Low Safety Risk Observed in Office-Based, Operating Room Anti-VEGF Intravitreal Injections

A low risk of adverse safety outcomes was observed in anti–vascular endothelial growth factor (VEGF) intravitreal injections performed in office-based and operating room settings, with a higher rate of culture-positive endophthalmitis found in the office setting.

Anti–vascular endothelial growth factor (VEGF) intravitreal injections performed in office-based and operating room (OR) settings exhibited similarly low risk of adverse safety outcomes, according to study findings published today in JAMA Ophthalmology.

Regarded as one of the most widely performed ophthalmic procedures since the turn of the 20th century, intravitreal injections with anti-VEGF have been shown to significantly improve management and visual prognosis of angiogenic retinal diseases. However, the procedures have been linked with a small risk of endophthalmitis (EO), a severe form of eye inflammation that can lead to irreversible blindness if not properly treated.

Due to these concerns, researchers note that anti-VEGF intravitreal injections in resource-limited countries are primarily performed in ORs, as these settings are perceived to decrease risk of infection. Conversely, procedures conducted in the United States are typically administered in the office setting, which was noted to be a more cost-effective and convenient approach.

“Iatrogenic infection remains a primary concern for office-based intravitreal injections, yet evidence from primary research remains controversial,” said the study authors.

Seeking to compare the safety outcomes of anti-VEGF intravitreal injections performed in OR and office-based settings, they conducted a meta-analysis of 31 studies derived from PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov up until July 2020.

The analysis included 1,275,815 injections overall, in which 17 studies reported 944,765 injections administered in the office setting and 14 studies reported 302,039 injections administered in the OR.

Primary outcomes assessed were the rates of EO and culture-positive EO, as well as retinal detachment, vitreous hemorrhage, intraocular pressure elevation, intraocular inflammation, and other ocular and systemic adverse events following anti-VEGF intravitreal injections in both settings.

In the comparative analysis, no significant differences were found between rates of EO after anti-VEGF intravitreal injections performed in the office and OR settings (odds ratio, 3.06; 95% CI, 0.07-139.75; P = .57), but significant heterogeneity was found (I2 = 80%).

Notably, a higher rate of culture-positive EO was observed in the office setting, with no statistical heterogeneity observed (odds ratio, 21.52; 95% CI, 2.39-193.55; P = .006; I2 = 0%).

Pooled rates of EO following anti-VEGF intravitreal injections were 0.03% (95% CI, 0.03-0.04) in the office and 0.02% (95% CI, 0.01-0.04) in OR settings, with pooled rates of culture-positive EO also relatively low in office-based (0.01%; 95% CI, 0.01-0.02) and OR (0.01%; 95% CI, 0-0.02) setting. Pooled rates of other ocular and systemic adverse events were low.

With findings indicating a low risk of clinically suspected or culture-positive EO following anti-VEGF intravitreal injections in both OR and office-based settings, the researchers noted that the meta-analysis could not determine whether findings applied to resource-limited regions.

“Bacterial spectrum could differ between the 2 settings,” they concluded. “Using antisepsis from drug packaging and loading the syringes to the completion of intravitreal injections in a well-controlled, clean environment may contribute to prophylaxis of post-injection EO.”

Reference

Li T, Sun J, Min J, et al. Safety of receiving anti–vascular endothelial growth factor intravitreal injection in office-based vs operating room settings. JAMA Ophthalmol. Published online August 19, 2021. doi:10.1001/jamaophthalmol.2021.3096