www.diabeticretinopathy.org.uk

Post injection endophthalmitis, technique, professional notes

David Kinshuck

Risk Factors

  1. Infections Eye 12 "Significant risk factors
    1. were failure to administer topical antibiotics immediately after the injection (P=0.001),
    2. blepharitis (P=0.006),
    3. subconjunctival anaesthesia (P=0.021),
    4. patient squeezing during the injection (P=0.021), and
    5. failure to administer topical antibiotics before anti-VEGF injection (P=0.05)."
  2. Infection is related to eye cleaning rather rather than drapes/gloves see 09. Strep Retina 2011
  3. must wait 3 minutes after the eye is cleaned.
  4. Operating theatre ...far fewer infections than an outpatient room, even a clean room.

Symptoms of infection

Eye 12..these are the common symptoms that patients notice.       

  1. blurred vision........96%
  2. pain/photophobia...73%
  3. redness ...............50%
  4. floaters................25%
  5. lid swelling ...........10%
  6. discharge .............10%

Notes for professionals

  1. Intravitreal injections, precautions:
    • wrong drug injected
    • if pressure very high and central retina artery occluded, paracentesis
    • if patient has severe cupping, pre-treat with diamox
    • post-injection prophylaxis does not help Retina 11
    • infections Ophth 2011
  2. 30 Gauge needles and deeper injections reduce reflux and retina incarceration. (Retina 2010)
  3. The technique for traimsinolone
    • topical anaesthetic and dilating agents
    • polvidone iodine to clean eye; 
    • 4mm behind limbus,
    • 29 gauge needle
    • (triamcinolone dose: 4mg = 0.1ml triamcinolone; check suitability for intravitreal injection as here)
    • expect a pressure rise in 50% at 1 month, many requiring drops/treatment, sometimes severe, as here
    • some patients were retreated..most patients benefit, but usually the effect is temporary (6 months)
    • one patient on anticoagulants developed a large subconjunctival haemorrhage, another developed a cataract (out of 20 patients)
    • these patients had had macular oedema for years
    • in our experience triamcinolone does not work if the oedema has been present for more than a year.
    • it is critical to shake the triamcinolone vial and inject immediately or as soon as possible...a 10 minute delay introduces a great variation in the dose given.
  4. symptoms
    1. vitritis 91%
    2. hypopyon 75%
    3. hyperaeima 75%
    4. corneal oedema 24%
    5. raised IOP 10%
  5. outcomes Retina 19

Infections may occur 1/100-1/10000. This paper is worth reading in detail, with extracts as below.

  1. apply 5% polvidone-iodine (p-i) & irrigate fornix with p-i,
  2. apply sterile drape and speculum keeping all eyelashes covered
  3. apply drops of p-i over injection site
  4. intravitreous injection of Lucentis etc..wait a few seconds...immediately apply cotton tip to injection site to prevent reflux of injected drug
  5. facemask or no talking
  6. organisms BJO 14
  7. vitrectomy within 14 days may help Retina 17

Iodine allergy