Usama Iqbal ( Ophthalmology Department, Gujranwala Medical College/ Teaching Hospital, Gujranwala, Pakistan. )
Irfan Qayyum Malik ( Ophthalmology Department, Gujranwala Medical College/ Teaching Hospital, Gujranwala, Pakistan. )
Aamna Jabran ( Ophthalmology Department, Gujranwala Medical College/ Teaching Hospital, Gujranwala, Pakistan. )
The article titled: ‘Incidence of endophthalmitis following intravitreal anti VEGF injections at a tertiary care hospital in Pakistan’ by F. Shaheen et al (Vol. 71, No. 4, April 2021) was discussed in our ward journal club. We have a few concerns to mention.
The authors have mentioned that there is lack of an integrated protocol for intravitreal injections. We would like to mention here that, The Royal College of Ophthalmologists (RCOphth) has issued an ophthalmic service guidance for intravitreal injection therapy.1 This guidance is updated regularly with inclusion of latest advancement. It was last reviewed in February 2021.1 These guidelines can be adopted by the ophthalmic care setups providing intravitreal injection facility.
Also the authors have mentioned that there are only two local studies reporting infective endophthalmitus following anti-VEGF injections in Pakistan. We would like to mention here that two reports have been published form Lahore General Hospital one in 20122 and second in 20193 on this topic reporting 0.134% and 0.04% incidence of endophthalmitus respectively. The latest one published in 2019 is in fact a multi-center audit from five different hospitals.
The use of peri-injection antibiotics in no longer recommended1,4 and is an issue for debate in major ophthalmic conferences at national and international level. There is ambiguity about reporting the use of antibiotic prophylaxis in this study. Whether they were used both before and after the injection or only for post-injection period. The authors have written in the patients and methods section of the study that topical moxifloxacin eye drops were installed just before shifting the patient to the injection room, while in discussion section the authors have written that in their study only post injection antibiotics were used.
Another concern is about the injection protocol because there is no mention of any check of light perception or intraocular pressure just after the injection which should have been checked to rule out any non- perfusion of central retinal artery.
Conflicts of interest: None.
Funding disclosure: None.
1. Ophthalmologists TRCo. Ophthalmic Service Guidance Intravitreal injection therapy. Ophthalmic Services Guidance. Website: The Royal College of Ophthalmologists; 2018. p. 16. Can be accessed from: https://www.rcophth.ac.uk/wp-content/uploads/ 2018/02/Intravitreal-Injection-Therapy-August-2018-2.pdf
2. Khaqan HA, Lateef Q, Haider SA. Incidence of Endophthalmitis after Bevacizumab (Avastin). Pak J Ophthalmol 2012;28:66-68.
3. Khaqan HA, Khan T, Tayyab H, khan Marwat T, Lateef MQ, Tayyab MJ. Pak J Ophthalmol. Complications of Three Different Intravitreal Anti VEGF at Five Different Centers Observing Different Inravitreal Injection Protocols. 2019; 35: 25-30.
4. Bhavsar AR, Googe JM, Jr., Stockdale CR, Bressler NM, Brucker AJ, Elman MJ, et al. Risk of endophthalmitis after intravitreal drug injection when topical antibiotics are not required: the diabetic retinopathy clinical research network laser-ranibizumab-triamcinolone clinical trials. Arch Ophthalmol. (Chicago, Ill: 1960). 2009; 127: 1581-3.