Face Masking and Risk of Endophthalmitis after Intravitreal Injection: A Network Meta-analysis of 2.6 Million Injections.
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TOPIC: To compare face-masking protocols for post-intravitreal injection endophthalmitis (PIE) prophylaxis. CLINICAL RELEVANCE: Although mask mandates are lifted, ophthalmologists may question whether continued investment into face masks will influence rates of PIE. METHODS: We included comparative studies of PIE incidence by masking policy (i.e., standard care [no restrictions], no-talking, physician masking, or universal masking [patient and physician]). A frequentist network meta-analysis (Mantel-Haenszel method with fixed effects) synthesized direct and indirect evidence. Subgroup analysis excluded studies that systematically introduced new prophylactic techniques (e.g., prefilled syringes) during the observation period. The Risk of Bias in Nonrandomized Studies of Interventions Risk of Bias in Nonrandomized Studies of Interventions and Grading of Recommendations, Assessment, Development, and Evaluation tools evaluated risk of bias and evidence certainty. RESULTS: We analyzed 17 studies (2 595 219 injections, 830 events [0.032%]). For the overall PIE outcome (17 studies; 2 595 219 injections), PIE incidence was significantly lower with no-talking (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.39-0.82; I2 = 0%) and physician masking (OR, 0.72; 95% CI, 0.53-0.99; I2 = 0%) policies when compared to standard care. Although PIE rates between standard care and universal masking did not differ in the main analysis (OR, 0.83; 95% CI, 0.67-1.02), subgroup analysis revealed a significantly lower rate of any PIE with universal masking (OR, 0.70; 95% CI, 0.55-0.91; I2 = 0%) compared with standard care. For the culture-positive (14 studies; 2 347 419 injections), Streptococcus (10 studies; 1 966 903 injections), and culture-negative (15 studies; 2 213 322 injections) outcomes, PIE rates between pairs of intervention groups generally did not reach significance, likely due to limited study power. As one exception, the incidence of culture-positive PIE was significantly lower with a no-talking policy (OR, 0.45; 95% CI, 0.23-0.92; single direct estimate) compared with standard care, although this result was not consistent in the subgroup analysis. As well, in the subgroup analysis, universal masking was significantly associated with a lower incidence of culture-negative PIE than standard care (OR, 0.68; 95% CI, 0.47-0.98; I2 = 0%). DISCUSSION: Low- or very low-certainty evidence suggests that no-talking and physician masking policies may reduce PIE rates compared with standard care. Although data were available only for endophthalmitis, the overall comparative safety of these interventions remains unclear. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.
