Intravitreal injections for macular degeneration, diabetic macular edema, and other conditions are becoming more and more common. The risk of endophthalmitis, or infection in the eye, is the most concerning ocular risk of these injections. Recently, vitreoretinal surgeons have been changing their minds about antibiotics before, during, and after intravitreal injections and many patients have questions about the sudden change.
When intravitreal injections first began for macular degneration, they were a newer procedure. We had done a few before for various conditions, but never before in the quantity and regularity we are doing them now. For many intraocular procedures such as cataract surgery, glacuoma surgery, or even retinal surgery, post-operative antibiotic drops are recommended. So, we routinely used them after intravitreal injection.
In 2011, an ARVO poster from Bascom Palmer showed that with merely providone-iodide pre and post injection, and no post-operative antibiotic drops, there was no greater risk of post-injection infection (1). An article was then published showing routine use of post-injection antibiotics selects resistant bacteria (2).
Subsequently, in 2012, a large study of 15,895 patients was published that showed infeciton rates by Cheung, et al 5 in 8259 for patients who were given antibiotics for 5 days after injection, 2 in 2370 for those who received antibiotics immediately after each injection, and 2 in 5266 who received no antibiotics. There was no statistically significant difference amongst the groups. Several smaller studies have all confirmed that the risk remains about 1 in 1000 to 1 in 5000 patients that get an infection after intravitreal injection.
In light of all of the data showing no benefit to antibiotic drops after injection, and data suggesting maybe a negative effect of antibiotic drops after injection, many retina specialists have stopped using them post injection.
If you have any signs of infection after your injection such as decreasing vision, increasing eye pain, or redness or swelling of the eye or eyelid, you should contact your eye physician.
This is not intended to be medical advice and is for informational purposes only. Please consult a qualified eye care professional if you have questions or concerns.
1. Rumya R. Rao, Golnaz Javey, Philip J. Rosenfeld, William J. Feue. Elimination of Post-Injection Topical Antibiotics after Intravitreal Injections. ARVO May, 2011
2. Kim SJ, Toma HS. Ophthalmic antibiotics and antimicrobial resistance a randomized, controlled study of patients undergoing intravitreal injections.Ophthalmology. 2011 Jul;118(7):1358-63. Epub 2011 Mar 21.
Tuesday, October 30, 2012
Wednesday, October 24, 2012
Fluoroquinolones and retinal detachment?
A recent patient brought to mind the possible link between fluorquinolone antibiotics (ciprofloxacin, moxifloxacin, levofloxacin, etc) and the risk of retinal tears or detachments. Fluoroquinolones are one of the most often prescribed antibiotics, and if there is such a risk, could affect a large number of people.
An article posted in JAMA in April 2012 revealed a possible link between these antibiotics and retinal detachments. The article was a case control study of 989,591 patients who took the antibiotic between 2000-2007. 4384 patients had experienced a retinal detachment. Statistically, current use of fluoroquinolones carried a higher risk of retinal detachment but recent use and past use did not.
This article does not prove that fluorquinolones were the cause of the detachments, but merely suggests that there might be a correlation. The proposed mechanism is that the drug may have a destructive effect on collagen and connective tissue. In fact, there is a known risk between fluoroquinolone use and tendon rupture. Since the vitreous contains collagen, this could be the mechanism that leads to the increased risk of retinal detachment or tears.
So, what is the take home message of this possible risk? As a patient, be aware that there is a theoretical risk of retinal detachments with the use of this drug. If you are a prescriber, educate your patients about the signs of retinal tears and detachment such as flashes and floaters. If you are currently using a fluorquinolone antibiotic and experience flashes, floaters, or other symptoms of a retinal detachment, you should contact your physician and an eye care professional. They will perform an dilated exam to look for retinal pathology.
This blog post is for informational purposes only. It is not intended to medical advice. Please seek the advice of a qualified professional.
An article posted in JAMA in April 2012 revealed a possible link between these antibiotics and retinal detachments. The article was a case control study of 989,591 patients who took the antibiotic between 2000-2007. 4384 patients had experienced a retinal detachment. Statistically, current use of fluoroquinolones carried a higher risk of retinal detachment but recent use and past use did not.
This article does not prove that fluorquinolones were the cause of the detachments, but merely suggests that there might be a correlation. The proposed mechanism is that the drug may have a destructive effect on collagen and connective tissue. In fact, there is a known risk between fluoroquinolone use and tendon rupture. Since the vitreous contains collagen, this could be the mechanism that leads to the increased risk of retinal detachment or tears.
So, what is the take home message of this possible risk? As a patient, be aware that there is a theoretical risk of retinal detachments with the use of this drug. If you are a prescriber, educate your patients about the signs of retinal tears and detachment such as flashes and floaters. If you are currently using a fluorquinolone antibiotic and experience flashes, floaters, or other symptoms of a retinal detachment, you should contact your physician and an eye care professional. They will perform an dilated exam to look for retinal pathology.
This blog post is for informational purposes only. It is not intended to medical advice. Please seek the advice of a qualified professional.
Tuesday, October 16, 2012
At home visual acuity monitoring
SightBook is an application that you can download onto your iPhone or iPad that offers visual acuity testing, amsler grid testing, and various other vision tests.
When you register your account, it will record your results over time and allows you to not only keep track of your vision but also your treatments. The app will also notify you daily, weekly, or monthly to remind you that you need to take your test.
If your visual acuity changes, your application will automatically notify the physician you have selected.
Today, we have treatments for many vision threatening diseases, but prompt visits to your physician when you experience a change have been shown to improve your visual outcome over time. This free app allows you to keep track of your vision and be aware sooner of any changes.
To download the app, go to App Store and download SightBook. Make sure your register your account so that your results are stored and can be shared with your physician.
If you have an account and would like to add us, we are account number 149.
For more information, please go to www.digisight.net
Visit us at www.ncretina.com
When you register your account, it will record your results over time and allows you to not only keep track of your vision but also your treatments. The app will also notify you daily, weekly, or monthly to remind you that you need to take your test.
If your visual acuity changes, your application will automatically notify the physician you have selected.
Today, we have treatments for many vision threatening diseases, but prompt visits to your physician when you experience a change have been shown to improve your visual outcome over time. This free app allows you to keep track of your vision and be aware sooner of any changes.
To download the app, go to App Store and download SightBook. Make sure your register your account so that your results are stored and can be shared with your physician.
If you have an account and would like to add us, we are account number 149.
For more information, please go to www.digisight.net
Visit us at www.ncretina.com
Monday, October 15, 2012
Avastin and Compounding
The recent fungal meningitis outbreak has brought to light the possible consequences of compounded drugs. The outbreak occurred from a contaminated steroid injection into the spinal cavity.
We, as retina specialists, often use compounded medications in the form of Avastin as an intraocular injection. Intravitreal Avastin is used to treat macular degeneration, retinal vein occlusions, and diabetic macular edema.
A compounded medication is one that is removed from a larger vial and mixed to smaller concentrations or dosages and then sent for use. This process occurs for many medications that are used for a vast array of conditions. Since one vial creates many doses, one contamination can affect a large number of people.
Lucentis and Eylea, also used to treat macular degneration, retinal vein occlusions, and diabetic macular edema, are not compounded medications. They arrive at our office in a one time use vial. Therefore the risk of one single vial affecting multiple people is zero. However, there is always a risk of infection using any medication for intraocular injection.
Many patients have become concerned about the risk of receiving Avastin since it is a compounded medication. However, this is a complex discussion that is best had between the treating physician and the patient. Overall, patients need to weigh all of their choices when receiving any treatment or considering changing treatment regimen.
This is for informational purposes only and not intended to be medical advice. Please consult a medical professional for medical advice.
Please visit us at www.ncretina.com
We, as retina specialists, often use compounded medications in the form of Avastin as an intraocular injection. Intravitreal Avastin is used to treat macular degeneration, retinal vein occlusions, and diabetic macular edema.
A compounded medication is one that is removed from a larger vial and mixed to smaller concentrations or dosages and then sent for use. This process occurs for many medications that are used for a vast array of conditions. Since one vial creates many doses, one contamination can affect a large number of people.
Lucentis and Eylea, also used to treat macular degneration, retinal vein occlusions, and diabetic macular edema, are not compounded medications. They arrive at our office in a one time use vial. Therefore the risk of one single vial affecting multiple people is zero. However, there is always a risk of infection using any medication for intraocular injection.
Many patients have become concerned about the risk of receiving Avastin since it is a compounded medication. However, this is a complex discussion that is best had between the treating physician and the patient. Overall, patients need to weigh all of their choices when receiving any treatment or considering changing treatment regimen.
This is for informational purposes only and not intended to be medical advice. Please consult a medical professional for medical advice.
Please visit us at www.ncretina.com
Wednesday, October 3, 2012
Should I take "eye vitamins?"
A common question that patients ask is whether they should be using "Eye vitamins." In addition, there are several brands of vitamins designed for the health of the macula, and the choices can be overwhelming for patients.
The AREDS study (age related eye disease study) was a large clinical trial sponsored by the National Eye Institute. The goal of the study was to determine if taking a specific combination of vitamins and minerals could delay the progression of age related macular degeneration (AMD) and cataract.
The study revealed that taking this specific combination of vitamins did indeed delay the progression of AMD to the advanced stage but did not delay the formation of cataracts.
Today, the formula of AREDS has been modified to removed the beta carotene component from the original formula. Also, the AREDS II trial is underway. This trial uses, in addition to the original composition, lutein and zeazanthin and Omega-3 fatty acids. The results of this trial have not yet been released, but many vitreoretinal physicians are recommending adding these additional supplements as well.
We do not recommend these vitamins to patients without AMD. There are no studies to show that it helps for other retinal conditions such as retinal detachment, diabetic retinopathy, epiretinal membrane, or macular hole. However, we do encourage all of our patients to lead a healthy lifestyle.
Many patients become overwhelmed in the drug store aisles with the vast array of choices. So, to make things easier for the patient, we sell Focus vitamins ( http://www.focusvitamins.com/) at our NC retina locations.
This is not intended to be medical advice. Please consult your physician or qualified medical personnel for advice.
Please visit us at www.ncretina.com
The AREDS study (age related eye disease study) was a large clinical trial sponsored by the National Eye Institute. The goal of the study was to determine if taking a specific combination of vitamins and minerals could delay the progression of age related macular degeneration (AMD) and cataract.
The study revealed that taking this specific combination of vitamins did indeed delay the progression of AMD to the advanced stage but did not delay the formation of cataracts.
Today, the formula of AREDS has been modified to removed the beta carotene component from the original formula. Also, the AREDS II trial is underway. This trial uses, in addition to the original composition, lutein and zeazanthin and Omega-3 fatty acids. The results of this trial have not yet been released, but many vitreoretinal physicians are recommending adding these additional supplements as well.
We do not recommend these vitamins to patients without AMD. There are no studies to show that it helps for other retinal conditions such as retinal detachment, diabetic retinopathy, epiretinal membrane, or macular hole. However, we do encourage all of our patients to lead a healthy lifestyle.
Many patients become overwhelmed in the drug store aisles with the vast array of choices. So, to make things easier for the patient, we sell Focus vitamins ( http://www.focusvitamins.com/) at our NC retina locations.
This is not intended to be medical advice. Please consult your physician or qualified medical personnel for advice.
Please visit us at www.ncretina.com
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