The Impact of Prefi I led Syringes on
`Endophthalmitis Fol lowing lntravitreal Injection
`of Ranibizumab
`
`PHILIPP. STOREY, ZUJAJA TAUQEER, YOSHI HI RO YONEKAWA, BOZHO TODORICH, JEREMY D. WOLFE,
`SUMIT P. SHAH, ANKOOR R. SHAH, TAKASHI KOTO, ASH KAN M. ABBEY, YUKI MORIZANE, PRIYA SHARMA,
`EDWARD H. WOOD, MIO MORIZANE-HOSOKAWA, POOJA PENDRI, MAITRI PANCHOLY, SHAWN HARKEY,
`KAREN W. JENG-MILLER, ANTHONY OBEID, DURGA S. BORKAR, ERIC CHEN, PATRICK WILLIAMS,
`ANNABELLE A. OKADA, MAKOTO INOUE, FUMIO SHIRAGA, AKITO HIRAKATA, CHIRAC P. SHAH,
`JONATHAN PRENNER, AND SUNIR GARG, FOR THE POST-INJECTION ENDOPHTHALMITIS (PIE) STUDY
`GROUP
`
`• PUR POSE: T o compare the rates of infectiou s endoph(cid:173)
`th alrnitis following intravitreal injection of ranibizurnab
`using prefilled syringes vs conventional preparation.
`• DESIGN: Multicenter retrospective cohort study.
`• METHODS: All eyes receiving intravitreal inj ection of
`0.5 mg ranibizurnab for retinal vascular diseases at 10
`retina practices across the U nited States (20 16 to
`201 7) and Japan ( 2009 to 20 1 7 ) were included. The total
`numbers of eyes and inj ections were determined from
`billing codes. Endophthalrnitis cases were determined
`from billing records and evaluated with chart review.
`Primary outcome was the rate of postinj ection acute
`endophthalrnitis. Secondary outcomes were visual acuity
`and microbial spectrum.
`• RESULT S: A total of 243 754 intravitreal 0.5 mg rani(cid:173)
`bizurnab injections (165 34 7 conventional and 78 4 07
`prefilled) were administered to 43 132 unique patients
`during the study period. In the con ventional ranibizu(cid:173)
`rnab group, a total of 43 cases of suspected endophthal(cid:173)
`rnitis occurred (0.026%; 1 in 384 5 injections) and 22
`cases of cultu re-positive endophthalrnitis occurred
`
`~
`~ Supplemental Material available at A JO.com.
`Accepted for publication Nov 30, 2018.
`From Mid Atlantic Retina, Wills Eye Hospital, Thomas Jefferson
`University, Philadelphia, Pennsylvania, USA (P.P.S., M.P., A.O.,
`D.S.B., S.G.); Massachusecrs Eye and Ear Infirmary, Harvard Medical
`(Z.T., Y.Y., K.W.J.M.);
`School, Boston, Massachusecrs, USA
`Pennsylvania Retina Specialists, K:, Camp Hill, Pennsylvania, USA
`( B.T.); Associated Retina Consultants, Oakland University William
`Beaumont School of Medicine, Royal Oak, Michigan, USA Q.D.W.,
`E.H.W.); Rutgers Roben Wood Johnson Medical School, NJ Retina,
`New Brunswick, New Jersey, USA (S.P.S., P.P., J.P.); Retina
`Consultants of Houston, Blanton Eye Institute, Houston, Texas, USA
`(A.R.S., S.H., E.C.); Kyorin Eye Center, Kyorin University School of
`Medicine, Tokyo, Japan (T.K., A.A.O., M.I., A.H.); Texas Retina
`Associates, Dallas, Texas, USA (A.M.A., P.W.); Department of
`Ophthalmology, Okayama University Medical School, Okayama, Japan
`(Y.M., M.M.H., F.S.); and Ophthalmic Consultants of Boston, Tufts
`University School of Medicine, Boston, Massachusetts, USA (P.S.,
`C.P.S.).
`Inquiries to Sunir Garg, Professor of Ophthalmology, Mid Atlantic
`Retina, The Retina Service ci Wills Eye Hospital, Thomas Jefferson
`University, 840 Walnut St, Suite 1020, Philadelphia, PA 19107, USA;
`e -mail: sgarg@midatlanticretina.com
`
`(0.0 13%; 1 in 7516 injections). In the prefilled ran ibi(cid:173)
`zurnab group, 12 cases of suspected endophthalrnitis
`occurred (0.0 15%; 1
`in 6534
`injections) and 2
`cases of culture-positive endophthalrnitis occurred
`(0.0026%; 1 in 3 9 204 inj ections). P refilled syringes
`were associated with a trend toward decreased risk of
`suspected endophth alrnitis (odds ratio 0.59; 95% confi(cid:173)
`dence interval 0.3 1-1.12; P
`.10) and a statistically
`significant decreased risk of culture-positive endophthal(cid:173)
`rnitis (odds ratio 0.19 ; 95% confidence interval 0.04 5-
`0.82 ; P
`.025). A verage logMA R vision loss at final
`follow-up was significantly worse for eyes that developed
`the conventional ranibizurnab
`endophthalrnitis from
`preparation compared to the prefilled syringe group
`(4.45 lines lost from baseline acuity vs 0.38 lines lost ;
`.0062). Oral-associated flora was found in 27.3%
`P
`(6/22) of conventional ranibizurnab culture-positive
`endophthalrnitis cases (3 cases of Streptococcus viridans,
`3 cases of En terococcus faecalis) compared to O cases in
`the prefilled ranibizurnab group.
`• CONCLUSION: In a large, rnulticenter, retrospective
`study the use of prefilled syringes during intravitreal
`injection of ranibizurnab was associated with a reduced
`rate of culture-positive endophthalrnitis, including from
`oral flora, as well as with improved visual acuity
`outcomes.
`(Arn J O phthalrnol 2019; 199:200-208. ©
`2018 Elsevier Inc. All rights reserved. )
`
`V ASCULAR ENDOTHELIAL GROWTH FACTOR INHIBI(cid:173)
`
`tors (anti-VEGF) remain the standard of care to
`treat several common retinal diseases, primarily
`neovascular age-related macular degeneration (AMO),
`retinal vein occlusion (RVO), and diabetic macular edema
`(DME). Since the advent of anti-VEGF therapy, intravi(cid:173)
`treal injection use has become one of the most commonly
`performed procedures in all of medicine. In 2000, fewer
`than 2000 injections were performed across the United
`States; in 2016, over 3.2 million injections were adminis(cid:173)
`tered. '
`
`200
`
`@ 2018 ELSEVIER INC. ALL RIGHTS RESERVED.
`
`0002-9394/$36.00
`https://doi.or!Y'l 0.1 016/j .ajo.2018.1 1.023
`
`Novartis Exhibit 2215.001
`Regeneron v. Novartis, IPR2021-00816
`
`

`

`While uncommon, acute bacterial endophthalmitis
`following intravitreal
`injection can be visually devas-
`tating.2 Reported incidence rates have ranged from as
`high as 1 case in approximately 500 injections to as low
`as 1 in 19 000 injections, with the majority of large studies
`reporting an incidence rate of approximately 1 in 2000
`injections.1,3–9 While certain measures such as topical
`povidone-iodine10,11 or aqueous chlorhexidine12 and
`reducing dispersion of oral flora by minimizing speaking
`or use of a face mask may reduce endophthalmitis inci-
`dence,13 other measures such as postinjection antibi-
`otics,6,14 operating room setting,15 and lid scrubbing16 do
`not seem to have an effect on the risk of postinjection
`endophthalmitis.
`Traditionally, anti-VEGF medication is packaged in a
`glass vial and in order to prepare the medicine for injection,
`multiple steps must be taken, including aspiration with a
`large bore needle. The transfer of medication often occurs
`in a clinic or procedure room. Endophthalmitis likely
`occurs when bacteria are introduced into the eye at the
`time of a procedure. It is possible that transferring medica-
`tion from a glass vial to a syringe could enable contamina-
`tion of the medication, thereby increasing the risk of
`endophthalmitis.
`Syringes prefilled with sterile medication eliminate the
`transfer process from storage vial to syringe, which reduces
`risk of contamination and may subsequently decrease the
`risk of infection. In June 2014, prefilled 0.5 mg ranibizumab
`syringes were commercially available in Japan. In October
`2016, the United States Food and Drug Administration
`approved 0.5 mg prefilled ranibizumab syringes. The pur-
`pose of this study is to evaluate the rate and outcomes of
`endophthalmitis
`following prefilled vs
`conventional
`0.5 mg ranibizumab intravitreal injection.
`
`PATIENTS AND METHODS
` OVERVIEW: This multicenter retrospective comparative
`cohort study was prospectively approved by the Wills Eye
`Hospital Institutional Review Board as well as institutional
`review boards at each of the 10 participating centers. The
`study adhered to the tenets of the Declaration of Helsinki.
`Billing records were used to retrospectively identify all
`cases of endophthalmitis secondary to intravitreal injec-
`tion of 0.5 mg ranibizumab (Genentech, South San Fran-
`cisco, California, USA) in both conventional vials and
`prefilled syringes. Billing data were used to determine the
`total number of intravitreal injections, eyes, and patients;
`whether a conventional or prefilled injection was adminis-
`tered; sex; age; and indication for treatment. Charts of all
`patients who were treated for endophthalmitis were
`reviewed, and the diagnosis was confirmed. Recorded
`data included date of causative injection; date of tap and
`injection and/or vitrectomy; visual acuity before causative
`
`injection, at time of tap and inject and/or vitrectomy, at 3
`and 6 months postprocedure, and at final follow-up; and
`microbial culture results.
` INCLUSION AND EXCLUSION CRITERIA: All eyes with
`presumed infectious endophthalmitis at each study site
`following intravitreal
`injection of
`ranibizumab were
`included. Suspected endophthalmitis was defined as any
`case in which clinical suspicion was high enough to warrant
`a tap and antimicrobial injection or pars plana vitrectomy.
`Culture-positive endophthalmitis was defined as any pa-
`tient with bacterial growth on culture or a positive Gram
`stain from a vitreous or anterior chamber tap. Patients
`with presumed inflammatory endophthalmitis
`treated
`with topical steroids without tap and inject were excluded.
`Dates of inclusion were January 1, 2016 to December 31,
`2017 for United States sites. As prefilled syringes were
`available earlier in Japan, dates of inclusion for Japanese
`sites were June 1, 2009 to December 31, 2017. We include
`dates prior to the availability of prefilled syringes within
`both countries during which only conventional prepara-
`tion was available. Our study includes both conventional
`and prefilled syringes after the date on which prefilled
`syringes were approved in both countries.
` INJECTION TECHNIQUE: Across all 10 clinical sites, all
`injections were performed in office-based settings, either
`in a designated procedure room or in a clinical room where
`the examination was conducted. Eyes were prepped with a
`topical anesthetic and topical povidone-iodine per the
`routine of the injecting physician. Injection with a 30,
`31, 32, or 33 gauge needle was performed 3.5 to 4.0 mm
`from the limbus. Physicians individually determined use
`of subconjunctival lidocaine, use of a bladed lid speculum,
`conjunctival displacement prior to injection, and superior
`vs inferior injection site. Injection techniques were not
`altered during the study period.
` ENDOPHTHALMITIS TREATMENT PROTOCOL: All eyes
`developing presumed infectious endophthalmitis immedi-
`ately underwent a pars plana vitreous tap with aspiration
`and subsequent injection of intravitreal antibiotics and/or
`pars plana vitrectomy with vitreous culture and intravitreal
`antibiotics. If the physician was unable to obtain vitreous
`fluid, an aqueous tap was performed. Patients typically
`received intravitreal vancomycin (1 mg/0.1 mL) and
`ceftazidime
`(2 mg/0.1 mL).
`Intravitreal
`amikacin
`(400 mg/0.1 mL) was substituted for ceftazidime for patients
`with penicillin allergy at some sites. Patients were variably
`prescribed cycloplegic agents,
`topical antibiotics, and
`topical steroid drops.
` OUTCOMES: The primary outcome was
`the rate of
`endophthalmitis following intravitreal injection of ranibi-
`zumab. The secondary outcomes were visual acuity and mi-
`crobial spectrum of culture-positive cases. Endophthalmitis
`
`VOL. 199
`
`THE IMPACT OF PREFILLED SYRINGES ON POSTINJECTION ENDOPHTHALMITIS
`
`201
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`
`

`

`TABLE 1. Rates of Suspected and Culture-Positive Endophthalmitis for Prefilled Syringes vs Conventional Preparation of Ranibizumab
`
`Prefilled Syringes
`
`Conventional Preparation
`
`Odds Ratio
`
`Injections
`
`Cases (Incidence)
`
`Injections
`
`Cases (Incidence)
`
`(95% Confidence Interval)
`
`P Value
`
`Suspected endophthalmitis
`
`78 407
`
`Culture positive endophthalmitis
`
`12 (0.015%)
`1 in 6534 injections
`2 (0.0026%)
`1 in 39 204 injections
`
`165 347
`
`43 (0.026%)
`1 in 3845 injections
`22 (0.013%)
`1 in 7516 injections
`
`0.59 (0.31 1.12)
`
`.10
`
`0.19 (0.045 0.82)
`
`.025
`
`was considered culture-positive if there was a positive
`Gram stain and/or positive growth on culture plates as
`reported by the institutional microbiology laboratory.
`Snellen visual acuity was converted to logMAR equivalent.
`studies,17,18 vision levels of
`As established by prior
`counting fingers, hand motion, light perception, and no
`light perception were assigned visual acuity values of
`1.0/200, 0.5/200, 0.25/200, and 0.125/200 (logMAR
`equivalent 2.3, 2.6, 2.9, 3.2,
`respectively). Clinical
`variables were
`analyzed
`using
`Excel
`(Microsoft,
`Redmond, Washington, USA) and statistical analysis was
`performed using Stata Version 14 (StataCorp, College
`Station, Texas, USA).
`
`RESULTS
` RATE OF ENDOPHTHALMITIS: During our study period, a
`total of 243 754 intravitreal injections of ranibizumab were
`administered to 43132 unique patients across all 10 institu-
`tions. Average patient age was 80.3 years and 61.5% of
`patients were female. Treatment indication was neovascu-
`lar AMD for 82.1% of injections, branch retinal vein occlu-
`sion (BRVO) 7.9%, central retinal vein occlusion (CRVO)
`5.3%, DME 0.5%, and other pathologies 4.2%, including
`myopic choroidal neovascularization. Overall, a total of
`55 patients were treated for suspected endophthalmitis
`(0.023%, 1 in 4432 injections) and 24 cases were culture-
`positive (0.0098%, 1 in 10 156 injections).
`In the conventional ranibizumab group, a total of 165 347
`injections were administered. A total of 43 cases of
`suspected endophthalmitis occurred (0.026%; 1 in 3845
`injections), of which 22 cases were culture-positive endoph-
`thalmitis (0.013%; 1 in 7516 injections) (Table 1). Thirty-
`three eyes received ranibizumab injection for neovascular
`AMD, 5 received injection for BRVO, 4 for CRVO, and 1
`for DME. Causative organisms
`included 11 cases of
`coagulase-negative Staphylococcus, 3 cases of Streptococcus
`viridans, 3 cases of Enterococcus faecalis, 1 case of Staphylo-
`coccus aureus, 1 case of Stenotrophomonas maltophilia (a
`gram-negative rod), and 3 cases of gram-positive cocci on
`Gram stain with no growth on cultures (Table 2).
`In the prefilled ranibizumab group, 78 407 injections
`were administered and 12 cases of suspected endophthalmi-
`
`tis occurred (0.015%; 1 in 6534 injections), of which 2
`cases were culture-positive (0.0026%; 1 in 39 204 injec-
`tions) (Table 1). Eight eyes received ranibizumab injection
`for neovascular AMD, 3 received injection for BRVO, and
`1 for CRVO. Causative organisms included 1 case of
`coagulase-negative Staphylococcus and 1 case of Staphylo-
`coccus aureus (Table 3).
`Compared to the conventional vial, use of prefilled
`syringes was associated with a trend toward decreased risk
`of suspected endophthalmitis (odds ratio 0.59; 95% confi-
`dence interval 0.31-1.12; P ¼ .10) and a statistically signif-
`icant decreased risk of culture-positive endophthalmitis
`(odds ratio 0.19; 95% confidence interval 0.045-0.82;
`P ¼ .025) (Table 1). Oral-associated flora was found in 6
`of the 22 (27.3%) cases of conventional ranibizumab
`culture-positive endophthalmitis (3 cases of Streptococcus
`viridans, 3 cases of Enterococcus faecalis) compared to 0 of
`the 2 culture-positive cases in the prefilled ranibizumab
`group (P ¼ 1.0).
`Overall, patients with presumed endophthalmitis
`presented an average of 6.0 days after injection (range
`0-61 days). No patients had any intraocular surgeries or pro-
`cedures between administration of the intravitreal injection
`and presentation with presumed endophthalmitis. The vast
`majority of cases presented within 7 days of intravitreal
`injection (85.5%). Eight patients (6 in the conventional
`group, 2 in the prefilled group) presented more than 7 days
`after injection. Of these 8 patients with delayed presenta-
`tion, 6 patients presented within 3 weeks of injection. One
`patient in the prefilled group presented 24 days after injec-
`tion; however, this patient reported severe pain and vision
`loss beginning approximately 1 week after injection. One
`patient in the conventional group presented 61 days after
`injection; this patient reported pain and decreased vision
`for several weeks prior to returning to the clinic for further
`evaluation. Patients receiving conventional ranibizumab
`injection presented an average of 5.9 days after injection
`compared to an average of 6.8 days for patients receiving
`prefilled syringes (P ¼ .70). Regardless of method of drug
`preparation, culture-positive cases presented an average of
`7.3 days after injection (range 1-61 days) compared to
`5.1 days (range 0-24 days) for culture-negative cases
`(P ¼ .42). Fewer of the prefilled ranibizumab cases were
`culture-positive (16.7%; 2/12) compared to the conven-
`tional ranibizumab group (51.1%; 22/43) (P ¼ .049).
`
`202
`
`AMERICAN JOURNAL OF OPHTHALMOLOGY
`
`MARCH 2019
`
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`
`

`

`TABLE 2. Visual Acuity Outcomes Following Endophthalmitis From Conventional Preparation of Ranibizumab
`
`Patient
`
`VA at Injection
`
`VA at 3 Months
`Post Endophthalmitis
`
`VA at 6 Months
`Post Endophthalmitis
`
`VA at Final Follow-up
`
`Culture Results
`
`Streptococcus viridans
`Streptococcus viridans
`Streptococcus viridans
`Enterococcus faecalis
`Enterococcus faecalis
`Enterococcus faecalis
`Staphylococcus epidermidis
`Staphylococcus epidermidis
`Staphylococcus epidermidis
`Staphylococcus epidermidis
`Staphylococcus capitis
`Staphylococcus aureus
`Coag Staphylococcus
`Coag Staphylococcus
`Coag Staphylococcus
`Coag Staphylococcus
`Coag Staphylococcus
`Coag Staphylococcus
`Stentrophomonas maltophilia
`
`1
`20/25
`CF
`CF
`CF
`2
`20/400
`CF
`CF
`CF
`3
`20/400
`CF
`CF
`20/400
`4
`20/50
`CF
`HM
`HM
`5
`20/200
`20/400
`20/200
`20/200
`6
`20/30
`HM
`LP
`LP
`7
`20/25
`20/30
`20/20
`20/20
`8
`20/40
`20/60
`20/40
`20/60
`9
`20/70
`20/200
`20/80
`20/60
`10
`20/20
`20/30
`20/25
`20/100
`11
`20/40
`20/70
`20/50
`20/50
`12
`20/50
`LP
`LP
`LP
`13
`20/30
`20/200
`20/60
`20/40
`14
`20/60
`20/80
`20/60
`20/80
`15
`20/50
`20/50
`20/30
`20/40
`16
`20/50
`CF
`20/400
`20/200
`17
`20/30
`CF
`20/200
`20/200
`18
`20/80
`20/100
`20/60
`20/60
`19
`CF
`n/a
`n/a
`NLP
`20
`20/30
`20/50
`20/40
`20/25
`Gram positive cocci (Stain)
`21
`20/60
`CF
`CF
`CF
`Gram positive cocci (Stain)
`22
`20/70
`n/a
`n/a
`CF
`Gram positive cocci (Stain)
`23
`20/200
`20/200
`20/200
`20/200
`Negative
`24
`20/70
`20/400
`20/400
`20/400
`Negative
`25
`20/40
`20/30
`20/30
`20/30
`Negative
`26
`4/200
`n/a
`n/a
`CF
`Negative
`27
`20/40
`20/30
`20/30
`20/30
`Negative
`28
`20/80
`20/50
`20/40
`20/40
`Negative
`29
`20/40
`20/100
`20/60
`20/200
`Negative
`30
`20/80
`20/60
`20/200
`20/200
`Negative
`31
`1/200
`5/200
`3/200
`3/200
`Negative
`32
`20/60
`20/200
`n/a
`20/200
`Negative
`33
`20/30
`20/50
`20/60
`20/40
`Negative
`34
`20/200
`20/60
`20/60
`20/40
`Negative
`35
`CF
`CF
`CF
`CF
`Negative
`36
`20/40
`20/200
`20/200
`20/60
`Negative
`37
`20/25
`20/25
`20/25
`20/25
`Negative
`38
`20/25
`NLP
`NLP
`NLP
`Negative
`39
`20/25
`20/80
`20/30
`20/30
`Negative
`40
`20/50
`20/25
`20/30
`20/25
`Negative
`41
`20/30
`20/30
`20/50
`20/40
`Negative
`42
`HM
`HM
`HM
`CF
`Negative
`43
`20/30
`20/40
`20/30
`20/25
`Negative
`CF ¼ count fingers; Coag ¼ coagulase negative; HM ¼ hand motion; LP ¼ light perception; n/a ¼ not available; NLP ¼ no light perception;
`VA ¼ visual acuity.
`
`Overall, affected eyes received an average of 19 injections
`(range 1-106 injections) prior to developing suspected
`endophthalmitis. Patients treated with conventional ranibi-
`zumab injection received an average of 18 injections prior to
`developing suspected endophthalmitis vs an average of 24 in-
`jections for patients receiving prefilled syringes (P ¼ .50).
`Regardless of method of drug preparation, culture-positive
`
`cases received an average of 19 injections compared to 20
`injections for culture-negative cases (P ¼ .98).
` VISUAL OUTCOMES: Mean follow-up for all suspected
`endophthalmitis cases was 11.3 months (range 1 day to
`43.4 months). Average follow-up for patients with endoph-
`thalmitis
`receiving
`conventional
`preparation was
`
`VOL. 199
`
`THE IMPACT OF PREFILLED SYRINGES ON POSTINJECTION ENDOPHTHALMITIS
`
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`
`

`

`TABLE 3. Visual Acuity Outcomes Following Endophthalmitis From Prefilled Syringes of Ranibizumab
`
`Patient
`
`VA at Injection
`
`VA at 3 Months
`Post Endophthalmitis
`
`VA at 6 Months
`Post Endophthalmitis
`
`VA at Final Follow-up
`
`Culture Results
`
`1
`20/25
`20/30
`2
`20/50
`n/a
`3
`20/70
`n/a
`4
`20/200
`20/400
`5
`20/20
`20/20
`6
`20/100
`20/200
`7
`20/30
`20/40
`8
`20/30
`20/40
`9
`20/25
`20/25
`10
`20/200
`20/40
`11
`20/25
`20/30
`12
`20/40
`20/40
`n/a ¼ not available; VA ¼ visual acuity.
`
`n/a
`n/a
`n/a
`20/400
`20/20
`20/200
`20/40
`20/30
`20/30
`20/40
`20/30
`20/60
`
`20/30
`20/50
`20/50
`20/400
`20/20
`20/200
`20/40
`20/30
`20/30
`20/40
`20/30
`20/60
`
`Staphylococcus epidermidis
`Staphylococcus aureus
`
`Negative
`Negative
`Negative
`Negative
`Negative
`Negative
`Negative
`Negative
`Negative
`Negative
`
`TABLE 4. Visual Acuity Outcomes at Final Follow-up for
`Endophthalmitis Following Prefilled Syringes vs
`Conventional Preparation of Ranibizumab
`
`Prefilled
`Syringes
`
`(N 12)
`
`0.38
`
`Conventional
`Preparation
`
`(N 43)
`
`4.45
`
`P Value
`
`.0062
`
`0.42 (20/50)
`
`1.13 (20/250)
`
`.00039
`
`0%
`
`27.9%
`
`.050
`
`Average lines of
`Snellen visual
`acuity lost from
`baseline
`Average visual
`acuity logMAR
`(approximate
`Snellen
`equivalent)
`Visual acuity of
`count fingers or
`worse
`
`12.8 months and 6.1 months
`for prefilled syringes
`(P ¼ .0017). Overall average baseline visual acuity was
`logMAR 0.58 (approximately 20/80) with no statistically
`significant difference between conventional
`syringes
`(logMAR 0.63; approximately 20/80) and prefilled syringes
`(logMAR 0.39; approximately 20/50) (P ¼ .091). By
`6 months post endophthalmitis a minority of eyes
`(35.4%) lost 3 or more lines of visual acuity compared to
`baseline vision.
`Visual acuity outcomes of endophthalmitis cases were
`generally better for patients receiving prefilled ranibizumab
`compared to patients receiving conventional ranibizumab.
`Average vision loss at final follow-up was significantly worse
`for eyes that developed endophthalmitis from the conven-
`
`tional preparation compared to the prefilled syringe group
`(4.45 lines lost from baseline acuity vs 0.38 lines lost;
`P ¼ .0062) (Table 4). While average baseline vision was
`not significantly different between the groups, at 6 months
`post endophthalmitis treatment average visual acuity for
`the prefilled group returned nearly to baseline, with
`logMAR 0.44 (approximately 20/50) compared to logMAR
`1.07 (approximately 20/250) for the conventional ranibizu-
`mab group (P ¼ .0060). At final follow-up, average visual
`acuity for the prefilled group was logMAR 0.42 (approxi-
`mately 20/50) compared to logMAR 1.13 (approximately
`20/250)
`for
`the
`conventional
`ranibizumab
`group
`(P ¼ .00039). Overall, 12 patients (21.8%) who developed
`endophthalmitis had visual acuity of count fingers or worse
`at final follow-up
`all of whom received an injection of
`conventional
`ranibizumab. Patients who developed
`endophthalmitis after receiving the conventional prepara-
`tion of ranibizumab were more likely to have vision of count
`fingers or worse at final follow-up (27.9%) compared to
`patients receiving prefilled ranibizumab (0%) (P ¼ .050).
`Visual outcomes were generally worse for culture-
`positive endophthalmitis cases compared to culture-
`negative cases
`regardless of
`ranibizumab preparation.
`Average vision loss at final follow-up was significantly
`worse for eyes with culture-positive endophthalmitis
`compared to culture-negative endophthalmitis (6.47 lines
`lost from baseline acuity vs 1.32 lines lost; P ¼ .015)
`(Table 5). Average visual acuity 6 months post endoph-
`thalmitis was 1.22 logMAR (approximate Snellen equiva-
`lent 20/320) for culture-positive cases compared to 0.77
`logMAR (approximate Snellen equivalent 20/125) for
`culture-negative cases (P ¼ .12). At final
`follow-up,
`average visual acuity for culture-positive cases was
`logMAR 1.23 (approximately 20/320) vs logMAR 0.78
`(approximately
`20/125)
`for
`culture-negative
`cases
`
`204
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`
`MARCH 2019
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`Novartis Exhibit 2215.005
`Regeneron v. Novartis, IPR2021-00816
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`

`TABLE 5. Visual Acuity Outcomes at Final Follow-up for Culture-Positive and Oral-Associated Culture-Positive vs Culture-Negative
`Endophthalmitis Cases Regardless of Ranibizumab Preparation
`
`Average lines of Snellen visual acuity lost
`from baseline
`Average visual acuity logMAR (approximate
`Snellen equivalent)
`Visual acuity of count fingers or worse
`
`Average lines of Snellen visual acuity lost
`from baseline
`Average visual acuity logMAR (approximate
`Snellen equivalent)
`Visual acuity of count fingers or worse
`
`Culture-Positive
`Endophthalmitis (N 24)
`
`Culture-Negative
`Endophthalmitis (N 31)
`
`6.47
`
`1.32
`
`1.23 (20/320)
`
`0.78 (20/125)
`
`33.3%
`
`12.9%
`
`Oral-Associated Culture-Positive
`Endophthalmitis (N 6)
`
`Culture-Negative
`Endophthalmitis (N 31)
`
`11.73
`
`1.32
`
`2.06 (<20/2000)
`
`0.78 (20/125)
`
`66.7%
`
`12.9%
`
`P Value
`
`.015
`
`.089
`
`.10
`
`P Value
`
`.068
`
`.0060
`
`.013
`
`(P ¼ .089). For culture-positive cases, 33.3% of cases had
`visual acuity of count fingers or worse at final follow-up
`compared
`to
`12.9% of
`culture-negative
`patients
`(P ¼ .10). While the number of culture-positive cases in
`the prefilled group was too small for statistical comparison,
`we compared results of culture-negative cases between pre-
`filled and conventional preparation. For culture-negative
`cases, average vision loss at final follow-up compared to
`baseline acuity was no different between conventional in-
`jections and prefilled syringes (1.8 lines lost vs 0.4 lines
`lost; P ¼ .26).
`Visual acuity outcomes for culture-positive endophthal-
`mitis cases associated with oral flora were poor. Overall, 6
`cases of culture-positive endophthalmitis were caused by
`oral flora (3 cases of Streptococcus viridans, 3 cases of Entero-
`coccus faecalis), all of which occurred in the conventional
`ranibizumab group. Average vision loss at final follow-up
`was 11.73 lines from baseline for oral flora associated
`endophthalmitis compared to 1.89 lines for non oral
`flora associated culture-positive endophthalmitis (P ¼
`.19). Average visual acuity 6 months post infection for
`the oral flora associated endophthalmitis cases was 2.23
`logMAR (Snellen equivalent <20/2000) compared to
`0.78 logMAR for non oral flora associated culture-
`positive cases (approximately 20/125; P ¼ .0012). At final
`follow-up, average visual acuity for the oral flora associated
`endophthalmitis cases was 2.06 logMAR (Snellen equiva-
`lent <20/2000) compared to 0.96 logMAR for non oral
`flora associated culture-positive cases (approximately 20/
`160; P ¼ .014) (Table 5). For oral flora associated endoph-
`thalmitis cases, visual acuity of count fingers or worse was
`present in 5 of 6 eyes at 6 months and 4 of 6 eyes at final
`follow-up.
`Initial treatment was intravitreal tap and injection of an-
`tibiotics in 50 cases and primary pars plana vitrectomy with
`injection of antibiotics in 5 cases (4 in the conventional
`group, 1 in the prefilled group). Pars plana vitrectomy
`
`was performed as a secondary procedure in 6 cases (5 in
`the conventional group, 1 in the prefilled group). No differ-
`ence in final average visual outcomes was found between
`endophthalmitis cases receiving initial procedure of tap
`and injection (logMAR 0.93; approximate Snellen
`20/160) vs primary pars plana vitrectomy (logMAR 1.44;
`approximate Snellen 20/500; P ¼ .41).
`
`DISCUSSION
`
`ENDOPHTHALMITIS FOLLOWING INTRAVITREAL INJECTION
`remains an uncommon event. Any prophylaxis measure
`that might lower the risk of infection requires assessment
`of a large number of injections in order to achieve adequate
`power to detect a significantly decreased risk. In our study
`of 10 institutions across the United States and Japan, we
`assessed endophthalmitis rates after nearly 250 000 intravi-
`treal ranibizumab injections with detailed confirmation of
`the diagnosis and clinical course. Although the difference
`in suspected endophthalmitis rates was not statistically
`significant, there was a trend toward a lower rate in the
`prefilled syringe group. Prefilled syringes of ranibizumab
`were associated with lower
`rates of culture-positive
`endophthalmitis and with improved visual outcomes,
`driven in part by fewer cases of endophthalmitis caused
`by oral flora, which had worse outcomes.
`Currently, few studies have investigated the impact of
`prefilled syringes on endophthalmitis risk. A recent nation-
`wide study in France of acute endophthalmitis with intra-
`vitreal injections of corticosteroids or anti-VEGF agents
`reported a lower risk of endophthalmitis with prefilled
`injections.19 In this study, prefilled syringes of ranibizumab
`decreased the rate of endophthalmitis by 40% compared to
`room preparation of nonprefilled ranibizumab and by 46%
`for aflibercept, only available as a nonprefilled medication.
`
`VOL. 199
`
`THE IMPACT OF PREFILLED SYRINGES ON POSTINJECTION ENDOPHTHALMITIS
`
`205
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`
`

`

`One prior study evaluated the effect of prefilled syringes on
`endophthalmitis risk with intravitreal injection of bevaci-
`zumab. Endophthalmitis rates were reduced from 1 in 425
`injections with bevacizumab drawn multiple times from
`the same vial to 1 in 2000 injections with prefilled syringes
`of bevacizumab made by a compounding pharmacy
`(P < .003).20 Important differences exist between this
`study and our own. A single manufacturer makes ranibizu-
`mab, whereas bevacizumab must be compounded by a phar-
`macy. Prefilled syringes of bevacizumab indicate that a
`compounding pharmacy not
`the manufacturer has
`filled the syringes with the medication prior to arrival in
`the clinic. Additionally, in our study, we compare prefilled
`ranibizumab syringes to ranibizumab drawn in a clinic from
`an individually assigned vial injected into a single patient.
`In the aforementioned study, prefilled syringes of bevacizu-
`mab were compared to bevacizumab repeatedly drawn in a
`clinic from a large vial that was injected into multiple
`patients.
`Several studies have reported that oral-associated flora
`are more common with endophthalmitis occurring after
`intravitreal injection than after other vitreoretinal proced-
`ures.2,21–24 For the 22 culture-positive cases of endophthal-
`mitis in the conventional group, 6 cases grew Streptococcus
`or Enterococcus species (27.3%), which could be secondary
`to oral droplet transmission. One difference between intra-
`vitreal injections and other ocular procedures is that injec-
`tions are often performed in an office-based setting, often
`with variable to no masking of the physician, patient, or
`technician. In contrast, all persons in the operating room
`are masked and, in the case of the patient, draped. Some
`studies have suggested rates of endophthalmitis may be
`lower when performed in an operating room setting.24
`One suggested strategy to reduce droplet transmission is
`cessation of talking during the injection, which has shown
`modest evidence of lowering endophthalmitis risk.13
`Several possibilities could contribute to a decreased rate
`of endophthalmitis with prefilled syringes. By eliminating
`several steps required to transfer medication from vial to sy-
`ringe with conventional preparation of anti-VEGF medica-
`tions, there may be a lower risk of introducing bacteria
`during this process. Given that the drug transfer with con-
`ventional preparation typically is performed in a nonsterile
`environment, the possibility of contaminating the medica-
`tion exists. If an individual touches the top of the vial or the
`transfer needle, skin flora may be introduced. Additionally,
`oropharyngeal droplets may be inadvertently introduced
`onto the uncapped vial or transfer needle. While our results
`trended toward lower rates of suspected endophthalmitis
`for prefilled syringes, we did find a statistically significant
`decreased risk of culture-positive endophthalmitis with
`prefilled syringes. Interestingly, in our study approximately
`one quarter of culture-positive endophthalmitis cases were
`caused by oral-associated flora in the conventional prepara-
`tion group compared to no cases within the prefilled group,
`which lends support to the hypothesis that fewer steps to
`
`prepare the drug for injection limits exposure to aerosolized
`droplets containing oral bacteria.
`Visual acuity outcomes following endophthalmitis were
`better in eyes receiving prefilled ranibizumab syringes
`compared to conventional preparation. Average loss of
`vision from baseline acuity was less than half of one line
`for the prefilled group and 4.5 lines for the conventional
`preparation. While baseline visual acuities were not signif-
`icantly different between the groups, average postendoph-
`thalmitis visual acuity at final follow-up was substantially
`better for prefilled injections compared to the conventional
`group, with approximate Snellen acuities of 20/50 vs
`20/250. The difference in visual outcomes between the
`groups appears to be primarily driven by culture-positive
`and oral flora associated endophthalmitis cases, both of
`which were more frequent in the conventional preparation
`group. Visual outcomes of culture-negative cases were no
`different between conventional preparation and prefilled
`syringes.
`Regardless of medication preparation, visual outco