RWC 2024: Strategies to minimize pain with intravitreal injections

Sunir Garg, MD, FACS, shares strategies to minimize pain with intravitreal injections at the 2024 Retina World Congress meeting in Fort Lauderdale, Florida.

Video Transcript:

Editor's note: The below transcript has been lightly edited for clarity.

Sunir Garg, MD, FACS:

I am Sunir Garg. I'm professor of ophthalmology at Wills Eye Hospital in Philadelphia and a partner with Mid Atlantic Retina. I have a talk on minimizing pain with intravitreal injections. We do a lot of injections every year as profession. And while most patients tolerate them fine, some patients really hate it. Usually they hate it because the feeling that they get with the povidone iodine. We know that sterilizing the ocular surface is critically important and povidone iodine is really the agent that's been shown to reduce the risk of endophthalmitis. But there's a few interesting things about povidone iodine; number one, the concentration of povidone iodine doesn't really seem to influence the rate of endophthalmitis. There [were] a couple of studies that looked at 5% versus 10% topical povidone iodine, and there's no big difference there. One of the really interesting things about povidone iodine is the concentration doesn't really seem to matter. What matters is the amount of free iodine that's available, and the amount of free iodine available actually goes up as the concentration of povidone iodine goes down. So that's a little bit counterintuitive. Number two: Just because you're using a higher concentration of povidone iodine, doesn't mean that it works any more quickly. Some patients, though, you know, don't want to have the injections if they have to have that feeling afterwards. So some people will skip the povidone iodine. Please never do that. There has been a few series that have looked at patients who've had just topical antibiotics. The endophthalmitis rate is too high, so that's not a great option. Sometimes I'll irrigate the fornices after the injection, and that can be very helpful. Using a topical steroid or nonsteroidal drops can be helpful in reducing pain. Sometimes I'll hold the eyelids open and just paint the quadrant of the eye, keep the eyes open for about 30 seconds and do the injection there. That can be a useful technique. Then the other thing that I find to be very helpful is using aqueous chlorhexidine. There's a couple of different versions of aqueous chlorhexidine. There's an alcohol-based one. That one's not so good for the cornea. But then there's a non-alcohol version. That works really well. Patients find that to be a lot more comfortable. We did a study where one eye got povidone iodine, the other I got aqueous chlorhexidine. It's no surprise that the eye that got aqueous chlorhexidine was a lot more comfortable for patients, including the day after the injection. One of the drawbacks of aqueous chlorhexidine, at least in the United States, is you can either get it from a compounding pharmacy, which is $100 a bottle. It's only patient-specific, and it's only good for 28 days. That becomes cost prohibitive. There's commercially available versions that are available. You can buy a 450 ml bottle for about $130 But that only has a 24-hour [inaudible] date on it. So after it's open, after 24 hours, you're supposed to throw it away. And medical legally, that may pose some concerns for people. So until we have those things sorted out, it's limited my use of it. Thank you.