Abstract
Compared with the operating room (OR), office-based intravitreal injection (IVI) is considered a more cost-effective and convenient approach, yet clinical outcomes of IVIs with anti-vascular endothelial growth factor (VEGF) agents in different settings (office-based vs OR) have not been systematically evaluated. To evaluate the safety outcomes of IVI with anti-VEGF agents in the OR vs office-based setting. PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov were searched from inception to July 2020. Eligible studies reporting on patients who received IVIs with anti-VEGF drugs with a clearly stated injection setting of the office or OR. Two reviewers independently screened studies, extracted data, and assessed risk of bias. A meta-analysis was conducted to determine the rates of endophthalmitis (EO) and culture-positive EO. Rates of EO and culture-positive EO following anti-VEGF IVIs in the OR and office-based setting. Thirty-one studies with a total of 1 275 815 injections were included. Comparative analysis suggested no difference between rates of EO after IVIs performed in the office and OR settings (odds ratio, 3.06; 95% CI, 0.07-139.75; P = .57; I2 = 80%) were identified, yet a higher rate of culture-positive EO was found in the office setting (odds ratio, 21.52; 95% CI, 2.39-193.55; P = .006; I2 = 0%). The pooled rates of EO following anti-VEGF IVIs were 0.03% (95% CI, 0.03-0.04) and 0.02% (95% CI, 0.01-0.04) in office and OR settings, respectively, and the pooled rates of culture-positive EO were 0.01% (95% CI, 0.01-0.02) and 0.01% (95% CI, 0-0.02). The pooled rates of other ocular and systemic adverse events were low. The rate of clinically suspected or culture-positive EO following anti-VEGF IVIs was low whether the procedure was performed in the office or OR setting. Bacterial spectrum could differ between the 2 settings. This meta-analysis could not determine if it is more appropriate to give treatment in the OR for safety reasons in low-income compared with higher-income regions in the world.
Highlights
Iatrogenic infection remains a primary concern for officebased intravitreal injection (IVI),[12] yet evidence from primary research remains controversial; while Abell et al[13] found a significantly higher risk of EO following office-based IVIs than in the operating room (OR), no significant difference was observed between the 2 settings in the study by Tabandeh et al[8]. These findings suggest a need for systemic evidence on EO rates and other safety outcomes following anti-VEGF IVIs in the 2 settings
Eligibility Criteria A study was eligible for inclusion if the following criteria were met: (1) the study focused on patients who received IVI with anti-VEGF drugs alone or combined with panretinal photocoagulation, laser, or photodynamic therapy; (2) there was a clearly stated injection setting of office or OR; (3) the article reported the safety outcomes following anti-VEGF IVIs; and (4) the study was primary clinical research, including randomized clinical trials (RCTs), nonrandomized comparative cohorts, cross-sectional studies, and case series
Seventeen studies reported a total of 944 765 injections administered in the office setting,[8,13,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36] while 14 studies reported 302 039 injections administered in the OR.[6,7,8,13,37,38,39,40,41,42,43,44,45,46]
Summary
To evaluate the safety outcomes of IVI with anti-VEGF agents in the OR vs office-based setting. STUDY SELECTION Eligible studies reporting on patients who received IVIs with anti-VEGF drugs with a clearly stated injection setting of the office or OR. A meta-analysis was conducted to determine the rates of endophthalmitis (EO) and culture-positive EO. MAIN OUTCOMES AND MEASURES Rates of EO and culture-positive EO following anti-VEGF IVIs in the OR and office-based setting. The pooled rates of EO following anti-VEGF IVIs were 0.03% (95% CI, 0.03-0.04) and 0.02% (95% CI, 0.01-0.04) in office and OR settings, respectively, and the pooled rates of culture-positive EO were 0.01% (95% CI, 0.01-0.02) and 0.01% (95% CI, 0-0.02). The pooled rates of other ocular and systemic adverse events were low
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