<p>Reduction of Intraocular Pressure Spikes Due to Intravitreal Bevacizumab Injections by Scleral Indentation with Cotton Swab or Digital Ocular Massage: Innovative Techniques Compared</p>

Abstract

This study aims to evaluate the effectiveness of different decompressive injection techniques in reducing intraocular pressure (IOP) spikes, if compared to the injection without pressure applied on the eye, following the intravitreal injection of bevacizumab. Patients and Methods: Two hundred patients with indication to intravitreal therapy were randomized into five arms: 40 received intravitreal injection without ocular decompression (arm A), 40 with pre-injection scleral indentation with cotton swab (arm B), 40 with preinjection digital ocular massage (arm C), 40 with post-injection scleral indentation with cotton swab (arm D) and 40 with post-injection digital ocular massage (arm E). All patients underwent measurement of the IOP with Goldamm applanation tonometer 10 minutes before and 10 minutes after the injection. The primary endpoint of the study was variation of the post-injection IOP with the different techniques. Results: An increase in post-injection IOP was observed in all the arms, if compared to preinjection values. The greatest increase was observed in arm A with a mean IOP rise of 17.60 mmHg. All other techniques showed lower mean IOP increases: arm B 10.76 mmHg, arm C 9.35 mmHg, arm D 8.8 mmHg, arm E 3.4 mmHg. The post-injection IOP differences of innovative techniques compared to the technique without ocular decompression were all statistically significant (p-value <0.01). If compared to arm A (35%), a reduction in IOP spike ≥40 mmHg frequency was also observed. The status of phakia/pseudophakia, a previous diagnosis of glaucoma and the underlying pathology for which indication was given to inject bevacizumab did not significantly alter the post-injection IOP in any of the protocols. Conclusion: The introduction of new injection protocols, such as injections performed before or after decompressive treatments, could be a safe and effective approach to control post-injection IOP increase.

Transient Vision Loss Associated with Prefilled Aflibercept Syringes

“…7,16 Second, performing intraocular decompression with a cotton tip applicator prior to intravitreal injection may be considered to reduce the incidence of an IOP spike following J o u r n a l P r e -p r o o f injection, though this method has yet to be validated for pre-filled syringes in larger prospective studies. [17][18][19] Third, we recommend injecting at a slower rate. Our data demonstrate that injection speed is directly proportional to injection force; decreasing injection speed by adding an extra second may result in significantly lower injection forces.…”

Changes of Ocular Biometry and Intraocular Pressure in Patients Treated With Intravitreal Injection of Antivascular Endothelial Growth Factors

“…Some suggested that the inflammation in trabecular area causes direct raise in IOP (19). Some postulated direct damage to trabecular meshwork after multiple injection (20). On the other hand, there is also possibly of ranibizumab (48-kilodalton (kDa)) accumulated in trabecula and schlemm's canal causing direct or indirect obstruction of the outflow (19).…”

“…Interestingly, some innovative manipulations such as scleral indentation with cotton swab and ocular digital massage pre-and post-procedure significantly reduces the excessive rise of IOP post intravitreal injection (20). The mechanism of this maneuver is yet to be elucidated.…”

Novel Needle for Intravitreal Drug Delivery: Comparative Study of Needle Tip Aspirates, Injection Stream and Penetration Forces

“… 46 Hence, improvement of the IVI technique and perfection of the required instrumentation remain the focus of numerous studies aimed to reduce the rate of complications. 47–51 Since the last decade, a number of different devices for IVI were proposed and introduced into clinical practice. Among the main issues which hypothetically could reduce the complication rates associated with IVIs are the stability of the eye, enhanced sterility of the injected area, diameter of the needle and premeasured distance from the limbus, which are all required for safe procedures.…”