tangentially to the sclera. Once past the trocar sleeve, the angle was changed to 90 degrees perpendicular to the surface and the trocar and cannula inserted. Vitreous gel was removed until the intraocular edge of the infusion cannula was free from the gel. The cannula was extracted with insertion of a light probe. The sclerotomy site was evaluated endoscopically through another cannula in 32 eyes; in five eyes, another infusion tube was inserted into the cannula to maintain intraocular pressure, the original infusion was removed, and the sclerotomy site observed.
Results
No vitreous incarceration occurred in 30 (94%) eyes when one cannula was removed with insertion of a light probe, and minimal incarceration occurred in two (6%) eyes. No incarceration occurred in five eyes with observation of the infusion site.
Conclusion
The incidence of vitreous incarceration is low when a light probe or vitreous cutter is inserted. Inserting the light probe through the cannula during its removal and creating an oblique sclerotomy may reduce vitreous incarceration.
... Others propose that lower infusion rates are a feature of sutureless vitrectomy, and the reduced influx and efflux of fluid may allow a greater bacterial inoculum to remain in the eye [73]. In addition, less vitreous gel is removed during sutureless PPV versus 20-gauge PPV and the residual vitreous skirt may facilitate bacterial adherence and sequester bacteria [74,75]. Future retrospective or prospective trials need to take into consideration certainly several factors. ...
Diabetes mellitus is a systemic disease that increases the risk of infections. Exogenous endophthalmitis is an inflammatory disease to which diabetic patients are more predisposed to than nondiabetic patients undergoing any intraocular intervention. This might be because of the change in the immune and inflammatory factors that intervene in wound healing and in the bacterial flora of the ocular adnexa. We conducted a literature review to assess the risk of exogenous endophthalmitis in diabetic patients undergoing cataract extraction, pars plana vitrectomy, and intravitreal injections and to check whether its treatment differ from in non-diabetics. We found that diabetic patients are more predisposed to virulent organisms and that the incidence of ophthalmic symptoms was not substantially different in diabetic versus nondiabetic patients. Regarding treatment, all patients with light perception should receive pars plana vitrectomy, while those with hand motion and better vision should be given an intravitreal antibiotics injection. Some authors recommend vitrectomy to diabetic patients with even counting figure vision.
... A minority of injections may result in a small amount of liquid reflux back under the conjunctiva, resulting in a temporary bleb. It is unclear whether the fluid in this bleb represents medication or vitreous, but it has been proposed that vitreous reflux may be a risk factor for endophthalmitis [38]. An animal study using radiolabeled anti-VEGF agents demonstrated that this material is most likely the medication itself [39]. ...
The use of anti-vascular endothelial growth factor (VEGF) agents has led to a dramatic increase in the number of intravitreal injections. Endophthalmitis remains a rare but potentially vision-threatening complication of intravitreal injections. Recent large series have estimated this risk to be about one in 3,000 injections or less. Bevacizumab, which is generally prepared by a compounding pharmacy, is associated with additional risks of contamination. Although endophthalmitis cannot be prevented in all cases, certain risk reduction strategies have been proposed, including the use of an eyelid speculum, povidone iodine, avoidance of needle contact with the eyelid margin or eyelashes, and avoidance of routine post-injection antibiotics. Despite these precautions, some patients will develop endophthalmitis following intravitreal anti-VEGF injections, and outcomes may be poor despite prompt and appropriate therapy.
... Weitere mögliche Infektionsquellen sind eine Kontamination des Medikaments oder der noch nicht benutzten Injektionskanülen selbst sowie ein postoperativ undichter Injektionskanal ggf. mit Glaskörperinkarzeration [5]. Unter Berücksichtigung dieser wahrscheinlichen Infektionsquellen wurden Behandlungsempfehlungen entwickelt, die die Notwendigkeit einer ausgiebigen Desinfektion des Bindehautsacks und der periokulären Region mit Povidon-Jod (PVI) sowie einer strikt aseptischen Injektionstechnik betonen [1,2,11]. ...
Hintergrund
Prospektive Untersuchung der bakteriellen Kontamination für die intravitreale operative Medikamenteneingabe (IVOM) verwendeter Injektionskanülen.
Material und Methoden
Zwischen 12/2007 und 12/2010 wurden in der Fundación Visión, Asunción, Paraguay 549 Augen von 413 Patienten intravitreal mit Bevacizumab 1,25 mg behandelt: 322 Patienten erhielten eine, 91 Patienten mehrfache Behandlungen. Vor dem Eingriff erfolgte bei allen Patienten eine periorbitale Desinfektion mit 10% Povidon-Jod (PVI) sowie eine Spülung des Bindehautsackes mit 10 ml 1% PVI. Antibiotika wurden präoperativ nicht gegeben. Unmittelbar nach der IVOM wurden die Kanülen 3-mal in Thioglycolat-Nährlösung gespült, die anschließend 5 Tage lang bei 37°C kultiviert wurde. Als Negativkontrolle dienten 73 unbenutzte Kanülen, die auf dieselbe Weise gespült und kultiviert wurden.
Ergebnisse
Acht der untersuchten 549 (1,45%) Kanülen waren nach der IVOM bakteriell kontaminiert. Die identifizierten Bakterien waren: koagulasenegative Staphylococcus (n = 7), Propionibacterium acnes (n = 1) und Klebsiella pneumoniae (n = 1; Kokontamination bei einer Kanüle).
Schlussfolgerung
Nach präoperativer PVI-Desinfektion fanden wir eine niedrige Rate kontaminierter Injektionskanülen. Zur Prävention postoperativer Infektionen empfehlen wir daher eine sorgfältig Prophylaxe mit PVI.
... 2,3 Since the implantation of the TSV, numerous studies have analyzed different aspects of the sclerotomies such as the presence of incisional vitreous incarceration. [4][5][6][7][8][9][10][11] This vitreous entrapment may work as an incisional plug, favoring postoperative sclerotomy closure; however, it has been also related to some postoperative complications, such as peripheral retinal tears as a result of postoperative vitreous contraction, [12][13][14] acute endophthalmitis due to the presence of incisional vitreous wick that may facilitate the entry of bacteria into the vitreous cavity, 15 and fibrovascular proliferation that is considered a major risk factor for recurring vitreous hemorrhage in diabetic patients. 16 Previously, some authors have described different maneuvers aimed to reduce this postoperative vitreous incarceration. ...
To evaluate the effect of the cannula removal technique on postoperative vitreous incarceration using an experimental model of vitrectomized eye.
In a prospective, experimental, randomized, and observer-masked study, 118 cadaveric pig eyes were vitrectomized through 23-gauge transconjunctival sclerotomies. Once vitrectomy was finished, one of the superior cannulas was extracted with the illumination probe inserted through it, and the other cannula was removed with a cannula plug inserted. Postoperative incisional vitreous entrapment was evaluated by direct visualization. No vitreous incarceration was classified as grade 0 (G0), thin vitreous entrapment was classified as grade 1 (G1), and thick vitreous strands as grade 2 (G2).
Considering the sclerotomies whose cannulas were extracted with the light probe inside, vitreous incarceration was detected in 93.2% (73.7% G1, 19.5% G2) of the incisions. In turn, vitreous entrapment was observed in 95.8% (43.2% G1, 52.6% G2) of the entry sites whose cannulas were extracted with the plug inserted. Statistical analysis showed significant differences when comparing postvitrectomy vitreous incarceration grades in sclerotomies according to the cannula extraction technique (P < 0.0001).
Interposing the light probe through the cannula during its removal reduces vitreous incarceration grade in our experimental model. This simple maneuver may decrease complications related to vitreous entrapment, such as peripheral retinal tears and acute endophthalmitis.
... Finally, after the injection, organisms from the normal conjunctival flora may enter the vitreous through the sclerotomy created by the needle, possibly with the assistance of a vitreous wick. 5 Despite these possible routes of vitreous inoculation, clinical infections are rare. In a study of over 24,000 intravitreal injections performed at Bascom Palmer Eye Institute, 7 cases of acute endophthalmitis occurred (Moshfeghi AA et al., Invest Ophthalmol Vis Sci. ...
To determine the incidence of bacterial contamination of needles used for intravitreal injections.
Patients undergoing intravitreal injections were enrolled prospectively. No pre-injection antibiotics were administered. Following povidone-iodine irrigation, conjunctival cultures were taken and the injection was performed. The needle was cultured. A dry control needle was exposed to the surgical field and cultured.
No patients developed endophthalmitis. Eighteen injection needles (18%) yielded positive bacterial growth. The most commonly encountered organisms were Propionibacterium acnes (n = 8) and Staphylococcus epidermidis (n = 6). Four control needles showed positive growth, in 2 cases with the same organism as a matching positive used needle. The difference between contamination rates of used and control needles was significant (p = .002, McNemar's test).
Bacterial contaminants are present on a substantial proportion of needles. Since the needle contacts both the ocular surface and the vitreous, it is possible that inoculation of the vitreous cavity occurs in such cases.
... The angle of the incision through the sclera should be oblique, using an oblique or tunneling technique (458), as rectangular radial incisions (908) may remain open, inducing vitreous incarceration or drug reflux under the conjunctiva. 15 Previously, we observed persistent unsealed sclerotomies after radial injections using 30-gauge needles. 16 The depth of the insertion should be between 5 and 7 mm, so that the tip of the needle is placed presumably in the center of the vitreous cavity. ...
To report the incidence of traumatic lens injuries as a complication of intravitreal injection at 5 high-volume academic centers.
We determined in a retrospective, interventional, multicenter case series the consecutive number of the injections between January 5, 2006 and December 22, 2008 from the injection log books. All injections were performed under sterile conditions in a laying position, 3.5-4.0 mm behind the limbus in an oblique fashion. The main outcome measure was the incidence of lens damage.
A total of 32,318 intravitreal injections were performed, and 3 cases of iatrogenic lens damage were reported during 36 consecutive months. All affected eyes were hyperopic. The overall incidence rate of lens injury was 0.006% (2/32,318) for intravitreal injections and 1 during a paracentesis 0.003 (1/32,318). The rate of phakic eyes determined was 67%, and thus, the incidence rate of lens damage in phakic eyes was 0.009% (2/21,653) (95% confidence interval, 0.00%-0.05%).
Although there is no agreement regarding the proper intravitreal injection technique, the incidence of traumatic injuries to the crystalline lens was very low in a large series of injected patients in a community setting. The incidence compares favorably with that reported in clinical trials in which much more extensive preinjection preparation was mandated. A good preparation of the surgical incision with proper anesthesia and detailed information of the patient, as well as good anatomical skills of the treating physician, are mandatory to prevent this rare adverse event.
... 22 Finally, prolapse of a vitreous wick through the sclerotomy site may create a potentially open conduit through the conjunctival and scleral wound that may facilitate entry of bacteria into the eye. 23 At our institution, we utilize a standardized infection prevention procedure for all patients in the operating room. This protocol includes lid scrubbing with shampoo by the operating room nurse in the operating room and povidone-iodine preparation, including povidone-iodine placed into the conjunctival fornices by a medical doctor. ...
Recent retrospective analyses have suggested that postoperative endophthalmitis may be more frequent with 25- than 20-gauge pars plana vitrectomy (PPV). Because the infection risk may depend on the suturing status of the sclerotomy, and the perioperative anti-infection protocol, we compared the incidence rate of endophthalmitis after sutureless 25-gauge versus sutured 20-gauge PPV on a large cohort of patients operated with a standardized perioperative anti-infection protocol.
Retrospective comparative case series.
Consecutive patients who underwent 20- or 25-gauge PPVs at a single center over a multi-year period.
We analyzed 3597 consecutive PPVs. Patients with a pre-PPV diagnosis of endophthalmitis, PPVs performed for implantation of drug delivery devices, or 25-gauge PPVs with all sclerotomies sutured closed were excluded. Patients with > or =1 week of follow-up were divided into 2 study groups by sclerotomy status at the end of surgery: the 20-gauge group had 3 sutured 20-gauge sclerotomies, and the 25-gauge group had > or =1 unsutured 25-gauge sclerotomy. Endophthalmitis was defined by clinical criteria independent of microbiological results.
The incidence of endophthalmitis was compared between 25- versus 20-gauge groups.
Of 3372 PPV surgeries meeting inclusion and exclusion criteria, 1948 and 1424 surgeries were 20- and 25-gauge PPVs, respectively. Average age (+/- standard deviation) of patients was 54.6 (+/- 22.6) and 64.4 (+/- 16.5) years in the 20- and 25-gauge PPV groups, respectively (P<0.0001). Median post-PPV follow-up time was not significantly different between the 2 groups (12.5 vs 13.0 months; P = 0.69). Endophthalmitis was observed in 1 patient (0.07%; 95% confidence interval, 0%-0.21%) from the 25-gauge group and none in the 20-gauge group (P = 0.42; Fisher exact test, 2-tailed). The use of air/gas endotamponade (P<0.0001) and intravitreal triamcinolone (P<0.001) was more common in 25- versus 20-gauge PPV.
The incidence of endophthalmitis was low in both groups. We were unable to show a significant difference in the incidence of endophthalmitis between sutureless 25-gauge and sutured 20-gauge PPV, and conclude that a careful perioperative anti-infection protocol may reduce 25-gauge PPV endophthalmitis risk to that of 20-gauge PPV.
Intravitreous injections are presently the second most frequently performed ophthalmic procedure and the most common vitreoretinal procedure. In diabetic patients, intravitreous injections are frequently performed for the treatment of center-involved diabetic macular edema, proliferative diabetic retinopathy, or other co-existing retinal vascular disease. Diabetic patients may be at higher risk of adverse events compared to non-diabetic individuals, given frequent systemic comorbidities, such as cardiovascular and renal disease and increased susceptibility to infection. This review highlights the potential complications and safety considerations in intravitreous injections in patients with diabetes.
Postoperative endophthalmitis is one of the most feared complications of intraocular surgery. The most common types of intraocular surgeries performed worldwide are cataract extraction, glaucoma drainage implants/trabeculectomy, and pars plana vitrectomy. This review will focus on the clinical features, risk factors, prophylaxis, and treatment of endophthalmitis in these three main intraocular surgeries.
An 82-year-old man presented with right eye discomfort 3 days after an intravitreal aflibercept injection using a 32-gauge needle for treatment of neovascular age-related macular degeneration. His visual acuity was stable however slit lamp examination of the right eye showed prolapsed vitreous extending to the lower eyelid arising from the inferotemporal pars plana scleral injection site. There was no evidence of intraocular inflammation and his fundus examination was stable. The scleroconjunctival defect and prolapsed vitreous were repaired in the operating room. Postoperatively his vision remained stable with no signs of endophthalmitis or retinal detachment.
Purpose:
To determine the effect of cannula removal over the light pipe on the incidence of sclerotomy leakage and to evaluate other factors that may influence the incidence of sclerotomy leaks and hypotony on conclusion of small-gauge transconjunctival pars plana vitrectomy.
Methods:
Retrospective, interventional clinical study of consecutive patients who underwent small-gauge transconjunctival pars plana vitrectomy at a single academic center. Eyes were divided into a group in which cannulae were removed over the light pipe (Group L) and a group in which cannulae were simply pulled out (Group N). The primary comparison was the comparison in requirement for suturing of sclerotomies between Groups L and N.
Results:
Forty-eight eyes of 48 patients were included in the study (Group L: 21 eyes; Group N: 27 eyes). In Group L, 14/42 (33%) superior sclerotomies required suturing compared with 7/54 (13%) sclerotomies in Group N (P = 0.024). Superior sclerotomy leaks were also more common in Group L (28/42, 67%) compared with Group N (23/54, 43%, P = 0.024). Similarly, more eyes had hypotony after cannula removal in Group L (11/21; 52%) compared with Group N (5/27; 19%, P = 0.03). There were no differences in any of these measures when comparing fluid-filled to air- or gas-filled eyes.
Conclusion:
Removing the cannula over the light pipe results in a greater frequency of leaking, including leaking that results in hypotony or that requires suturing. The technique of cannula removal affects the risk of leakage and the risk of requiring suturing of a sclerotomy.
Während früher allein Medikamente des vorderen Augenabschnitts – insbesondere Augentropfen – den Markt der ophthalmologischen Präparate dominiert haben, spielen retinale Strukturen als Angriffspunkte eine zunehmende Rolle. Obwohl das Konzept, den Glaskörper als Medikamentenreservoir oder Depot zu nutzen, ursprünglich schon von Machemer (PVR-Prophylaxe) stammt, wurden die ersten Erfahrungen mit der intravitrealen Pharmakotherapie hauptsächlich in der Behandlung infektiöser Retiniden und Endophthalmitiden weiterentwickelt. Indem Erreger wie Bakterien oder Cytomegalieviren direkt am Ort der Erkrankung behandelt wurden, konnte die systemische Exposition und so auch die Nebenwirkungen reduziert werden. Gleichzeitig kann die Dosis an die okulären Anforderungen angepasst werden, weil die Blut-Netzhaut-Schranke der retinalen Gefäße nicht mehr zu überwinden ist. Nach kristalloiden Wirkstoffen, die definierte Mengen entsprechend des Löslichkeitsprodukts abgeben, stehen heute ausgeklügelte Drug-Release-Systeme für den Glaskörperraum zur Verfügung.
Recent evolution in vitreoretinal procedures has led to a significant reduction in intraoperative and postoperative complications.
Endophthalmitis following pars plana vitrectomy is a very uncommon cause of endophthalmitis. Cases reported over the last decade show a decrease in incidence over time. To optimize visual outcome, early diagnosis and treatment are essential. In this review we report a summary of the incidence of endophthalmitis following vitrectomy, various risk factors for their occurrence, the microbiological profile and the visual outcomes post treatment.
Objective:
To describe intravitreal injection (IVI) techniques and treatment protocols by retina specialists in Canada from August 1, 2012, to October 1, 2012.
Design:
Cross-sectional survey.
Participants:
All fellowship-trained retina specialists across Canada, as identified from the Canadian Ophthalmological Society directory and the Canadian Retina and Vitreous Society directory.
Methods:
An anonymous 28-question survey was sent to 125 retina specialists across Canada by email. Reminder letters were sent by email, mail, and fax as necessary.
Results:
A total of 75 (63%) retina specialists responded to the survey. Most IVIs were performed in the office. Most surgeons did not use gloves (61%), sterile draping (91%), or surgical mask (71%). Antisepsis was used on conjunctiva by 100% and on periocular skin by 48%. Nearly all specialists used a sterile lid speculum (91%). Common anaesthetics included topical proparacaine or lidocaine drops (90%), topical lidocaine gel (25%), topical pledget (23%), and subconjunctival lidocaine injections (23%). Most (83%) dilate the pupil before IVI. Prophylactic topical antibiotics were used by 43%; 50% of these were started immediately after IVI. Injection location was estimated by visualization by 45%. A majority (63%) inject inferotemporally. Anterior chamber paracentesis was performed routinely by 5%. Optic nerve perfusion was formally assessed by 48%. The most common treatment protocol for age-related macular degeneration was treat and extend. For both diabetic and retinal vein occlusion-related macular edema, the most common protocol was 3 initial monthly injections with PRN follow-up.
Conclusions:
A wide variety of IVI practice patterns exist in terms of aseptic technique, anaesthetics, prophylactic antibiotics, postinjection monitoring, and treatment protocol.
Background
When pars plana vitrectomy is performed, the sizes of the sclerotomy cannula vary between 20 and 23 gauge. We examined the morphology of the scleral tunnels by ultrasound biomicroscopy additionally taking into account the incision angle.
Material and methods
In each of 16 enucleated porcine eyes three 20 or 23 gauge sclerotomies with varying angles between 30 and 90° to the horizontal level were performed. The vertical 20 gauge sclerotomies were additionally sealed by 7.0 vicryl cross-stitching. The resulting scleral channels were analysed by 3-D ultrasound biomicroscopy.
Results
The sclerotomies were echographically detectable in all cases. Analysis revealed that the sutured straight 20 gauge tunnels were hyporeflective in only some parts while the other incisions showed continuous hyporeflectivity along the complete channel in many cases. The smaller the instruments used and the flatter the scleral angles chosen, the smaller were the measured widths of the incision tunnels.
Conclusion
Imaging sclerotomies ex vivo by ultrasound biomicroscopy is reliably reproducible. In the echographic pictures straight 20 gauge incisions appeared to be safely sealed by the sutures while the nonsealed tunnels often showed continuous patency. By choosing small instruments and flat incision angles the width of the resulting scleral channels can be reduced.
The treatment of ophthalmologic conditions by intravitreal injection of therapeutic agents has taken an increasingly central role in conditions such as age-related macular degeneration, diabetic retinopathy and retinal vein occlusions. At the time of needle withdrawal following intravitreal injection, material may reflux through the needle incision into the subconjunctival space and form a bleb. This has been estimated to occur in about 20-30% of clinical cases.(1) However, it is unclear whether the refluxed material is drug or vitreous. Drug reflux may result in lower intravitreal agent dosage, while vitreous reflux may be associated with vitreous wick syndrome, predisposition to the formation of retinal holes and an increased risk of endophthalmitis by providing a track for bacteria through the incision site and into the vitreous cavity.(2).
Intravitreal injection of triamcinolone acetonide (IVTA) has been used as an off-label strategy in the management of a wide range of edematous, neovascular and inflammatory retinal diseases. Despite the variable success rates achieved in each disease, a variety of adverse events have been reported. These may be associated with the intravitreal injection procedure (endophthalmitis, vitreous hemorrhage and retinal detachment), preservatives in the vehicle of the drug (intraocular toxicity and noninfectious endophthalmitis) and the corticosteroid itself (cataract, ocular hypertension and infection). This article aims to review the incidence and mechanisms of the potential adverse effects of IVTA injection.
Background and objective:
To compare anterior-segment optical coherence tomography (AS-OCT), ultrasound biomicroscopy (UBM), and direct visualization for detecting vitreous incarceration in sutureless sclerotomies.
Materials and methods:
Prospective, randomized, and observer-masked experimental study in which 23-gauge vitrectomy was performed in pig eyes. Postoperative incisional vitreous incarceration was evaluated by AS-OCT, UBM, and direct visualization.
Results:
One hundred eighteen pig eyes were included. Vitreous entrapment was found in 7.9% (28 of 354), 59.6% (211 of 354), and 95.5% (338 of 354) of the sclerotomies analyzed by AS-OCT, UBM, and direct visualization, respectively. Direct visualization was the most sensible method for identifying incisional vitreous when compared with UBM and AS-OCT (P < .0001). In turn, UBM was superior to AS-OCT for observing vitreous incarceration (P < .0001).
Conclusion:
Direct visualization is the most effective method for detecting vitreous entrapment. Regarding the imaging techniques, UBM was superior to AS-OCT for identifying vitreous incarceration.
The study was designed to prospectively evaluate the bacterial contamination of needles used for intravitreal injection during surgery.
Between December 2007 and December 2010, 549 eyes of 413 patients were treated with intravitreal injections of 1.25 mg bevacizumab. Of the patients 322 received a single injection and 91 multiple injections. Preoperatively the periorbital skin of all patients was treated with 10% povidone iodine (PVI) and the conjunctival sac was irrigated with 1% PVI. No pre-injection antibiotics were administered. Immediately after the injection the needles were rinsed 3 times in thioglycolate broth which was then cultured at 37°C for 5 days. As a negative control 73 sterile unused needles were treated in the same way.
Out of the 549 needle points tested 8 (1,45%) were found to be contaminated after intravitreal injections. The isolated bacteria were coagulase negative Staphylococcus (n = 7), Propionibacterium acnes (n = 1) and Klebsiella pneumoniae (n = 1) (co-contamination in one case).
Contamination of needles is minimal after prophylactic povidone iodine irrigation before intravitreal injections. Therefore, this prophylaxis technique is recommended before intravitreal injections in order to prevent postoperative infections.
Die intravitreale Injektion gilt allgemein als sicher. Viele mögliche Komplikationen durch die Prozedur sind extrem selten
und können bei gewissenhafter Inspektion vor der Injektion und sachgerechter Durchführung vermieden werden. Daneben können
in seltenen Fällen aber auch die applizierten Medikamente unterschiedliche pharmakologische Nebenwirkungen hervorrufen. In
dieser Übersicht werden die Sicherheitsprofile von Macugen® und Lucentis® aus den Zulassungsstudien zusammengefasst sowie
erste Erkenntnisse über mögliche oder beobachtete Nebenwirkungen nach intravitrealer Gabe von Avastin® beschrieben. Daneben
werden wichtige Hinweise zur Vermeidung von intra- und postoperativen Komplikationen gegeben.
Intravitreal injection is generally regarded as safe. Many of the potential complications caused by this procedure are extremely
rare and can be avoided by careful inspection beforehand and proper performance of the injection. In rare cases, however,
the administered drugs may cause various pharmacological side effects. This article summarizes the safety profiles of Macugen®
and Lucentis® from the drug approval studies and describes initial findings on possible or observed side effects after intravitreal
administration of Avastin®. In addition, important points to observe in order to avoid intra- and postoperative complications
are provided.
To evaluate the influence of the cannula removal maneuver on the postoperative incisional vitreous incarceration using an experimental model of vitrectomized eye.
Prospective, experimental, randomized and observer-masked experimental study in which 23-gauge transconjunctival sutureless vitrectomy was performed through oblique sclerotomies in cadaveric pig eyes. Once the vitrectomy was finished, one of the superior cannulas was removed with the light probe introduced through it, and the other cannula was extracted with the cannula plug inserted. Postoperative incisional vitreous incarceration was evaluated by ultrasound biomicroscopy (UBM).
60 eyes included. Considering the 60 superior sclerotomies whose cannulas were extracted with the light pipe inserted, vitreous incarceration was observed in 35% of them. On the other hand, 71.6% of the incisions whose cannulas were removed with the cannula plug inserted showed vitreous incarceration (p = 0.00013).
Interposing the light probe through the cannula when it is removed seems to reduce the postoperative wound vitreous incarceration rate in our experimental model.
To report a case of localized conjunctival necrosis following intravitreal injection of triamcinolone acetonide (TA).
Single observational case report.
A 63-year- old man presented with inferotemporal branch retinal vein occlusion and macular edema in his left eye (OS). He underwent pars plana vitrectomy combined with arteriovenous sheathotomy. Postoperatively, as the macular edema persisted, he underwent an uneventful intravitreal injection of TA.
Ten days following the intravitreal injection, he presented with an area of localized conjunctival necrosis overlying the scleral entry site. Gram stain showed a few white blood cells and no organisms. The conjunctival swab showed no growth on culture. The area of conjunctival necrosis responded well to intense topical antibiotic therapy.
Conjunctival necrosis is a rare anterior segment complication of intravitreal injection of TA. With the increased usage of intravitreal TA for various posterior segment disorders, the treating physician should be aware of this complication.
: To assess the rate of retained subretinal perfluorocarbon liquid (PFCL) in patients undergoing rhegmatogenous retinal detachment (RRD) repair with sutureless 23-gauge vitrectomy versus traditional 20-gauge vitrectomy.
: A retrospective, consecutive, interventional comparative case series. All patients with a diagnosis of RRD who underwent pars plana vitrectomy with PFCL for RRD repair from November 1, 2005 through October 31, 2008 were included.
: A total of 234 RRD repairs were performed during the study period by one surgeon. Subretinal PFCL occurred in 4 of 176 eyes (2.3%) who underwent sutured 20-gauge pars plana vitrectomy and in 6 of 58 eyes (10.3%) who underwent sutureless 23-gauge pars plana vitrectomy for repair of retinal detachment (P = 0.0167, Fisher exact test, 2-tailed).
: There is a statistically significant 4.5-fold increased incidence of retained subretinal PFCL in patients undergoing RRD repair with sutureless 23-gauge vitrectomy versus traditional 20-gauge vitrectomy. This may be because of higher fluid flow through open 23-gauge cannulas, which causes disruption of the PFCL surface tension resulting in formation of small PFCL bubbles that can enter the subretinal space. Reduction of fluid flow may help prevent this complication.
As the intravitreal injection of therapeutic medication plays an increasingly large role in ophthalmology, its implementation continues to be modified and refined. Variations in injection technique are discussed, and the authors combine their clinical and research experience with a review of the literature to propose a recommended intravitreal injection protocol.
To describe the intravitreal injection technique practice patterns of retinal specialists in the United States from April 8, 2010 to April 21, 2010.
Questionnaire survey.
All members of the American Academy of Ophthalmology who self-categorized as "Retinal/Vitreous Surgery" were contacted by e-mail to complete an anonymous, 20-question, internet-based survey.
A total of 765 retinal specialists (44%) responded to the survey. Most respondents wear gloves (58%) and use an eyelid speculum (92%) when performing an intravitreal injection. More than 99% use povidone-iodine preinjection. The majority measure the injection site from the limbus (56%) and inject straight into the vitreous cavity (96%). Most do not displace the conjunctiva (83%). Seventy-two percent routinely assess postinjection optic nerve perfusion, primarily by gross visual acuity measurement (32%). While nearly one third of participants use prophylactic topical antibiotics preinjection, more than two thirds use topical antibiotics postinjection. Forty-six percent perform bilateral simultaneous intravitreal injections. The majority of respondents use a 30-gauge needle for the injection of ranibizumab (78%) and bevacizumab (60%). However, respondents use both a 27- and 30-gauge needle for the injection of triamcinolone acetonide.
Retinal specialists in the United States participate in a range of techniques for the care before, during, and after intravitreal injections. Further study is needed to elucidate best practice patterns.
To determine the baseline antibiotic susceptibility patterns of conjunctival and nasopharyngeal flora isolated from patients undergoing intravitreal (IVT) injections for choroidal neovascularization (CNV).
Prospective, observational study.
Forty-eight eyes of 24 patients undergoing unilateral IVT injections for CNV.
Bilateral conjunctival and unilateral nasopharyngeal cultures on the treatment side were taken before application of any topical medications.
Bacterial isolates were identified and tested for antibiotic susceptibility to 16 different antibiotics using the Kirby-Bauer disc diffusion technique.
A total of 57 bacterial isolates were obtained from the conjunctiva of 48 eyes. Coagulase-negative staphylococci (CNS) accounted for 37 of the 57 isolates (65%). The most common CNS organisms were Staphylococcus epidermidis and Staphylococcus lugdunensis accounting for 73% and 11% of CNS isolates, respectively. More than half of S. epidermidis isolates demonstrated some level of resistance to ofloxacin and levofloxacin, and 33% and 37% of isolates showed some level of resistance against gatifloxacin and moxifloxacin, respectively. Some 60% and 30% of CNS isolates were resistant to ≥ 3 and ≥ 5 antibiotics, respectively. Among the 24 nasopharyngeal cultures, 8 (33%) grew Staphylococcus aureus, and 1 of the 8 isolates (13%) was resistant to all penicillin, cephalosporin, macrolide, and fluoroquinolone antibiotics tested.
Our results demonstrate subtantial levels of resistance to third- and fourth-generation fluoroquinolones and multiresistance among ocular CNS isolated from patients undergoing IVT injections for CNV.
Objective
To evaluate the clinical outcome of an intravitreal injection of triamcinolone acetonide as treatment of diffuse diabetic macular edema.
Participants
This prospective, interventional, clinical case series study included 20 patients (26 eyes) who received an intravitreal injection of 25 mg of triamcinolone acetonide for treatment of diffuse diabetic macular edema. Mean ± SD follow-up time was 6.64 ± 6.10 months. The study group was compared with a control group of 16 patients who underwent macular grid laser coagulation.
Main Outcome Measures
Visual acuity and intraocular pressure.
Results
In the study group, visual acuity improved significantly (P<.001), from 0.12 ± 0.08 at baseline to a maximum of 0.19± 0.14 during follow-up. Seventeen (81%) of 21 eyes with a follow-up period of more than 1 month had improved visual acuity. In the control group, visual acuity did not change significantly. In the study group, intraocular pressure increased significantly (P<.001), from 16.9 ± 2.5 mmHg to a mean maximal value of 21.3 ± 4.7 mmHg, and decreased significantly (P = .03) to 17.7 ± 4.7 mmHg at the study's end.
Conclusion
Intravitreal injection of 25 mg of triamcinolone acetonide may be beneficial for improving visual acuity in patients with clinically significant diffuse diabetic macular edema.
A 67-year-old man developed a central retinal artery occlusion and was treated with an oral carbonic anhydrase inhibitor, oral glycerin, carbachol rebreathing, and anterior chamber paracentesis. He subsequently developed an anterior segment endophthalmitis. Vigorous medical and surgical management cured the endophthalmitis, but his visual acuity remained at light perception.
To the best of our knowledge, this patient represents the first reported case of a culture-positive, anterior segment endophthalmitis following anterior chamber paracentesis.
Eleven cases of a previously undescribed entity which we have entitled the "vitreous wick syndrome" are reported. This syndrome characteristically occurs two to four weeks following cataract surgery with a fornix-based conjunctival flap. In our opinion, it is caused by a microscopic wound breakdown resulting from overly tight corneoscleral sutures. Vitreous incarceration and prolapse follow this wound breakdown. Intraocular inflammation secondary to this open communication completes the syndrome. It is our feeling that in the presence of a vitreous wick, normal bacterial flora of the conjunctiva may cause intraocular infection. Careful evaluation of the vitreous face and corneoscleral wound may allow detection of the vitreous wick before endophthalmitis results. Once diagnosis of a vitreous wick is established, prophylactic surgical repair should be carried out without delay.
To evaluate the clinical outcome of an intravitreal injection of triamcinolone acetonide as treatment of diffuse diabetic macular edema.
This prospective, interventional, clinical case series study included 20 patients (26 eyes) who received an intravitreal injection of 25 mg of triamcinolone acetonide for treatment of diffuse diabetic macular edema. Mean +/- SD follow-up time was 6.64 +/- 6.10 months. The study group was compared with a control group of 16 patients who underwent macular grid laser coagulation.
Visual acuity and intraocular pressure.
In the study group, visual acuity improved significantly (P<.001), from 0.12 +/- 0.08 at baseline to a maximum of 0.19 +/- 0.14 during follow-up. Seventeen (81%) of 21 eyes with a follow-up period of more than 1 month had improved visual acuity. In the control group, visual acuity did not change significantly. In the study group, intraocular pressure increased significantly (P<.001), from 16.9 +/- 2.5 mm Hg to a mean maximal value of 21.3 +/- 4.7 mm Hg, and decreased significantly (P =.03) to 17.7 +/- 4.7 mm Hg at the study's end.
Intravitreal injection of 25 mg of triamcinolone acetonide may be beneficial for improving visual acuity in patients with clinically significant diffuse diabetic macular edema.
To determine the safety and efficacy of intravitreal triamcinolone acetonide (TAAC) injections in patients with refractory cystoid macular edema (CME) after cataract extraction.
LSU Eye Center, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA.
In this nonrandomized retrospective case review, 8 eyes of 8 patients with a history of pseudophakic CME recalcitrant to current standard treatment modalities were enrolled. The mean duration of the CME was 20 months. The patients received intravitreal injections of 1 mg of TAAC and were followed for a mean of 8 months. The main outcome measures included visual acuity, the presence of CME on biomicroscopic examination, angiographic evidence of perifoveal leakage, intraocular pressure (IOP), and complications related to treatment.
The visual acuity increased in all patients. The magnitude of improvement was mainly restricted by underlying macular pathology and correlated well with the level of visual acuity at entry into the study. Angiographic improvement occurred in all patients. Temporary increases in IOP were easily controlled with topical medications. No other adverse effects could be attributed to this technique. Repeated injections were required.
Intravitreal administration of TAAC was safe and effective in recalcitrant cases of pseudophakic CME with a beneficial effect on the macular edema and visual acuity. A prospective randomized study is needed to determine with accuracy the efficacy, safety, and exact timing of this technique and possibly to recognize subtypes with a more favorable response. Repeated injections were required in all eyes. The development of a sustained-release intravitreal drug-delivery system would be beneficial.
To evaluate the effect of intravitreal triamcinolone acetonide on the visual acuity of patients with exudative age related macular degeneration, to assess the duration of a possible effect, and to evaluate clinical side effects of the treatment.
The study included 67 patients (71 eyes) who presented with exudative age related macular degeneration of predominantly or total occult type (n = 68) or classic type (n = 3), and who received once, or repeatedly, an intravitreal injection of 25 mg of crystalline triamcinolone acetonide. Mean follow up time was 7.46 (SD 3.54) months (range 3.1-19.57 months).
Visual acuity increased significantly (p <0.001) from 0.16 (0.11) to a mean maximum of 0.23 (0.17). Postoperative visual acuity was highest 1-3 months after the injection. 47 (66.2%) eyes gained in maximal visual acuity and 11 (15.5%) eyes lost in visual acuity. Intraocular pressure increased significantly (p <0.001) from 15.1 (3.1) mm Hg at baseline to a maximal value of 23.0 (8.25) mm Hg. At the end of follow up, intraocular pressure again decreased significantly (p<0.001) to 16.8 (4.9) mm Hg. No cases of postoperative infectious endophthalmitis, rhegmatogenous retinal detachment, or proliferative vitreoretinopathy occurred. Owing to a decrease in visual acuity after an initial increase, six patients received a second intravitreal triamcinolone acetonide injection after which visual acuity increased again in three eyes.
Intravitreal injection of 25 mg of crystalline triamcinolone acetonide merits further study for the treatment of exudative age related macular degeneration.
Recent studies have suggested that intravitreal triamcinolone acetonide may be a therapeutical possibility for treating of various intraocular neovascular, oedematous and proliferative diseases.
Gain in visual acuity was relatively highest for eyes with intraretinal oedematous diseases such as diffuse diabetic macular oedema and various types of cystoid macular oedema due to reasons such as retinal venous occlusions and uveitis. Intravitreal triamcinolone may be useful as angiostatic therapy in eyes with iris neovascularisation and proliferative ischaemic retinopathies. Possibly, intravitreal triamcinolone may be helpful for exudative age-related macular degeneration. In eyes with chronic therapy resistant ocular hypotony, intravitreal triamcinolone can induce an increase in intraocular pressure. The role of intravitreal triamcinolone as adjunctive treatment of proliferative vitreoretinopathy has not been determined so far. Complications of intravitreal triamcinolone include secondary ocular hypertension in about 50 % of the eyes injected, with one per cent of the eyes necessitating antiglaucomatous filtrating surgery; a cataractogenic effect; and postoperative infectious endophthalmitis. Long-term studies of more than 3 years follow-up have been missing so far, so that there is no reliable information on long-term complications. The injection can be combined with cataract surgery. Cataract surgery performed some months after the injection did not show a markedly elevated rate of complications. If vision increases after the intravitreal triamcinolone injection, the injection can be repeated. The duration of the effect of a single intravitreal injection of triamcinolone ranges between 2 and 9 months. Triamcinolone acetonide was detected in the aqueous humour nine months after an intravitreal injection of 25 mg.
Intravitreal triamcinolone acetonide may offer a possibility for adjunctive treatment of intraocular oedematous, neovascular and proliferative diseases.