ABSTRACT
Objectives:
To describe the intravitreal injection (IVI) techniques, practices, and treatment protocols of ophthalmologists in Turkey from May 20, 2020 to June 4, 2020.
Materials and Methods:
All members of the Turkish Ophthalmological Association were contacted by e-mail to complete an anonymous, 47-question internet-based survey.
Results:
Thirteen percent of the participants prescribed prophylactic antibiotics pre-injection, 63.8% (406/636) used antibiotic drops immediately after injection, and 91.8% prescribed topical antibiotics. The majority of IVI procedures were performed in an operating room (65.3%) or clean room (33.6%). Most surgeons used sterile gloves, masks, sterile drape, sterile fenestrated cover, and sterile eyelid speculum. Multispecialists (M) preferred to wear sterile gloves more than retina specialists (RS) (99.0% vs. 95.3%; p=0.004). Also, M prescribed antibiotics more than RS (93.7% vs. 88.8%; p=0.029). RS dilated the pupil more frequently than M (48.3% vs. 39.0%) (p=0.020). RS were more familiar to use different quadrants (right p=0.012; left p=0.001). Most surgeons (82.8%) did not perform injections in both eyes on the same day.
Conclusion:
Ophthalmologists in Turkey employ a wide range of techniques in care before, during, and after IVI. In addition, IVI techniques and treatment protocols differed between RS and M. Further research is needed to elucidate best practice patterns.
Keywords:
Intravitreal injections, survey, retina specialists, anti-VEGF
Introduction
Intravitreal injections (IVI) are widely used by ophthalmologists for the treatment of various retinal diseases. The IVI technique was first described in 1911 and has been used to administer anti-vascular endothelial growth factors, corticosteroids, and other drugs for many years.1,2 There are several published guidelines describing the indications and procedures of IVI.3,4,5 However, there is no consensus among clinicians on the intravitreal injection technique or pre-injection and post-injection care.
The aim of this study was to determine the personal preferences of ophthalmologists in Turkey regarding IVI procedures.
Materials and Methods
All members of the Turkish Ophthalmological Association were contacted via e-mail in May 2020 to complete a 47-question internet-based survey. Three reminder e-mails were sent to the participants who had not completed the survey. SurveyMonkey (www.surveymonkey.com; SurveyMonkey, San Mateo, CA) was used for the data collection. The final results were collected on June 4, 2020. Thirty-five questions related to injection and follow-up procedures were evaluated. In the first 3 questions, participants were asked about demographic data (institution, society membership). The fourth question asked if the participant had experience with IVI. Participants who did not have any experience with IVI were directed to the end of the questionnaire. Reimbursement regulations in Turkey indicate 3 consecutive monthly injections of bevacizumab for the treatment of diabetic macular edema (DME), age-related macular degeneration (AMD), and retinal vein occlusion. Therefore, there was no question about the timing of IVI in the survey. Protocol differences regarding the injection techniques were also evaluated. Participants were divided into the retina specialist-only group (RS) and multispecialty group (M) and protocol differences were compared between groups.
Results
A total of 892 ophthalmologists answered the questionnaire. Of these, 232 participants reported having no experience related to IVI. The other 660 participants who were actively performing IVI were included in our analysis of practice patterns.
Discussion
Several guidelines for intravitreal drug injections have been published in recent years.6,7 However, pre-injection preparation, injection technique, and post-injection care preferences vary in daily practice. In this study, we report the preferred IVI techniques of surgeons in Turkey.
Conclusion
In this study, the response rate was 90% and our results showed that ophthalmologists in Turkey have varying preferences regarding IVI techniques. Furthermore, their practices differ in some ways from those of Canadian surgeons and ASRS members. In many countries, IVI is considered a surgical procedure and is performed in an operating room. In the United States, IVI is performed as an office-based procedure to reduce costs and accommodate the large number of patients. Office-based procedures are generally performed in the examination room without using a sterile drape, sterile gloves, sterile surgical clothes, or mask. The results of our survey are more similar to European surgeon practices.36
The results of this study are generally compatible with IVI guidelines, except for the high rate of postoperative antibiotic prescription and performing bilateral intravitreal injections on the same day.
IVI are generally administered only by retina specialists around the world, which differs from the practice of surgeons in Turkey. Current healthcare practices allow IVI to be performed not only by retina specialists, but also by other ophthalmologists. This may lead to differences in IVI practices of our country. These discrepancies should be considered when performing retrospective studies to examine the efficacy and safety of IVI. More evidence-based medicine is required to identify IVI techniques that combine safety and efficacy.
References
1Ohm J. Über die Behandlung der Netzhautablösung durch operative Entleerung der subretinalen Flüssigkeit und Einspritzen vom Luft in den Glaskörper. Graefe Arch Klin Ophthalmol. 1911;79:442-450.
2Fung AE, Rosenfeld PJ, Reichel E. The International Intravitreal Bevacizumab Safety Survey: using the internet to assess drug safety worldwide. Br J Ophthalmol. 2006;90:1344-1349.
3Aiello LP, Brucker AJ, Chang S, Cunningham ET Jr, D’Amico DJ, Flynn HW Jr, Grillone LR, Hutcherson S, Liebmann JM, O’Brien TP, Scott IU, Spaide RF, Ta C, Trese MT. Evolving guidelines for intravitreous injections. Retina. 2004;24(5 Suppl):S3-19.
4Korobelnik J-F, Weber M, Cohen SY, groupe d’Experts. Recommendations for carrying out intravitreal injections. J Fr Ophtalmol. 2009;32:288-289.
5Weber M, Cohen SY, Tadayoni R, Coscas G, Creuzot-Garcher C, Devin F, Gaudric A, Mauget-Faysse M, Sahel JA, Soubrane G, Souied E, Korobelnik JF. Evolving intravitreous injection technique. J Fr Ophtalmol. 2008;31:625-629.
6Grzybowski A, Told R, Sacu S, Bandello F, Moisseiev E, Loewenstein A, Schmidt-Erfurth U; Euretina Board. 2018 Update on Intravitreal Injections: Euretina Expert Consensus Recommendations. Ophthalmologica. 2018;239:181-193.
7Nikkhah H, Karimi S, Ahmadieh H, Azarmina M, Abrishami M, Ahoor H, Alizadeh Y, Behboudi H, Daftarian N, Dehghan MH, Entezari M, Farrahi F, Ghanbari H, Falavarjani KG, Javadi MA, Karkhaneh R, Moradian S, Manaviat MR, Mehryar M, Nourinia R, Parvaresh MM, Ramezani A, Haghi AR, Riazi-Esfahani M, Soheilian M, Shahsavari M, Shahriari HA, Rajavi Z, Safi S, Shirvani A, Rahmani S, Sabbaghi H, Pakbin M, Kheiri B, Ziaei H. Intravitreal Injection of Anti-vascular Endothelial Growth Factor Agents for Ocular Vascular Diseases: Clinical Practice Guideline. J Ophthalmic Vis Res. 2018;13:158-169.
8Uhr JH, Xu D, Rahimy E, Hsu J. Current Practice Preferences and Safety Protocols for Intravitreal Injection of Anti-Vascular Endothelial Growth Factor Agents. Ophthalmol Retina. 2019;3:649-655.
9Green-Simms AE, Ekdawi NS, Bakri SJ. Survey of intravitreal injection techniques among retinal specialists in the United States. Am J Ophthalmol. 2011;151:329-332.
10Storey P, Dollin M, Rayess N, Pitcher J, Reddy S, Vander J, Hsu J, Garg S; Post-Injection Endophthalmitis Study Team. The effect of prophylactic topical antibiotics on bacterial resistance patterns in endophthalmitis following intravitreal injection. Graefes Arch Clin Exp Ophthalmol. 2016;254:235e242
11Hunyor AP, Merani R, Darbar A, Korobelnik JF, Lanzetta P, Okada AA. Topical antibiotics and intravitreal injections. Acta Ophthalmol. 2018;96:435-441.
12Casparis H, Wolfensberger TJ, Becker M, Eich G, Graf N, Ambresin A, Mantel I, Michels S. Incidence of presumed endophthalmitis after intravitreal injection performed in the operating room: a retrospective multicenter study. Retina. 2014;34:12-17.
13Wen JC, McCannel CA, Mochon AB, Garner OB. Bacterial dispersal associated with speech in the setting of intravitreous injections. Arch Ophthalmol. 2011;129:1551-1554.
14Avery RL, Bakri SJ, Blumenkranz MS, Brucker AJ, Cunningham ET Jr, DʼAmico DJ, Dugel PU, Flynn HW Jr, Freund KB, Haller JA, Jumper JM, Liebmann JM, McCannel CA, Mieler WF, Ta CN, Williams GA. Intravitreal injection technique and monitoring: updated guidelines of an expert panel. Retina. 2014;34(Suppl 12):S1eS18.
15Gordon DF, Jong BB. Indigenous flora from human saliva. Appl Microbiol. 1968;16:428e429.
16McCannel CA. Meta-analysis of endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents: causative organisms and possible prevention strategies. Retina. 2011;31:654e661.
17Casparis H, Wolfensberger TJ, Becker M, Eich G, Graf N, Ambresin A, Mantel I, Michels S. Incidence of presumed endophthalmitis after intravitreal injection performed in the operating room: a retrospective multicenter study. Retina. 2014;34:12e17
18Doshi RR, Leng T, Fung AE. Reducing oral flora contamination of intravitreal injections with face mask or silence. Retina 2012;32:473-476.
19Ogoina D. COVID-19: The Need for Rational Use of Face Masks in Nigeria. Am J Trop Med Hyg. 2020;103:33-34.
20Berkelman RL, Holland BW, Anderson RL. Increased bactericidal activity of dilute preparations of povidone-iodine solutions. J Clin Microbiol 1982;15:635-639.
21Xing L, Dorrepaal SJ, Gale J. Survey of intravitreal injection techniques and treatment protocols among retina specialists in Canada. Can J Ophthalmol. 2014;49:261-266.
22Mansour AM, Shahin M, Kofoed PK, Parodi MB, Shami M, Schwartz SG. Collaborative Anti-VEGF Ocular Vascular Complications Group: Insight into 144 patients with ocular vascular events during VEGF antagonist injections. Clin Ophthalmol 2012;6:343-363.
23Rahimy E, Fineman MS, Regillo CD, Spirn MJ, Hsu J, Kaiser RS, Maguire JI, Brown GC, Chiang A. Speculum versus bimanual lid retraction during intravitreal injection. Ophthalmology 2015;122:1729-1730.
24Anijeet DR, Hanson RJ, Bhagey J, Bates RA. National survey of the technique of intravitreal triamcinolone injection in the United Kingdom. Eye. 2007;21:480-486.
25Wykoff CC, Flynn HW Jr, Rosenfeld PJ. Prophylaxis for endophthalmitis following intravitreal injection: antisepsis and antibiotics. Am J Ophthalmol 2011;152:717-719.e712.
26Tabandeh H, Boscia F, Sborgia A, Ciracì L, Dayani P, Mariotti C, Furino C, Flynn HW Jr. Endophthalmitis associated with intravitreal injections: office-based setting and operating room setting. Retina. 2014;34:18-23.
27Knecht PB, Michels S, Sturm V, Bosch MM, Menke MM. Tunnelled versus straight intravitreal injection: Intraocular pressure changes, vitreous reflux, and patient discomfort. Retina. 2009;29:1175-1181.
28Wykoff CC, Croft DE, Brown DM, Wang R, Payne JF, Clark L, Abdelfattah NS, Sadda SR; TREX-AMD Study Group. Prospective Trial of Treat-and-Extend versus Monthly Dosing for Neovascular Age-Related Macular Degeneration: TREX-AMD 1-Year Results. Ophthalmology. 2015;122:2514-2522.
29Wykoff CC, Ou WC, Brown DM, Croft DE, Wang R, Payne JF, Clark WL, Abdelfattah NS, Sadda SR; TREX-AMD Study Group. Randomized Trial of Treat-and-Extend versus Monthly Dosing for Neovascular Age-Related Macular Degeneration: 2-Year Results of the TREX-AMD Study. Ophthalmol Retina. 2017;1:314-321.
30Erden B, Bölükbaşı S, Özkaya A, Karabaş L, Alagöz C, Alkın Z, Artunay Ö, Bayramoğlu SE, Demir G, Demir M, Demircan A, Erdoğan G, Erdoğan M, Eriş E, Kaldırım H, Onur İU, Osmanbaşoğlu ÖA, Özdoğan Erkul S, Öztürk M, Perente İ, Sarıcı K, Sayın N, Yaşa D, Yılmaz İ, Yılmazabdurrahmanoğlu Z; Bosphorus Retina Study Group. Comparison of two different treatment regimens’ efficacy in neovascular age-related macular degeneration in Turkish population-based on real life data-Bosphorus RWE Study Group. Int J Ophthalmol. 2020;13:104-111.
31Özkaya A, Karabaş L, Alagöz C, Alkın Z, Artunay Ö, Bölükbaşı S, Demir G, Demir M, Demircan A, Erden B, Erdoğan G, Erdoğan M, Eriş E, Kaldırım H, Onur İU, Osmanbaşoğlu Ö, Özdoğan Erkul S, Öztürk M, Perente İ, Sarıcı K, Sayın N, Yaşa D, Yılmaz İ, Yılmazabdurrahmanoğlu Z. Real-World Outcomes of Anti-VEGF Treatment for Neovascular Age-Related Macular Degeneration in Turkey: A Multicenter Retrospective Study, Bosphorus Retina Study Group Report No: 1. Turk J Ophthalmol. 2018;48:232-237.
32Borkar DS, Obeid A, Su DC, et al. Endophthalmitis Rates after Bilateral Same-Day Intravitreal Anti-Vascular Endothelial Growth Factor Injections. Am J Ophthalmol. 2018;194:1-6.
33Juncal VR, Francisconi CLM, Altomare F, Chow DR, Giavedoni LR, Muni RH, Berger AR, Wong DT. Same-Day Bilateral Intravitreal Anti-Vascular Endothelial Growth Factor Injections: Experience of a Large Canadian Retina Center. Ophthalmologica. 2019;242:1-7.
34Kim JE, Mantravadi AV, Hur EY, Covert DJ. Short-term intraocular pressure changes immediately after intravitreal injections of anti-vascular endothelial growth factor agents. Am J Ophthalmol. 2008;146:930-934. e931.
35Doshi RR, Bakri SJ, Fung AE. Intravitreal injection technique. Semin Ophthalmol. 2011;26:104-113.
36Huang K, Sultan MB, Zhou D, Tressler CS, Mo J. Practice patterns of ophthalmologists administering intravitreal injections in Europe: a longitudinal survey. Clin Ophthalmol. 2016;10:2485-2488.
