Providing Safe and Effective Intravitreal injections - Episode 4
Nadia K. Waheed, MD, MPH, and David M. Brown, MD, discuss how to accurately and safety monitor a patient post-intravitreal injection.
Nadia K. Waheed, MD, MPH: David, how do you monitor your patients after an intravitreal injection? Do you test vision after, do you like to look at the optic nerve, or is the risk low enough with the 0.05 … that we usually put in that you don’t feel the need to do that?
David M. Brown, MD: I always check for hand motion or a count-finger vision. It either goes to nothing—it either goes to gray—or they can see your hand and then they can see everything. And anybody that grays out repetitively or has RNFL [retinal nerve fiber layer] damage, I do an AC [anterior chamber] tap beforehand. It’s just easier. And it makes me feel better that I’m not hurting their optic nerve.
Nadia K. Waheed, MD, MPH: I think that makes a lot of sense. I know back in the day we used to call patients up on postoperative day 1 after the injection to make sure they were doing well. I don’t see the need to do that anymore. The risk is so low and I’m not even sure that you would catch anything with a postop day 1 phone call. But I’m wondering if you still do that or still do any kind of monitoring outside of just giving them precautions, and having them come in if there is anything unusual?
David M. Brown, MD:Outside of my patients that are coming from hundreds of miles away, I try to do a 1-week postop check, really to go over the risk, and signs and symptoms, of endophthalmitis. With that first injection, they’re so worried about the needle and everything else. I’m not sure they really comprehend much of what else you tell them. The next visit, if I can show them improvements on the OCT [Optical Coherence Tomography test], that’s great. But the main reason I do that 1-week postop visit is for education. After that I don’t do it, but I say if anything’s different, contact our office immediately.
Nadia K. Waheed, MD, MPH: You actually bring them in one week after the injection, into the office?
David M. Brown, MD: We try to for education, that’s it.
Nadia K. Waheed, MD, MPH: That’s very interesting. I haven’t done that, but I think that’s something to think about.
David M. Brown, MD: It depends on the clinic. Coming into inner-city Boston, I’m sure it is a big deal. And that may be more of a burden than it’s worth, especially if I’m in a clinic that’s in more of a suburban area, where it’s not that inconvenient for them to come. It makes them feel good, too, because this time they’re not getting an injection, you’re showing them: “Look, we’re already seeing some benefit. There’s no inflammation. And here’s what to look out for in the future.”
Nadia K. Waheed, MD, MPH: I think certainly my nonresponders or the ones that I’m questioning, whether it’s a VEGF [Vascular Endothelial Growth Factor inhibitor] mediated process, I do tend to call them in a week or a couple of weeks after the injection. But outside of that, generally not.
Transcript Edited for Clarity