Providing Safe and Effective Intravitreal injections - Episode 2

Guidelines To Properly Administer Intravitreal Injections

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Nadia K. Waheed, MD, MPH, and David M. Brown, MD, discuss guidelines available to ensure proper intravitreal injections.

Nadia K. Waheed, MD, MPH: We had intravitreal injection guidelines published in 2004, and then there was an update in 2014. How have they changed your approach to intravitreal injections, and what is your protocol at this point?

David M. Brown, MD: Originally, you’re right, we did drip, we did a lot of Betadine. We always did a speculum, originally, we didn’t do bilaterals. The most important thing, I think, we realized long before COVID-19 that just wearing a mask and having the patient in a mask and not talking decreased the rate of oral pathogens, like streptococci viridans and others that were terrible in endophthalmitis. We started doing masks for patients and doctors way before it was cool, way before COVID-19, and that’s made, I think, the biggest difference. You basically need to know what are the goals, and the goals are to decrease endophthalmitis. All the guidelines recommended a lid speculum to keep the eyelashes away from the field. I learned from my friends at Wills Eye Hospital, if you’re able to hold the eyelids open and keep the lashes away from the fields, you do the same thing, and you might even express less bacteria from the lid speculum squeezing on the meibomian glands and lids. Now, with most of my patients I do not use the lid speculum; with the …. you do, you want to make sure you can keep the lashes away. We still use Betadine. It’s the most effective thing. A lot of us use more of a soppy Q-tip right in the area of the injection, as opposed to the eye drop that goes everywhere. The current rate of endophthalmitis in busy clinics is about 1 per 7,000. And that’s irrespective of those that do it as long as you keep the eyelashes away, use Betadine; that’s why the rate is low. We wish it was lower. But in today’s clinic, patients want the least amount of hassle if they’re having to come in every month. We typically don’t dilate them every month. I don’t, some of my partners do; it’s real variable. I like to look in the eye at least every three months to make sure I don’t see a peripheral complication, a new hemorrhage, the kind of thing I couldn’t pick up in the OCT [optical coherence tomography test].

Nadia K. Waheed, MD, MPH: That’s really interesting. I still use an eyelid speculum when I’m doing my injections, but of course that’s the piece that patients complain the most about. They hate the eyelid speculum.…You’re moving the eyelashes out of the way. Are you also making sure that the eyelid is kind of everted as you’re doing that? Do you have an assistant hold the eyelids open while you’re doing your injection? How exactly does that work?

David M. Brown, MD: Those of us who are vitreoretinal surgeons, who are used to spinning a contact lens around the eye while operating, are pretty adept at working with two hands at once. I typically hold the eyelids with my left hand, keep them apart, and then inject with my right hand, go over with my index finger to push the plunger. Certainly, you have to be comfortable with a lot of dexterity to do that. Some of my partners have the technician hold the lids. With the more viscous drugs, you actually have to move to where you can put counter traction on the syringe.

Nadia K. Waheed, MD, MPH: And do you wear gloves?

David M. Brown, MD: I always wear gloves. I always wear masks.

Nadia K. Waheed, MD, MPH: And sterile gloves.

David M. Brown, MD: I do not use sterile gloves. I use procedure gloves, but new ones every time.

Nadia K. Waheed, MD, MPH: Tell me a little bit about this – the retina expert consensus recommendations that came out in 2018, have they changed anything that you do, or has it pretty much been experiential from what you’ve seen has worked most in your clinic?

David M. Brown, MD: I really evolved when I was a visiting professor at Wills and so I’m not using a speculum and I go, “Wow, you can do that.” And then I went home and tried it and patients love it, but, certainly, in Europe they do a lot more injections in the operating theater. That’s not practical here in the United States.

Transcript Edited for Clarity