When treating patients with age-related macular degeneration, do you perform bilateral same-day intravitreal injections?
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Safe and efficient boost for the patient and office
“Git-R-Done!” That is what my patients say to me whenever I ask them if they prefer bilateral intravitreal injections on the same day. This is the sentiment of the vast majority of my patients with bilaterally active choroidal neovascularization or diabetic macular edema undergoing intravitreal injection therapy. As many of the patients require 4 to 8 weeks of follow-up and depend on transportation to the visits, the ability to reduce the number of appointments is essential. It is not only an efficiency boost for the patients, but one for the office as well, reducing unnecessary visits, thus increasing room for additional patient scheduling.
The main argument against bilateral same-day injections is the potential for simultaneous bilateral endophthalmitis or serious noninfectious inflammation. However, the risk is extremely low when proper precautions are taken. We prep each eye with separate anesthesia and Betadine, and use a separate lid speculum (when one is needed) for each eye. In addition, we choose medications from separate lots for each eye and never perform bilateral simultaneous injections when it is the first time for an injection. Performing these precautionary steps should allow for nearly independent assortment of risk for each eye so that the risk for bilateral simultaneous infections (assuming the risk for one eye is one out of 2,000) is around one out of 4 million. Probably an underestimate, but conceivably less likely than being struck by lightning.
One must balance this risk with the risk of delaying treatment for the fellow eye and vision loss associated with disease progression. Although a week rarely makes a big difference in the disease state, missing follow-up appointments for one reason or another is not infrequent in these patients, and 1 week can easily become 2, 3 or more. Bilateral injections are not for every patient, and we accommodate for patient preferences; however, most patients and retina physicians prefer the same day.
Dante J. Pieramici, MD, is from California Retina Consultants, Santa Barbara, California. Disclosure: Pieramici reports he is a consultant for Genentech and does research for Genentech, Regeneron, Allergan, Alcon, ThromboGenics and Santen.
Patients report discomfort, and different batches not always available
Most of the time I inject one eye and postpone the second eye to 1 or 2 weeks later. Hong Kong is a relatively small area, well served by public transports, and patients do not have to travel more than half an hour, 1 hour at the most, to reach us in the clinic. It is not much of a burden, and they come regularly to their appointments. Strange as it may seem, most of them prefer to have the injections some time apart. This may be because the eye might be irritated by povidone-iodine, which we use for asepsis in the periorbital area and eyelids, but also in small amounts on the conjunctiva. Patients usually do not like to have this discomfort in both eyes. Vision might also be a little blurry when they go home, and they feel better not having both eyes affected. Another reason is that in Hong Kong patients are mostly paying for the treatment out of their own pocket or through private insurance. Bilateral injection is costly, and many prefer to pay two smaller bills 1 or 2 weeks apart. As a clinic, we have our own reasons for not adopting a bilateral same-day protocol. When we perform bilateral injections on the same day, we are supposed to use vials with different batch numbers and expiry dates. Most of the guidelines on intravitreal injections recommend this, including the Royal College of Ophthalmologists’ guidelines. However, we do not usually store such a large amount of drugs as to have different batch numbers for the two eyes on the same day. Therefore, if we do bilateral, we often inject one eye with ranibizumab and the other one with aflibercept because we simply do not have the same drug in two different batches. Bilateral infection is rare, but we prefer to be on the safe side and avoid even that small chance of such a dramatic event.
Last but not least, when using a drug that contains the Fc portion, such as aflibercept and bevacizumab, there is a risk that increased systemic absorption of the anti-VEGF agent might increase the risk for cardiovascular events. This is something patients should be made aware of when offering them bilateral injections on the same day. I do offer this option in some cases, when patients come from distant areas of China and have a long way to come to the clinic. To release their burden and ensure treatment adherence, I often treat them on the same day in both eyes.
Timothy Lai, MD, FRCS, FRCOphth, is an honorary clinical associate professor, Department of Ophthalmology & Visual Sciences, The Chinese University of Hong Kong. Disclosure: Lai reports he is a consultant for Allergan, Bayer, Boehringer Ingelheim, Novartis and Roche.