feature
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