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Injecțiile intravitreene: ce sunt si cand se utilizeaza? Clinica Oftalmologica Dr. Munteanu

Articles - 24th October 2022

Intravitreal injections: what are they and when are they used?

Intravitreal injections - when they are needed
and why not fear them?

Injectiile intravitreene reprezintă proceduri medicale inovatoare, utilizate în tratamentul afecțiunilor oftalmologice. Acestea constau în administrarea unei substanțe medicamentoase direct în cavitatea vitreană a ochiului, cu ajutorul unei seringi subțiri și precise. Injectiile intravitreene sunt utilizate în diverse indicații, precum degenerescenta maculară legată de vârstă, retinopatia diabetică sau edemul macular, și se bazează pe eliberarea controlată a medicamentului în apropierea retinei, pentru a obține un efect terapeutic optim. Prin intermediul acestor proceduri minim invazive, se pot obține rezultate semnificative în îmbunătățirea vederii și gestionarea complicațiilor oculare, oferind pacienților o opțiune terapeutică eficientă și sigură.

1. What are intravitreal injections?

An intravitreal injection is a small but effective dose of medicine inserted into the vitreous cavity inside the eye to treat certain retinal conditions. The eye contains inside it a cavity filled with a gel-like fluid called the vitreous body, which is in intimate contact with the retina, responsible for projecting images. In certain retinal pathologies such as age-related macular degeneration or diabetic macular oedema, the administration of therapy via intravitreal injections provides an effective therapeutic concentration at the site of the lesion without systemic side effects.

2. When do we need intravitreal injections?

  • Degenerescența maculară legată de vârstă (DMLV)If you have been diagnosed with this condition, especially its ''wet'' form, you are prone to a disorganisation of the retinal macular region responsible for central vision. This occurs with the formation of choroidal neoplasms, accumulation of intraretinal fluid and macular oedema. The gold-standard therapy in this case is intravitreal angiogenic agents (anti-VEGF) given at regular intervals.
  • Diabetic maculopathy : most often associated with type II diabetes mellitus, it is a diabetic eye disease affecting the centre of vision. Normal blood vessels dilate in response to the ischemic response of the retina, becoming permeable. Remaining fluid accumulates in the macula, distorting central vision.
  • Retinopatia diabetică proliferativă : an aggravated form of diabetic retinopathy, proliferative retinopathy involves the destruction of small retinal blood vessels, resulting in tissue ichemization and a strong angiogenic response leading to the formation of new ''bad'' vessels. Very thin and permeable, these bleed and exude, disrupting the retina and potentially leading to irreversible vision loss. They are inhibited by repeated injections of a specific anti-VEGF, to which a good therapeutic response is observed.
  • Central retinal vein occlusion (CRVO) or branch vein occlusion ischemic events: these ischemic events occur in the presence of atherosclerosis and the formation of a blood clot obstructing the flow of blood returning from the retina. Without proper treatment early on, they can lead to other serious complications such as macular oedema or neovascular glaucoma. You may be advised to have a combination injection containing an anti-VEGF and a glucocorticoid anti-inflammatory to treat this condition.
  • Choroidal neovascularization in myopia : this condition occurs in people with strong myopia, in which case the retina is stretched and thinned due to the large size of the eye and is prone to disorganization and invasion of choroidal neoplasms that must be inhibited with anti-VEGF factors.
  • Uveitis Inflammation of the uveal layers of the eye can lead to serious damage to vision if early action is not taken. In the case of infectious uveitis, intravitreal injections with specific antibiotic, antiviral or antifungal agents are recommended, depending on the cause found. When infectious aetiology is excluded, intravitreal injections with a steroidal anti-inflammatory agent such as triamcinolone, as a single dose or as an extended-release implant.

3. How often do I need to have injections?

For anti-vascular endothelial growth factor (anti-VEGF) injections, there are two major international protocols by which treatment intervals are planned: Treat And Extent (T&E) and Pro Re Nata (PRN). In a T&E regimen, after an initial loading phase of three doses of anti-VEGF given one month apart, patients are injected at monthly intervals until the exudative disease activity has resolved. At that point, the interval for the next injection is extended by 1 to 2 weeks to a maximum of 12 weeks. In a PRN regimen treatment is initiated with three monthly injections. Retreatment is applied only when intra- or subretinal changes such as fluid or haemorrhage are detected after SD-OCT evaluation.

4. What do intravitreal injections contain?

  • Bevacizumab (AVASTIN, Genentech, San Francisco, CA)
  • Ranibizumab (LUCENTIS, Genentech, San Francisco, CA)
  • Aflibercept (EYLEA, Regenereon Pharmaceuticals Inc, Tarrytown, NY)
  • Brolucizumab (BEOVU, Novartis, Cambridge, MA)

These are anti-VEGF (anti-vascular endothelial growth factor) drugs that stop abnormal blood vessels, called neovase to grow, ooze and bleed.

  • Triamcinolone acetonide (VITREAL S, Fidia Farmaceutici, Italy)
  • Dexamethasone (OZURDEX, Allergan TechAlliance)

These are drugs in the glucocorticoid category, with a strong anti-inflammatory effect.

  • Vancomycin
  • Clindamycin
  • Amikacin

These are some of the antibiotic drugs that can be used intraocularly.

5. What is the procedure?

Even though it is a standardised and relatively simple procedure that takes between 5 and 10 minutes, intravitreal injection must always be performed under special aseptic and antiseptic conditions. Thus, it takes place in the operating theatre, with trained and experienced staff, under microscopic control, with rigorous preparation of the periocular area beforehand.

After a topical, drop anesthesia, the patient is placed on their back, the ocular attachments and periocular area are disinfected, a sterile drape is placed over the face, and the eye is isolated and opened using an eyelid support. A betadine solution is instilled into the conjunctival bags on the ocular surface for asepsis. The patient is asked to look up and sideways, the injection site is marked according to the presence or absence of a lens implant and a very fine needle is entered perpendicular to the ocular surface and a maximum of 0.1 ml of active substance is injected. After removing the needle, the injection site is gently swabbed and the betadine solution is instilled back onto the ocular surface. The sterile field is taken off and an opaque or transparent eye dressing is applied until the end of the day.

It is important to note that this procedure may be contraindicated if your intraocular pressure is too high, in which case we will prescribe a treatment schedule to lower it and postpone the intravitreal injection for another time.

After receiving an intravitreal injection there is no need to administer any topical antibiotics unless your ophthalmologist specifically asks you to do so.

 

At the Prof. Dr. Munteanu Ophthalmology Centre we perform over 150 intravitreal injections per month to patients who cross our threshold with confidence. For a thorough consultation and expert treatment, we look forward to seeing you!

 

Descoperiți mai multe informații valoroase despre oftalmologie și sănătatea ochilor vizionând materialele realizate de experți în domeniu de pe canalul nostru de YouTube.

Oftalmologie Timisoara - Doctor oftalmolog Timisoara - Dr. Leila Al Barri, Medic specialist oftalmolog

Dr Leila Al Barri

Specialist Ophthalmologist, with specialization carried out under the coordination of Prof. Dr. Mihnea Munteanu, assistant professor at UMF Victor Babes Timisoara.

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