Updated Guidelines Issued for Intravitreal Injections

Saranya C. Balasubramaniam, MD; Sophie J. Bakri, MD


June 26, 2015

Intravitreal Injection Technique and Monitoring: Updated Guidelines of an Expert Panel

Avery RL, Bakri SJ, Blumenkranz MS, et al
Retina. 2014;34 Suppl 12:S1-S18

Study Summary

There has been dramatic growth in the number of intravitreal injections performed annually. This paper features expert panel consensus regarding the use of intravitreal injections and serves as an update of previous published guidelines from 2004. The guidelines summarize the evidence as pre-, peri-, and post-injection.

Preinjection considerations. There are no absolute contraindications to intravitreal injections. Physicians should use clinical judgement with regard to advanced glaucoma, prior ocular surgeries, postcataract patients, and complex medical conditions. Intravitreal injections are safe in patients on anticoagulation. Active external infections, including blepharitis, increase the risk for endophthalmitis and should be treated prior to intravitreal injections. True allergy to povidone-iodine is rare, and anaphylaxis has not been reported from ophthalmic application. Sterile saline can be used to reduce the irritation associated with povidone-iodine. There is insufficient evidence to support the use of antibiotics to reduce the rate of endophthalmitis. Physicians should exercise caution with bilateral injections, and injections for each eye should be completely separate procedures (ie, separate syringes, medication lots).

Peri-injection management. Gloves and draping have not been shown to reduce the risk for endophthalmitis. Minimizing speaking and/or use of surgical masks during the injection may reduce spread of aerosolized droplets containing oral contaminants. Povidone-iodine 5%-10% should be the last agent applied prior to injection, and eyelid scrubs should be avoided as they may express material from the meibomian gland. Injections can be achieved with a speculum or with manual lid retraction. The eyelashes and eyelids should not be allowed to come into contact with the injection site after povidone-iodine is placed. Topical anesthetics should be used; if gel is used, povidone-iodine should be applied to the injection site before and after its application.

Intravitreal injections should be delivered between the horizontal and vertical rectus muscles 3.5-4.0 mm posterior to the limbus with a 30-gauge or smaller needle that is 18 mm or shorter. Globe softening is generally not required but can be considered in patients with advanced glaucoma or those at risk of visually significant optic nerve damage with the postinjection intraocular pressure spike.

Postinjection management. For patients with advanced glaucoma, intraocular pressure monitoring and treatment may be warranted based on the physician's judgement. There is no evidence to support dilation at the time of the injection. The physician should confirm the presence of formed vision prior to the patient leaving. Postinjection follow-up should be tailored to each patient.


The overall risk for serious complications from intravitreal injections is low. Evidence supports the use of povidone-iodine to lower endophthalmitis rates. Active external infections, such as blepharitis, should be treated prior to intravitreal injections. Gloves and draping do not result in reduced endophthalmitis rates. In addition, intravitreal injections are safe in patients on anticoagulation. Bilateral injections, if necessary, should be performed as completely separate procedures. Of note, there is insufficient evidence to support the use of antibiotics for intravitreal injections to reduce the rate of endophthalmitis.



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