Shot in the Eye: Safe and…..Painless

Intraocular injections are given all the time. They don’t hurt. Intraocular injections of anti-VEGF medications (e.g. Avastin®, Lucentis ®and Macugen®) are given for the treatment of macular degeneration and also, sometimes, diabetic retinopathy.

Intraocular Injection

Intraocular Injection (Mark Erickson, JirehDesign.com)

A retinal specialist sees a variety of patients with retina disease, but most of the patients have either macular degeneration or diabetic retinopathy. The amount of injections given will continue to rise.

When I first recommend an intraocular injection for treatment, the apprehension is palpable. When I describe the process, the biggest question is really regarding pain and discomfort. A needle in the eye?

The Process

I almost never inject the same day I may recommend an injection; regardless of cause. I think patients need time to digest the reasons for the intraocular injection and to get comfortable about having a needle injected into their eye.

Antibiotics

Infection is a risk. The risk is small, but the effects could be devastating. The the rate of intraocular infection is somewhere around 1:2000. This is comparable to cataract surgery. Prior to anticipated injection, I like patients to receive antibiotic drops 4x a day starting 4 days prior to the injection.  We are not sure if this really is effective.  Some docs will inject at the same day.  It’s not malpractice.

Other possible complications include bleeding, cataract and retinal detachment (very unlikely).

Topical Numbing

Upon arrival to the office. Visual acuity and intraocular pressure are documented. The eye is dilated. We use cotton-tipped applicators dipped in Lidocaine (numbing solution) to numb the eye for about 15-20 minutes.

Topical Antiseptic

Remember, infection is a risk.  We place a couple of drops of a povidone-iodine solution (Betadine®) on the eye to act as a microbicide (i.e. kills germs).  This, in theory, should further reduce the risk of infection.  This is the exact same preparation we use before intraocular surgery.

“Wow” That Didn’t Hurt!

The actual injection is anti-climatic.  A wire speculum is placed to keep the lids open.  The Betadine® is used again.  The injection is delivered straight into the eye (a small, but very sharp needle is key).  Done!

Instructions are given to continue antibiotic drops for 4 more days and to call if there is any loss of vision or pain (common signs of infection).

What Does This Mean?

Over time, more and more injections will be delivered for the treatment of macular degeneration and diabetic retinopathy.  Intraocular injections have become favorable as it directly delivers the needed medication to the target tissue.  In addition, there are several sustained release drug delivery systems; Ozurdex® and Iluvien® are great examples.  These will be delivered as “injections” as well.

Remember:  No pain.

“Randy”

Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist
Fairfax, Virginia

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Randall V. Wong, M.D.

Ophthalmologist, Retina Specialist
Fairfax, Virginia

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***This post is for information purposes only. This posting does not offer legal or medical advice, so nothing in it should be construed as legal or medical advice. The information on this blog/post is only offered for informational purposes. You shouldn’t act or rely on anything in this blog or posting or use it as a substitute for legal/medical advice from a licensed professional. The content of this posting may quickly become outdated, especially due to the nature of the topics covered, which are constantly evolving. The materials and information on this posting/blog are not guaranteed to be correct, complete, or timely. Nothing in this posting/blog and nothing you or I do creates a doctor-patient relationship between you and the blog; between you and me; or between you and Randall Wong, M.D. or RetinaEyeDoctor.com. Even if you try to contact me through the blog or post a comment on the blog you are still not creating a doctor-patient relationship. Although, I am a doctor, I’m not YOUR doctor until and unless there is a written agreement specifically providing for a doctor-patient relationship.***

Comments

  1. Very well described procedure. I have had quite a few intraocular injections and wish I could have read this first!
    My first experience was to have an injection of Avastin the day I was seen in the clinic.
    While I am numbed adequately I still feel the last push through the eye but the pain is momentary.
    I am given antibiotic drops just before the injection and for 4 days after.
    I have had about 20 injections and never had an infection. I have had some side effects from the Avastin but have other health issues that may have intensified things.
    I don’t regret a single injection as my vision has been preserved . At first I thought I was going to go blind ~ that was 2 years ago and I still have my vision and it is good enough for me to function!

  2. I think, too often, we physicians get too caught up in the treatment and get too worked up about end product or result. Often we forget the psychological aspects of what we do. I still hate going to the dentist – always afraid of the potential for pain.

    The injections are a great treatment as you can tell. The ability to pro-actively help patients with macular degeneration was basically unheard of 15 years ago. The injections have changed what we do. Even treating diabetic retinopathy has become less frustrating!

    As I have written before, the next generation of therapeutics will involve sustained release systems. These systems will be injected into the eye and will release their cargo for weeks or months; depending on design. Imagine a sustained release of Avastin!

    All this to say that we will be “injecting” for a long time.

    Thanks for commenting!

    r

  3. Hi, thanks for the excellent account. I have had 9 jabs: my doc. injects in the lower anterior quadrant i.e. I don’t see it coming, although I know it is.
    A tip: I get the doc. to say just before he injects and I push my head back in the headrest a. far a. p. This is ‘cos once the jab hurt so much that I winced & jerked backwards. Best wishes, Ron (UK).

  4. Thanks for commenting. Happy New Year.

    Actually, there is are other reasons for choosing the “lower anterior quadrant.” Yes, we can be “sneaky,” but it gives us the most exposure (i.e. room to work with) and should there be any bleeding, gravity might keep the blood from obscuring the vision as it might settle in the bottom part of the eye. Last, when injecting steroids, such as Kenalog/Triamcinolone, the drug is injected as a suspension (white powdery mixture). The suspension will dissolve after several weeks, but may cause “floaters” until the drug dissolves.

    Thanks again.

    r

  5. I am an 86 yr old lady who has had 2 Avastin shots in one eye in 2006. One before Cataract
    surgery.. No Betadine used. Had a really bad eye infection after my second Cataract Surgery.
    This lasted 5 weeks. I had very good sight for 4 years.
    This summer I noticed that I had a dark
    shadow in my left eye vision. I had another Doctor give me a shot of Avastin and he used
    Betadine in and around my eye. I had a dark floater the first day but that went away. Then for
    5 days my eye and surounding area was very sore. Still have a little distorted vision but hope
    it gets better with time. I’m not looking forward to getting another shot too soon tho
    Thelma

  6. Thelma,

    Thanks for sharing. Sounds like you are doing very well considering the usual severity of macular degeneration. I think the “floater” after the second shot was actually a tiny air bubble which absorbed within a day or so.

    It also sounds as if you are very sensitive to Betadine. Ask your doctor, if you ever need another shot, if there are alternatives to Betadine. We use a diluted soap solution with patients sensitive to Betadine.

    All the best. Stay well.

    Randy

  7. very interesting read…..except…mine did hurt. It’s really uncomfortable and my eye stung the next few days. Not sure why.

  8. Dear Lisa,

    Could be small scratch on the eye/cornea or sensitivity to the solutions before the injection (assuming they were used). Ask your doctor.

    Randy

  9. I have had5 Lucentis injections.Only once was there no pain. I have actually jumped once so badly that the Dr had to inject me twice that time because I jumped so bad that the needle pulled back out of my eye. I wish there were a better method of numbing my eye They use a combo of numbing drops & gel, but only do the qtip for a minute or two. Betadine is used too, but I just feel the meds are not getting my eye numb. What should I say to the eye Dr next time? Are there different numbing meds we could try?

    Thanks,

    Nancy

  10. Dear Nancy,

    I have a handful of patients that do NOT tolerate the Betadine.

    Do you have pain AFTER the injection lasting until the next day?

    Once we identified this as the culprit…the injections became easier to tolerate.

    Ask your doctor about this possibility.

    He is free to call me or email me.

    Randy

    RWong@RetinaEyeDoctor.com

  11. Gary cullen says:

    i have a question ,I am a professional tattoo artist and i have been reading about some new craze that is going on ,the new fad /craze is having colored dyes injected into your eyeball to change the eyes color ,my question/query is – this procedure is being called eyeball tattooing but it is done with a hyperdermic injection needle which tattooing does not use while tattooing can this be a legal loophole that unqualified people are using to use injection needles into a clients eye to get round the law ,what qualifications does a person need to have to perform this procedure on a client/patient can you clarify the qualifications training required to inject or do this procedure on anyone as this precedure is being done in some tattoo studios and i feel the law is being broken in this respect and being done by shady tattoo studios ….

  12. Dear Gary,

    I have no idea with regard to legalities of injecting for tattooing.

    I don’t even know what actual qualifications are needed for the intravitreal injections I give routinely.

    Sorry I’m no help.

    Randy

  13. dan sciarra says:

    dear Dr Wong i have had brvo for 4 years now started with avistin then lucentis each one seemed to not work after a year . do most of the shots turn out like this. i was told tha if i go to steroids they have more side effects. thanks dan

  14. Dear Dan,

    Geez. Tough to say given I can’t examine you, but I usually use Ozurdex (steroid) in conjunction with Avastin. How old are you?

    r

  15. My first injection last week was not painful but the rest of my night an following morning was very bad. Like I had glass shards in my eye. It was maddening, why don’t they give you numbing drops to take home, just incase? All night the eye was watering profusely and extremely sensitive to light. I had a lot of bleeding and now, 5 days later, it has begun to be sore again and now the bleeding is spreading down into a visible part of my eye. I wish my RS did what other doctors do and give the me the worst recovery I should expect, so I’d know if this was serious of not.

  16. Caren,

    Can’t give numbing drops – not for repeated use, just when you’re in the office.

    Make sure to tell your docs about your issues….some of my patients had lots of pain afterwards and we discovered that they are sensitive to Betadine.

    r

  17. Last Tuesday I had 4 injections (one was for a sample) after a suspected infection from an eye injury but thought I would let you know that I would not want to go home to think about it and lose sleep that night. I was so glad he said it would be done right away so there was no worry and absolutely no pain with all the numbing drops he gave me. The Betadine he used afterward did bother me awhile though and I still don’t see clearly yet but I am continually putting several different kinds of drops in my eye and still seeing the Retina drs.
    Thank you for your column.
    Jean

  18. VERONICA FOLKS says:

    I went to the eye doctor to get my eyes examined for new glasses and ended up being referred to a Retina Eye Specialist. I wore glasses as long as I can remember, 12 ys old maybe and I am 62 now. I didn’t notice a real change in my vision but looking a computers all day at work made me feel like I was going blind. I would look over the top of my glasses to read and I could see find, glasses were for distance vision, never had bifocals. Anyway to make a long story short, I went to the retina specials who did a series of test and he mention something about the over growing of blood vessels in my right eye. I just notice when I cover my left eye and read out of my right, there is distortion of the words. I had never heard of eye injections before, Lasix eye surgery, but never this. I don’t think the doctor explained the purpose of the avastin injection or what he was trying to accomplish by injecting my eye, and I really got frightened about it. I did not schedule for injection yet because I felt like I had to do more research on this and weigh my options, or do I have option? If I wait to see if the eye worsens, would that be to late to seek help. I feel bad because of all the testing I would like help but I am afraid of perhaps the side affects, pain, or med just not working for me. Do you feel I should try these injections even though I feel ok at this time, just need new glasses.

  19. Dear Veronica,

    If you’ve got abnormal blood vessels growing underneath the retina, the injections are probably best. Don’t wait until the vision becomes involved, be lucky that you have lost vision.

    If you don’t trust the retina specialist you saw….see another.

    Don’t wait.

    Randy

    Randall V. Wong, M.D.
    Retina Specialist
    Fairfax, Virginia
    http://www.RetinaEyeDoctor.com

  20. Even though the comments here are 3-4 years old, they are very good! I’ve been recently diagnosed with MD and had my first injection of Lucentis last week. My specialist seems very good but like many doctors, lack the ability to talk to their patients and actually tell them what they are doing and why and what to expect. So I am forced to surf the net for information, hoping what I find is accurate. My first injection went so well, and pain free I’m almost nervous to have more for fear the first one was a “good glitch”. Only slight burning with the betadine (or lidocaine). But I’ve had worse burning when accidentally getting soap in my eye. Absolutely no ill effects from the first injection. I’m very pleased. I cringe at the thought of long term injections because they are obnoxiously expensive considering the hundreds of thousands of seniors and others that need them. Can’t understand why they need to be so expensive. (was told $2000 per injection). Thank you for your site! Recommending it to others.

  21. Dear Bonnie,

    1. Thank you for your kind comments regarding the site. We are building a nice “retina” community here.

    2. Take it one shot at a time. My experience has been that Avastin is quite comparable to Lucentis, but I don’t know if your own doc feels the same way.

    All the best and thanks again for taking the time to comment. It is very helpful for others.

    Randy
    Randall V. Wong, M.D.
    Retina Specialist
    Fairfax, VA 22030

    http://www.TotalRetina.com

  22. Thelma meacci says:

    I have central cyrus retinopathy. I have had two injections, one five years ago, and one yesterday. The first injection, no problems. The last injection I experienced , what I thought was an allergic reaction occurring on my way home from my office visit. I became very nervous and a feeling of tightness in my stomach. I called the nurse at my doctors office, and she said that I was given nothing that would cause this reaction. Some thing caused this, as I am very sensitive to many medications. I don’t know what drug I was given, but I do know that Betadine was used. Am I crazy, or can this happen?

  23. Thelma,

    How did things turn out?

    My experience says that reactions are limited to the eye only, but you could be an exception.

    Randy
    Randall V. Wong, M.D.
    Retina Specialist
    Fairfax, VA 22030

    http://www.TotalRetina.com

  24. My wife has diabetic retinopathy made worse by 25 years of Aspartame (diet soda) toxicity. Most eye docs refuse to admit this because the truth affects their bottom line. In treatment, her Dr gave her steroid injections which caused Glaucoma and yet he never warned her of the risks. I don’t trust this doctor whose eye pressure readings were suspect and who wanted to do surgery. Now he gives her eye injections every month ongoing for the last 4 years. As a responsible honest Retinal Specialist, do you feel that endless eye injections for the rest of her life are safe?

  25. Rick,

    Be careful with your assumptions, e.g. diabetic retinoapthy and aspartame.

    I assume she is receiving Avastin or Lucentis? Repeated injections are often necessary, but probably not for the rest of her life. I’ve got patients who’ve had dozens.

    Thanks and Happy Holidays!

    Randy
    Randall V. Wong, M.D.
    Retina Specialist
    Fairfax, VA 22030

    http://www.TotalRetina.com

  26. I’ve had two injections so far, steroids to treat this dang swelling of my retina I had a retinal detachment and two operations to fix it. Anyway….what I wanted to say to people going for an injection, neither one of mine hurt, he leaves the q-tip with the lidocane on my eye, like under the upper lid for like 5 minutes, plus before that puts numbing drops in too, and antiseptic stuff….anyway….don’t psych yourself out, that’s the main thing, really. If you think you’re really sensitive maybe tell him or her (your opthalmologist) to leave the q-tip on a lot longer, maybe dose you twice with them….but really it’s pretty pain free, mine have been I really think it’s about 90% a fear thing, and of course you’re afraid, but trust your doc. I trust mine 100%, the dude KNOWS his stuff!! I htink Dr Wong here does too.

  27. Dr. Wong,

    I hope you are still answering questions via your website. I have AMD and have had two injections of Eylea and a third with either Avastin or Lucentis in my right eye. After the numbing wears off I experience torturous burning and a scratchiness around my eyeball, which leads to severe pain over my brow line and right temple. My eye and nose water and run profusely, and must hold my hand over my eye to control eye movement and the resulting pain. My lids become swollen and I cannot open my eye. In addition, I feel nauriated and weak all over my body. I’ve tried pain relievers plus an antibiotic eye ointment, none bring relief. The only short term relief is to hold a washcloth dipped in ice water over my eye. This may relieve some of the swelling on my eye lids. I am convinced that I am allergic to Betadine. My doctor says there is no other antiseptic substitute. I have had these reactions following the first and third injections. The second one was painful, but not as much so. I am beside myself with the discomforts for at least five hours before I notice any limprovement. I cannot imagine going through this again, and wonder if there is anything that can be done to make the aftermath less painful. I would appreciate your opinion as someone who seems so empathetic. My doctor is not and I have trouble communicating with him. He said if I don’t want to go blind, I will just have to “suck it up.” Easy for him to say. He’s never experienced this excruciating pain. .

  28. Dear Steve,

    Thanks for your kind words and the support you are giving others!

    Best of luck!

    Randy

    Randall V. Wong, M.D.
    Retina Specialist
    Northern Virginia
    Fairfax, VA. 22030

    http://www.vitrectomyforfloaters.com

  29. Dear Mary,

    I have several patients who share exact symptoms. I, too, used to discount the complaints, but then realized the problem after daring to inject without Betadine….no more pain!

    Here’s an article I wrote about this;

    http://www.retinaeyedoctor.com/2011/05/do-avastin-injections-hurt/

    For my patients who do not want Betadine, we simply use additional topical antibiotics.

    Best of luck!

    Randy

    Randall V. Wong, M.D.
    Retina Specialist
    Northern Virginia
    Fairfax, VA. 22030

    http://www.vitrectomyforfloaters.com

  30. Rodolfo C, Anastacio says:

    Two years ago I have been diagnosed that my right eye have the wet macular degeneration, My retina specialist started my treatment with Avastin eye injection. He did’nt see any progress with Avastin so he switched me to Lucentis eye injection. I have never experienced any bad side effects or pain in all of my monthly injections. My doctor switched to my 3rd medication Eylea with better progressed. My latest injection I notice dark round bubbles appeared, I thought it will go away the next day but it didn’t, it’s still in the lower side 2 bubbles. I am just curious to know if this will go away.

  31. CHRISTOPHER LANCASTER says:

    I HAVE CENTRAL SEROUS RETINOPATHY FOR ABOUT 1.2 YEARS AT THIS POINT. I HAD A FIRST INJECTION WITH AVISA THEN ANOTHER SIX WEEKS AGO WITH lucentis. SINCE THE SECOND INJECTION I HAVE A FLOATER IN MY VISION. NIETHER MEDICATION HAD ANY EFFECT ON THE CENTRAL SEROUS RETINOPATHY THAT I CAME IN TO HAVE TREATED IN THE FIRST PLACE. NOW THIS FLOATER IS HERE EVERY TIME I TURN MY HEAD AND IT IS THE SINGLE WORST THING TO HAPPEN TOM ME. I HAVE SEEN THREE RETINA SPECIALISTS. I HAVE BEEN TOLD CSR IS RARE AND THAT CHRONIC CSR WHICH THEY THINK I HAVE IS EVEN MORE RARE AND TO HAVE A FLOATER AFTER AN INJECTION IS EVEN MORE RARE. I AM SICK AND TIRED OF PEOPLE TELLING ME HOW RARE MY CONDITION IS. I AM STARTING TO THINK THE TECHNIQUE OF THE SECOND INJECTION CAUSED THE FLOATER. I AM NOW VERY DEPRESSED AND HAVE A HARD TIME GOING INTO DIRECT SUNLIGHT BECAUSE I CANT DEAL WITH THE FLOATER. I AM TRYING TO GET INTO BASCOM PALMER BUT THEY WONT BE ABLE TO SEE ME UNTIL SEPTEMBER.

  32. Dear Dr. Wong,

    Is there anything else that can be done more for an AMD patient who has had 4 Lucentis jabs and has been told the degeneration has gone too far. This patient is in his early 70s. His diabetes, high blood pressure and high cholesterol are all under control currently.

    What other medication or treatment is there possible? He is a Malaysian.

    Thank you
    regards
    K N Low (Ms)

  33. Rodolfo,

    By now, you must have determined the cause of the round bubbles in your vision. I, too, would have guessed it was air.

    Randy

  34. Christopher,

    Hang in there. Keep us updated.

    r

  35. K N Low,

    No doesn’t sound like much else can be done.

    Randy

  36. I’ve had 2 separate series of injections of Kenalog (Triamcinolone-steroid) for Iritis and all its complications. But basically I have inflammation , posterior synechaie (my iris is adhered to the lens and pupil doesn’t dilate), macula edema, hemorrhage, etc. After trying many dilators and prednisone drops and tablets…the only thing that helps a bad flare up is the injection. I’ve had 3 in one week -2years ago. As well as 2 this week. 4 out of 5 were done in a sterile operating room, but today I had one done in the doctor’s office. It doesn’t hurt much at all, but the actual thought of having a needle in your eye is disturbing and the longest minute ever. For a day or two there is always post-swelling and a mild tenderness. I woke up this morning and had a blackish purple area in the corner of my eye and blood inside my lid. The optho says it is a bleed from broken vessels in the lid. I didn’t see floaters but I did see small “fizzing out” lights, I would describe it as looking at sparklers. But it wasn’t as scary as seeing big arcs of light and huge bubbles that seemed to be turning downwards in the corner of my eye prior to injections-which I was told was likely to be the hemorrhage. But on a good note—I hadn’t had any issues for 2 years since the last episode where I had 3 injections in one week–until now. However I have had several flare ups in my other eye (never injected).

  37. Val,

    Thanks for sharing.

    Uveitis can be very, very tough to treat as you are certainly aware.

    I wish you the best.

    Randy

  38. I have had 4 avastin injections. Three were painless. On the first one I felt a prick and voluntarily blinked and lurched. It was ok because he had already injected. Since then they give be a double application of the gel. This last time I felt a prick/burn near the top of my eye like a needle prick and involuntarily blinked. This was before he had injected so he didn’t inject and had them look to be sure that the cornea wasn’t scratched. Then they gave me more gel and some liquid numbing agent and proceeded with the injection. While I did feel the entry a bit and the pressure of the med going in it wasn’t the prick that caused me to blink.

    I don’t know what to do. I’m so nervous about getting the shot not because it is uncomfortable but I’m afraid I will blink. Could the betadine be causing the prick/burn sensation in one area? If the gel was numbing would you still be able to feel the betadine burn.

    After the injections he has you flush with artificial tears to remove the gel.

    Thank you, you are very kind to respond to questions.

  39. Betty,

    I’d recommend telling your doctor about your concerns. There are other methods to numb your eye. Your doctor can also use a speculum to keep your eyes from blinking.

    Randy

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