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Review
. 2025 Oct 1:S0039-6257(25)00184-5.
doi: 10.1016/j.survophthal.2025.09.025. Online ahead of print.

Prefilled syringes and post-intravitreal injection endophthalmitis: A network meta-analysis

Brendan K Tao  1 , Jiwon Hwang  2 , Shihyun Park  3 , David Mikhail  4 , Angelica Hanna  4 , Ryan S Huang  4 , Andrew Mihalache  4 , Jim S Xie  1 , Marko M Popovic  1 , Yaping Jin  1 , Parampal Grewal  5 , Bernard Hurley  6 , Peter Kertes  1 , Amin Kherani  7 , Matthew Tennant  5 , John Chen  8 , Eduardo Navajas  9 , Wai-Ching Lam  9 , Rajeev H Muni  1 , Peng Yan  10
Affiliations
Free article
Review

Prefilled syringes and post-intravitreal injection endophthalmitis: A network meta-analysis

Brendan K Tao et al. Surv Ophthalmol. .
Free article

Abstract

Optimally, syringe-filling technique may reduce the risk of post-injection endophthalmitis (PIE), yet there is wide variation between ophthalmologists and jurisdictions regarding syringe-filling practices. This frequentist network meta-analysis (PROSPERO: CRD42024555196) of rare events sought to compare the odds of PIE between manufactured prefilled syringes (PFS), compounded syringes, and traditional vial preparation of syringes (VPS) for intravitreal anti-vascular endothelial growth factor therapy. Given outcome rarity, we included studies whose primary outcome was PIE incidence. From 20 observational studies (3,746 PIE events; 41,611,960 injections), the odds of PIE were significantly lower with PFS (OR: 0.45, 95% confidence interval [CI]: 0.40-0.49) and compounded syringes (OR: 0.69, 95% CI: 0.64-0.74) compared to VPS. The odds of PIE were significantly lower with PFS compared to compounded syringes (OR: 0.65, 95% CI: 0.58-0.72). The odds of culture-positive PIE were significantly lower with PFS than both VPS (OR: 0.15, 95% CI: 0.06-0.41) and compounded syringes (OR: 0.15, 95% CI: 0.05-0.44). No significant difference in culture-positive PIE was observed between VPS and compounded syringes (OR: 1.02, 95% CI: 0.66-1.58). Low certainty evidence supports that PFS significantly reduce the rate of clinical and culture-positive PIE compared to VPS and compounded syringes. Future studies should further characterize the role of confounding.

Keywords: compounded syringe; manufactured syringes; post-injection endophthalmitis; pre-filled syringe; vial.

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Conflict of interest statement

Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:1. Receiving grants from the PSI Foundation and Fighting Blindness Canada (MMP). 2. Principal investigator for the Investigate Treat and Extend (INSITE) trial for faricimab (Vabysmo) (MT). 3. Receiving personal fees for advisory board service from Novartis, Alcon, Bayer, Roche, Allergan, and Novelty Nobility; research funding (paid to institution) from Bayer, Roche, and Novartis; and grants from Apellis, Novartis, Bayer, Roche, Boehringer Ingelheim, Pfizer, Zeiss, and RegenxBio outside the submitted work. In addition, reported serving as an equity owner of ArcticDx and receiving personal fees from Viatris, Biogen, and Boehringer Ingelheim (PK) 4. President of the Canadian Retina Society, a consultant for AbbVie, Alcon, Bayer, Bausch & Lomb, and Novartis. JC received consulting fees from Bayer and Novartis and honoraria from Bayer and Novartis (AK). 5. Has/had an affiliation (financial or otherwise) with Alcon, Allergan, Bayer, Novartis, and Roche (WCL). 6. Has/had an affiliation (financial or otherwise) with Alcon Canada, Allergan, Appelis, Bayer, Biogen, and Novartis Canada (BH). 7. Has served on advisory boards (Allergan, Bayer, Novartis, Roche), served as a consultant (Alcon, Bausch & Lomb, Bayer, Novartis, and Roche), and has received research funding from Bayer, Novartis, and Roche (RM). 8. On the advisory board for Novartis and Bayer and has received a research grant from Bayer (PY). 9. All other authors report no disclosures. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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