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Editorial
Implementation of a checklist for intravitreal injections
Implementación de un checklist en inyecciones intravítreas
R. Bouchikh-El Jarroudia,b,
Corresponding author
rachid.bascara@gmail.com

Corresponding author.
, L. Broc Iturraldea, F.J. Valentín-Bravoa,c
a Servicio de Oftalmología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
b Unidad de Oftalmología Basada en Evidencias (Oftalmoevidencia), Scientia Clinical and Epidemiological Research Institute, Trujillo, Peru
c Institut Català de la Retina (ICR), Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Intravitreal injections are a widely adopted and effective procedure&#44; whose use has grown exponentially in recent years due to the rising incidence of retinal diseases such as neovascular age-related macular degeneration&#44; diabetic retinopathy&#44; retinal vein occlusions&#44; and neovascularization from pathological myopia&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The development of new therapeutic agents with different molecular targets&#44; such as faricimab&#44; has shown promising results in terms of safety and efficacy&#44; ensuring the continued prevalence of this practice in ophthalmology&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Despite the generally high safety profile of intravitreal injections&#44; there are complications that can be potentially devastating for the patient&#44; such as the much-feared endophthalmitis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The incidence of post-injection endophthalmitis varies widely in the literature &#40;0&#46;0053&#37;&#8211;0&#46;095&#37;&#41;&#44; with a commonly reported estimate of 1 in every 2000 injections&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This scientific letter stems from a recent case of endophthalmitis caused by <span class="elsevierStyleItalic">Streptococcus oralis</span> in a patient with active neovascular age-related macular degeneration who had punctal plugs for dry eye management&#46; Since the patient was allergic to iodine&#44; prophylaxis was performed with 0&#46;1&#37; aqueous chlorhexidine&#46; The patient experienced severe pain within less than 12&#8239;h after the injection and presented to the ER with signs of ocular infection 24&#8239;h later&#46; Despite antibiotic therapy and early vitrectomy&#44; endophthalmitis progressed rapidly&#46; Cultures of aqueous humor&#44; vitreous&#44; and the punctal plugs confirmed the presence of the pathogen&#46; This suggests that punctal plugs may act as a reservoir for the microorganism and&#47;or facilitate its growth on the ocular surface&#46; Therefore&#44; we believe that these devices may represent an additional risk for intraocular infections during invasive procedures such as intravitreal injections&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This incident highlights the importance of carefully evaluating the risks and benefits of punctal plugs in patients requiring intravitreal injections&#46; Despite the lack of evidence&#44; the potential contamination of the plugs and subsequent bacterial colonization could increase the risk of serious intraocular infections&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Although&#44; to our knowledge&#44; no cases of endophthalmitis due to the presence of punctal plugs have ever been reported&#44; there is a known association between these devices and certain infections of the lacrimal apparatus&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> as well as their ability to promote biofilm formation in bacteria&#44; which increases resistance to the immune system&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Preventing endophthalmitis is not only a clinical priority but also an ethical and professional responsibility&#46; Various studies have shown that adherence to standardized protocols and checklists can significantly reduce errors and complication rates in any invasive procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Despite the mandatory use of these in all surgical procedures&#44; checklists are not officially implemented when administering minimally invasive treatments like intravitreal injections&#44; which are typically performed in offices and&#47;or less sterile environments&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Implementing a checklist can improve patient care for those requiring intravitreal treatments&#46; The use of a checklist during intravitreal injection procedures can help ensure compliance with all critical steps to minimize the risk of infection&#44; including selecting the appropriate drug&#44; assessing risk factors such as plugs or blepharitis&#44; preparing the patient&#44; adequately sterilizing the instruments&#44; and monitoring postoperatively&#46; Furthermore&#44; we believe that active involvement of the entire health care team is essential&#44; with the application of the checklist being multidisciplinary and involving all participants in the intravitreal injection process&#44; including nursing assistants&#44; nurses&#44; and ophthalmologists&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Therefore&#44; 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&#46; This checklist not only promotes patient safety but also fosters a culture of precision and accountability among healthcare professionals&#46; In this context&#44; implementing a pre-injection checklist can be presented as an effective and necessary strategy to minimize the risk of endophthalmitis and other adverse effects&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion&#44; protecting our patients&#39; vision is a goal that deserves all our efforts and commitments&#46; Despite the heavy workload we face daily&#44; we must devote our full attention to reducing complications in every action we take&#46; The adoption of a checklist in these processes not only safeguards patients&#39; visual health but also strengthens ophthalmological practice by promoting a culture of safety and excellence&#46; Implementing a standardized checklist as a systematic verification tool ensures that every critical step of the intravitreal injection procedure is rigorously followed&#44; minimizing the risk of complications and improving outcomes for patients&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0050" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0055" class="elsevierStylePara elsevierViewall">This manuscript is an original work by the authors and has not been submitted to other scientific journals&#46; The original idea came from the first author&#44; and all four authors equally contributed to and approved the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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ISSN: 21735794
Original language: English
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