We have read with a lot of interest the article by Dossarps and associates. First of all, we would like to congratulate the authors for conducting such a thorough study, because they explore a very important topic. Intravitreal injections of anti–vascular endothelial growth factor (anti-VEGF) have caused a huge revolution in treatment of a variety of conditions. At present the number of intravitreal injections is increasing all over the world. Between 1997 and 2001, fewer than 5000 intravitreal injections were performed annually, whereas more than 800 000 were performed in 2007 worldwide. The first injection of anti-VEGF in our hospital’s University Clinic Center in Tuzla, Bosnia and Herzegovina, was performed back in 2006; since then, each year we have performed an increasing number of injections. It is expected that in the near future, given the increasing number of applications of anti-VEGF, the overall number of endophthalmitis cases will increase as well. Currently ranibizumab and aflibercept are labeled for intravitreal use, while bevacizumab is still being used “off-label.” All over the world, bevacizumab is the most frequently used intravitreal anti-VEGF because of its very low price.
However, we have a few queries regarding the methodology. Dossarps and associates failed to explain whether they divided the large volume of bevacizumab into the smaller units that are suitable for single-use intravitreal doses. Usually bevacizumab comes in preservative-free 100 mg/4 mL vials. This monoclonal antibody is approved by the US Food and Drug Administration to be used in metastatic tumors in breast, colon, and non–small cell lung cancer. It would be interesting to find out whether the bevacizumab vial for multiple injections increases the frequency of endophthalmitis. It is also not clear whether intravitreal bevacizumab injections were prepared by a qualified pharmacist in a pharmacy laboratory or elsewhere. For these reasons, we kindly ask the authors to present the data regarding these issues.
Also, it is not clear from the article whether any of these intravitreal injections were performed by ophthalmology residents or only by ophthalmologists. According to the article by Falavarjani and associates, the risk of endophthalmitis after resident intravitreal injection is low and similar to when supervising surgeons perform the procedure. We believe that residents should be educated during their third or fourth year of residency regarding intravitreal injections.
Finally, we conclude that endophthalmitis remains an infrequent but very severe complication of intravitreal injections. Diverse steps have been taken in an attempt to reduce the risk of intravitreal injection–associated endophthalmitis. With a use of strict protocols, we could reduce the incidence of infection. Apart from this, it is necessary to establish guidelines regarding the intravitreal injection procedure and technique that would give us the best possible results.