OSLI Retina

July 2020

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July 2020 ยท Vol. 51, No. 7 403 comparing intravitreal bevacizumab to laser treat- ment, 6 used a 31-gauge 7.93-mm needle for anti- VEGF delivery. The prospective RAINBOW study comparing ranizumab to laser treatment, 3 on the other hand, used a 30-gauge 1/2-inch (12.7-mm) needle. The recently published study by Wright et al. 7 used a 32-gauge 4-mm needle (TSK SteriJect; Air-Tite Products, Virginia Beach, VA) and was the first published technique to standardize guidelines for intravitreal injections in ROP. They demon- strated, with use of pathological specimens, how standard 12-mm-long needles could penetrate the lens or retina upon injection. In contrast, the 4-mm length needle was able to effectively penetrate into the vitreous cavity without damaging the lens or retina. 7 A retrospective chart review investigating the safety of this technique by Austin Retina As- sociates and Bascom Palmer Eye Institute, revealed no cases of cataract formation, endophthalmitis, vitreous hemorrhage, or corneal infection. 8 In this paper, we expand upon this technique and propose the first published ROP treatment protocol entitled SAFER-ROP in order to deliver effective treatment while minimizing avoidable complications. MATERIALS AND METHODS SAFER is an acronym used to describe the injec- tion protocol (Figure 1), which consists of the fol- lowing: (S)hort needle, (A)ntiseptic/antibiotic, (F) ollow-up, (E)xtra attention to detail, and (R)echeck every 1 to 2 weeks post-injection until complete reti- nal vascularization or additional laser has been ad- ministered to avascular retina. The "short needle" is a 32-gauge, thin-walled, stainless steel hypodermic needle 4 mm in length. The "antiseptic/antibiotic" utilized is topical 5% or 10% betadine. It is instilled before and after the injection. "Follow-up" should be performed 48 to 72 hours post-injection to rule out endophthalmitis. "Extra attention to detail" includes use of the ora nomogram to determine the safest in- jection distance from the limbus in each quadrant, 9 clean instruments, gloves, and masks for all involved in the injection, including nurses or respiratory thera- pists holding the baby. Additional attention should focus on risk factors for endophthalmitis by assessing the patient for the presence of nasolacrimal duct ob- struction and conjunctivitis. It is common in the neo- natal intensive care unit (NICU) for the team to have already started topical antibiotics for mild discharge Figure 1. SAFER protocol checklist.

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