Implementation of a checklist for intravitreal injections

Bouchikh-El Jarroudi, R.; Broc Iturralde, L.; Valentín-Bravo, F.J.

doi:10.1016/j.oftale.2024.10.001

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Bouchikh-El Jarroudi, L. Broc Iturralde, F.J. Valentín-Bravo" "autores" => array:3 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Bouchikh-El Jarroudi" "email" => array:1 [ 0 => "rachid.bascara@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "L." "apellidos" => "Broc Iturralde" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "F.J." "apellidos" => "Valentín-Bravo" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Oftalmología Basada en Evidencias (Oftalmoevidencia), Scientia Clinical and Epidemiological Research Institute, Trujillo, Peru" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Institut Català de la Retina (ICR), Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Implementación de un checklist en inyecciones intravítreas" ] ] "textoCompleto" => "Intravitreal injections are a widely adopted and effective procedure, whose use has grown exponentially in recent years due to the rising incidence of retinal diseases such as neovascular age-related macular degeneration, diabetic retinopathy, retinal vein occlusions, and neovascularization from pathological myopia, among others.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The development of new therapeutic agents with different molecular targets, such as faricimab, has shown promising results in terms of safety and efficacy, ensuring the continued prevalence of this practice in ophthalmology.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>Despite the generally high safety profile of intravitreal injections, there are complications that can be potentially devastating for the patient, such as the much-feared endophthalmitis.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> The incidence of post-injection endophthalmitis varies widely in the literature (0.0053%–0.095%), with a commonly reported estimate of 1 in every 2000 injections.<a class="elsevierStyleCrossRefs" href="#bib0020">4,5</a>This scientific letter stems from a recent case of endophthalmitis caused by Streptococcus oralis in a patient with active neovascular age-related macular degeneration who had punctal plugs for dry eye management. Since the patient was allergic to iodine, prophylaxis was performed with 0.1% aqueous chlorhexidine. The patient experienced severe pain within less than 12 h after the injection and presented to the ER with signs of ocular infection 24 h later. Despite antibiotic therapy and early vitrectomy, endophthalmitis progressed rapidly. Cultures of aqueous humor, vitreous, and the punctal plugs confirmed the presence of the pathogen. This suggests that punctal plugs may act as a reservoir for the microorganism and/or facilitate its growth on the ocular surface. Therefore, we believe that these devices may represent an additional risk for intraocular infections during invasive procedures such as intravitreal injections.This incident highlights the importance of carefully evaluating the risks and benefits of punctal plugs in patients requiring intravitreal injections. Despite the lack of evidence, the potential contamination of the plugs and subsequent bacterial colonization could increase the risk of serious intraocular infections.Although, to our knowledge, no cases of endophthalmitis due to the presence of punctal plugs have ever been reported, there is a known association between these devices and certain infections of the lacrimal apparatus,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> as well as their ability to promote biofilm formation in bacteria, which increases resistance to the immune system.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>Preventing endophthalmitis is not only a clinical priority but also an ethical and professional responsibility. Various studies have shown that adherence to standardized protocols and checklists can significantly reduce errors and complication rates in any invasive procedure.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> Despite the mandatory use of these in all surgical procedures, checklists are not officially implemented when administering minimally invasive treatments like intravitreal injections, which are typically performed in offices and/or less sterile environments.Implementing a checklist can improve patient care for those requiring intravitreal treatments. The use of a checklist during intravitreal injection procedures can help ensure compliance with all critical steps to minimize the risk of infection, including selecting the appropriate drug, assessing risk factors such as plugs or blepharitis, preparing the patient, adequately sterilizing the instruments, and monitoring postoperatively. Furthermore, we believe that active involvement of the entire health care team is essential, with the application of the checklist being multidisciplinary and involving all participants in the intravitreal injection process, including nursing assistants, nurses, and ophthalmologists.Therefore, we propose the incorporation of a standardized checklist as a systematic verification tool to ensure that every critical step of the intravitreal injection procedure is rigorously followed. This checklist not only promotes patient safety but also fosters a culture of precision and accountability among healthcare professionals. In this context, implementing a pre-injection checklist can be presented as an effective and necessary strategy to minimize the risk of endophthalmitis and other adverse effects.In conclusion, protecting our patients' vision is a goal that deserves all our efforts and commitments. Despite the heavy workload we face daily, we must devote our full attention to reducing complications in every action we take. The adoption of a checklist in these processes not only safeguards patients' visual health but also strengthens ophthalmological practice by promoting a culture of safety and excellence. Implementing a standardized checklist as a systematic verification tool ensures that every critical step of the intravitreal injection procedure is rigorously followed, minimizing the risk of complications and improving outcomes for patients.FundingNone declared.Authors’ contributionsThis manuscript is an original work by the authors and has not been submitted to other scientific journals. The original idea came from the first author, and all four authors equally contributed to and approved the manuscript.Conflicts of interestNone declared." 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Vol. 99. Issue 11.

Pages 469-470 (November 2024)

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