www.diabeticretinopathy.org.uk

Ocular steroid & anti-VEGF injections

Post injection endophthalmitis, technique etc

David Kinshuck

Risk Factors

  1. Infections Eye 12 "Significant risk factors
    1. were failure to administer topical antibiotics immediately after the injection (P=0.001),
    2. blepharitis (P=0.006),
    3. subconjunctival anaesthesia (P=0.021),
    4. patient squeezing during the injection (P=0.021), and
    5. failure to administer topical antibiotics before anti-VEGF injection (P=0.05)."
  2. Infection is related to eye cleaning rather rather than drapes/gloves see 09. Strep Retina 2011
  3. must wait 3 minutes after the eye is cleaned.
  4. Operating theatre ...far fewer infections than an outpatient room, even a clean room.

Symptoms of infection

Eye 12..these are the common symptoms that patients notice.       

  1. blurred vision........96%
  2. pain/photophobia...73%
  3. redness ...............50%
  4. floaters................25%
  5. lid swelling ...........10%
  6. discharge .............10%

Notes for professionals

  1. Intravitreal injections, precautions:
    • wrong drug injected
    • if pressure very high and central retina artery occluded, AC tap or IV diamox
    • if patient has severe cupping, pre-treat with diamox
    • post-injection prophylaxis does not help Retina 11
    • infections Ophth 2011
  2. 30 Gauge needles and deeper injections reduce reflux and retina incarceration. (Retina 2010)
  3. The technique
    • topical anaesthetic and dilating agents
    • polvidone iodine to clean eye
    • 4mm behind limbus, 3.5mm if pseudophakic
    • 29 gauge needle 4mg = 0.1ml triamcinolone (check suitability for intravitreal injection as here)
    • expect a pressure rise in 50% at 1 month, many requiring drops/treatment, sometimes severe, as here
    • some patients were retreated..most patients benefit, but usually the effect is temporary (6 months)
    • one patient on anticoagulants developed a large subconjunctival haemorrhage, another developed a cataract (out of 20 patients)
    • these patients had had macular oedema for years
    • in our experience triamcinolone does not work if the oedema has been present for more than a year.
    • it is critical to shake the triamcinolone vial and inject immediately or as soon as possible...a 10 minute delay introduces a great variation in the dose given.
  4. symptoms
    1. vitritis 91%
    2. hypopyon 75%
    3. hyperaeima 75%
    4. corneal oedema 24%
    5. raised IOP 10%