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Intravitreal Injection Survey
Part 2 - Dealing with complications.
Retina specialists are now performing more intravitreal
injection procedures than ever before.
Almost all of the emerging therapies for the
wet form of AMD are currently administered by intravitreal injection, including
pegaptanib sodium (Macugen, OSI/Eyetech, Pfizer), bevacizumab (Avastin, Genentech),
ranibizumab (Lucentis, Genentech), and triamcinolone (Kenalog, Bristol-Myers Squibb).
With retina specialists now routinely using 1 or more of these drugs in everyday
practice, the incidence and types of complications associated with intravitreal
injections are an increasing concern.
With this in mind, the editors of Retinal Physician have
conducted a 2-part survey to determine how doctors are performing intravitreal injections,
how closely they are following various recommendations for infection control, and
what types of complications they are seeing, if any.
In Part 1 of the survey, published in the May/June issue of Retinal
Physician, responders reported on the drugs they are using intravitreally, the
infection control measures they are taking, and the type and incidence of complications
they are seeing associated with intravitreal injections.
Part 2 of the survey dealt with how retina specialists are treating
these complications and the seriousness of the complications they are reporting.
FEW COMPLICATIONS REPORTED
One point should be made at the outset.
Almost all of the physicians noted that the incidence of complications associated
with intravitreal injection is extremely low. Forty-seven percent of responders
specifically said they have experienced only 1 complication in their history of
giving these injections and 21% reported no complications at all.
The following response is typical:
"I have had 1 case of uveitis after 500 Avastin injections,
managed with topical steroids. No long-term complications."
The most common complications reported in the survey were endophthalmitis
and increased IOP, with at least 1 case of endophthalmitis reported by 31% of
survey responders and at least 1 incidence of increased IOP reported by 26% of responders.
All of the responders who reported endophthalmitis used intravitreal
antibiotics to treat the condition. The following is a typical response:
"One case of culture-positive strep endophthalmitis in a diabetic
patient after injection of Kenalog. Treated with intravitreal antibiotics."
All of the responders who reported increased IOP (or glaucoma)
used pressure-lowering drops to treat this complication.
The following is a typical response:
"Complication related to to intravitreal Kenalog — increased
intraocular pressure managed with topical therapy."
Other complications reported in the survey were 2 incidences of
cataract, 1 incidence of corneal abrasion, 1 incidence of subjunctival hemorrhage,
and 1 incidence of vitreous hemorrhage. Responders said they initially treat cataract
by observation, followed by cataract surgery if needed. Corneal abrasion was treated
with antibiotic drops and a bandage contact lens. Subjunctival hemorrhage was treated
with cold compresses, and vitreous hemorrhage required observation.
LOW INCIDENCE OF VISION
LOSS
In terms of vision loss associated with
intravitreal infections, responders reported short-term vision loss associated with
endophthalmitis and progressive vision loss associated with cataract prior to cataract
surgery. One patient with pre-existing diabetic retinopathy and 1 patient with pre-existing
CRVO continued to lose vision after intravitreal injections.
Of the patients who sustained vision loss after intravitreal injections,
only 16% were given additional intravitreal injections following treatment for the
initial complication.
BASIC SURVEY RESULTS:
Complications reported associated with intravitreal
injections:
• None - 21%
• 1 - 47%
• More than 1 - 32%
Types of complications reported:
• Endophthalmitis - 31%
• Increased IOP - 26%
• Cataract - 11%
• Other - 16%
Vision loss reported with:
• Endophthalmitis
• Cataract
• Pre-existing diabetic retinopathy and CRVO
Retinal Physician, Issue: July 2006