To drape or not to drape during Intravitreal Injection

[vrnp1]

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There is an argument as to whether it is necessary to use the drape during Intravitreal injections. Some say it is not as long as adequate cleaning of lashes, lids etc is done. Some say they uses drape only to keep lashes away.

I'd be interested in feedback from the others: drapers or non-drapers???

Thanks

 

[Free Radicle]

Our attending said that there has recently been a case series done of whether or not antibiotic gtts ( I have not seen the paper) are necessary afterwards, apparently the answer is no on both accounts. All we do is betadine to the adnexae, squirt alcaine on the betadine stick and let it drip into the eye, put the speculum in and inject. I still give cipro qid x 4 days anyway.

 

[Mirror Form]

I still give cipro qid x 4 days anyway.

Even on your AMD patients who're getting lucentis is each eye, and consequently get an injection like every couple weeks (arrrgg)?

 

[Visionary]

None of our staff drape. Interestingly, the injection protocol does vary considerably amongst our staff. The commonalities are:

1) Anesthetic
2) Speculum in
3) 1/2 strength povidone iodine
4) Measure (3.5 mm if pseudophakic, 4 mm if phakic)
5) Inject
6) Vigamox QID x 4 days

Most give only topical anesthetic (tetracaine from a new bottle). One gives subconj Lido at the injection site. Some give 3 sets of 3 gtts (povidone iodine, tetracaine, Vigamox), while others give only one. All give post-injection Vigamox. Of note, we've never had a case of post-injection endophthalmitis (that I'm aware of), despite these varied approaches.

To paraphrase one of my attendings, "if there is more than one way to do something, there must not be one 'best' way."

As the incidence of endophthalmitis is so low, there will likely never be a good controlled study of this.

 

[idoc]

I would agree with visionary's post, as he is quite smart. I never drape my patients, but they do get a drop of betadine, and vigamox/zymar qid X 4 days post injection. I have probably done 100 injection myself, and I have not had one case of endophthalmitis...yet. Hopefully this is good advice, but it is definitely the way things are done at my institution.

As for anesthetizing the eye, we use topical 4% lidocaine on cotton tip applicator applied locally for about 1 min directly over the injection site. I have also used viscous lidocaine jelly which works well and saves time because you can put it in the eye as soon as they sign the consent, and then gather the supplies. By the time you come back, they are numb and you are good to go. I also use 3.5mm markings for both phakic and pseudophakic patients, and some of my attendings will go 3.0mm from the limbus, so I guess this is a matter of personal preference as well. Good luck to all.

 

[idoc]

I know this is not the original topic of conversation, but I have a intravitreal injection instructions list I have put together for our in house resident handbook, and I thought I would share it. Any critiques are welcomed. Hope some might find this helpful.

How to do an Avastin/Lucentis injection.

Step 1. Consent
Step 2. Obtain the following: Gloves, lucentis/avastin, 1cc syringe, lid speculum, marking device, 4%lidocaine, betadine, tetracaine drop, vigamox, alcohol foam.
Step 3. Place tetracaine drop in eye, and then also place drop of vigamox and betadine. Then open gloves up, and make a sterile field to put your other items on in a peel pack manner. These would be the syringe, the avastin/lucentis, the scleral marker, and the lid speculum.
Step 4. Wash hands with alcohol foam, and prepare the drug. Remember, draw up Lucentis with the filter needle, and then place 30g needle on. Also, remember you need to make sure you have 0.05 ml in the syringe.
Step 5. Put lid speculum in.
Step 6. Numb inferolateral quadrant with 4% lidocaine solution.
Step 7. Mark the inferolateral scleral 3.0mm to 3.5mm pos to the limbus. A tb syringe hub is 3.0mm, and the marker is 3.5mm on one end and 4.0mm on the other end.
Step 8. Inject 0.05ml of drug in the vitreous
Step 9. Make sure patient can see your hand waving in front of the eye you injected.
Step 10. Remove speculum and place vigamox drop in the eye.
Tell patient to use vigamox 4times per day for the next 4 days, and call with any concerns, especially red eye/ decreased vision/ signs of infection.

 

[vrnp1]

Thankyou all for your replies:

I have got another question. Do most of you use topical anaethesia? i know some uses subconj aneathesia.

 

[Mirror Form]

Thankyou all for your replies:

I have got another question. Do most of you use topical anaethesia? i know some uses subconj aneathesia.

I think most use topical.