Providing Safe and Effective Intravitreal injections - Episode 8

Techniques for Numbing the Eye When Using Intravitreal Injection

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Nadia K. Waheed, MD, MPH, and David M. Brown, MD, provide expert advice on techniques to numb the eye before intravitreal injections.

Nadia K. Waheed, MD, MPH: I know that everyone has a different approach to numbing patients. I started out by doing subconjunctival injections or used to do a lot of subconjunctival injections. And since then, I’ve almost exclusively moved to using a gel. And you do have to leave the gel in the eye, I think, for a few minutes for it to have an effect. But I do think that the psychological effect of not having to get a couple of needles, as well as the fact that someone else can put the gel in after the OCT [optical coherence tomography test] is done, and then the patient can sit with the gel and numb while they’re waiting for the physician to come in, works really well in our clinics. But what is your preferred method of numbing the eye?

David M. Brown, MD: I’m a little unique in my practice. I’m just like you—I’m either gel or pure topical. Some of my partners just are convinced that everybody has to have subconj [subconjunctival]. If you do topical on everyone, there is probably 5% to 10% that really have discomfort going to the colloid; those need subconj. I get it. There’s another 20% to 30%, they kind of flinch when you put the needle in the eye, but they don’t really feel it or say that it’s a problem. And I think a lot of doctors are treating that as opposed to asking the patient, “What do you want?” To me, the subconjunctival hemorrhages, especially for a younger patient, are socially stigmatizing. You just get way more subconj hemorrhages with subconj lidocaine. In surgery and in everything else, I try to minimize. I’m a minimalist and my patients love it, but it may be a selection bias. If you’re a minimalist, you may like me. And if you want a subconj, you may want Tien Wong, MD, at Retina Consultants of Texas in Houston]. And it gravitates to the guys that do it the way they like it.

Nadia K. Waheed, MD, MPH: No, absolutely. And, you know, you’re very right. There’s a certain percentage of patients who will flinch, but they will tell you: “That did not hurt. I just felt you there.” And it’s a natural reaction. And I wonder if they would also flinch once you did subconj lidocaine, or if you did the subconj lidocaine whether they would still be flinching because they know you’re bringing a needle close; you’re bringing a needle close to their eyes.

Transcript Edited for Clarity