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INTRAVITREAL INJECTION TECHNIQUE AND MONITORING: Updated Guidelines of an Expert Panel

Avery, Robert L. MD*; Bakri, Sophie J. MD; Blumenkranz, Mark S. MD; Brucker, Alexander J. MD§; Cunningham, Emmett T. Jr MD, PhD, MPH‡,¶,**,††; D'Amico, Donald J. MD‡‡; Dugel, Pravin U. MD§§; Flynn, Harry W. Jr MD¶¶; Freund, K. Bailey MD***; Haller, Julia A. MD†††; Jumper, J. Michael MD¶,††; Liebmann, Jeffrey M. MD‡‡‡; McCannel, Colin A. MD, FACS, FRCS(C)§§§; Mieler, William F. MD¶¶¶; Ta, Christopher N. MD****; Williams, George A. MD††††

doi: 10.1097/IAE.0000000000000399
Guidelines
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Purpose: To review evidence and provide updated guidelines on intravitreal (IVT) injection technique and monitoring.

Methods: A review of the published literature on IVT injection from 2004 to 2014 formed the basis for round table deliberations by an expert panel of ophthalmologists.

Results: The dramatic increase in the number of IVT injections has been accompanied by a comparable increase in evidence surrounding IVT practice patterns and techniques. The expert panel identified a number of areas that have evolved since publication of the original IVT injection guidelines in 2004, the most notable of which were a lack of evidence to support the routine use of pre-, peri-, and postinjection antibiotics to reduce the risk of endophthalmitis, and the role of aerosolized droplets containing oral contaminants from the patient and/or providers as a potential source of infection. The panel emphasized the continued importance of applying povidone–iodine to and avoiding eyelid contact with the intended injection site and needle.

Conclusion: Updated guidelines on IVT injection technique and monitoring are proposed based on a review of published literature and expert panel deliberations.

Use of intravitreal injections and the evidence surrounding injection safety and techniques have expanded dramatically since publication of the initial intravitreal injection guidelines in 2004. An expert panel recently reconvened to evaluate the growing evidence on intravitreal injection techniques and monitoring and to provide updated consensus guidelines.

*California Retina Consultants and Research Foundation, Santa Barbara, California;

Mayo Clinic, Rochester, Minnesota;

Byers Eye Institute, Stanford University School of Medicine, Stanford, California;

§Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania;

California Pacific Medical Center, San Francisco, California;

**The Francis I. Proctor Foundation, UCSF School of Medicine, San Francisco, California;

††West Coast Retina, San Francisco, California;

‡‡Weill Cornell Medical College, New York-Presbyterian Medical Center, New York, New York;

§§Keck School of Medicine, University of Southern California, Los Angeles, California;

¶¶Bascom Palmer Eye Institute, University of Miami, Miami, Florida;

***Vitreous–Retina–Macula Consultants of New York, New York;

†††Wills Eye Hospital, Philadelphia, Pennsylvania;

‡‡‡Manhattan Eye, Ear & Throat Hospital, New York University Medical Center, New York, New York;

§§§Jules Stein Eye Institute, University of California, Los Angeles, California;

¶¶¶University of Illinois, Chicago, Illinois;

****Stanford University School of Medicine, Stanford, California; and

††††Oakland University William Beaumont School of Medicine, Beaumont Eye Institute, Royal Oak, Michigan.

Reprint requests: Emmett T. Cunningham, Jr., MD, PhD, MPH, West Coast Retina Medical Group, 1445 Bush Street, San Francisco, CA 94109; e-mail: emmett_cunningham@yahoo.com

R. L. Avery is a consultant for Alcon, Allergan, Inc, Bausch + Lomb, Genentech, Novartis, and Regeneron Pharmaceuticals, Inc. M. S. Blumenkranz is a Director for Optimedia Corporation, Avalanche Biotech, and Oculogics, Inc. D. J. D'Amico is a consultant for and has equity in Ophthotech Corporation and Neurotech Pharmaceuticals. He is a consultant for Genentech, PanOptica, LPath Incorporated, and Alcon. P. U. Dugel is a consultant for Abbott, Alcon, Alimera Sciences, Allergan, Inc, Arctic DX Inc, Annidis Corporation, Acucela Inc, DigiSight Technologies, Inc, Genentech, Lux Biosciences, Inc, MacuSight, Inc, NeoVista, Inc, ORA, Inc, Regeneron Pharmaceuticals, Inc, and ThromboGenics NV. He is a stock shareholder of Alimera Sciences, Arctic DX Inc, DigiSight Technologies, Inc, MacuSight, Inc, NeoVista, Inc, and Ophthotech Corporation. K. B. Freund is a consultant for Bayer HealthCare AG, Genentech, Regeneron Pharmaceuticals, Inc, and ThromboGenics NV. J. A. Haller is a consultant for Advanced Cell Technology, Inc, Alcon, KalVista Pharmaceuticals, Second Sight, Merck, ThromboGenics NV, and Regeneron Pharmaceuticals, Inc. J. M. Jumper has received research grants from Allergan, Inc, Genentech, and Regeneron Pharmaceuticals, Inc. J. M. Liebmann is a consultant for Alcon, Allergan, Inc, Bausch + Lomb, Carl Zeiss Meditec, Inc, Diopsys, Inc, Heidelberg Engineering, Inc, Merz, Inc, Optovue, Inc, Quark Pharmaceuticals, Inc, Sustained Nano Systems LLC, and Valeant Pharmaceuticals. He has received grant support from Allergan, Inc, Bausch + Lomb, Carl Zeiss Meditec, Inc, Diopsys, Inc, Heidelberg Engineering, Inc, National Eye Institute, New York Glaucoma Research Institute, Optovue, Inc, Reichert, Inc, SOLX, Inc, and Topcon Medical Systems, Inc. He is also an equity owner of Diopsys, Inc, SOLX, Inc, and Sustained Nano Systems LLC. W. F. Mieler is a consultant for Genentech and is on the Data and Safety Monitoring Committee for Acucela, Inc. C. N. Ta is a consultant for Bausch + Lomb. None of the other authors have any financial/conflicting interests to disclose.

These guidelines were based on the best available data as interpreted by a panel of knowledgeable health professionals. These guidelines are general and meet the needs of most patients but cannot possibly meet the needs of every patient. Adherence to these guidelines will not ensure a successful outcome in every situation. These guidelines should not be deemed inclusive of all proper methods of intravitreal injection or exclusive of other methods of obtaining the best results for a given patient. It may be necessary to approach different patients' needs in different ways. The injecting physician must make the ultimate judgment regarding the propriety of care of a particular patient in light of all of the circumstances presented by that patient. The panelists specifically disclaim any and all liability for injury or any damages of any kind from negligence or otherwise for any and all claims that may arise out of the use of any guidelines or other information contained herein.

© 2014 by Ophthalmic Communications Society, Inc.