As demand for intravitreal injections continues to rise, finding ways to streamline retina clinic workflow without compromising patient care is essential.1,2 Patients want an experience that feels seamless and reassuring, while physicians and staff need protocols that optimize efficiency without adding unnecessary complexity. A refined approach to preinjection preparation can create a process that is not only faster but also more comfortable, ultimately improving both patient satisfaction and clinical productivity.
Figure 1. Esther Lee Kim, MD, instills Povicaine as part of her clinic’s preinjection protocol. Image courtesy Esther Lee Kim, MD.
Improving Adherence
Data show that US ophthalmologists perform about 2.5 million injections every year, with the busiest retina specialists performing as many as 50 injections per day.2 Projections show that by 2030, about 14 million individuals will require intravitreal injections for retinal disease.3 Although most patients receive between 4 and 8 injections (an average of 5) per year to preserve their vision,3,4 others require more depending on the disease and its severity. For instance, in a study of 54,392 patients in the IRIS Registry database, the most common interval in year 1 of anti-VEGF treatment for treatment-naïve neovascular age-related macular degeneration (nAMD) was 4 to 5 weeks.4 Nearly 40% of individuals who received anti-VEGF therapy needed injections less often than every 8 weeks during the first 2 years of treatment.
The patient experience can be a barrier to long-term adherence with intravitreal injections. If an injection visit is prolonged, uncomfortable, or anxiety-inducing, patients may be less likely to return as scheduled. Even for patients who present routinely, each injection experience can be daunting. Wet AMD usually affects individuals over the age of 50, and the additional costs of time for appointments, lost productivity, and discomfort for them and their caregivers is burdensome.5
Efficiency is crucial to reduce bottlenecks and maintain clinic productivity. We recently found a way to reduce patient appointment time and discomfort by making strategic changes to our preinjection protocols that still allow us to seamlessly manage a high volume of intravitreal injections.
A Simplified Protocol
For many years, our practice in Orange County, California, followed an elaborate preinjection routine: topical proparacaine, lidocaine-soaked pledgets, lidocaine hydrochloride ophthalmic gel, 3.5% (Akten; Akorn Pharmaceuticals), and povidone-iodine 5% solution (Betadine; Alcon) followed by a sterile rinse after the injection. Although effective, our process was cumbersome and lengthy. Patients spent 20 to 30 minutes prepping for a procedure that literally takes seconds. We wanted to simplify the injection process while maintaining its integrity and simultaneously improve the patient experience.
Practical Strategies for Optimizing Workflow
Beyond adopting a simplified preinjection protocol, consider these additional strategies to improve efficiency and patient satisfaction in a busy retinal clinic:
Standardized Staff Training: Ensure that all technicians follow a consistent protocol to minimize variability and keep the preinjection process running smoothly.
Technology Integration: Adopt electronic medical records and automated scheduling tools to reduce administrative bottlenecks, alleviate typographical errors, and provide convenience for patients.
Clear Communication: Integrate clear lines of communication that promote coordination between staff and providers to prevent unnecessary delays and keep patient flow efficient.
Patient Education: Incorporate handouts and instructional videos to help educate patients and set realistic expectations. Providing patient education materials prior to the visit may help reduce the need for lengthy explanations during appointments, freeing up more time in the clinic.
A fellow retina specialist introduced me to a compounded triple-acting drop combining povidone-iodine 1.25% and proparacaine 0.5% (Povicaine; ImprimisRx). He had been using it exclusively for 3 years with great success. Intrigued by the potential to simplify our protocol, I decided to give it a try. Under our current preinjection protocol, we use 3 sets of Povicaine drops every 5 minutes, followed by 1 or 2 lidocaine-soaked pledgets (Figure 1).
Incorporating Povicaine into our preinjection process was a game-changer. By combining sterilization and anesthesia in a single drop, we eliminated the need for pricey lidocaine hydrochloride gel and irritating povidone-iodine solution. For some physicians, this new process obviates the need for a postinjection rinse, which allows us to streamline our workflow, make the injection experience more consistent from technician to technician, and free up staff for other tasks. (Some of my colleagues still prefer to rinse the eye, but the rinse time is drastically reduced.)
There are several benefits for patients, who no longer experience the stinging sensation associated with povidone-iodine 5% solution or the cold shock and messiness of a postinjection rinse. Additionally, most patients note clearer vision immediately after the injection and report minimal time to regain their preinjection vision. They also say there is less irritation on the day of their injection, and they can go about their day much more easily than they could previously. Knowing that the process is quicker, predictable, and less uncomfortable helps to alleviate patient anxiety, and eliminating unnecessary steps significantly reduced both preinjection preparation and patient wait times, allowing us to maximize time with patients without feeling rushed. Offering a simplified preinjection protocol that features a single drop for sterilization and anesthesia is a way we can meet, and even exceed, patient expectations for care.
I was initially concerned about how established patients would react to the change in our preinjection protocol, but the feedback was overwhelmingly positive. Returning patients appreciated the streamlined visit and quicker recovery. New patients who had no prior expectations adapted seamlessly. Within 2 weeks of consistent use in a variety of patient types, my team fully embraced the updated protocol. We then scaled the new protocol to the entire clinic.
For those patients who remain highly sensitive and have voiced unwillingness to tolerate any pain during the procedure, I still offer subconjunctival lidocaine, but for the vast majority, Povicaine has proven more than sufficient. A simple tweak—holding a cotton swab over the eye for 60 seconds after applying the drop—enhances and provides durability in its anesthetic effect and ensures consistency in the treatment. Small adjustments like these can have a significant effect on patient comfort.
Consistency Is Key
Patients who present for retinal injections appreciate knowing what to expect. A predictable, comfortable experience fosters trust and encourages adherence to their injection schedules. By refining our approach to intravitreal injections—incorporating a triple-acting drop, reducing unnecessary steps, and prioritizing patient comfort—we have created a system that benefits both our practice and our patients.
Rethinking the basics of our preinjection protocol has allowed us to maintain high standards of safety and efficacy while elevating the patient experience. Ultimately, a streamlined, patient-centric approach ensures that we meet growing demand while keeping our patients comfortable, confident, and committed to their treatment. RP
References
1. Wong WL, Su X, Li X, et al. Global prevalence of age-related macular degeneration and disease burden projection for 2020 and 2040: a systematic review and meta-analysis. Lancet Glob Health. 2014;2(2):e106-e116. doi:10.1016/S2214-109X(13)70145-1
2. Patel S. Medicare spending on anti–vascular endothelial growth factor medications. Ophthalmol Retina. 2018;2(8):785-791. doi:10.1016/j.oret.2017.12.006
3. MacCumber M. Real-world injection intervals in wet AMD. Retina Today. May/June 2020. Accessed February 25, 2025. https://retinatoday.com/articles/2020-may-june/real-world-injection-intervals-in-wet-amd
4. MacCumber M, Yu JS, Sagkriotis A, et al. Injection intervals in treatment-naïve neovascular AMD patients who received anti-VEGF agents: an analysis of the IRIS Registry. Paper presented at: American Academy of Ophthalmology annual meeting; October 12-15, 2019; San Francisco.
5. Macular Society. Age-related macular degeneration. Accessed February 5, 2025. https://www.macularsociety.org/macular-disease/macular-conditions/age-related-macular-degeneration