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EW SHOW DAILY 30 ASCRS Symposia Sunday, May 8, 2016 by Lauren Lipuma EyeWorld Contributing Writer R etina specialists shared their expertise with ante- rior segment surgeons in Saturday afternoon's "In- travitreal Injections: How, What, When and Why" symposium. Moderator Keith Warren, MD, Overland Park, Kansas, kicked off the discussion by asking attendees who among them performs intrav- itreal injections. The vast majority of attendees who responded "yes" live in urban areas, cities, or towns, indicating that access is not the issue when choosing to inject, Dr. Warren said. Before going into the specifics of intravitreal injection, David Boyer, MD, Los Angeles, looked at the bigger picture of treating cata- ract patients who have wet AMD or diabetic retinopathy. Cataract surgery is 1 of the most successful surgical procedures performed today, but in the past, treating cataract patients with wet AMD has had limited success, Dr. Boyer said. The advent of anti-VEGF therapy, however, has changed all that: Anti-VEGF agents have stabi- lized and in some cases improved visual acuity in patients with AMD, he said. The big question retina specialists get from anterior seg- ment surgeons, however, is whether cataract surgery causes dry AMD to progress to wet AMD. The short answer, Dr. Boyer said, is probably not, but patients with dry AMD need careful preoperative evaluations. Another question often asked is whether cataract surgery worsens existing diabetic macular edema (DME). Diabetics who undergo cat- aract surgery risk doubling the rate at which their vision deteriorates because of damage to the capillaries that nourish the retina, Dr. Boyer said. The good news, however, is that phacoemulsification leads to less disease progression than older surgical methods, he said. Cataract surgery may be associated with wors- ening DME in some cases nowadays, but DME and wet AMD are not con- traindications for surgery, he said. Do not remove a cataract until the macula is either dry or has stabi- lized, and use an OCT to determine if the macula is stable and dry, Dr. Boyer said. Consider anti-VEGF therapy or steroid injections 1 to 2 weeks prior to surgery, and use steroidal and non-steroidal anti-in- flammatory agents before and after surgery, he concluded. Injection safety Steve Charles, MD, Memphis, Ten- nessee, discussed the ways in which surgeons can reduce the risk of serious infection when performing intravitreal injections. First, always examine patients at the slit lamp before injecting to check for blepha- ritis, conjunctivitis, and other signs of disease, Dr. Charles said. "Sticking needles in people's eyes without knowing the anterior segment situation is not a good idea," he said. Second, always have the patient, technician, and physician wear masks to prevent oral and nasal bacteria from contaminating the needle; simply not talking and holding your breath are unrealistic options, he said. Third, use 5% betadine (po- vidone-iodine) antiseptic for all patients, Dr. Charles said. Although some patients think they are allergic to iodine because of allergies to seafood, they are actually allergic to the contrast agents, he said. No one is actually allergic to iodine, he continued, because it is essential to the function of a healthy thyroid. "No one has ever had anaphy- lactic shock from betadine," he said. Next, use a sterile bladed specu- lum on all patients to hold back the lids and lashes, Dr. Charles said, and wear sterile gloves. Finally, never use topical antibiotics after the injection; patients require multiple injections, and over time, they will develop resistance to the topical antibiotic, he said. Although there is no consensus in the retinal community about whether these steps are necessary, Dr. Charles said, he thinks they are essential to offering patients the highest level of safety. "Everybody is concerned about costs: masks are not free, sterile bladed speculums are not free, and sterile gloves are not free," he said. "But on the other hand, endoph- thalmitis isn't free either." EW Editors' note: The physicians have no financial interests related to this article. What you need to know about intravitreal injections Dr. Charles discusses ways to reduce the risk of endophthalmitis when performing intravitreal injections. " Sticking needles in people's eyes without knowing the anterior segment situation is not a good idea. " –Steve Charles, MD

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