Cross My Heart and Hope to Die, Stick a Needle in My Eye
Cross my heart…. the ubiquitous childhood pledge with the threat of an eye injection as the ultimate consequence for lying.
I guess that makes me the embodiment of evil. While my wife might not disagree with this, I sure hope that our patients aren’t miserable with the frequent eye injections some of them require in order to preserve their vision. We actually go to great lengths to minimize pain with intravitreal injections (IVI), and I thought it would be helpful to discuss this topic as we can absolutely use all of your help with this. This month I would like to discuss why injections can hurt, and how to mitigate this, both during the injection process as well as following the injection, as some patients can even have days of discomfort, which sounds like torture, and is very likely preventable.
While this might seem obvious, let’s first discuss why intravitreal injections might hurt. The main issues are 1) the needle, 2) the lid speculum, 3) the topical antiseptic (i.e. povidone iodine aka betadine), and 4) iatrogenic ocular surface disease from all of the above. If we tackle these one- by-one, we can minimize their impact and make the experience less uncomfortable. In fact, many of our patients (especially new patients and snowbirds who receive injections elsewhere) often happily remark that they can’t even believe we did the injection. The needle is the most obvious point, and perhaps the easiest to minimize. To start, with #1, the needle, we are very careful about our topical and local anesthesia, using what I call “layers” of numbing – we apply topical tetracaine, followed by a cotton pledget soaked in 4% lidocaine applied to the injection site, followed by either subconjunctival lidocaine or several minutes of topical Tetravisc. We then give the anesthesia 5-10 minutes to take effect before performing the IVI. For the injection itself, we nearly always use very small 32-gauge needles. For #2, the lid speculum, this is easy. At least for myself I simply do not use one. I gently retract the upper lid with my finger with no issues. Problem solved. For #3 and #4, these really go together and this is where we can use your help. Unfortunately, betadine is the most commonly-used topical antiseptic to prophylax against endophthalmitis, but it can sting like hell. While IVIs used to involve copious use of betadine, we now use only a drop or two on the injection site. Even with this, about 20% patients can 2 occasionally have lingering burning and discomfort. This mostly affects our patients with pre- existing ocular surface disease, including rosacea and dry eye syndrome. We can and do treat it with topical NSAIDs and occasionally corticosteroids, the best treatment is prevention and I frequently try to educate my patients on optimizing their ocular surface. This is where you all come in – while I am decent at Retina, I am not a great dry eye doctor. The extent of my advice is usually aggressive lubrication prior to the injections, but I nearly always encourage them to see their optometrist.
So, we can use your help. I am sure you all have patients receiving IVIs and if you do, please ask them about pain with the injections. If they have it, please let them know that it is mostly preventable and that the best thing is to probably work with you to develop a comprehensive plan for treating ocular surface disease. If anyone is interested, I would love to work together to develop guidelines for our patients, and maybe even study their effect. Maybe something similar to the DEWS stepladder algorithm for dry eye management. Might be a nice presentation or publication!
Well, that’s our Retinal Corner for this month. Please take care, everyone. As always, feel free to contact me anytime with questions.
Best wishes, and until next time,
Nikolas London, MD FACS
President and Director of Research, Retina Consultants San Diego
Chief of Ophthalmology, Scripps Memorial Hospital La Jolla
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