Nailing intravitreal implant injections
Experienced user details proper handling, injection technique of FAc implant for DME
All intravitreal injection procedures should include adequate anesthesia and should be carried out under aseptic conditions with generous application of 5% aqueous povidone iodine (Betadine) drops to the ocular surface.
It is also advisable to clean the lid margins, eyelashes, and periocular skin with a commercially available cotton-tipped swab soaked in 10% povidone iodine solution. A sterile speculum keeps the eye open and frees the other hand that holds a sterile cotton tipped applicator.
My assistant and I wear facemasks to prevent contamination of the operative field by oral flora. The injection is performed in the office by reclining the examination chair to a near-horizontal position under the illumination provided by a binocular indirect ophthalmoscope (BIO) and magnification provided by +2 D lenses contained in the eyepieces of the BIO and my presbyopic glasses. I no longer prescribe pre- or post-injection antibiotic drops.
My preference for anesthesia is subconjunctival infiltration of the quadrant of intravitreal injection with 0.2 to 0.3 mL 1 to 2% lidocaine without epinephrine using a sterile 30-gauge needle. A drop of proparacaine instilled 5 minutes prior to subconjunctival injection of lidocaine provides surface anesthesia. The subconjunctival injection is performed several millimeters from the limbus, where tissues are less sensitive to pain.
The patient must be warned that the lidocaine injection due to its acidic pH is often associated with temporary stinging that lasts a few seconds. I allow 5 to 10 minutes for anesthetic to take full effect.
After verifying presence of the implant through the window of the applicator, push in the center of the button to visibly depress it, and then advance it by continuous and steady forward pressure to the curved black line on the device.
Release the button and visually ensure that it rises up. If the button does not rise up, the device cannot be used and must be discarded.
I advise holding the button with the finger and thumb of the supporting hand and nudge it to ensure it has risen completely. Keep the device level or the needle end pointing slightly up during this step to maintain correct implant positioning. Once the button is in up position at the curved black line, the device is ready.