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The Connection of Board Certification and Risk of Endophthalmitis After Intravitreal Injection

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Medicare billing claims reveal that endophthalmitis after intravitreal injection is more likely when the clinician is not board certified in ophthalmology. This result indicates that board certification is helpful in predicting which ophthalmologists administer intravitreal injection most safely. The study further suggests that extending the scope of practice for intravitreal injection beyond ophthalmology may present safety concerns.   

Endophthalmitis is the most feared complication of intravitreal injection, occurring 1 in 2,000 injections. Endophthalmitis often results in pain, multiple surgeries, and permanent blindness.  Several risk factors for postinjection endophthalmitis are known, including young patient age, injection of steroid medication, incomplete povidone iodine prep, and talking during the procedure. However, it is not known whether the credentials of the clinician may also impact the odds of endophthalmitis.   

In this study of Medicare claims, 2,907,324 intravitreal injections in 219,640 patients resulted in 1,088 endophthalmitis outcomes. Proceduralists who were board certified by the American Board of Ophthalmology (ABO) had an endophthalmitis rate of 0.037% as compared to 0.050% for non-certified providers (P = 0.047), a 28% reduced odds of endophthalmitis for the board certified cohort. ABO board certification status was determined using an internet search algorithm and the ABO “Verify a Physician” webpage. Postinjection endophthalmitis was defined as a new endophthalmitis diagnosis with vitrectomy or vitreous tap within two weeks after the intravitreal injection, excluding patients who had recent eye surgery or a prior diagnosis of endophthalmitis. As a coauthor alongside, Rahman, Kim, Stein, and VanderBeek, we found similar odds of postinjection endophthalmitis for ophthalmologists versus a subset of ophthalmologists with fellowship training in retina. Our study is in press at Journal of VitreoRetinal Diseases.

Intravitreal injection is the most common eye procedure worldwide, fueled by an aging population and the high prevalence of macular degeneration and diabetic retinopathy in older patients. In the U.S. the number of intravitreal injections is growing 6% per year, putting pressure on the healthcare system and on the ophthalmologists who administer intravitreal injections.  

In some countries such as New Zealand and the UK, nurses aid in the administration of intravitreal injections. Some states, including Alaska, New Mexico, and Oklahoma, have expanded intravitreal injection authority to optometrists or other APPs. Some additional states have also considered relaxing scope of practice for intravitreal injection. However, this study suggests that there may be safety concerns in doing so.  

Nevertheless, in the U.S., 99.98% of injections are administered by physicians. The U.S. proceduralists are highly credentialed, 94% of whom are board certified in ophthalmology, and 73% of whom have completed retina fellowship training beyond ophthalmology residency.  The authors conclude that board certification is likely beneficial, especially for invasive procedures such as intravitreal injection.

Dr. Emerson reports grants received from National Eye Institute, Research to Prevent Blindness, Phillips Eye Institute.

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