Helio Francisco Shiroma

Effect of Needle Type and Injection Technique on Pain Level and Vitreal Reflux in Intravitreal Injection

PURPOSE To evaluate the amount of reflux and degree of pain with intravitreal injection (IVT) using 6 different types of syringes/needles and 5 techniques of scleral incision, including 3 modifications of a beveled scleral incision. METHODS This was a study conducted in 205 eyes of 205 patients. IVT of bevacizumab for retinal pharmacotherapy with 6 types of needles and 5 techniques of scleral incision. The severity of subjectively evaluated pain (0-10) and the width of the subconjunctival bleb arising from the vitreal reflux. Secondary outcomes were increase in intraocular pressure and complication rate. RESULTS The straight technique caused greater vitreal reflux than the beveled approaches, when compared individually or as a group (P < 0.01). No difference in the severity of pain was found among all 5 types of incisions (P > 0.05). There was greater reflux with 26- and 27-gauge needles in comparison to 29- and 30-gauge needles (P < 0.001); however, the width of the needle significantly affected the degree of reflux only when using the nonbeveled incision (P < 0.001). The patients injected with the 26- or 27-gauge needle experienced more pain matched to the 29- and 30-gauge needles (P < 0.001). No difference was found between the incision technique or width of subconjunctival reflux and the increase in intraocular pressure (P > 0.05). Postinjection events included transient mild uveitis, disease-related vitreous hemorrhage, foreign body sensation, conjunctival hemorrhage, and mild punctuate keratitis. CONCLUSIONS The beveled scleral incision showed benefit in performing IVTs. The 29- and 30-gauge needles caused less pain.

Safety and efficacy of various concentrations of topical lidocaine gel for intravitreal injection

Introduction: Intravitreal injection (IVT) is one of the most common vitreoretinal procedures, a large majority are performed with local anesthesia. The purpose of this study was to investigate the safety to the cornea and anesthetic efficacy of five concentrations of lidocaine gel. Methods: A prospective clinical trial was conducted testing lidocaine gel in five preparations: 2, 3.5, 5, 8 and 12%. Patients with macular degeneration, diabetic edema or retina vein occlusion were scheduled for intravitreal treatment received topical anesthesia with lidocaine gel 5 and 10 min before the procedure. Patients answered the visual analog scale for pain during the procedure. Corneal and conjunctival was evaluated using the Oxford scale. Results: In total, 260 patients were randomized into five groups. The mean pain scores (± standard deviation) were 2.63 (± 1.68) in the 2% group, 2.08 (± 1.35) in the 3.5%; 2.00 (± 1.65) in the 5%, 1.93 (± 1.40) in the 8% and 1.83 (± 1.35) in the 12% group. Mean pain score among all groups was similar (p = 0.077). There was no significant difference between groups in regard to keratitis mean score (p = 0.897). Conclusions: Lidocaine gel at concentrations from 2 to 12% induced similar anesthetic effect for IVTs, without adverse effects on cornea and conjunctiva.

Survey: technique of performing intravitreal injection among members of the Brazilian Retina and Vitreous Society (SBRV)

PURPOSE To evaluate and describe the precautions involved in the technique of intravitreal injection of antiangiogenic drugs adopted by the ophthalmologists who are members of the Brazilian Society of Retina and Vitreous (SBRV). METHODS A questionnaire containing 22 questions related to precautions taken before, during, and after intravitreal injection was sent electronically to 920 members of SBRV between November 15, 2013 and April 31, 2014. RESULTS 352 responses (38%) were obtained. There was a predominance of men (76%) from the southwest region of Brazil (51%). The professional experience varied between 6 and 15 years after medical specialization (50%). Most professionals (76%) performed an average of 1 to 10 intravitreal injections a week, and 88% of the procedures were performed in the operating room using povidone iodine (99%), sterile gloves, and blepharostat (94%). For inducing topical anesthesia, usage of anesthetic eye drops was the most used technique (65%). Ranibizumab (Lucentis®) was the most common drug (55%), and age-related macular degeneration (AMD) was the most treated disease (57%). Regarding the complications treated, 6% of the ophthalmologists had treated at least one case of retinal detachment, 20% had treated cases of endophthalmitis, 9% had treated cases of vitreous hemorrhage, and 12% had encountered cases of crystalline lens touch. CONCLUSION Intravitreal injection is a procedure routinely performed by retina specialists and has a low incidence of complications. Performing the procedure in the operating room using an aseptic technique was preferred by most of the respondents. Ranibizumab was the most used drug, and AMD was the most treated disease.

Development and initial experience with a colored perfluorocarbon liquid for intraocular tamponade in vitreoretinal surgery

Purpose: To present the development and initial experience of a novel colored perfluorocarbon liquid (PFCL) in vitreoretinal surgery. Methods: This was an experimental laboratory study and prospective human interventional study. F6H8 (Fluoron GmbH) was colored by adding 0.3 g/L blue anthraquinone dye. Subsequently, 20% colored F6H8 was prepared by mixing with perfluorooctane or perfluorodecalin (Fluoron GmbH). The novel product is not yet FDA approved for human application. In the laboratory, the colored PFCL was covered with 1) uncolored PFCL, 2) BSS, and 3) silicone oil. Cell toxicity was evaluated in L929 mouse fibroblasts using a growth inhibition assay. Porcine ex vivo eyes were evaluated after vitrectomy followed by intravitreal and subretinal colored PFCL infusion. A pilot, prospective, noncomparative interventional study was conducted in patients with retinal detachment with proliferative vitreoretinopathy (PVR). Results: The density of the colored PFLC mixture was 1.664 g/cm3 for perfluorooctane and 1.802 g/cm3 for perfluorodecalin. There was no relevant cell growth inhibition with any concentration of colored PFCL tested. Experiments in pigs revealed that infusion of the colored PFCL caused neither staining of the internal limiting membrane nor intravitreal residual droplets. In the prospective study, 9 eyes (75%) underwent surgery for rhegmatogenous retinal detachment with at least grade C PVR. The colored PFCL enabled retinal break examination and detection of residual intravitreal droplets in all surgeries. There was no case of separation or leakage of the dye from the PFCL solution that could have caused unwanted staining of the vitreous or epiretinal surface. Conclusion: The colored PFCL enabled intraoperative maneuvers such as endolaser use. In addition, removal of the colored PFCL was easily achieved at the end of surgery.

Comparative Study between Lidocaine Gel 2% and 5% for Ophthalmic Procedures

PURPOSE To compare same-day pain control and safety of 2 different anesthetic gels utilizing 5% and 2% lidocaine gel. Main outcome is to determine whether 5% lidocaine gel is more effective in decreasing pain during conjunctival clamping compared to 2% lidocaine gel 5 and 10 min after gel application. METHODS This is a prospective, randomized double-blind clinical trial. Patients were randomized to receive 2% or 5% lidocaine gel in each eye. Discomfort during the gel instillation and pain during conjunctival clamping 5 and 10 min after gel application were compared. Extent of corneal conjunctival staining was graded according to the Oxford scale. RESULTS Eighty eyes of 40 patients were enrolled. The groups were similar in gender, with a mean age of 48 ± 16.26 years. The 5% lidocaine gel resulted in higher discomfort during initial instillation (P = 0.092), however, the pain during conjunctival clamping was lower in the 5% lidocaine gel eyes (P = 0.564) in both 5 and 10 min later (P < 0.001). The majority of patients (80%) had no corneal conjunctival dye staining. The tear break-up time was not statistically different after lidocaine gel 2% (20.35 ± 7.37 s) and lidocaine 5% (19.75 ± 7.00 s). CONCLUSION Five percent and 2% lidocaine gel have similar efficacy controlling pain 5 min after instillation, however, 5% lidocaine gel appears to be more effective with a longer duration of action, without corneal toxicity. There was no corneal toxicity noted with either concentration.