Graefes Arch Clin Exp Ophthalmol (2013) 251:1885 1890
`DOI 10.1007/s00417 013 2274 y
`
`RETINAL DISORDERS
`
`Minimizing the endophthalmitis rate following intravitreal
`injections using 0.25 % povidone–iodine irrigation and surgical
`mask
`
`Hiroyuki Shimada & Takayuki Hattori & Ryusaburo Mori &
`Hiroyuki Nakashizuka & Kyoko Fujita & Mitsuko Yuzawa
`
`Received: 11 October 2012 / Revised: 15 January 2013 / Accepted: 22 January 2013 / Published online: 7 February 2013
`# Springer Verlag Berlin Heidelberg 2013
`
`Abstract
`Background To examine the efficacy of complying with an
`infection control manual for intravitreal injection of anti-
`vascular endothelial growth factor (VEGF) preparations in
`reducing the rate of endophthalmitis.
`Methods We retrospectively reviewed intravitreal anti-
`VEGF injections conducted by vitreoretinal specialists at
`the outpatient injection room of a single university hospital
`between July 2009 and July 2012. The injections were
`conducted following an infection control manual established
`by our department. Doctors and nurses wore surgical masks,
`and disinfected the patient’s eyelid skin with 10 % povi-
`done–iodine and then the conjunctiva with 0.25 % povi-
`done–iodine. After putting a drape on the patient’s face, a lid
`speculum was placed. The conjunctival surface was again
`washed with 5 ml of 0.25 % povidone–iodine. After waiting
`at least 30 seconds, intravitreal injection was performed
`through povidone–iodine. Following injection, the injection
`site was again washed with 5 ml of 0.25 % povidone–
`iodine. Patients were treated with topical levofloxacin 4
`times a day for 3 days before and after the injection.
`Results A total of 15,144 injections comprising 548 injections
`of pegaptanib sodium, 846 injections of bevacizumab, and
`13,750 injections of ranibizumab were performed. During this
`period, no case of suspected or proven infectious endophthal-
`mitis occurred. The endophthalmitis rate was 0 per 15,144
`injections, (95 % confidence interval, 0.0–0.0 %).
`Conclusion The results suggest that endophthalmitis can be
`reduced to a minimum by preventing normal flora of the
`
`H. Shimada (*) : T. Hattori : R. Mori : H. Nakashizuka :
`K. Fujita : M. Yuzawa
`Department of Ophthalmology, School of Medicine, Surugadai
`Hospital of Nihon University, 1 8 13 Surugadai, Kanda,
`Chiyodaku, Tokyo 101 8309, Japan
`e mail: sshimada@olive.ocn.ne.jp
`
`conjunctiva and bacteria in the oral cavity from entering the
`vitreous. For this purpose, an infection control manual that
`requires nurses and doctors to wear surgical mask and drape
`the patient’s face, irrigate the conjunctiva with 0.25 % povi-
`done–iodine and wait at least 30 seconds before performing
`intravitreal injection is useful.
`
`Keywords Bevacizumab . Conjunctival flora .
`Endophthalmitis . Eye drape . Eyelid speculum . Face mask .
`Intravitreal injection . Oral flora . Pegaptanib . Povidone–
`iodine . Ranibizumab . Vascular endothelial growth factor
`
`Introduction
`
`Topical antibiotics and povidone–iodine are widely used for
`reducing the ocular surface bacterial load during intravitreal
`injections. However, Moss et al. [1] showed that although
`topical gatifloxacin use is effective in reducing the frequen-
`cy of conjunctival bacterial growth, antibiotic use confers no
`additional benefit in combination with povidone–iodine
`than eyes receiving povidone–iodine alone. Therefore povi-
`done–iodine is a more effective agent than antibiotics for
`infection prophylaxis in intravitreal injections. In a prospec-
`tive multicenter study reported by Stewart et al. [2] in 2011,
`culture of the needles that had been used to perform intra-
`vitreal injection after povidone–iodine disinfection yielded
`bacteria from 18 % of the needles. This result suggests that
`disinfection with povidone–iodine by conventional methods
`cannot effectively kill the bacterial flora that inhabit the
`complicated structures of the conjunctiva.
`To obtain transient sterilization of the conjunctiva, it is
`essential to use a volume of povidone–iodine that infiltrates
`the complicated structure [3], wait for the bactericidal effect
`to take place [4], and inject through the povidone–iodine used
`
`~ Springer
`
`Novartis Exhibit 2315.001
`Regeneron v. Novartis, IPR2021-00816
`
`

`

`1886
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`Graefes Arch Clin Exp Ophthalmol (2013) 251:1885 1890
`
`in washing. Since a 22-gauge needle is used for intravitreal
`injection [5], the povidone–iodine that enters the vitreous via
`the needle has important clinical implications with respect to
`ocular toxicity. Therefore, repeated washing with a concentra-
`tion of povidone–iodine that is safe for ocular tissues is
`essential [6, 7]. We reported that in 25-gauge vitrectomy,
`irrigating the surgical field with 0.25 % povidone–iodine after
`placing the lid speculum and waiting for at least 30 seconds
`before creating three sclerotomies with trocars reduced bacte-
`rial contamination of the vitreous to 0 % (0/103 eyes) [7].
`In operating rooms, doctors and nurses wear surgical
`masks; therefore, deposition of oral flora onto the operative
`field is probably adequately prevented.
`Face masks are not generally used in preparation and
`administration of intravitreal injections [8]. Hence, deposi-
`tion of oral bacterial flora on the injection site or the needle
`tip may be a potential cause of endophthalmitis. A meta-
`analysis of endophthalmitis following intravitreal injection
`of anti-VEGF agents reported by McCannel [9] in 2011
`shows that Streptococcus species are isolated approximately
`three times more frequently after intravitreal anti-VEGF
`injection than after intraocular surgery. It is speculated that
`the Streptococcus species originate from the respiratory
`tract. An experimental study has proven that use of a surgi-
`cal mask or silence effectively decreases the oral flora
`contamination of intravitreal injections, and that application
`of 5 % povidone–iodine prevents bacterial growth even
`when bacteria have deposited on the injection site [10].
`With this background, we prepared an infection control
`manual for anti-VEGF intravitreal injection, which requires
`nurses and doctors to wear surgical masks, drape the
`patient’s face as a substitute for a mask, irrigate the con-
`junctiva with 5 ml of 0.25 % povidone–iodine, and wait at
`least 30 seconds before performing intravitreal injection. We
`report here that by complying with the infection control
`manual, we have achieved an extremely low endophthalmi-
`tis rate of 0/15,144 intravitreal injections performed by
`vitreoretinal specialists in an outpatient office setting.
`
`Methods
`
`Between July 2009 and July 2012, vitreoretinal specialists at
`Surugadai Hospital of Nihon University performed intravitreal
`injections of anti-VEGF agents in accordance with an infection
`control manual compiled at the hospital. Intravitreal injections
`were conducted in an outpatient injection room, which is
`separated from the outpatient clinic and equipped with two
`microscopes and a bed. Physicians and nurses working in the
`injection room wore white coats and sterile caps and surgical
`masks. The caps and masks were changed twice a day (morn-
`ing and afternoon). Preoperative antisepsis was conducted by
`ocular instillation of topical antibiotics (levofloxacin) 4 times a
`
`~ Springer
`
`day for 3 days before intravitreal injection. Single-use topical
`antibiotic was used in each injection.
`The patient, wearing his/her own clothes, was instructed to
`lie on the bed without taking off the shoes. The patient wore a
`sterile cap but not a mask. A nurse was always present to
`provide assistance. During injection, the physician and the
`nurse refrained from talking, coughing, and sneezing. The
`physician disinfected the eyelid skin with 10 % povidone–
`iodine (Meiji Seika, Tokyo, Japan) and the conjunctiva with
`0.25 % povidone–iodine diluted in physiological saline. Using
`sterile gloves, a sterile drape was placed on the upper body of
`the patient, and a sterile adhesive eye drape on the eye. After
`placing the lid speculum, 4 % xylocaine was instilled. The
`conjunctiva was irrigated with 5 ml of 0.25 % povidone–
`iodine. After waiting for at least 30 seconds, with residual
`0.25 % povidone–iodine remaining in the conjunctival sac,
`2 % xylocaine was injected subconjunctivally into a predeter-
`mined site. A caliper was used to determine a site 4 mm from
`the limbus, and the conjunctiva was displaced with the caliper
`toward the cornea. With the eye ball immobilized with the
`caliper, intravitreal injection was performed through povi-
`done–iodine using a 30-gauge needle attached to a syringe.
`To prevent vitreous reflux, the site of injection was gently
`compressed with a cotton tip. Then the conjunctiva was again
`irrigated with 5 ml of 0.25 % povidone–iodine, followed by
`instillation of topical antibiotics. After injection, no eye patch
`was worn, and topical antibiotics (levofloxacin) was instilled
`4 times a day for 3 days. The patient was educated about the
`symptoms of endophthalmitis and the need for immediate
`consultation should the symptoms arise. Appropriate follow-
`up appointments were scheduled.
`Statistical analysis of the data was performed using SPSS
`software for Windows, version 12 (SPSS, Chicago, IL, USA).
`
`Results
`
`A total of 15,114 injections comprising 548 injections (215
`eyes) of pegaptanib sodium, 846 injections (270 eyes) of
`bevacizumab, and 13,750 injections (2,350 eyes) of ranibizu-
`mab were performed. All patients in this study had at least
`2 months follow-up after an injection. There was no case of
`suspected or proven infectious endophthalmitis. The endoph-
`thalmitis rate was 0 per 15,114 injections (95 % confidence
`interval, 0.0–0.0 %).
`
`Discussion
`
`In the present study, by performing office-based intravitreal
`anti- VEGF injection according to an infection control man-
`ual prepared for a single university hospital, we achieved a
`very low endophthalmitis rate of 0/15,114 injections.
`
`Novartis Exhibit 2315.002
`Regeneron v. Novartis, IPR2021-00816
`
`

`

`Graefes Arch Clin Exp Ophthalmol (2013) 251:1885 1890
`
`1887
`
`Between 2006 and 2012, 22 papers on infectious endoph-
`thalmitis following intravitreal anti-VEGF injections, which
`each evaluated over 3,000 injections, were published
`(Table 1) [11–32]. The cumulative average endophthalmitis
`rate was 141/291,328 or 0.048 %. This rate is similar to the
`reported frequencies of endophthalmitis after cataract surgery,
`typically 0.048 % (109 of 225,471 eyes) [33] and 0.052 % (52
`of 100,539 eyes) [34]. If one considers that intravitreal injec-
`tions are often conducted several times in the same eye, there
`is an urgent need to reduce the infection rate further.
`Much progress has been made in research on the risk
`factors associated with endophthalmitis following intravi-
`treal injections of anti-VEGF agents. The factors that have
`no significant association with the risk include use of lid
`speculum, [26] conjunctival displacement, [26] injection site
`(inferior hemisphere or superior hemisphere), [26] and type
`of anti-VEGF agent (bevacizumab or ranibizumab) [26].
`Reducing bacteria in the operative field is an important
`factor to prevent endophthalmitis. Use of povidone–iodine
`[10, 35], use of surgical mask [10, 36], and silence when a
`surgical mask is not used [10, 36] have been shown to be
`effective measures to achieve ocular surface antisepsis.
`
`Table 1 Studies of the rate of endophthalmitis following anti VEGF
`agent injection (more than 3,000 injections in each study)
`
`Study
`
`Suspected or proven
`endophthalmitis cases
`
`Number of
`injections
`
`Endophthalmitis
`rate (%)
`
`Rosenfeld et al.
`[11] (MARINA)
`Fung et al. [12]
`Singerman et al.
`[13] (VISION)
`Fintak et al. [14]
`Mason et al. [15]
`Pilli S et al. [16]
`Wu et al. [17]
`Diago et al. [18]
`Artunay et al. [19]
`Klein et al. [20]
`Brown et al.
`(ANCHOR) [21]
`Lima et al. [22]
`Bhavsar et al.
`(DRCR.net) [23]
`Moshfeghi et al [24]
`Inoue et al. [25]
`Shah et al. [26]
`Inman & Anderson [27]
`Chen et al. [28]
`Bhatt et al. [29]
`Martin et al.
`(CATT group) [30]
`Lad et al. [31]
`Cheung et al. [32]
`Total
`
`5
`
`1
`12
`
`6
`1
`3
`7
`3
`2
`15
`3
`
`3
`3
`
`12
`5
`23
`0
`11
`5
`6
`
`8
`7
`141
`
`10,443
`
`7,113
`7,545
`
`26,905
`5,233
`10,254
`4,303
`3,874
`3,022
`30,736
`5,921
`
`3,068
`3,226
`
`60,322
`5,236
`27,736
`4,690
`29,995
`7,054
`10,957
`
`8,802
`14,893
`291,328
`
`0.048
`
`0.014
`0.159
`
`0.022
`0.019
`0.029
`0.163
`0.077
`0.066
`0.049
`0.096
`
`0.098
`0.093
`
`0.020
`0.095
`0.083
`0
`0.037
`0.071
`0.055
`
`0.045
`0.047
`0.048
`
`The major route of transmission of the bacteria contam-
`inating the vitreous body during intravitreal injection is
`considered to be direct inoculation via the needle during
`injection. As mentioned above, to obtain transient steriliza-
`tion of the conjunctiva, it is essential to use a volume of
`povidone–iodine that infiltrates the complicated structure
`[3], wait for the bactericidal effect to take place [4], and
`inject through the povidone–iodine used in washing [6, 7].
`First, the povidone–iodine concentration has to be non-
`toxic for ocular tissues. The bactericidal effect of povidone–
`iodine has been observed over a wide range of concentra-
`tions from 0.005 % [37] to 10 %. Jiang et al. [38] reported
`that corneal epithelial cell damage was observed with 0.5 ml
`of 2.5 % povidone–iodine, and endothelial cell damage with
`0.05 ml of 1.5 % povidone–iodine, and therefore recom-
`mended that povidone–iodine at 1.0 % or lower is safe. No
`damage to rabbit retina was observed after intravitreal in-
`jection of 0.1 ml of 0.4 % povidone–iodine [39] or 0.1 ml of
`0.5 % povidone–iodine [40]. From their studies, Trost et al.
`[40] stated that 0.05 0.5 % povidone–iodine is safe for
`ocular tissues. The 0.25 % solution that we use is the
`intermediate value between 0.05 and 0.5 %, and a concen-
`tration that is safe even if introduced into the intraocular
`environment [6, 7].
`Second, the volume of povidone–iodine has to be large
`enough to infiltrate the conjunctival structures. Since bacte-
`ria of the conjunctival flora are sheltered between complex
`structures of the conjunctiva, applying a few drops of povi-
`done–iodine does not attain sufficient bactericidal effect.
`Miño de Kaspar et al. [3] reported that irrigation of the
`conjunctival fornices with 10 ml of 5 % povidone–iodine
`before cataract surgery significantly reduced conjunctival
`bacterial flora compared to applying two drops of povi-
`done–iodine on the conjunctiva.
`Third, adequate time has to be allowed for povidone–
`iodine to act. The time taken for povidone–iodine to kill
`bacteria is shorter at concentrations of 0.1 1.0 % (15 sec)
`than at concentrations of 2.5 10 % (30 120 sec) [4]. We use
`0.25 % povidone–iodine to wash the surgical field, and wait
`for 30 seconds before performing intravitreal injection
`through povidone–iodine. In Europe and America, 5 %
`povidone–iodine instillation is widely used during intravi-
`treal injections. When 5 % povidone–iodine is used, it is
`also essential to use a volume of at least 5 ml and wait for at
`least 30 seconds before injecting intravitreally.
`During talking, coughing, or sneezing without a surgical
`mask, infectious droplets containing saliva and oral flora
`such as Streptococcus species may fall onto the ocular
`surface or needle [9, 28]. As is practiced in intraocular
`surgeries, the patient’s face is covered with a drape as a
`substitute for a surgical mask, to prevent deposition of oral
`flora onto the injection site. Although silence has been
`reported to be effective to prevent contamination by oral
`
`~ Springer
`
`Novartis Exhibit 2315.003
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`
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`Graefes Arch Clin Exp Ophthalmol (2013) 251:1885 1890
`
`flora even without using a mask [36], surgical mask wearing
`is considered necessary if doctors, assistants, or patients
`with upper respiratory infections are involved in intravitreal
`injections [9].
`In the present study, antibiotic was instilled 4 times a day for
`3 days before intravitreal injection. In a survey of retinal
`specialists in the United States published in 2011, 34 % of the
`doctors used antibacterial eye drop before intravitreal injection
`[41]. Topical antibiotics require much longer killing time (ap-
`proximately 60 minutes) than povidone–iodine (approximately
`60 seconds). Therefore, when antibiotics are given immediately
`prior to an intravitreal injection, there is insufficient time for
`adequate bactericidal effect [42]. Therefore, injection of anti-
`biotics either before the day of injection or immediately prior to
`injection is not generally recommended [43]. A recent prospec-
`tive study found that topical moxifloxacin 0.5 % had no addi-
`tional effect on reducing conjunctival bacterial counts beyond
`the effect of 5 % povidone–iodine alone [44].
`In the present study, antibiotic was instilled 4 times a day
`for 3 days after intravitreal injection. In a survey of retinal
`specialists in the United States, 81 % of the doctors use
`antibacterial eye drop after intravitreal injection [41]. In the
`case of bacterial contamination in intravitreal injection, bac-
`teria are inoculated into the vitreous. However, the antibacte-
`rial eye drop used after intravitreal injection does not penetrate
`the vitreous adequately [45]. Since topical fluoroquinolone
`instillation before and after intravitreal injection is repeatedly
`used in a patient, the emergence of resistant bacteria is an issue
`[46]. A study reported a higher incidence of endophthalmitis
`when antibiotic prophylaxis was used after intravitreal injec-
`tions compared with no antibiotic use [32]. The common
`practice of repeated use of fluoroquinolone before and after
`intravitreal injection in many facilities has to be re-examined.
`This study was conducted in a single center. All the
`patients were followed for at least 2 months after surgery.
`Review of all the clinical charts found no case of endoph-
`thalmitis after intravitreal injection detected in our depart-
`ment and no case treated for endophthalmitis in other
`facilities. Therefore, we are confident that the endophthal-
`mitis rate was 0 per 15,144 injections.
`A limitation of the present study is that it was a retrospec-
`tive single-center consecutive case series and not a controlled
`study. Without a control group, it is not possible to delineate
`which factors are important. Apart from the factors discussed
`above, other measures that we undertake routinely, such as
`perioperative topical antibiotics may also contribute to the low
`rate. However, this study does show that if the exact protocol
`described by the current paper is followed, it may be possible
`to achieve the same low risk of endophthalmitis.
`If use of surgical mask further reduces the incidence of
`streptococcal endophthalmitis by 50 %, a trial with 700,000
`patients would be required to demonstrate a significant
`difference [47]. This result suggests that endophthalmitis
`
`~ Springer
`
`can be reduced to a minimum by preventing normal flora
`of the conjunctiva and bacteria in oral cavity from entering
`the vitreous. For this purpose, an infection control manual
`that requires nurses and doctors to wear surgical mask and
`drape the patient’s face, irrigate the conjunctiva with 0.25 %
`povidone–iodine and wait at least 30 seconds before
`performing intravitreal injection is useful.
`From the perspective of cost-effectiveness, the cost per
`injection for implementing our preventive measures, includ-
`ing masks, drapes, povidone–iodine and perioperative topical
`antibiotics, is around ¥2,500 (about US$28). Assuming that
`15,000 intravitreal injections are performed each year, the
`annual cost amounts to ¥37,500,000 (US$420,000). On the
`other hand, the cost for clinical management of a case of
`endophthalmitis is around ¥3,000,000 (US$3,300).
`Assuming that 7–8 cases of endophthalmitis can be prevented
`per year, our infection control measures may be low in terms
`of cost-effectiveness. However, rather than the cost, the pre-
`vention of endophthalmitis, which has devastating clinical
`consequences, is a priority in many countrie, including Japan.
`In summary, this retrospective study of 15,144 intravi-
`treal injections demonstrated that a very low rate of endoph-
`thalmitis can be achieved by following a protocol that
`includes wearing surgical masks by doctors and nurses,
`draping patient’s face, irrigating the conjunctiva with
`0.25 % povidone–iodine and waiting at least 30 seconds
`before performing intravitreal injection.
`
`Acknowledgments/Disclosure This study was financed by regular
`departmental research funds. No financial or material support was
`received from other sources. There is no conflict of interest associated
`with this work or its publication.
`Contributions were made by authors in each of these areas: Concep
`tion and design (HS); Analysis and interpretation (HS, TH, RM, HN, KF,
`MY); writing the manuscript (HS); critical revision of the article (HS, TH,
`RM, HN, KF, MY); final approval of the article (HS, TH, RM, HN, KF,
`MY); data collection (HS); provision of materials (HS); statistics (HS);
`literature search (KF), administrative, technical or logistic support (RM,
`HN, KF)
`
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`Novartis Exhibit 2315.004
`Regeneron v. Novartis, IPR2021-00816
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`
`

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`~ Springer
`
`Novartis Exhibit 2315.006
`Regeneron v. Novartis, IPR2021-00816
`
`