A network meta-analysis evaluated the impact of different face masking protocols on the incidence of post-intravitreal injection endophthalmitis.
The researchers analyzed 17 studies that encompassed 2.6 million injections to compare outcomes of masking policies—universal masking, physician-only masking, or no-talking protocols—during intravitreal injection procedures and whether they influenced post-intravitreal injection endophthalmitis (PIE) rates compared to standard care. Outcomes assessed incidence of any PIE, including culture-positive or culture-negative PIE, as well as streptococcus-specific PIE.
In their pre-proof published in Ophthalmology, the investigators described mandatory masking protocols during intravitreal injections (IVIs) in North America and Europe, as well as conflicting reports of PIE incidence during the COVID-19 pandemic when masking was mandated outside of the procedure. “While several large observational studies have suggested that the incidence of PIE remains unchanged with the adoption of universal masking policies during the pandemic, other reports have refuted these findings, suggesting a greater risk of PIE was observed with patient masking. For instance, it has been hypothesized that patient masks may redirect aerosolized oral flora superiorly towards the eyes through gaps in the mask nosepiece, potentially contaminating the injection site, and increasing the risk of PIE,” they wrote.
They found that the raw PIE rate across all studies was 0.032% (1 per 3,127 injections). A no-talking policy showed reduced PIE incidence and lower culture-positive PIE rates compared to standard care. Physician masking also reduced PIE incidence compared to standard care. Universal masking showed no significant difference in overall PIE rates compared to standard care, but it did show a reduced culture-negative PIE rate compared to standard care. Physician masking was more effective than universal masking for overall PIE reduction. The investigators found no significant differences in Streptococcus-specific PIE rates among the masking policies.
While no-talking policies seemed to be effective in reducing PIE rates, they also introduced concerns regarding communication: “Patients who are older or are anxious with receiving IVIs may prefer step-by-step verbal cues or instructions during the injection procedure, in which case a physician masking policy may be preferred to avoid procedural miscommunications that could result in complications (e.g., being unable to verbally instruct a moving patient to maintain their position during injection, increasing risk of retinal detachment or lens perforation),” the researchers noted. They also raised safety concerns with no-talking policies, and suggested, “this issue may be mitigated by reviewing instructions with the patient and marking the eye immediately before the procedure.”
Regarding the hypothesis that nose taping of patient masks could mitigate PIE risks, the researchers noted that there was not enough data across the studies analyzed to draw meaningful conclusions.
Ultimately, they wrote, “more important and modifiable risk factors should be optimized, including antisepsis protocol, use of pre-filled syringes, training of the administrating care provider, and a sterile technique, among other factors.”
A full list of author disclosures can be found in the published research.