Endophthalmitis after Anti-VEGF Intravitreal Injections with Aqueous Chlorhexidine versus Povidone–Iodine as Ocular Antiseptics

Abstract

To compare the rates and outcomes of endophthalmitis after intravitreal injections (IVIs) for patients pretreated with 5% povidone-iodine (PI) and 0.05% chlorhexidine (CHX). A retrospective, single-center, comparative cohort study. A total of 8686 patients were included in the study, and a total of 67 695 anti-VEGF injections were performed from January 1, 2019, to November 30,2021. A private retina practice of 13 retina specialists in Colorado. Using electronic health records, patients with preinjection preparation with PI or CHX were compiled retrospectively. Use of prefilled versus nonprefilled syringes was also tabulated. Patients with postinjection endophthalmitis (PIE) were identified among the 2 groups. Postinjection endophthalmitis is defined as an inflammation of the eye from infectious agents after an IVI. Logarithm of the minimum angle of resolution (logMAR) visual acuity (VA) was determined at the time of causative anti-VEGF injection, endophthalmitis presentation, and 3-month follow-up. A total of 67 695 IVIs were administered by 13 retina specialists during the study period. A total of 13 of 32 802 (0.0396%; 1 in 2523 injections) cases of presumed endophthalmitis occurred in the PI group, and 9 of 34 893 (0.0258%; 1 in 3877 injections) cases in the CHX group (P= 0.395). For the PI group, there were 2 culture-positive endophthalmitis cases (0.0061%, 1 in 16 401), compared with 2 cases in the CHX group (0.00573%, 1 in 17 447) (P= 1.000). No significant difference was observed in the average logMAR VA of PI and CHX at causative injection (P= 0.3851), endophthalmitis encounter (P= 0.7718), and 3-month follow-up (P= 0.6152). A significant reduction in presumed endophthalmitis (P= 0.0445) and culture-positive cases (P= 0.0130) was present for prefilled IVI compared with nonprefilled injections. No significant difference in the rate of endophthalmitis or visual outcomes were found in the CHX group compared with the PI group. Prefilled syringes were associated with a significant reduction in endophthalmitis rate. Further multicenter studies are needed to validate the efficacy and safety of CHX compared with PI for IVI preparation. The author(s) have no proprietary or commercial interest in any materials discussed in this article.