Letters

Comprehensive Ophthalmologists Should Do Intravitreal Injections

To the editor:

I was pleased to see the recent guest editorial, "Intravitreal Injections for Retinal Disease" by Jason S. Slakter, M.D. in the January 2007 issue of Ophthalmology Management.¹ I agree with Dr. Slakter that now is the time to examine critically the therapeutic use of anti-vascular endothelial growth factor (VEGF) agent injections by comprehensive ophthalmologists. But while Dr. Slakter feels that "retinal specialists are best-suited to perform these procedures," I believe that comprehensive ophthalmologists can and should be able to successfully and safely do these injections. I would like to present my experience as a comprehensive ophthalmologist who has been doing these injections for the past 18 months.

As Dr. Slakter points out, rural communities such as the one in which I practice may not have a retinal specialist. Besides the distance needed to travel to see the retinal specialist (60 miles in my case), the patients who need these injections are usually elderly and often can no longer drive such a distance, especially when going to a larger, unfamiliar city. They often must depend on others for transportation, adding another layer of inconvenience. Even if they knew how to get there on their own, because of their visual impairment they are often unable to see well enough to drive safely. Also, our Minnesota winters can be treacherous, making long distance travel dangerous.

To mitigate these problems, I have partnered with a retina specialty group in a major university clinic in our location. I spent time with the retinal specialists to learn how to do these injections correctly. My office manager also went to observe the patient flow and scheduling issues. Our coding department got up to speed on proper coding and billing.

At this point, we developed a strict protocol using many of the suggestions from the guidelines published by Aiello et al in 2004.^2,3 Maintaining aseptic injection technique and instrument sterility during the procedure is key in minimizing the risk of endophthalmitis. By following this protocol I have not had any infections to date. The other complications that Dr. Slakter lists (retinal tears, lens damage) can also be avoided. Because I examine the eye immediately after the injection, any such complication would be readily identified. I would then treat it myself or ask for help from my retina colleagues. They have always been generous in administering care to my patients when necessary.

I do my own digital fluorescein angiography (FA) to differentiate the type of macular degeneration and which kind of neovascular membrane (if any) my patient may have. This way, I can counsel patients more accurately on which therapy is best suited for them. I do not believe that the comprehensive ophthalmologist who wants to do anti-VEGF injections needs to do FA. The patient is then referred to the retinal specialist for consultation and the first anti-VEGF injection. The patient is given the option to complete any subsequent injections at the retina clinic or with me. The vast majority of patients are thrilled that they can receive further treatment close to home.

One test that the comprehensive ophthalmologist should perform to manage these patients successfully is optical coherence tomography (OCT). The OCT combined with a fundus examination helps tailor the injection schedule for each patient. All the other equipment (speculum, calipers, sterile gloves, etc.) is inexpensive and probably already available in all our offices.

I believe that Dr. Slakter's concerns about patient expectations are easily handled by educating patients about their disease, this new treatment and the fact that not all patients have the same outcome. Furthermore, I find that these patients are just as enthusiastic about their potential to recover as are my cataract patients. They are equally thankful for any sight that is restored.

With the anticipated increase in the number of patients with macular degeneration, the need for comprehensive ophthalmologists in administering this mode of treatment should shortly be in high demand. Now is the time to have this discussion.

Sincerely,

Leonid Skorin, Jr.

D.O., F.A.A.O., F.A.O.C.O.

References

1. Slakter JS. Intravitreal injections for retinal disease. Ophthalmology Management. 2007;11:8-10.

2. Aiello LP, Brucker AJ, Chang S, et al. Evolving guidelines for intravitreous injections. Retina. 2004:24(suppl):S3-S19.

3. Skorin L, Schweitzer JA. Intravitreal Macugen injection for the comprehensive ophthalmologist. Clinical & Surgical Journal of Ophthalmology. 2006;24:176-182.