Management of Wet Age-Related Macular Degeneration - Episode 8
Lloyd Clark, MD, and Roger A. Goldberg, MD, MBA, share the process for giving injections in the eye for patients who have wet AMD.
John W. Kitchens, MD: It should be noted that all of these drugs are given as injections in the eye. Lloyd, for our primary care partners, can you describe what a process is to give an injection in the eye to a patient and how well tolerated it is?
Lloyd Clark, MD: Roger brought up pegaptanib [Macugen] a little while ago. One of the interesting things about this drug is, this is the first drug we had as an injectable for the eye. We weren’t used to doing high-volume intravitreal injections in the office. There were limited indications for intravitreal injections, let’s say in 2003, 2004. Once these drugs hit the market and we were able to see how effective they were in the treatment of age-related macular degeneration [AMD] and other conditions, we had to completely change the way our practices operated. We went from seeing half the number of patients we’re seeing now to developing incredible efficiencies to deliver these drugs to 40, 50, 60 patients a day, just injection patients alone in the practice, which can be staggering numbers. We all have a different way of doing this to some degree, of delivering high-volume efficient intravitreal injections in our offices, but there are a few common threads.
There are a few things that we have to do in order to do this safely and effectively. We’ve got to deliver these drugs in an aseptic fashion, so the drug has to be sterile. That was more of an issue prior to the advent of prefilled syringes. We now have prefilled syringes for the approved agents, and that’s helped not only with efficiency but with the ability to ensure sterility of the drug as it goes in the eye. It’s important that we sterilize as best as possible the ocular surface, and we do that with betadine, we apply a betadine solution. Most people apply it to the surrounding skin, and then a less concentrated betadine solution into the conjunctival fornices. That’s a critical step because we’ve got to get as much of the bacteria off of the ocular surface as possible because if a patient gets an infection, it typically occurs with the needle introducing bacteria into the eye.
There’s a number of other things that some physicians use, for example, a lid speculum. Some physicians hold the eyelids open, some use sterile gloves, some use nonsterile gloves, and some use no gloves at all. There’s variability there as well, and then the choice of anesthesia. The majority of physicians today use a topical anesthetic that is applied to the eye via a drop, but there are other ways to apply anesthesia as well. The critical components of delivering these safely and effectively is a sterile drug, and an aseptic technique with betadine to the surface of the eye. If you do that, then we’re able to do this efficiently and safely for dozens of patients every day for each physician.
John W. Kitchens, MD: Roger from a patient’s perspective, how do they do getting shots in the eye?
Roger A. Goldberg, MD, MBA: The scariest time is the time between when a patient is told they need a shot in the eye, and when they get their first injection because it goes back to that childhood taunt about, “stick a needle in your eye.” It sounds scary, but then they get that first injection, and they realize they don’t feel it. The typical response I get is, “Wait doctor, did you do it yet?” I always take that as a compliment when they don’t know that they were given an injection. Then they realize, “I didn’t need to be so worried about that.” I want to emphasize for the audience here, to the extent that you know patients who either might need to get an injection or you’re sending, where you say, “Geez, you’ve got wet AMD.” Or maybe it’s an optometrist who’s listening now and they’ve diagnosed it, reassure your patients that, “You might need treatment. You might need an injection in the eye, but don’t be scared it doesn’t hurt, and they’re remarkably well-tolerated.”
John W. Kitchens, MD: It’s important to realize that when we talk about giving a shot in the eye, we’re talking about giving it through the white part of the eye off to the side. Patients are not having to sit there and stare at a needle as it gets closer and closer to their eye, as you might see in an episode of House or something along those lines.
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Transcript Edited for Clarity