The Italian zest for life may just have been translated (somewhat literally) into a promising prophylaxis to prevent the risk of a debilitating threat: endophthalmitis.
A new commercial ocular spray containing a citrus extract has been shown to significantly reduce the antimicrobial load in patients receiving intravitreal injections, thus reducing the risks of endophthalmitis, according to an Italian study.1
The researchers suggested that the “prophylactic administration of natural and chemical-free antiseptic compounds, such as bioflavonoids, could represent a viable treatment option in all efforts to decrease the incidence of IVT-related endophthalmitis.” This could be useful to overcome “common drawbacks in antibiotic agents,” they noted.
The Oftasecur ocular spray was developed by Off Health (Florence, Italy) with the aim of decreasing serious complications from infections during surgery. It was designed for pre-surgical use and its main ingredient is Biosecur®.
Researchers describe the Biosecur citrus extract as a non-toxic, natural and chemical-free antiseptic agent. This group of bioflavonoids derived from some specific layers of citrus fruits have already been developed in the food processing industry for their broad-spectrum effectiveness against both gram-positive and gram-negative microorganisms. A plus point was that these bioflavonoids could carry out their purpose without the need for synthetic preservatives.2
The cross-sectional multicenter trial and prospective and pilot study, took place at the University Eye Clinic of Genoa, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI).
The researchers looked at a common procedure: Intravitreal injections (IVT) with anti-vascular endothelial growth factor (VEGF) to manage neovascular age-related macular degeneration (nAMD). This is because the increase of anti-VEGF IVTs administered worldwide also comes with the increased risk of endophthalmitis, which has a reported incidence of 0.019% to 0.083%.3-5
So far, only the use of 5% povidone iodine eye drops has been studied6 and shown as efficacious in decreasing the risk of endophthalmitis after intraocular surgeries.
Sprayin’ Each Day to Keep the Germs Away
Each of the 30 patients (15 male and 15 female) undergoing this trial received IVTs in one eye while the contralateral eye was the control eye. They were required to spray Oftasecur into the eye to be injected four times daily for four days prior to the anti-VEGF injection.
Conjunctival swabs were taken from both eyes before the IVT and at the time of the IVT after the four days of treatment. Swabs were sent to the International Centre for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus (Venice, Italy) for microbiological analysis.
Before treatment, microbiological analysis showed that 53.3% of the eyes tested positive but after the prophylactic treatment, only 20% of the eyes were positive during the time of the injection.
The researchers isolated the microorganisms which were mostly gram-positive coagulase-negative micrococci (Staphylococcus epidermidis in particular) which were shown to have tested negative after treatment compared to control eyes. For them, this showed the broad spectrum efficacy of the ocular spray.
Patients reportedly tolerated the Oftasecur spray well, as none complained of any ocular discomfort during use.
“A-peeling” Potential
Furthermore, the researchers noted that the delivery of Oftasecur as an ocular spray may be advantageous for older patients who may struggle with adherence. The molecule droplets are administered to the eyelid margin, which allows patients to mix the drug with the tear with their eyes open. They said it might be more effective than traditional drops in cases of physical incapacity.
The potential represented in this study also comes at a time where the topic of antibiotic resistance has become an issue in the field of medicine. In ophthalmology, it was found that the routine usage of antibiotics as prophylaxis for multiple IVT courses has been linked with an increased risk of developing antibiotic resistance in the conjunctival flora. The use of azithromycin, for instance, incurred antibiotic resistance.7 Prolonged use of antibiotics may also lead to alterations in the conjunctiva’s flora along with the growth of Staphylococcus epidermidis.
Oftasecur ocular spray, according to the research paper, does not only reduce the risk of endophthalmitis postoperatively, but also does not alter the normal conjunctival flora composition.
The researchers said this class of bioflavonoid at a concentration of 2% was found to have similar high levels of antimicrobial activity as tetracyclines, along with long-lasting residual effects.8 They deem the bioflavanoid’s organic profile as highly advantageous over other non-organic and potentially more toxic products.2
Considering the limitations of this pilot study’s small sample size and the sensitivity profile of the isolated microorganisms which had not been investigated, the institution is currently developing a larger randomized trial and further studies to further verify the results.
References
- Vagge A, Ferro Desideri L, Carnevali A, et al. Efficacy of a New Commercial Ocular Spray Containing Oftasecur Citrus Extract for Reducing Microbial Load in the Conjunctiva of Patients Receiving Intravitreal Injections. Ophthalmol Ther. 2021;10(4):1025-1032.
- Cormier J, Scott R, Janes M. Antibacterial activity of biosecur citrus extract surface cleaner against Vibrio vulnificus. Open Microbiol J. 2013;7:130–134.
- Fileta JB, Scott IU, Flynn H, Jr. Meta-analysis of infectious endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents. Ophthalmic Surg Lasers Imaging Retina. 2014;45(2)5:143–149.
- Bhavsar AR, Googe JM, Jr, Stockdale CR, et al. Risk of endophthalmitis after intravitreal drug injection when topical antibiotics are not required: the diabetic retinopathy clinical research network laser-ranibizumab-triamcinolone clinical trials. Arch Ophthalmol. 2009;127(12):1581–1583.
- Englander M, Chen TC, Paschalis EI, Miller JW, Kim IK. Intravitreal injections at the Massachusetts Eye and Ear Infirmary: analysis of treatment indications and postinjection endophthalmitis rates. Br J Ophthalmol. 2013;97(4):460–465.
- Pinna A, Donadu MG, Usai D, et al. In vitro antimicrobial activity of a new ophthalmic solution containing povidone-iodine 0.6% (IODIM). Acta Ophthalmol. 2020;98(2):e178–e180.
- Dave SB, Toma HS, Kim SJ. Ophthalmic antibiotic use and multidrug-resistant staphylococcus epidermidis: a controlled, longitudinal study. Ophthalmology. 2011;118(10):2035–2040.
- Duthie G, Crozier A. Plant-derived phenolic antioxidants. Curr Opin Clin Nutr Metab Care. 2000;3(6):447-451
