Intravitreal Injections for Retinal Disease

By Jason S. Slakter, MD

Retinal specialists are best-suited to perform these procedures.
A significant percentage of the patients visiting a retinal specialist today will undergo an intravitreal injection of an anti-vascular endothelial growth factor (anti-VEGF) agent or an anti-inflammatory agent in the management of their disease. While the vitreoretinal surgeon has become adept at performing these treatments, the question remains as to the role of the general ophthalmologist in performing these procedures. Should a general ophthalmologist be doing intravitreal injections for the management of retinal disease? The answer to the question is certainly open to debate, but here are several points that should be considered in formulating a response.

Decision-Making
The first thing to think about is whether the comprehensive ophthalmologist will be in a position to make the decision regarding the need for treatment and, perhaps more importantly, the decision for retreatment over time.
Specifically, does the ophthalmologist have the diagnostic instrumentation to perform the assessments required to determine if there is a necessity for the procedure to be performed? In addition, does the general ophthalmologist have the expertise and experience to make an appropriate decision in the more difficult cases that are often encountered, particularly with exudative AMD?
One scenario in which a general ophthalmologist may play a critical role in patient management would be in situations where local retina specialists are not readily available.
In such a setting, a retinal specialist may have determined a patient�s need for anti-VEGF therapy with ranibizumab (Lucentis, Genentech), initiated treatment, and then recommended that a monthly regimen of retreatments be followed. If the treatment plan would be to follow this monthly injection regimen for a period of time, then there may be a rationale for the comprehensive ophthalmologist to become involved in managing the patient and delivering the ranibizumab injections. However, surveys within the retinal community have shown that the majority of patients are managed on a modified treatment regimen, with additional ranibizumab injections determined by a combination of clinical evaluation and diagnostic testing, thus making it less likely that the comprehensive ophthalmologist would be able to manage the patient.
Managing Complications

A second and perhaps more important concern would be whether the comprehensive ophthalmologist is prepared to manage the complications of the procedure. Without question, intravitreal injections have proven to be generally quite safe with respect to ocular side-effects. Occasional irritation and local inflammation from the injection site may occur, but the more serious complications of infection are relatively rare. However, as clinical
trials for both pegaptanib sodium (Macugen, OSI/Eyetech) and ranibizumab have shown, the potential for retinal tears, lens damage and, more critically, endophthalmitis do persist even in the most controlled
situations.
Moreover, the VISION trial, which studied the efficacy of pegaptanib for exudative AMD, showed that the rate of endophthalmitis was higher in the initial stages of the trial and was reduced by a more rigid adherence to an aseptic protocol and injection procedure. This raises the possibility that those with less established injection protocols may have a higher rate of endophthalmitis. Even in the best of cases, endophthalmitis may occur and the physician performing the injection must be prepared to promptly recognize the problem as well as to rapidly institute therapy.

Patient and Practice Management
Another consideration is one of practice and patient management. With the rapid increase in the number of intravitreal injections performed on a daily basis, major changes in staffing and patient flow are now required. While practice modifications have taken place in most retinal specialists� offices, such adoption in the setting of a general ophthalmology practice might be more problematic.
The general ophthalmologist must have available the antibiotics, topical antiseptics, speculum and other equipment needed for the procedure, as well as a space for the treatment to be performed and the pre- and postop evaluation for pressure and inflammation. In addition, there are economic aspects to delivering some of the new intravitreal agents, where the prices for the drugs themselves range between $1,000 and $2,000 per injection. This necessitates proper collection and billing procedures being in place to avoid potentially costly errors that may have a significant financial impact on the practice.

Patient Expectations
A final important point to consider is the need for the treating physician to manage patient expectations. In today�s environment, particularly with the advent of the newer antiangiogenic agents, many patients expect excellent visual outcomes that may not be possible, even with the newer treatments.
Patients must be properly prepared for the details of the procedure itself, the need for regular follow-up and retreatment, and the limited visual expectation that may be present in the majority of patients. Even with the dramatic results from treatments such as ranibizumab, a majority of patients still do not regain a significant percentage of their vision. Patients must be prepared to accept this as part of their ongoing therapy. In the comprehensive ophthalmology setting, physicians may not be comfortable with patients with significant degrees of vision loss intermingling on a regular basis with patients undergoing cataract or refractive procedures where the expectations for visual recovery are much higher.

Better Left to Specialists
So what is the role of the general ophthalmologist with respect to intravitreal injections? Given all of the cautions noted above, it would seem that for now, the majority of intraocular injections for retinal disease should be managed by the retinal specialist whose experience, diagnostic equipment and practice-management design is best suited to handle these intraocular procedures. In certain circumstances, where access to a retinal specialist is limited, exceptions can certainly be made. It would seem prudent for the comprehensive ophthalmologist to become fully versed in the procedures and complications of intraocular injections before beginning to offer this service in regular practice. OM

Jason Slakter, M.D., is a partner at the Vitreous Retina Macula Consultants of New York and clinical professor of ophthalmology, NYU School of Medicine. Dr. Slakter is also the Editor-in-Chief of Retinal Physician, a publication directed to the retinal community.