Management of cataract caused by inadvertent capsule penetration during intravitreal injection of ranibizumab

Abstract

We describe an approach to phacoemulsification of complicated cataract with preexisting posterior capsule tear caused by an intravitreal injection. Careful preoperative planning and attention to fluidics, low bottle height, appropriate incisions, careful hydrodelineation without hydrodissection, avoidance of nuclear rotation, and use of a dispersive ophthalmic viscosurgical device to tamponade vitreous allows safe phacoemulsification with secure posterior chamber intraocular lens implantation. Biaxial microincision cataract surgery can achieve efficient removal of the lens matter without rotating the nucleus, reducing the chance of capsule tear extension and loss of nuclear fragments into the posterior pole.

A safety audit of the first 10 000 intravitreal ranibizumab injections performed by nurse practitioners

“…7 The four cases of endophthalmitis in this study represent an incidence of 0.04% for injections given by the NPs, which is favourable relative to the rates observed in the MARINA and ANCHOR studies and similar to that reported by the British Ophthalmological Surveillance Unit. Traumatic lens damage following ranibizumab injection has been reported, 8 but no patients treated by the NP had evidence of inadvertent lens damage on follow-up medical review.…”

Post-intravitreal anti-VEGF endophthalmitis in the United Kingdom: incidence, features, risk factors, and outcomes

“…The mean age at presentation was 78.45±7.29 years (range 62 to 91 years). The mean number of intravitreal injections before PIAE was 5.2 ± 3.6 (range [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15]. The mean number of days from injection to presentation was five (range 1-39).…”

“…Infectious endophthalmitis, sterile uveitis, retinal detachment, retinal tear, vitreous haemorrhage, raised intraocular pressure (IOP), and lenticular trauma have all been reported. [9][10][11][12][13] Following intravitreal injection of anti-VEGF, the incidence of endophthalmitis is thought to be low with rates of between 0.02 and 0.1% previously being reported. 9,10,12,[14][15][16][17][18][19][20][21][22] This is the first UK-wide population-based prospective study to determine the incidence and features of endophthalmitis following intravitreal injection of anti-VEGF therapy and to identify reversible risk factors for endophthalmitis so that reported incidence rates may be reduced.…”

Rate of intraoperative complications during cataract surgery following intravitreal injections

“…Similarly, cataract surgeons should include a careful preoperative assessment of the posterior capsule in patients with a history of prior IVTs, particularly in the presence of any PSC, and understand precautions and surgical procedure modifications that may minimize complications associated with pre-existing posterior capsule defects. 6 Increased awareness of this potential complication by injecting practitioners may increase prevention, and we urge cataract surgeons to carefully examine the posterior capsule prior to cataract surgery in these patients.…”

“…Anecdotal reports by cataract surgeons of IVT-related lenticular trauma are corroborated by a few published individual reports of both subclinical lenticular damage as well as cataract-inducing needle penetration into the lens. [4][5][6][7] A single case of 'lens trauma' was reported in the combined phase 3 data of the pivotal ANCHOR (Anti-VEGF Antibody for the Treatment of Predominantly Classic Choroidal Neovascularization in AMD) and MARINA (Minimally Classic/Occult Trial of the Anti-VEGF Antibody Ranibizumab in the Treatment of Neovascular AMD) trials following a total of 754 ranibizumab (Lucentis; Genentech, Inc; San Francisco, CA, USA) injections for treatment of age-related macular degeneration (AMD). 8,9 In addition, repeated IVTs may be associated with sustained elevation of the IOP, which may secondarily increase rates of openangle glaucoma.…”