Injectable medications in eye care Injectable medications No financial disclosures Brad Sutton, O.D.,F.A.A.O. IU School of Optometry Clinical Professor Indianapolis Eye Care Center No financial disclosures Injections by OD’s Types of injections Subcutaneous Allowed in 36 states Intramuscular Intravenous 22 of those allow for counteraction of anaphylaxis only Periocular Intraocular 14 allow for varying degrees of diagnostic and therapeutic use Always ask about allergies! NBEO Sterile draw technique Gloves Injections now a permanent NBEO Alcohol swab cleaning of vial top Part III station Always inject an amount of air in to Sterile technique vial first that is equal to amount of IM desired fluid removal: Vacuum sealed IV After draw, remove any air from Model arm pads only syringe before use 1 One hand scoop technique : Sharps NBEO All needles Needle used disposed of in a only for the sharps container drawing up of a fluid to be capped (FL) using the “one hand scoop technique” Re-capping needles Syringe basics Needles that 1ml (TB) have been used 3ML on people are 5ML never re-capped before Larger (less discarding them common except for blood draws) High risk of “stick” with contamination Needles / Syringes Needle basics Bevel Gauge: larger number = smaller needle 19, 23, 25, 27, 30 May have second # indicating length: 27 ½ G 2 Injection sites Subcutaneous Deposits medication below the skin Can use any site that is not over a bony structure and is free of large blood vessels and nerves Typical sites include the thigh, back of the arm, and abdomen CPT code 96372 Subcutaneous sites Subcutaneous technique Clean site Pinch skin Insert needle at 90 degree angle Inject medication Release skin Subcutaneous technique Subcutaneous Medication absorbed more slowly when injected in this manner than with intramuscular or intravenous injections Requires small, thin needles which are short Used with insulin, anesthetics, PPD testing, copaxone Good for small doses of non-irritating solutions. Bad for larger volumes and irritating solutions 3 Intramuscular Intramuscular technique Deposits medication into muscular tissue Clean site free of major vessels and nerves Pull skin taught Typically given in the deltoid or gluteus muscles ( outer buttocks ) Insert needle at 90 degree angle Much more rapid onset of action than SQ route due to the greater blood supply of Pull back syringe the tissue to assure not in Good for concentrated or oily substance blood vessel Requires thick, long needles (epipen and Inject obesity?) medication CPT code 96372 Intravenous IV injections: tools Utilized in eye care for IVFA, ICG Must first fill 3 angiography, and laser assisted macular or 5 CC syringe surgery (visudyne, etc. ) with fluorescein Very rapid onset of action using large Greater chance of early onset allergic needle response Then discard Remember……once a medication is that needle and injected by any means it can not be attach butterfly retrieved! tubing: the shorter the better! IV Injections: technique IV technique Place tourniquet on upper arm (downstream from injection site) Locate vein in antecubital space (preferred) or back of hand (if you must) With bevel up, inject butterfly needle (23 – 25 gauge) in to vein at an angle of around 30 degrees 4 No good! IV Injections Draw back on syringe to get blood flow in to tubing until full (unless tubing filled with saline) Remove tourniquet and inject 3-5 cc of dye depending upon % Periocular injections Intralesional injections Intralesional Utilized in the treatment of chalazia and less frequently pyogenic granulomas. Subconjunctival Form of subdermal/SQ injection Subtenons Inject steroids into the lesion to hasten Peribulbar/local resolution anesthetic blocks Typically will use kenalog 10 or 40 mg/ml Specialty uses- (triamcinalone) or dexamethasone 2.0 or botulinum toxin 4.0mg/ml Dexamethsone is a clear solution and is more readily absorbed than the kenalog suspension-more later! Intralesional injections Intralesional injection Utilize TB syringe with 27 or 30 Contraindications/adverse reactions gauge needle include allergic responses and skin Bevel up depigmentation with kenalog (questionable -personal experience ) Inject approximately .2 cc of steroid Follow up in two weeks…..some lesions (usually kenalog) in to lesion will require a second injection Can do skin side or palpebral side; Billable procedure with its own CPT code skin side more comfortable. Can’t 11900, 11901 if more then seven! really pinch skin Lesion may be too hard 5 Intralesional injection Subconjunctival injections Utilized to deliver high dose of long acting steroid or antibiotic to the anterior segment Main uses include steroid delivery in cases of recalcitrant inflammation or CME as well as post operative administration of antibiotics and steroids Can give antibiotic injection for severe corneal ulcers or in endopthalmitis cases Subconjunctival injections Subconjunctival injections Adverse reactions include allergic Perform on bulbar conjunctiva response and increased IOP with steroids under upper lid (hides any subconj. IOP elevation can be difficult to control heme) because med can not be “discontinued” like with topical steroids Use jewelers / colibri forceps to tent conjunctiva and create potential Can occur weeks to months after the injection space Can occur with long history of not Insert small gauge needle bevel up pressure responding to topical steroids in to space, release conjunctiva, Dexamethasone or Durezol trial? and inject .1-.2 cc CPT code 68200 Subconjunctival injection Colibri forceps 6 Subtenons injections Subtenons injection Similar to subconjunctival in uses and Utilizing small needle (27 or 30 indications gauge), insert needle in to lower Only difference in procedure is that the needle penetrates Tenon’s capsule fornix where bulbar and palpebral Indications include pars planitis or other conjunctiva meet forms of intermediate uveitis and CME Move needle laterally and observe In the majority of cases this technique globe to ensure no movement holds little advantage over a more simple subconjunctival injection Inject approximately .2 cc New glaucoma meds? CPT code 67515 Intravitreal injections Anesthetic application Done to prepare for Generally not surgical procedures performed by OD’s such as lid lesion removal, chalazion Kenalog, Lucentis, excision, etc. Avastin, Macugen, Eylea, Jetrea Many uses Peribulbar block Specialty uses-Botulinum Botulinum toxin is derived from the organism that is responsible for botulism It is a very powerful neurotoxin and its use results in paralysis of muscles It is utilized in the management of blepharospasm and strabismus Also used by plastic surgeons and dermatologists to temporarily remove wrinkles 7 Botulinum Botulinum In blepharospasm cases, it is In strabismus, the injected SQ at several locations to injection is paralyze affected muscles and directed into the eliminate or decrease the spasm muscle to be weakened (the Has to be repeated every few months overacting muscle) Complications include ptosis and exposure problems secondary to incomplete lid closure Pharmacokinetics Steroids Absorption dependent upon several One of the most common factors…… medications delivered via injection 1) route of administration when it comes to eye care 2) concentration of medication Uses include chalazia, recalcitrant iritis, CME, pars planitis, and others 2) solution / suspension (sol. Is more rapidly absorbed and shorter acting) Injectable steroids Dexamethasone Three main injectable steroids Dexamethasone 4.0 or 2.0 mg/ml 1) Dexamethasone Water soluble and very short acting Clear solution, not milky suspension like 2) Kenalog (Triamcinolone) kenalog 3) Depo-medrol Duration of action is often too short to be (methylprednisolone) utilized effectively with uveitis or long- standing chalazia 8 Kenalog 10 mg/ml Kenalog Triamcinolone 10 or 40 mg/ml Trivaris (Allergan) 80 mg/ml Suspension: slow absorption and moderately long acting Great choice for chalazia, sub- conjunctival / sub-tenons treatment of uveitis (usually 40 mg/ml) Watch for IOP increase and PSC! Depo-medrol Lucentis / Avastin Depo (long acting) version of Both designed to fight cancer, only methylprednisone Lucentis FDA approved for the eye Very slowly absorbed and very long Both work by blocking VEGF and acting stopping vessel growth Duration of action is often too long Avastin very cost effective to be practical ( increased IOP, etc) compared to Lucentis AMD, CRVO, DBM other causes of CNV, etc. What about geographic atrophy? Also Eylea (VEGF trap) Intravitreal injections Contrast dyes Not routinely performed by OD’s Fluorescein and Indocyanine Green right now in any state Fluorescein is an inert, What about nurses? Eye 2014; 28 vegetable based dye that is yellow-orange (6):734-740. Retinal specialists in in color (10% or 25%) England trained NP’s to give Absorbs blue intravitreal shots. Out of 4000 wavelengths and shots, the only complication was fluoresces at 520-530 nm SCH (5.7%) Inject 3cc of 25% or 5cc of 10% 9 Fluorescein Fluorescein Leaks from all vessels except those in the Nausea in 15%, vomiting in a small central nervous system (retina) number of those 80% binds to plasma proteins leaving Contraindicated in pregnancy or only 20% free to fluoresce nursing Allergic reactions are rare but can cause Yellowing of skin and urine hives (.05%) and even death (.00045%). Extravasation