Purpose
To describe the intravitreal injection technique practice patterns of retinal specialists in the United States from April 8, 2010 to April 21, 2010.
Design
Questionnaire survey.
Methods
All members of the American Academy of Ophthalmology who self-categorized as “Retinal/Vitreous Surgery” were contacted by e-mail to complete an anonymous, 20-question, internet-based survey.
Results
A total of 765 retinal specialists (44%) responded to the survey. Most respondents wear gloves (58%) and use an eyelid speculum (92%) when performing an intravitreal injection. More than 99% use povidone-iodine preinjection. The majority measure the injection site from the limbus (56%) and inject straight into the vitreous cavity (96%). Most do not displace the conjunctiva (83%). Seventy-two percent routinely assess postinjection optic nerve perfusion, primarily by gross visual acuity measurement (32%). While nearly one third of participants use prophylactic topical antibiotics preinjection, more than two thirds use topical antibiotics postinjection. Forty-six percent perform bilateral simultaneous intravitreal injections. The majority of respondents use a 30-gauge needle for the injection of ranibizumab (78%) and bevacizumab (60%). However, respondents use both a 27- and 30-gauge needle for the injection of triamcinolone acetonide.
Conclusions
Retinal specialists in the United States participate in a range of techniques for the care before, during, and after intravitreal injections. Further study is needed to elucidate best practice patterns.
Despite the widespread acceptance of intravitreal injections for the treatment of a variety of ocular diseases, there is no current consensus upon injection technique or preinjection or postinjection care. Serious adverse effects of intravitreal injection include endophthalmitis, retinal detachment, ocular hypertension, and cataract. With the increasing occurrence of patients receiving bilateral simultaneous injections, there remains a need to evaluate best practice pattern techniques to increase patient safety. There have been reports summarizing the risks of intravitreal injections and describing guidelines based on current best evidence and practice. However, few elements regarding intravitreal injection technique or peri-injection care stem from evidence-based medicine. This study aims to describe the intravitreal injection practice patterns of retinal specialists in the United States from April 8, 2010 to April 21, 2010.
Methods
All members of the American Academy of Ophthalmology (AAO) who self-categorized as “Retina/Vitreous Surgery” were contacted by e-mail to complete an anonymous, 20-question, internet-based survey. In March 2010, there were 2058 AAO members who self-categorized as “Retina/Vitreous Surgery.” Among those physicians, 253 did not list an e-mail address. Seventeen e-mail addresses were recorded for more than 1 physician. Therefore, 1788 surveys were e-mailed on April 8, 2010. Sixty-eight e-mails were returned to sender as the addresses were no longer valid. This study, therefore, included 1720 total survey participants. Three reminder e-mails were sent to participants who had not yet completed the survey. Study data were collected and managed using REDCap electronic data capture tools hosted at the Mayo Clinic. REDCap (Research Electronic Data Capture) is a secure, web-based application designed to support data capture for research studies, providing: 1) an intuitive interface for validated data entry; 2) audit trails for tracking data manipulation; and 3) automated export procedures for seamless data downloads to common statistical packages. Results were tabulated on April 21, 2010.
Results
By April 21, 2010, 765 of 1720 retinal specialists (44%) responded to the survey. Among participants, 279 (37%) worked in a retina-only group practice, 225 (29%) worked in a multispecialty group practice, 126 (16%) worked in a solo practice, 109 (14%) worked in a university setting, 19 (2%) worked in a combination of the above settings, and 6 (1%) described their setting as “other.” The participants were nearly evenly divided in terms of length of time practicing, after the completion of a retina/vitreous fellowship. Twenty-four percent (180/761) have practiced between 1 and 7 years post-fellowship, 26% (196/761) have practiced between 8 and 15 years post-fellowship, 28% (216/761) have practiced between 16 and 25 years post-fellowship, and 22% (169/761) have practiced for over 25 years since fellowship completion. Sixty-seven percent of respondents (513/762) performed 10 to 50 intravitreal injections per week. Eighteen percent (138/762) performed 0 to 10 injections per week, and 15% (111/762) performed >50 injections per week.
Preinjection Considerations
Fifty-eight percent (439/762) of respondents don gloves to perform an intravitreal injection. Among those who wear gloves, 58% (254/439) wear sterile gloves and 42% (185/439) wear clean gloves. The majority of respondents do not use a sterile drape (88%; 668/759), yet do use an eyelid speculum (92%; 700/760). Nearly all respondents use povidone-iodine preinjection (758/761). One third of retinal specialists use prophylactic topical antibiotics either for a multiday course preinjection or immediately prior to an injection (34%; 257/758).
Injection Technique
Approximately half of the survey respondents (56%; 424/762) measure the distance from the limbus to the injection site. Among those who measure, 66% use calipers (280/424), 28% use a tuberculin syringe (119/424), and 6% use another device (25/424). Few respondents displace the conjunctiva prior to injection (17%; 129/761) or tunnel the needle during injection (4%; 33/758). Among the 59% of participants (448/757) who consider the speed of the jet of fluid they inject, a majority (76%; 340/448) inject quickly. A majority of survey participants use a 30-gauge needle for the intravitreal injection of ranibizumab (Lucentis; Genentech, South San Francisco, California; USA) and bevacizumab (Avastin; Genentech) (78%; 581/745 and 60%; 455/759 respectively). Most respondents use a 27-gauge needle for the intravitreal injection of triamcinolone acetonide (Kenalog) (57%; 418/738). A similar amount of retinal specialists use a 27-gauge vs a 30-gauge needle for the injection of triamcinolone acetonide (Triesence) (43%; 301/697 and 44%; 310/697 respectively).
Postinjection Considerations
Nearly three quarters of the survey respondents routinely assess postinjection optic nerve perfusion (72%; 546/759). Among those who assess optic nerve perfusion, 32% (176/546) perform a gross visual acuity examination (finger count or hand motion assessment), 21% (116/546) visualize the optic nerve, 15% (83/546) measure the intraocular pressure, and 31% (171/546) use a combination of the above techniques. A majority of retinal specialists (81%; 608/753) use prophylactic topical antibiotics postinjection. Nearly half of the survey respondents (46%; 348/763) perform bilateral simultaneous intravitreal injections.
Results
By April 21, 2010, 765 of 1720 retinal specialists (44%) responded to the survey. Among participants, 279 (37%) worked in a retina-only group practice, 225 (29%) worked in a multispecialty group practice, 126 (16%) worked in a solo practice, 109 (14%) worked in a university setting, 19 (2%) worked in a combination of the above settings, and 6 (1%) described their setting as “other.” The participants were nearly evenly divided in terms of length of time practicing, after the completion of a retina/vitreous fellowship. Twenty-four percent (180/761) have practiced between 1 and 7 years post-fellowship, 26% (196/761) have practiced between 8 and 15 years post-fellowship, 28% (216/761) have practiced between 16 and 25 years post-fellowship, and 22% (169/761) have practiced for over 25 years since fellowship completion. Sixty-seven percent of respondents (513/762) performed 10 to 50 intravitreal injections per week. Eighteen percent (138/762) performed 0 to 10 injections per week, and 15% (111/762) performed >50 injections per week.
Preinjection Considerations
Fifty-eight percent (439/762) of respondents don gloves to perform an intravitreal injection. Among those who wear gloves, 58% (254/439) wear sterile gloves and 42% (185/439) wear clean gloves. The majority of respondents do not use a sterile drape (88%; 668/759), yet do use an eyelid speculum (92%; 700/760). Nearly all respondents use povidone-iodine preinjection (758/761). One third of retinal specialists use prophylactic topical antibiotics either for a multiday course preinjection or immediately prior to an injection (34%; 257/758).
Injection Technique
Approximately half of the survey respondents (56%; 424/762) measure the distance from the limbus to the injection site. Among those who measure, 66% use calipers (280/424), 28% use a tuberculin syringe (119/424), and 6% use another device (25/424). Few respondents displace the conjunctiva prior to injection (17%; 129/761) or tunnel the needle during injection (4%; 33/758). Among the 59% of participants (448/757) who consider the speed of the jet of fluid they inject, a majority (76%; 340/448) inject quickly. A majority of survey participants use a 30-gauge needle for the intravitreal injection of ranibizumab (Lucentis; Genentech, South San Francisco, California; USA) and bevacizumab (Avastin; Genentech) (78%; 581/745 and 60%; 455/759 respectively). Most respondents use a 27-gauge needle for the intravitreal injection of triamcinolone acetonide (Kenalog) (57%; 418/738). A similar amount of retinal specialists use a 27-gauge vs a 30-gauge needle for the injection of triamcinolone acetonide (Triesence) (43%; 301/697 and 44%; 310/697 respectively).
Postinjection Considerations
Nearly three quarters of the survey respondents routinely assess postinjection optic nerve perfusion (72%; 546/759). Among those who assess optic nerve perfusion, 32% (176/546) perform a gross visual acuity examination (finger count or hand motion assessment), 21% (116/546) visualize the optic nerve, 15% (83/546) measure the intraocular pressure, and 31% (171/546) use a combination of the above techniques. A majority of retinal specialists (81%; 608/753) use prophylactic topical antibiotics postinjection. Nearly half of the survey respondents (46%; 348/763) perform bilateral simultaneous intravitreal injections.
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