Bilateral Anti-VEGF on Same-Day-Investigation on Safety in Retinopathy of Prematurity: A Multicenter Retrospective Study

Abstract

Purpose: To report an incidence of procedure-related complications in preterm infants with retinopathy of prematurity (ROP) treated with intravitreal anti-VEGFs injection in both eyes on the same day.

Design: Retrospective, multicenter case series.

Subjects: Preterm infants with ROP treated with anti-VEGF bilaterally on the same day.

Methods: All included infants underwent intravitreal anti-VEGF injection in both eyes under aseptic precautions in an ophthalmic operation theater (OT) or neonatal intensive care unit (NICU). A postoperative examination was performed to look for procedure-related complications.

Main outcome measures: Incidence of procedure-related complication (presumed endophthalmitis, intraocular inflammation, lens injury, vitreous hemorrhage, and retinal tear) in the study cohort. To study the association of indication, type of anti-VEGF, type of needle used, setting of procedure, site of injection (distance from limbus), and experience of the treating ophthalmologist with the complications.

Results: Nine thousand nine hundred and eighty-four eyes of 4992 infants were analyzed. The procedure was most commonly performed in ophthalmic OT (8258, 82.7%) using a 29G (4514, 45.2%) needle between 1 and 1.5 mm (9984, 100%) from limbus. Aggressive ROP was the most common indication for anti-VEGF use (4866, 48.7%), whereas Bevacizumab was the most commonly used anti-VEGF agent (8642, 86.6%). Overall, 26 eyes (0.3%) had procedure-related complications. Lens injury (15, 0.15%) and presumed endophthalmitis (7, 0.07%) were the most common complications. One eye had culture-proven endophthalmitis with Pseudomonas aeruginosa. No case of bilateral endophthalmitis was noted. Endophthalmitis was not associated with the setting of a procedure or type of anti-VEGF used, whereas the risk of lens injury was 7 times higher when performed in NICU and 30 times higher when performed by an ophthalmologist with <1 year of experience in injecting anti-VEGF in preterm infants.

Conclusions: The incidence of presumed endophthalmitis after bilateral same-day anti-VEGF in infants with ROP is 0.07%. These infants can be treated in both eyes on the same day with the anti-VEGFs and needles (29-32G) evaluated in this study, with emphasis on the direction of needle parallel to the visual axis. Extra precaution is advocated if the procedure is planned in the NICU or by an ophthalmologist with limited experience.

Financial disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article.

Keywords: Anti-VEGF; Bevacizumab; Endophthalmitis; Ranibizumab; Retinopathy of prematurity.