Many retina practices have greatly increased their frequency of injections as new drugs to treat age-related macular degeneration have reached the market. You can never be too careful when it comes to injecting a patient with an intravitreal medication when treating retinal diseases. Follow specific protocols before, during, and after this procedure to ensure a safe and effective injection.

Before the procedure, make sure patients are aware of the benefits and risks. Have them sign a consent form and verbalize an understanding of the procedure. Do not give eye injections to patients who have inflammation or infection, such as conjunctivitis or meibomian gland dysfunction with active blepharitis.

Initial Eye Preparations

Before any preparations begin, the nurse should make sure the work station has been sterilized between patients and she should wash his/her hands, says Joy Bankert, BSN, RN, CRNO, clinical research nurse, Ophthalmic Consultants of Boston. All instruments and medication should be ready for the treating physician. Close the door to avoid distractions and maintain patient privacy. Make sure the patient’s head and neck are well supported, and that the headrest is secure.

“Perform a mandatory ‘time-out’ (to confirm the correct medication and correct eye); mark the patient’s eye,” says Dawn Williams, RN, nurse, Cole Eye Institute at Cleveland Clinic Foundation, in Cleveland, OH.

Next, put a drop of 5% providone-iodine solution (Betadine) directly on the globe at the injection site, Williams advises. Although a 10% solution used to be common, many patients experienced pain after the injection due to the cornea becoming overly dry. Moxifloxacin is another option, but rising resistance is an issue. Also, consider a patient’s previous tolerance to an antiseptic.

“Don’t talk to the patient or ask the patient to talk until after the procedure,” Ms. Williams says. “The person giving the injection should wear a mask or not talk while giving the injection to keep bacteria from their mouth from entering the sterile field,” she adds.

“Most of our physicians give patients another dose of Betadine in their eye right before and just after the injection,” says Lisa Samborski, BSN, RN, CRNO, staff nurse at New England Eye Center, also in Boston. “We clean along the lashes and lids with Betadine using a gauze pad or swabs.”

Many seasoned patients have their preferred method of anesthesia, Ms. Williams notes. The typical methods include proparacaine drops, 4% lidocaine placed with a cotton swab for one to three minutes, and/or a subconjunctival injection of lidocaine. Wait five minutes to effectively anesthetize the area before injecting.

Preparing Syringes

According to The Joint Commission and Hospital National Patient Safety Goals, all medications must be labeled unless an authorized user prepares the medication and directly administers it to the patient without a break or delay in the process. “It may be helpful to have preprinted labels with the most common drugs and dosages,” Ms. Williams suggests. “Multi-use vials, such as lidocaine, should be kept in the immediate patient treatment area; once accessed they should be dated and discarded within 28 days.”

Then, draw up the medication with a needle and switch to a 30 gauge needle aseptically. It is important to follow manufacturer’s guidelines. “It takes a little practice to prepare syringes without air bubbles,” Ms. Bankert says. “It is important to keep the needle within the liquid when drawing the medication into the syringe.” Place the capped syringe on a sterile towel.

Injection Technique

When the physician is about to give the injection, he or she should ask the patient to look 180 degrees away from the injection site. Each retina specialist has his or her own technique with intravitreal injections; inferior-temporally is a common technique that provides easy access. The retina specialist prepares for the injection by holding the syringe with the dominant hand and using the palm to stabilize the hand to the cheek.

The needle enters the mid-vitreous cavity 3 to 3.5 mm from limbus for pseudophakic patients and 3.5 to 4 mm for phakic patients. Then the specialist smoothly pushes the plunger with the non-dominant hand. After the medication is given, press a cotton swab on the injection site to prevent reflux, Ms. Williams explains.

After the injection, thoroughly rinse the patient’s eye with a sterile eye wash. Discard all syringes to eliminate confusion.

Handling Injection Side Effects

The physician may prescribe an antibiotic ointment if the patient has a stinging sensation from the iodine. Advise patients to use a new bottle of preservative-free artificial tears for irritation during the first night, Ms. Samborski says. Take Tylenol for discomfort.

By the next day, any irritation should subside. If the patient feels worse the next day, or if pain or vision is worse or the eye is red and painful, the patient should call the provider right away. Tell patients that there may be subconjunctival blood (a patch of bleeding in the white part of the eye) that can last for several days.

Communication Strategies

Patients should feel well informed and have easy access to urgent help if needed. Give patients phone numbers to access a doctor at all hours of the day. Encourage patients and family members to ask questions. “Teamwork between doctors, nurses, and technicians is what makes our patients comfortable and happy to return month after month,” Ms. Samborski says. OP