Aqueous Chlorhexidine Compared to Povidone Iodine as Ocular Antisepsis Prior to Intravitreal Injection: A Randomized Clinical Trial

ABSTRACT Objective Topical povidone iodine is widely used as an ocular surface antiseptic for intravitreal injections. While povidone iodine is generally well-tolerated, it can be associated with significant ocular irritation. Aqueous chlorhexidine has been described as a possibly better-tolerated antimicrobial for ophthalmic procedures. We compared patient pain scores, ocular surface characteristics, and antimicrobial efficacy between povidone iodine 5% and aqueous chlorhexidine 0.1% during intravitreal injections. Design Prospective single-center, randomized clinical trial Participants Patients receiving same-day bilateral intravitreal anti-VEGF injections. Intervention Each patient had one eye randomized to either povidone iodine or aqueous chlorhexidine, while the second eye received the other agent. Both eyes received topical proparacaine 0.5%. Main outcomes and measures After intravitreal injections, participants rated their pain (Wong-Baker, scale 0-10) for each eye one minute after povidone iodine or aqueous chlorhexidine instillation and one day after the procedure. Each eye was assessed using a standardized quantitative grading system of corneal epitheliopathy (ocular staining score). Microbial swab cultures of the conjunctiva both prior to instillation of topical antisepsis and ten minutes following intravitreal injections were taken. Results One hundred eyes of 50 patients were included. The mean patient age was 68 years (range 39-92) and 30/50 (60%) were male. Compared to aqueous chlorhexidine, eyes receiving povidone iodine had a greater mean pain score immediately after injection (1.44 vs 0.44, p Conclusions Povidone iodine demonstrated greater ocular surface discomfort and corneal epitheliopathy compared to aqueous chlorhexidine during same-day bilateral intravitreal injections. The two agents otherwise demonstrated no difference in positive microbial cultures or adverse events. Aqueous chlorhexidine may be a better-tolerated alternative to povidone iodine for antimicrobial prophylaxis during intravitreal injections for some patients.