2018 update on intravitreal injections
Reviewed by Sofia Rokerya

In this review article the authors have highlighted the standardised and structured approach to intravitreal injections (IVI) by examining the recent evidence-based literature. IVI is the most commonly performed procedure worldwide with low potential risk of endophthalmitis. IOP spikes are common immediately after IVI and return to safe levels within 30 minutes in majority. IOP however needs to be controlled in patients vulnerable to vascular optic nerve damage, predisposition to anterior ischaemic optic neuropathy, glaucoma or retinal vein occlusion (RVO). Topical IOP lowering drops, ocular decompression with a bag, or digital globe massage before the procedure is recommended. Anterior chamber paracentesis should be performed in case of pain or severe vision threat. If re-treatment is considered digital massage of the eye prior to the injection, along with slower injection speed is recommended. Injection should be avoided close to trabeculectomy sites, drainage devices, and scleral patch. If the vitrectomy is recent, it is prudent to choose an injection location that is far from the sclerotomy sites. Eyes with silicone oil can receive IVI, however adequate data is lacking on this. Pre-existing cardiovascular or cerebrovascular conditions, if recent or unstable, merit caution. Use of anticoagulants has not documented to be associated with an increased risk of haemorrhage following IVI. Active external infection including blepharitis should be treated prior to IVI. Conjunctiva and fornices can be rinsed with povidone iodine (PI), to reduce the potential risk for EO. The risk-benefit ratio of intravitreal steroidal agents is acceptable during pregnancy. Use of anti-VEGF should be weighed against the possible risk of fetal developmental abnormalities or pregnancy loss, especially during the first trimester. Treatment should only be administered following a thorough discussion with the patient, as well as consultation with an obstetrician. Of the currently available anti-VEGF agents, ranibizumab may be the safest choice as it has been shown to have the most rapid clearance from systemic circulation and weakest effect on plasma VEGF levels. Breastfeeding is not a contraindication to IVI therapy according to available evidence. Operating theatre, clean room or in office settings are recommended. Topical anaesthesia being least invasive is recommended. Topical administrations of 5% povidone-iodine at least 30 s into the conjunctival sac is recommended. Chlorhexidine is a safe alternative to PI. Currently there are not enough data to support preoperative lid scrubs or wash. Also, there is no evidence to consider perioperative antibiotics as a standard of care. Currently there is no concluding recommendation to dilate or not to dilate the pupil for IVI. Any effective way to avoid lid closure during the procedure is justified. Gloves are recommended. Draping may not be essential. Use of a face mask for the operator is recommended. Thirty-gauge or thinner needles are recommended for liquid injections whereas larger needles should be used when necessary. Guidelines suggest using any needle length from 13 to 18mm. Injections should be made through the pars plana, between 3.5 and 4mm from the limbus. There is no clear agreement on the exact location or quadrant for IVI. If patients receive repeated IVI, it is recommended to rotate injection sites. A risk-benefit assessment is advised to avoid the potential complication of bilateral EO. It is recommended to handle each procedure as a separate one and use separate equipment. 

2018 Update on Intravitreal Injections. Euretina Expert Consensus Recommendations.
Grzybowski A, Told R, Sacu S, et al.
OPHTHALMOLOGICA
2018;239:181-93.