Improving patient experience with intravitreal injections

An aging population combined with the increasing incidence of chronic disease has led to a steady rise in the number of patients requiring retinal care.

Thankfully, modern diagnostic imaging and better access to health care have allowed us to catch disease earlier and intervene sooner. Such advances help us achieve better long-term outcomes for our patients, but they also add to the volume and complexity of care.

I practice in Asheville, North Carolina, a city with a large retired population. I manage a high volume of patients with retinal diseases, including age-related macular degeneration (AMD) and diabetic retinopathy.

AMD represents approximately 80% of my clinical workload. Making sure these patients have a positive experience while they are in our care requires a fine balance of safety and efficiency. We achieve each element by establishing and following preinjection protocols and building trust with our patients. We believe in tailoring not only the procedure but also our anesthetic approach based on patient needs.

The burden of intravitreal injections

For most patients with wet AMD and diabetic macular edema, intravitreal injections (IVIs) remain the gold standard of care. Anti-VEGF agents have revolutionized outcomes, helping preserve sight in millions of patients who would have otherwise lost significant vision. But the treatment comes with a catch: the burden of frequent and repeated injections.

On any given day, I may perform between 40 and 80 injections. That is not unusual in a busy retina practice. IVI schedules are overwhelming for our clinic, but also for our patients. Even those who have been through the process before may be anxious or worried before the injection.

Particularly for those with bilateral disease, who sometimes require 2 different IVIs every month, there is a lot of associated emotional stress, transportation issues, and physical discomfort. As clinicians, we are always looking for ways to reduce the friction in this process. A smooth and efficient preinjection protocol not only ensures safe, effective, and consistent care but also may reduce patients’ stress and enhance their experience.

Addressing patient comfort

Discomfort during IVIs is one of the most common patient concerns. Although the injection only takes a few seconds, poor anesthesia or a rushed preinjection process may make those few seconds feel like a lifetime for a patient.

Over the years, I have explored myriad options to optimize anesthesia. Early in my practice, there were no FDA-approved anesthetics for IVIs. The standard approach was topical drops such as proparacaine and tetracaine, followed by povidone-iodine (Betadine) for antisepsis. Although fast and efficient, the method often left patients wincing in significant discomfort. More than occasionally, I found patients were reluctant to return for follow-up care and IVIs.

Viscous anesthetic gels offer better pain control. Products such as lidocaine hydrochloride ophthalmic gel (Akten; Théa Pharma) and tetracaine hydrochloride 0.5% ophthalmic gel (TetraVisc; OCuSOFT) help keep the anesthetic in place longer, allowing more effective numbing at the injection site. The trade-off, however, is that the thick gel may trap bacteria on the ocular surface, potentially increasing the risk of endophthalmitis.^1,2 Additionally, prolonged exposure of the gel to the cornea, especially when clinic flow is delayed, can result in epithelial toxicity and delayed wound healing, which can lead to large corneal abrasions and days of discomfort.³

Subconjunctival lidocaine provides the most complete pain relief but requires additional setup, an extra needle stick, and additional risk to the patient. This lengthens the preinjection process for our staff and reduces clinic efficiency. Even though the time difference may be only one minute per patient, the extra time in a long clinic day can add up to nearly an hour by the end of the day. Although patients feel less pain and discomfort during the injection, some experience anxiety around the numbing injection itself, and many have more prolonged discomfort when the anesthetic effect wears off.

Reducing patient burden

More recently, I discovered chloroprocaine hydrochloride ophthalmic gel 3% (Iheezo; Harrow) and have incorporated it into my injection anesthetic routine. The preservative-free gel is formulated with a lubricating component and is the first FDA-approved ocular anesthetic gel in more than 10 years specifically labeled for ophthalmic use, including IVIs.

I began using chloroprocaine hydrochloride ophthalmic gel because of its potential to offer more comfort than traditional drops while streamlining the process compared with subconjunctival injection.^4-6 Findings from a phase 3 trial showed that 1 dose (3 drops) achieved sufficient ocular surface anesthesia in less than 90 seconds and lasted approximately 21.5 minutes.⁷ This is much easier than other protocols that involve the use of multiple drugs and application methods.⁵

Chloroprocaine hydrochloride ophthalmic gel has an established safety profile comparable to other local ocular anesthetics.^4,5 Additionally, it is 75% less viscous than other FDA-approved anesthetic gels (Figure) and has demonstrated no barrier to the bactericidal actions of povidone-iodine 5%.^6,8,9

In my hands, chloroprocaine ophthalmic gel is preferred to other anesthetic approaches because it is safe, easy to apply, remains localized at the site of administration, and provides consistent anesthesia for most patients.

I appreciate that chloroprocaine hydrochloride ophthalmic gel is a single-use, sterile product, reducing concerns about cross-contamination from other patients as well as endophthalmitis rates compared with multiuse ophthalmic anesthetics. It also washes out quickly due to the lower viscosity, allowing patients to return to normal activity sooner.

With that said, ophthalmic gel is not a perfect solution for everyone. There is a theoretical risk of surface toxicity, infection, and delayed wound healing.^1-3 Although the data are not conclusive, it is a valid point of concern and underscores the importance of weighing the risks and benefits of anesthetic methods in each clinical context.

Balancing comfort, safety, and efficiency

Ultimately, every anesthetic approach comes with trade-offs:

• Topical drops are fast and efficient but provide the least amount of comfort for patients.
• Subconjunctival lidocaine offers complete anesthesia but slows clinic flow.
• High-viscosity gel-based agents can strike a balance but may raise questions about surface toxicity or infection risk depending on the product and protocol.⁹

In my practice, I tailor anesthesia to patient needs and the clinic day’s demands. For patients with high anxiety or those with a history of discomfort, I lean toward chloroprocaine ophthalmic gel with subconjunctival lidocaine.

For standard cases, however, chloroprocaine hydrochloride ophthalmic gel has become the standard of care for me. It has significantly improved patient satisfaction and adherence without significantly affecting efficiency.

Conclusion

As we continue to manage the growing burden of retinal disease, helping to improve the patient’s quality of life and experience matters more than ever. Streamlining the injection process while prioritizing comfort is key to building trust and ensuring adherence over years of ongoing retinal care.

Raj N. Patel, MD

E: rpatel286@carolinaeyemd.com

Vitreoretinal Surgeon, Carolina Ophthalmology, P.A., Asheville, North Carolina.

Dr Patel is a consultant for Harrow.

References

1. Lad EM, Maltenfort MG, Leng T. Effect of lidocaine gel anesthesia on endophthalmitis rates following intravitreal injection. Ophthalmic Surg Lasers Imaging. 2012;43(2):115-120. doi:10.3928/15428877-20120119-01

2. Stem MS, Rao P, Lee IJ, et al. Predictors of endophthalmitis after intravitreal injection: a multivariable analysis based on injection protocol and povidone iodine strength. Ophthalmol Retina. 2019;3(1):3-7. doi:10.1016/j.oret.2018.09.013

3. Miller DD, Wagner IV, Ten Hulzen RD, et al. Delayed corneal healing after the use of topical ophthalmic anesthetics. Cureus. 2024;16(9):e70455. doi:10.7759/cureus.70455

4. Iheezo. Prescribing information. Harrow IP LLC; 2022.

5. Data on File. Harrow IP LLC; 2023.

6. Chloroprocaine hydrochloride ophthalmic gel 3%. Pharmaceutical development. Sintetica; 2022.

7. Han J, Rinella NT, Chao DL. Anesthesia for intravitreal injection: a systematic review. Clin Ophthalmol. 2020;14:543-550. doi:10.2147/OPTH.S223530

8. Akten. Material safety data sheet. Akorn Pharmaceuticals; 2010.

9. Ilyas H, Costine R. The effects of low viscosity preservative-free chloroprocaine ophthalmic gel 3% versus BAK-containing tetracaine 0.5% on the bactericidal action of povidone-iodine. Clin Ophthalmol. 2024;18:825-831. doi:10.2147/OPTH.S454496