• Reference Number: HEY-020/2021
• Departments: Ophthalmology Department
• Last Updated: 16 September 2021

Introduction

This leaflet has been produced to give you general information about your procedure.  Most of your questions should be answered by this leaflet.  It is not intended to replace the discussion between you and the healthcare team, but may act as a starting point for discussion.   If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team.

What is an Intravitreal Injection?

You have probably been troubled by some symptoms due to a problem with leakiness,  swelling or bleeding in the retina at the back of the eye. Following discussion with your doctor you have been advised that a course of injections of a drug into the jelly inside the eye would be helpful.

There are now several drugs which are injected into the eye to reduce retinal swelling or bleeding:

• Ranibizumab (Lucentis)
• Aflibercept (Eylea)
• Brolucizumab (Beovu)
• Dexamethasone (Ozurdex)
• Fluocinolone (Iluvien)
• Bevacizumab (Avastin)

With the exception of Iluvien, these drugs usually work best if given on more than one occasion. You will probably need the injection repeating in the next month or so (Lucentis, Eylea, Beovu, Avastin) or in several months (Ozurdex) depending on how your eye responds to the treatment. It is therefore essential that you keep any eye clinic appointments that you are asked to attend.

The injection is given with a very fine needle through the white part of the eyeball. This procedure is usually carried out as an outpatient visit or as a day-case procedure for Ozurdex and Iluvien implants.

Why do I need a course of Intravitreal Injections?

Common diseases treated with this type of injection include age-related macular degeneration (sometimes called “wet” AMD), diabetic macular oedema (leakiness due to diabetic damage), retinal vein occlusion (blocked blood vessels in the retina causing leakiness), inflammation or short-sighted related abnormal blood vessel growth, or other rare problems with the blood supply to the retina.

Your doctor will have discussed other treatment options with you and will have explained the advantages and disadvantages of all the treatments available to you. These treatment options will vary depending on:

•  The cause of your eye problem
• The location of the leakiness in your retina
• What other treatments you have previously had (laser if appropriate or other eye injection treatment) and how your eye has responded to those treatments
• Whether you have previously had cataract surgery
• Other factors such as whether you have glaucoma

Intravitreal injections of drugs are usually very effective treatments and the majority of patients get some benefit from the treatment. Your doctor will explain the specific risks and benefits for the treatment course recommended for you and there is additional information available in our disease specific information leaflets.

Can there be any complications or risks?

Like all medical treatments, intravitreal injection treatment can cause side effects, although not everybody gets them. The side effects with these treatments are either from the medicine itself or from the injection procedure.  Most of the side-effects involve the eye alone.

Common side-effects include discomfort during and after injection, bruising of the white of the eye, an increase in the eye pressure and moving black dots in your vision. Each injection, regardless of the drug injected carries a 1:1000 risk of a complication, which may severely permanently reduce the sight in the eye injected.

The most serious risks are

• Infection inside the eye
• Blockage of the main artery to the eye

Other rare but serious complications include:

• Bleeding inside the eye
• Damage to the lens in the eye
• Immune reaction to the drug known as immunogenicity
• Inflammation in the eye
• Retinal detachment
• Retinal tear

These are all treatable but can compromise the vision in that eye.

Inflammation and immunogenicity reactions appear to be more common with Beovu than with the other medicines. The frequency of permanent visual loss with Beovu due to inflammation is that 1 in 100 patients would be affected over a course of treatment. For patients previously treated with another injection therapy prior to starting Beovu, injections should be given at a minimum of 8 weeks intervals to avoid a higher risk of sight-threatening inflammatory eye disease.

Ozurdex and Iluvien carry an additional risk of cataract or high pressure in the eye (see relevant patient information leaflets for more information).

How do I prepare for the Intravitreal Injection?

Please read the information leaflet. Share the information it contains with your partner and family (if you wish) so that they can be of help and support. There may be information they need to know, especially if they are taking care of you following this examination.

Before the injection you may continue with your daily activities as normal; this includes continuing with all routine medication and eye drops. You may eat and drink as normal prior to the injection.

You must not drive after your appointment as you will be having dilating drops in the eye under-going the injection treatment and these drops blur the vision for up to six hours.

If you intend to travel abroad, we advise that you receive your injection no later than one week before you travel where this is practical.

What will happen?

On the day of the injection you will need to report to the reception desk either on the ground floor or the first floor of the Eye hospital within the grounds of Hull Royal Infirmary. You will then be directed to the waiting area.

A nurse will verify your medical details including any recent changes to your health or medication so please bring a list of any new medication with you. You will have a vision test and dilating drops (identical to those used in the Eye Clinic) will be put in the eye/s to be injected. These take 20 – 30 minutes to work and will blur your vision for several hours particularly for close work. You will then have an OCT scan of both eyes performed.

Almost immediately you will feel well enough to return to the waiting area, you can then sit for a while if you wish before going home.

Please be aware that the Eye Department is a teaching unit and that some of the injections in whole or part can be carried out by trainee eye doctors under supervision.

Injections (Lucentis, Eylea and Beovu) may also be carried out by appropriately trained non-medical health care professionals (HCPs). Please note that the intravitreal injections performed by HCPs remain off-label for the licensed drugs.

We cannot give a guarantee that a particular person will perform the procedure. The person will however, have appropriate experience.

Povidone-iodine is known to cause some irritation or redness in the eye, but it does not mean that you are allergic to this. We make every effort to reduce the possible irritation by washing off the povidone-iodine at the end of the injection procedure.

Very rarely, patients could be truly allergic to povidone-iodine. If you have any known allergy or sensitivity to povidone-iodine, please inform the nurse or doctor when you attend the injection clinic appointment.

For patients who are sensitive to povidone-iodine eye drops, we may use a single drop of povidone-iodine localized to the area of the injection or use an alternative antiseptic agent called chlorhexidine; No clear evidence exists that these strategies are inferior to the licensed regimen of Povidone Iodine as large research studies would be needed to prove a statistically significant difference. However published research evidence on a large number of patients given Chlorhexidine 0.05% appears a non-inferior option (Merani et al Ophthalmology 2016).

What happens afterwards?

Do not drive for 6 hours after the injection as your vision will be blurred by the dilating drops.

It is normal for your eye to feel slightly gritty, uncomfortable or watery and the white of the eye may be red for a day or so after the injection. This should settle within 2 days.

Please do not rub your eye after the injection – there is a risk of you causing a scratch to the surface of the eye whilst the numbing drops are still working. The eye can be gently cleaned or dabbed using a ‘clean tissue’. You should dispose of the used tissue and use a fresh new tissue each time you clean the eye.

You should avoid getting water and shampoo or  soap into your eye for 48 hours after injection. Wash your hair “salon style” during this time. You should also avoid swimming for 48 hours after the injection.

If your eye feels gritty after the injection, lubricating “dry eye” eye drops can help to make the eye feel more comfortable. You should use a new bottle after each injection to minimise the risk of infection in the eye. We recommend you arrange a repeat prescription of these lubricating drops from your doctor.

Some patients notice floating dots or shadows in the eye being treated straight after the injection, these should gradually fade over the next 2 days. If you have had treatment with Iluvien or Ozurdex the floating rod will take a few weeks to fade away.

All these symptoms should steadily improve on a daily basis.

If you experience:

• INCREASING PAIN OR ACHE IN THE EYE
• PUS or DISCHARGE
• SUDDEN DECREASE or CHANGE IN VISION
• AN INCREASING NUMBER OF BLACK DOTS (FLOATERS) OR FLASHES OF LIGHT
• INCREASED SENSITIVITY TO LIGHT

Please CONTACT THE DEPARTMENT IMMEDIATELY via the phone numbers below. These symptoms may be a sign of infection or inflammation in the eye which is a serious complication. Serious complications must be treated quickly to minimise damage to the eye.

If you suspect you have any of the above symptoms please contact us:

Monday-Friday 9.00am- 5.00pm: (01482) 816658 or (01482) 608788.

Evenings, weekends and Bank Holidays: (01482) 604346 (Please listen to full voice message on how to access emergency out of hours service).

It is very important that you keep all appointments for review and treatment.

Depending on the drug injected you will be given a follow-up appointment either for review in the clinic or for a further injection. This will vary according to your eye condition and will have been explained at your consultation with more detailed information given.

Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the Ophthalmology Department (01482) 816658 or (01482) 608788

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

• you must be able to give your consent
• you must be given enough information to enable you to make a decision
• you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.