Publication date: Dec 09, 2024

To compare face masking protocols for post-intravitreal injection endophthalmitis (PIE) prophylaxis. Though mask mandates are lifted, ophthalmologists may question whether continued investment into face masks will influence their PIE rate. 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 ROBINS-I and GRADE tools evaluated risk of bias and evidence certainty. We analyzed 17 studies (2,595,219 injections, 830 events; 0. 032%). For the any PIE outcome (17 studies; 2,595,219 injections), compared with standard care, PIE incidence was significantly lower with no-talking (OR: 0. 56, 95%CI [0. 39, 0. 82], I: 0%) and physician masking (OR: 0. 72, 95%CI [0. 53, 0. 99], I: 0%) policies, which remained consistent in the subgroup analysis. 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], I: 0%) compared to 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 interventions groups generally did not reach significance, likely involving 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 to standard care, though this result did not persist in subgroup analysis. As well, in subgroup analysis, universal masking had a significantly lower incidence of culture-negative PIE than standard care (OR: 0. 68, 95%CI [0. 47, 0. 98], I: 0%). For all outcomes, by GRADE analysis, low- or very-low certainty evidence suggests that no-talking and physician masking policies may reduce culture-positive or clinical PIE rates, respectively, compared to standard care and universal masking. While data were only available for endophthalmitis, the overall comparative safety of these interventions remains unclear.

Semantics

Original Article