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Office setting allows for more efficient management with no increased risk
I believe intravitreal injections are best performed in the office for many reasons. First of all, it is safe. In the U.S., millions of intravitreal injections have been performed in the office, and the rate of endophthalmitis seems to be comparable to the OR setting, as confirmed in a recent study by Tabandeh. Second, from both the patient’s and the physician’s standpoint, it is much more efficient to evaluate whether or not an injection is needed and then have the possibility to perform it 10 minutes later, often with the patient remaining in the same exam chair. Treating immediately reduces the chance of disease progression and saves the time and the inconveniences of a second appointment.
We can manage intravitreal injections in a safe and effective manner in our offices. Our technicians are trained to prepare the eye using proparacaine and Betadine. I prefer to use a lid speculum, but do not use a mask, gloves or drapes, and do not talk and tell the patient not to talk right before the injection. This has been suggested so as to reduce the chances of oral contamination.
From the standpoints of efficiency, time and cost, I can only see disadvantages in performing intravitreal injections in ASCs and operating rooms. Safety in the OR is not significantly greater, while much greater is the burden for the patients and their families.
Dante J. Pieramici, MD, is from California Retina Consultants, Santa Barbara, USA. Disclosure: Pieramici reports he is a consultant to Genentech and does research for Genentech, Regeneron, Allergan, Alcon, ThromboGenics and Santen.
- Tabandeh H, et al. Retina. 2014;doi:10.1097/IAE.0000000000000008.
Evidence shows lower rates of endophthalmitis in operating rooms
I am not, in principle, against an office setting for intravitreal injections, but presently there is evidence for a higher rate of endophthalmitis in an office setting than in an operating room. We are about to publish in Retina the results of a retrospective series of 134,701 intravitreal injections, performed in ORs with the highest sterility standards and under laminar airflow. We found a very low endophthalmitis rate (one in 13,470), four to six times lower than what has been published in large meta-analyses and large cohort studies in which injections were performed in office settings (range of one in 2,000 to 2,800). Considering this on a worldwide basis, quite a significant number of eyes could be saved from vision loss.
I am aware of only one study directly comparing OR and in-office injections and showing that in-office is just as safe. However, in this study the rate of endophthalmitis in the OR was unusually high, with two cases in 3,063 injections. Questions arise if the operating room settings were comparable to our study, if the injections were performed under laminar airflow, and what the anti-sepsis protocol was. Before pushing forward the practice of doing intravitreal injections in the office outside the United States, I believe we should really know why there are differences in the endophthalmitis rate and evaluate what is mandatorily required to keep the endophthalmitis rate low.
Stephan Michels, MD, MBA, is vice chair, Department of Ophthalmology, City Hospital Triemli, Zurich, Switzerland. Disclosure: Michels reports the foundation for research in the City Hospital Triemli receives funding from Novartis, Bayer, Allergan and Roche.