“The journey of a thousand miles begins with a single step.” Lao Tzu vibrantly reminds us of how the little advances we make may eventually look like a giant leap forward when viewed through a much wider-angle lens.

In retina, we have witnessed this pattern firsthand. Think about the presentation by Phil Rosenfeld, MD, PhD, on his experience injecting bevacizumab off-label for the first time, setting off a wave of its use around the world before ranibizumab was even approved by the Food and Drug Administration—a legacy which continues nearly two decades later.

Another iconic event was the discovery that macular holes could be treated with surgery by Neil Kelley, MD, and Robert Wendel, MD. I remember stories of how no one initially believed that vitrectomy and gas tamponade alone could really close the hole in nearly 60 percent of cases. Incrementally, various modifications have been made, including internal limiting membrane peeling and inverted flaps among many other tweaks that have increased closure rates to more than 90 percent.

So going back to the little steps that make a difference, I am struck by how one of the most common complaints I hear nowadays revolves around patient discomfort after intravitreal injections. The most likely culprit is povidone-iodine. Enter aqueous chlorhexidine gluconate (CHG). Several large studies have demonstrated its efficacy in preventing endophthalmitis.1 (Note: It’s critical to distinguish aqueous CHG from alcohol-based as the latter may not be as effective in preventing endophthalmitis.)

Sunir Garg, MD, has been on the vanguard of studying this antiseptic. He demonstrated significantly less corneal epitheliopathy and pain after injections when aqueous CHG was used compared to povidone-iodine.2 Anecdotally, colleagues from practices that have converted to aqueous CHG describe night and day differences in patient discomfort and call back rates.

So why isn’t everyone jumping on the bandwagon and switching to aqueous CHG? There’s inertia. We retina specialists tend to be conservative. It also takes time and effort to change processes. Fear of the unknown is another issue, particularly when it comes to medicolegal concerns.

Finally, many worry about cost. Using a compounding pharmacy for CHG can be prohibitively expensive compared to povidone-iodine. Large bottles of aqueous CHG can be cost-effective but have a beyond-use date of 24 hours once opened.

Recently, Dr. Garg published a study looking at the stability and sterility of aqueous CHG 0.05% (Irrisept, Irrimax Corp.) aliquoted into 1 mL syringes and showed that it remained stable for at least 30 days.3

Armed with this knowledge, now may be the time to make the move to aqueous CHG, which may improve both patient satisfaction and even adherence. While this is a little step, it has the potential for a huge impact in the lives of our patients (and us!). RS

 







REFERENCES 

1. Ton NS, Goncharov V, Zapata I, Adam MK. Endophthalmitis after anti-VEGF intravitreal injections with aqueous chlorhexidine versus povidone-iodine as ocular antiseptics. Ophthalmol Retina. 2024;8:521-526.

2. Ali FS, Jenkins TL, Boparai RS, et al. Post-injection endophthalmitis study group. Aqueous chlorhexidine compared with povidone-iodine as ocular antisepsis before intravitreal injection: A randomized clinical trial. Ophthalmol Retina. 2021;5:788-796.

3.  Durrani AF, Momenaei B, Soni V, et al. Long-term stability, sterility, and cost-effectiveness of 0.05% chlorhexidine gluconate as antisepsis for intravitreal injection. J Ocul Pharmacol Ther. 2024;40:581-587.