Editorial

Endophthalmitis After Injections of AntiVascular Endothelial Growth Factor Drugs

he April 2011 edition of Retina featured 3 important articles regarding endophthalmitis after anti vascular endothelial growth factor drug injections: a meta-analysis of the existing literature byMcCannel,1 large Bascom Palmer Eye Institute series by Moshfeghi et al,2 and the editorial by Wykoff and Flynn.3 Two important conclusions emerge from these reports. First, the overall incidence of endophthalmitis is low and is not altered by the prophylactic use of topical antibiotics. Second, the frequency of streptococcal endophthalmitis is higher after intravitreal injections than after other ophthalmic surgical procedures. Given the high likelihood of permanent vision loss associated with streptococcal endophthalmitis, this second point deserves further discussion. For decades, physicians have been challenged with cases of streptococcal meningitis after lumbar puncture (spinal tap, spinal anesthesia, and particularly myelography). As early as 1985, investigators suggested that wearing masks was an integral component of the sterile technique for lumbar punctures,4 yet opposing editorials in 2000 emphasized the lack of consensus within the medical profession over face masks.5,6 Only after a series of 8 postmyelography streptococcal meningitis infections (masks were not worn by 7 of the physicians) did the Centers for Disease Control mandate (2005) the wearing of masks during lumbar punctures.7,8 Though this practice has become the standard of care, data showing lower infection rates with the use of face masks have not been forthcoming and individual cases continue to be reported.9 Though McCannel and Moshfeghi reported different overall endophthalmitis rates (1 in 4,059 vs. 1 in 8,617), the rates because of streptococcal species were quite similar (1 in 13,192 vs. 1 in 12,064). This suggests that steps taken by the Bascom Palmer Eye Institute to successfully reduce the overall incidence of endophthalmitis did little to reduce streptococcal infections. When viewing the recently reported ophthalmic series, while simultaneously considering the recommended approach to lumbar punctures, some epidemiologically trained infectious disease specialists would recommend that ophthalmologists should rou1981

tinely wear face masks during intravitreal injections (W. Hellinger, MD, personal communication, June 2011). The authors of the aforementioned endophthalmitis articles correctly point out that we lack sufcient data to warrant this recommendation, but we should ask what data would be required to prompt ophthalmologists to routinely use face masks. We have no clusters of streptococcal endophthalmitis cases upon which to mandate face mask use, because unlike postlumbar puncture streptococcal infections, clusters of endophthalmitis cases have not been reported, either because they have not occurred or because physicians are fearful of such admissions. Because ophthalmology is a data-driven profession, we would prefer to base procedural changes on randomized, casecontrol, clinical trials. However, if face masks reduce the incidence of streptococcal endophthalmitis by 50%, a trial with 700,000 patients would be required. The cost and logistics of such a large trial would be prohibitive. So what should retina surgeons do to prevent streptococcal endophthalmitis? Careful, sterile technique, of course, is always of utmost importance. Talking, sneezing, and coughing in the procedure room should be curtailed as much as possible. Face masks should be worn by members of the medical team or patients with symptoms of upper respiratory infections. Physicians should be encouraged to report cases of streptococcal endophthalmitis to compile a more comprehensive picture of incidence rates and risk factors. As the number of intravitreal injections continues to increase rapidly, our patients deserve our continuing vigilance and analysis. Michael Wesley Stewart, MD

Mayo Clinic Jacksonville, Jacksonville, Florida

References
1. McCannel CA. Meta-analysis of endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents. Retina 2011;31:654661. 2. Moshfeghi AA, Rosenfeld PJ, Flynn HW, Jr, et al. Endophthalmitis after intravitreal anti-vascular endothelial growth antagonists. Retina 2011;31:662668.

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3. Wykoff CC, Flynn HW, Jr. Endophthalmitis after intravitreal injection: prevention and management (Editorial). Retina 31: 633635. 4. Schelkun SR, Wagner KF, Blanks JA, Reinert CM. Bacterial meningitis following Pantopaque myelography. A case report and literature review. Orthopedics 1985;8:7376. 5. Baer ET. Iatrogenic meningitis: the case for face masks. Clin Infect Dis 2000;31:519521. 6. Black SR, Weinstein RA. The case for face maskszorro or zero? Clin Infect Dis 2000;31:522523.

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7. Hsu J, Jensen B, Arduino M, et al. Streptococcal meningitis following procedures. Infect Control Hosp Epidemiol 2007;28:614617. 8. Siegel JD, Rhinehart E, Jackson M, et al. 2007 guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. Available at: www.cdc.gov/ncidod/dhqp/ pdf/guidelines/isolation2007.pdf. Accessed June 10, 2011. 9. Centers for Disease Control and Prevention (CDC). Bacterial meningitis after intrapartum spinal anesthesiaNew York and Ohio, 20082009. MMWR Morb Mortal Wkly Rep 2010;59: 6569.