Intravitreal injections today: the challenges

An IVEG course at EURETINA 2025

Highlights and take-home messages

Jay Chablani, MD

Intravitreal injection sin vitrectomized eyes

  • After PPV, the vitreous gel is replaced by aqueous humor, and this increases diffusion and shortens the pharmacokinetic half-life of anti-VEGF drugs. More frequent injections might be needed.
  • These patients may benefit from longer-acting drugs with larger molecular weights
  • Steroids may be considered, as they have slower clearance than anti-VEGF, but monitoring IOP is mandatory
  • When injecting:
    • avoid prior scleral wounds, and use a tunneled 30-32G needle;
    • expect more reflux, apply prolonged compression
    • In silicon oil-filled eyes, inject slowly, consider the inferior quadrant

Patricia Udaondo, MD, PhD

Intravitreal injections in patients with glaucoma

  • Intravitreal injections are generally safe in patients with glaucoma, but the risk of causing RNFL changes and disease progression appears to be higher with frequent (>7) injections.
  • Longer intervals between injections may help minimize IOP elevation. Nowadays, we have new treatments that allow us to maintain the efficacy with extended intervals.
  • Prophylactic IOP-lowering medications are effective in reducing the risk.
  • Closer monitoring is mandatory.

Gemmy Cheung, MD

Intravitreal injection in pregnant and breastfeeding women

  • VEGF is important during the first trimester of pregnancy, as it is involved in the embryonic vascular development, as well as in maintaining the placenta throughout the pregnancy.
  • There are anecdotal reports of miscarriage following anti-VEGF intravitreal injections in women with diabetes, but it is unsure whether these might be due to the anti-VEGF injection or to poor diabetes control
  • Data are limited, and interpretation is challenging due to potential reporting bias, unbalanced risk factor profile and difficulty in ascertaining cause and effect relationship
  • Steroids might be a safer option
  • The use of these drugs during pregnancy and breast-feeding should be discussed case by case, involving a multidisciplinary team

Francesco Boscia, MD

Intravitreal injections: logistics, patient flow and adherence

  • 96,624 injections analyzed showed no significant differences between office, ambulatory surgery and OR in terms of safety, with an identical 0.02% endophthalmitis rate
  • Office-based injections lead to a reduction of 26% of cost and 14% productivity increase, and office is preferred by patients due to comfort and quick service
  • Same day assessment and injection leads to cost savings, reduced travel burden, quality of life improvement
  • A T&E injection regimen is non inferior to monthly and reduces the burden, with most patients achieving a Q12 or more interval
  • Reasons for non-adherence are patient dissatisfaction, financial burden, age and comorbidities, travel distances and time, appointment booking difficulties.
  • Same day assessment and injection, individualized T&E regimens and optimized care pathways correlate with better adherence.

Daniele Veritti, MD

Intravitreal injections, bilateral and symultaneous

  • Same-day, bilateral anti-VEGF injections are increasingly used worldwide in real-would retina practice
  • Large studies and meta-analyses show no increased risk of endophthalmitis
  • Logistic and clinical benefits include fewer visits, better adherence, reduced burden for the patient and the clinic
  • Professional guidelines from EURETINA, RCOphth, SFP, RANZCO, AAO/ASRS and other societies allow for bilateral injection, provided tht strict asepsis is observed and informed consent exclicitly documents bilateral treatment
  • Practical recommendations:
    • Treat each eye as a separate procedure using a new vial or pre filled syringe for the second eye
    • If compounded drugs are used, prefer different lots in order to minimize the risk of bilateral contamination.
    • Patient selection is also important: avoid bilateral injections in patients with active ocular inflammation or systemic frailty

Baruch Kuppermann, MD

Intravitreal injections: devices and robotics

  • Many ocular diseases are still seeking improved pharmacological solutions
    • Many effective drugs have a relatively short half-life intravitreally, which necessitates frequent injections
    • Drug delivery systems provide potential for extended durability
    • Gene therapy and cell-based systems allow for intraocular drug production
    • Systemic and topical options are being explored
  • Extended drug delivery technology to posterior segment is being further refined
    • Future generation devices will allow longer duration and increased target specificity
    • There is potential for “one and done” or “one and less” therapies, but this may result in a disconnect between treatment and examination intervals

Paolo Lanzetta, MD

Intravitreal injections and AI

  • The discussion focused on the evolving role of AI in ophthalmology, highlighting its applications in disease detection, diagnosis, and treatment.
  • AI aids in analyzing OCT imaging, predicting disease progression, and personalizing treatment regimens.
  • It can forecast visual acuity outcomes and treatment responses, such as anti-VEGF efficacy.
  • Through AI-driven retinal image analysis also specific systemic diseases can be identifies, such as cardiovascular diseases and Alzheimer’s disease
  • AI holds potential for drug development, and assist in analyzing large datasets from clinical trials
  • AI could tailor medical treatment to individual patient profiles, considering genetic makeup, lifestyle and social determinants of health and personalized medicine
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Legal information

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