Distinctions Regarding Injection Setting Inconclusive


Though operating room-based injections are predominantly performed, investigators could not find sufficient data that confirmed it as the only safe injection site.

intravitreal injections

intravitreal injections

A recent meta-analysis could not determine whether it was more appropriate to give endophthalmitis treatment via injections in the operating room (OR) or in an office-based setting.

In managing endophthalmitis, a severe form of eye inflammation, intravitreal injections with anti-vascular endothelial growth factor (VEGF) agents had been used in previous studies.

In the past, anti-VEGF injections required repeated injections on a regular basis, which were predominantly performed in the OR in resource-limited countries such as Europe, China, and India.

Additionally, previous studies regarding office-based IVIs had conflicting data, with one study noting a significantly higher risk of EO following office-based IVIs than in the OR while another observed no significant difference between the 2 settings

These findings suggest a need for systemic evidence on EO rates and other safety outcomes following anti-VEGF IVIs in the 2 settings.

Investigators led by Tong Li, MD, Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China, evaluated the safety outcomes of OR-based intravitreal injection (IVI) with anti-vascular endothelial growth factor (VEGF) agents versus office-based treatment.

The Study

Li and colleagues first performed a literature search on databases such as PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov from database inception to July 2020.

Studies were eligible for inclusion if the following criteria were met:

  • The study focused on patients who received IVI with anti-VEGF drugs alone or combined with panretinal photocoagulation, laser, or photodynamic therapy
  • There was a clearly stated injection setting of office or OR
  • The article reported the safety outcomes following anti-VEGF IVIs
  • The study was primary clinical research, including randomized clinical trials (RCTs), nonrandomized comparative cohorts, cross-sectional studies, and case series.

The studies were reviewed and variables such as study characteristics, intervention and/or comparison, and details of a specific safety outcome were extracted.

Heterogeneity across the studies was examined using I2 statistics.

The Findings

A total of 31 studies reported 1,275,815 injections, with 944,765 injections administered in an office setting and 302,039 OR-based injections.

Only 2 studies compared the 2 injection settings, with 1 finding no significant differences and the other study indicating a similar baseline diagnosis.

A total of 28 studies (90%) reported low risk bias in 50% or more items in methodological quality assessment.

Additionally, the study revealed a culture-positive EO rate of 0.01% (95% CI, 0.01-0.02) in the office setting and 0.01% (95% CI, 0-0.02) in the OR setting, while the comparative analysis observed that culture-positive EO rates were significantly elevated in the office setting.

A total of 11 microbial species accounting for the EO were reported in 16 studies. In the office setting, the 2 most common pathogens were Coagulase-negative staphylococci (CoNS) and Streptococcus viridans, whereas in the OR, the predominant pathogens were CoNS and Staphylococcus aureus (57% [13 of 23] and 26% [6 of 23], respectively).

Overall, the analysis found that injection setting did not appear to be an influential factor of post-injection EO.

Though bacterial spectrum could differ between the settings, the rate of clinically suspected or culture positive EO following the injections were low regardless.

“In resource-limited regions, we were unable to identify evidence that in-office procedures would lead to more EO than injections in the OR,” the team wrote. “Using antisepsis from drug packaging and loading the syringes to the completion of IVIs in a well-controlled, clean environment may contribute to prophylaxis of post-injection EO.”

The study, “Safety of Receiving Anti-Vascular Endothelial Growth Factor Intravitreal Injection in Office-Based vs Operating Room Settings: A Meta-analysis,” was published online in JAMA Ophthalmology.

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