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Endophthalmitis After Intravitreal Injections in Patients with Self-Reported Iodine Allergy

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Endophthalmitis After Intravitreal Injections in Patients with Self-Reported Iodine Allergy Endophthalmitis After Intravitreal Injections in Patients With Self-reported Iodine Allergy BOBECK S. MODJTAHEDI, TAVE´ VAN ZYL, HEMANG K. PANDYA, ROBERT E. LEONARD, II, AND DEAN ELIOTT PURPOSE: To present cases of endophthalmitis IMITING THE RISK OF POSTINJECTION ENDOPHTHAL- following intravitreal injections where povidone-iodine mitis is an area of considerable practical and aca- (PI) was not used as part of the surgical preparation. demic interest, especially in the era of regular L DESIGN: Retrospective case series. intravitreal injections. Although the incidence of postin- METHODS: All cases of presumed injection-related jection endophthalmitis is low (0.056% per injection in a endophthalmitis presenting to the Massachusetts Eye recent meta-analysis),1 the risk to an individual patient is and Ear Infirmary between June 2008 and November magnified by the recurrent nature of the procedure. Using 2014 and Dean McGee Eye Institute between January povidone-iodine (PI) for surgical antisepsis is well estab- 2010 and January 2015 were identified. Patients who lished and is the only preoperative measure shown to did not receive PI preparation owing to documented reduce the risk of endophthalmitis in patients undergoing self-reported allergy to iodine, iodine-containing contrast intraocular surgery.2 The importance of PI application material, or shellfish were identified and their injection prior to intravitreal injection has been observed by histories and clinical courses reviewed. Nentwich and associates,3 Bhavsar and Sandler,4 and Bryn- 5 RESULTS: The combined rate of postinjection endoph- skov and associates, the latter of whom described no cases thalmitis at these 2 centers was 0.019%. Among 42 of endophthalmitis after 20 293 injections. Patients with a patients with postinjection endophthalmitis, 5 (11.9%) reported allergy to iodine or iodine-containing agents pre- did not receive PI prophylaxis. The mean number of sent a clinical challenge and some clinicians modify the intravitreal injections without PI before the development standard ophthalmic preparation to avoid PI because of of endophthalmitis was 10.6 with a 9.4% rate of endoph- perceived iodine allergy. This study presents a series of thalmitis (5 cases per 53 injections). All patients under- cases of intravitreal injection–related endophthalmitis in went tap-and-inject procedures with vancomycin 1 mg patients who underwent modified surgical preparation and ceftazidime 2 mg. Two patients did not receive PI owing to reported iodine allergy. at the time of tap and inject; 1 of these patients required subsequent pars plana vitrectomy for worsening clinical course. Cultures were positive in 4 of 5 cases; all positive cultures grew coagulase-negative Staphylococcus. All METHODS patients who received subsequent intravitreal injections received PI prophylaxis without allergic reactions, thus INSTITUTIONAL REVIEW BOARD (IRB) APPROVAL FOR A demonstrating a lack of true PI allergy. retrospective chart review was obtained from the Massa- chusetts Eye and Ear Infirmary Human Studies Committee CONCLUSIONS: Avoiding PI owing to self-reported iodine ‘‘allergy’’ risks substantial ocular morbidity. and the University of Oklahoma Health Sciences Center Allergy testing can be pursued per patient request or in IRB. All cases of presumed intravitreal injection–associ- rare cases of suspected true PI allergy; however, in cases ated endophthalmitis diagnosed at 2 institutions—Massa- where delayed treatment would adversely affect visual chusetts Eye and Ear Infirmary (MEEI, Boston, outcome, the clinician should feel confident that minimal Massachusetts), between June 1, 2008 and November 1, allergic risk exists. (Am J Ophthalmol 2016;170: 2014, and Dean McGee Eye Institute (DMEI, Oklahoma 68–74. Ó 2016 Elsevier Inc. All rights reserved.) City, Oklahoma), between January 1, 2010 and January 1, 2015—were identified using International Classification of Disease (ICD)-9 billing codes. Patients who had received ophthalmic care by outside doctors and subsequently Supplemental Material available at AJO.com. Accepted for publication Jul 12, 2016. presented to either institution were included, in addition From the Retina Service, Department of Ophthalmology, to those who were established patients at the study centers. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Patients with documented self-reported allergy to iodine, Massachusetts (B.S.M., T.v.Z., D.E.); and Retina Service, Dean McGee Eye Institute, University of Oklahoma College of Medicine, Oklahoma iodinated contrast material, or shellfish were identified City, Oklahoma (H.K.P., R.E.L.). and their charts further reviewed to determine whether Inquiries to Dean Eliott, Retina Service, Department of PI was instilled as part of the antiseptic protocol prior to Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA 02114; e-mail: Dean_Eliott@meei. the injection that preceded endophthalmitis as well as sub- harvard.edu sequent tap and inject or pars plana vitrectomy. 68 Ó 2016 ELSEVIER INC.ALL RIGHTS RESERVED. 0002-9394/$36.00 http://dx.doi.org/10.1016/j.ajo.2016.07.010 Additionally, complete procedure history was reviewed, injections without PI prior to development of endophthal- including all intravitreal injections before and after mitis, which corresponds to an 11% rate of endophthalmi- endophthalmitis as well as further demographic and clin- tis and a mean of 8.8 injections without PI before ical characteristics including age, sex, medication injected, endophthalmitis. At MEEI, the median interval between ocular condition being treated, interval between last injec- injection and presentation with endophthalmitis was tion and endophthalmitis presentation, microbiology 4 days and 3.5 days for those receiving and not receiving results, visual acuity (at presentation and last follow-up), PI, respectively. At DMEI the median number of days and number of injections (before and after endophthalmi- between injection and presentation was 5 days in both tis) with and without preinjection PI antisepsis. groups. Patients presented for evaluation between 0 and 2 days after symptom onset. All 5 patients who did not receive PI at the time of their injection were managed with tap-and-inject procedures RESULTS and 3 received 5% PI antisepsis as part of the tap-and- inject procedure protocol, without complications. One INJECTION PROTOCOLS AT BOTH MEEI AND DMEI WERE patient (Case 5) did not receive PI at the time of tap and reviewed. The procedures were office-based at both institu- inject and required pars plana vitrectomy with intravitreal tions. To achieve anesthesia, proparacaine and lidocaine antibiotics within 24 hours because of worsening examina- were employed. Topical lidocaine was the norm at DMEI, tion findings. This surgery was done without preoperative whereas physicians were divided evenly between topical PI preparation. Cultures were positive in 4 of 5 cases: all and subconjunctival lidocaine use at MEEI. Topical PI grew coagulase-negative Staphylococcus. After resolution was applied to the ocular surface; eyelid scrubs were not of endophthalmitis, 4 of the 5 patients went on to receive typically used. Masks and eyelid drapes were not used but subsequent intravitreal injections, all with PI antisepsis and speculum, gloves, and caliper use were the norm at both without allergic reactions. One of these 4 patients received institutions. Topical antibiotics were typically not given af- a modified PI preparation, where a sterile cotton-tipped ter injections; however, 2 patients (Cases 2 and 3) who did applicator soaked in PI was applied directly over the con- not receive PI at the time of their injection received post- junctiva at the planned injection site immediately prior injection topical antibiotics, and 1 patient who did receive to injection, and ultimately went on to have another PI and went on to develop endophthalmitis (at MEEI) also episode of endophthalmitis. The 1 patient who did not received topical antibiotics. None of the patients with receive any post-endophthalmitis intravitreal injections endophthalmitis (with or without PI use at the time of did not have a reaction to PI use at the time of her tap injection) at DMEI received postinjection antibiotics. and inject. The patients’ individual case histories are There were 30 046 injections performed at MEEI during described below and summarized in Table 1. Table 2 the study period and 6 of these resulted in endophthalmitis, provides a summary of their injection histories. giving a 0.020% rate of postinjection endophthalmitis. There was a 0.018% rate of postinjection endophthalmitis INDIVIDUAL CASE HISTORIES: Case 1. An 86-year-old for patients injected at DMEI (33 699 injections, 6 infec- woman with a history of neovascular age-related macular tions). The combined rate of endophthalmitis was 0.019% degeneration (AMD) of the right eye, treated previously at both institutions. There were 21 postinjection endoph- with a total of 12 intravitreal aflibercept injections, thalmitis cases from outside doctors who referred the presented 5 days following the last injection with patients to MEEI and 9 cases referred to DMEI; however, worsening eye pain and nausea. She was found to have because the total number of injections in the patient catch- hand motion (HM) visual acuity (decreased from 20/32 ment area is unknown, the regional rate of endophthalmitis at last visit), a 1.5 mm hypopyon, and diffuse mobile outside these institutions
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