OSLI Retina

January 2020

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Practical Retina Incorporating current trials and technology into clinical practice Intravitreal Injections: Minimizing the Risk and Maximizing Comfort by Joseph Raevis, MD; and Eric M. Shrier, DO Intravitreal injection procedures have been performed in exponentially in- creasing numbers since 2004 due to availability of a greater number of drugs for a wider array of indica- tions. It is esti- mated that nearly 6 million intravit- real injections have been performed in the United States alone, making it one of the most commonly per- formed procedures in all of medicine. Eric M. Shrier, DO, and Joseph Raevis, MD, from New York provide us with a very interesting and concise review of how to decrease the risk of the intravitreal injections while maxi- mizing patient comfort. Despite the high number of intravitreal injections performed, it is fascinating to see that there is no "one best way" to perform the procedure based on what is found in our literature. Drs. Shrier and Raevis remind us of the importance of our community sharing ideas and learning from each other with the goal of helping our patients. The intravitreal injection procedure has clearly evolved dur- ing the last one to two decades due to our colleagues trying to perfect the procedure. Just in the past decade, our practice has decreased antibiotic use, implemented a "no-talk policy," and started using smaller needles. I am certain their review will be a wel- come reminder to those who read it of how important this procedure is in the management of a wide variety of reti- nal diseases. INTRODUCTION Intravitreal injections (IVIs) are one of the most common surgical procedures performed in the world, 1 with an estimated 5.9 million IVI in the United States in 2016. 2 These injections are the foundation of modern retinal treatment and are used in a wide variety of disorders such as diabetic retinopathy, exudative macular degeneration, and retinal vein occlusions. The injection techniques vary among in- jectors, with the goal being prevention of in- fectious endophthalmitis (IE) while provid- ing for patient comfort. IE is rare after IVI, with an incidence of only 0.028% (1/3,544), 3 but it is the most feared complication of IVI due to the potential for devastating outcomes, even with prompt treatment. We briefly sum- marize the evidence for different techniques of providing IVI in a safe and comfortable manner. PRE-PROCEDURE ANESTHESIA Patient comfort is of the utmost importance since many patients will need to receive many IVIs to have maximal visual benefit. Thus, the goal of any technique is to increase compliance through comfort. Methods of anesthesia include topical proparacaine, tet- racaine, lidocaine gel, soaked pledgets, and subconjunctival lido- caine injection. All of these methods have been shown to have a relatively low level of associated pain. A subconjunctival injection of 2% lidocaine has been shown to have benefit for certain patients who are sensitive to pain; 4 however, this technique requires a sec- ond injection. It should be noted that when anesthetic gel is used, povidone iodine (PI) should be applied to the ocular surface prior to ap- plication of the gel to prevent bacteria from being sequestered by the gel. 5 Joseph Raevis Eric M. Shrier doi: 10.3928/23258160-20191211-01 Seenu M. Hariprasad Practical Retina Co-Editor

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