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intravitreal injection procedure Flipbook PDF
steps of intravitreal injection procedure, TYPES precautions, how to inject
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Intravitreal Injection Procedure While most postsurgical endophthalmitis cases are believed to be related to the patient’s ocular surface flora (coagulase negative Staphylococcus species, many cases of endophthalmitis associated with intravitreal injection may be related to droplet transmission from the patient or from the health care providers.
Guideline • Povidone-iodine (5 percent for 30 seconds) should be the last agent applied to the intended injection site before injection. If a gel anesthetic is used, povidone-iodine should be applied both before and after gel application. • Use adequate anesthetic for a given patient (topical drops, gel and/or subconjunctival injection). • Topical antibiotics pre, peri or postinjection are unnecessary. Using of topical antibiotics associated with increased bacterial resistance. After each injection, one drop of the fluoroquinolone q.i.d. for four days is recommended. • No evidence supports the routine use of a sterile drape. • Avoid contamination of the needle and injection site by the eyelashes or the eyelid margins (Use of a speculum). • Avoid extensive massage of the eyelids either pre- or postinjection (to avoid meibomian gland expression). • Use sterile or nonsterile gloves. • Either surgical masks should be used or both the patient and providers should minimize speaking during the injection preparation and procedure to limit aerosolized droplets containing oral contaminants from the patient and/or provider. • Monitor IOP both pre- and post-injection. Confirm the presence of formed vision immediate postinjection. Give the patient 24-hour emergency contact information.
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Intravitreal injection | M. SHAFIE assistant lecturer
• Routine anterior chamber paracentesis is not recommended An active external infection, including significant blepharitis, should be treated prior to injection. In addition, eyelid abnormalities such as ectropion have been reported as risk factors for endophthalmitis. • Postinjection dilated examination of the posterior segment. (Although some viewed the return of formed vision as sufficient, others routinely dilate the pupil and examine the posterior segment after injection.)
Approach with the Needle *Intravitreal injections should be given between the horizontal and vertical rectus muscles at the pars plana…According to age& lens condition: 1-6 m. 6 m. - 1y. 1-2 y. 2-6 y. >6y.
1.5mm from limbus 2mm 2.5 mm 3mm 3.5 to 4 mm in phakic eyes and 3 to 3.5 mm in pseudophakic or aphakic.
*While the inferotemporal quadrant is generally the preferred site of injection due to ease of exposure (no need to pass the needle over the bridge of the nose or the brow), patient-specific considerations and the injecting physician’s preference should dictate quadrant selection.
*Although oblique and tunneled needle insertions have been described as attempts to minimize drug reflux after injection, a perpendicular injection approach is convenient and preferred in most settings. *Needle gauge is selected based on the drug being injected. A 30-gauge or smaller needle is generally preferred for nonviscous drugs (Anti VEGF 30 g needle- Triamcinolone 27 g needle- Dexamethasone implant 22 g).
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Intravitreal injection | M. SHAFIE assistant lecturer
Larger gauge needles may be considered for suspensions and for more viscous solutions. Needle length should be 5/8 inch (18 mm) or shorter, but long enough to permit complete penetration of the pars plana. Vancomycin 500mg vial 1mg/0.1ml Against gram +ve Fortum 1gm vial 2.25mg/0.1 ml Against gram -ve
Dil in 10 ml take 1ml شرط بسرنجه انسولين10 نسحب Dil in 10 ml take 1ml شرط بسرنجه انسولين10 نسحب
Amphotericin B 0.005mg/0.1ml Antifungal SF6 C3F8
Dil in 10 ml take 0.1ml Dil in 10ml شرط بسرنجه انسولين10 نسحب Inject .6 ml to give 1.2 ml after expansion Inject .3 ml to give 1.2 ml after expansion
Avastin
Lucentis
1.25mg/0.05ml
.3mg / 0.05ml
Bevacizumab
Ranibizumab .3mg
Recombinant humanized monoclonal Ab
monoclonal Ab fragment
Sys. Half-life: 20d
Sys. Half-life: 2h
Repeated after 1m.
Repeated after 1m.
Mucagen .3mg Pegaptanib
Triamcinolone 1-4mg/0.1ml Without dilution Repeated after 3-4m.
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Ozardex
Dil in 5ml Dil in 5ml
Retisert / ILUVIEN
Dexamethazone .7mg
Fluocinolone acetonide .19 mg
Duration of action:6m.
Duration of action:30m.
Eylea 2mg/0.05ml Aflibercept Rec fusion protein
Intravitreal injection | M. SHAFIE assistant lecturer
DRCR.net Protocol I, patients were started off with a loading dose of four injections, but if patients did not have 20/20 vision and no edema, they were given an additional two injections. So in reality, it was a six-dose loading phase. Comparatively speaking, in AMD it is traditionally a threedose loading phase.
COMPLICATIONS: 1-Post IV endophthalmitis: The risk is lower in RVO, higher in DME and AMD. the surgeons should consider every case of uveitis after intravitreal anti-VEGF injection as suspected endophthalmitis and should administer intravitreal antibiotics
2-Intraocular inflammation: Time of presentation: less than 1 d. No keratic precipitates, hypopyon, fibrin, or anterior synechia
3-Rhegmatogenous retinal detachment D2 induction of posterior vitreous detachment or an incorrect technique of injection
4-Intraocular pressure elevation lasts a few hours at most
5-Ocular hemorrhage Subconjunctival haemorrhage in patient taking aspirin massive choroidal detachment/haemorrhage or Massive subretinal haemorrhage discontinuation of the anticoagulants for intravitreal injections is not recommended 4
Intravitreal injection | M. SHAFIE assistant lecturer
6- considerations in DR and retinal vascular occlusions development or progression of TRD 5 days or more after the injection
Fortified eye drop الحقن الثنائي الحقن الثالثي الحقن الرباعي
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Vancomycin&Amikin ايام5 بالتبادل كل ساعه لمده -Dexamethazone -Atropin -Vancomycin -Amikin -Atropin -Vancomycin -Amikin -Atropin -Dexamethazone
Intravitreal injection | M. SHAFIE assistant lecturer