Pain with Intraocular Injections and Is One Injection Enough?

I recently received a question that I’ll paraphrase for brevity.

My 97-year old father recently developed wet AMD. He received an injection of Avastin® from a retinal doctor. The injection was very painful. He returned in two months, was told by the doctor that the leakage had stopped, and that therefore he didn’t need another injection. He didn’t have an OCT done though. I was wondering whether he should have another injection and what could be done about the pain?

An injection into the eye is painful for at least a few second unless an anesthetic is used. Some retina experts use Lidocaine® gel which is a topical anesthetic. The gel is placed under the lids and left in place for five or ten minutes. I’ve found that the gel works well in two out of three patients. The other patients feel a little or a lot of pain.

For this reason, I still inject an anesthetic under the conjunctiva before giving the intraocular injection. The disadvantage of the first injection is that it often causes a little bleeding under the conjunctiva. The blood makes the eye look fire engine red for a week. The blood goes away however and doesn’t cause harm. After the injection of anesthetic, I try to wait five minutes before doing the intraocular injection. Very few patients feel anything after a subconjunctival injection of anesthetic. That’s what should be used in your father.

I usually see a patient back six weeks after an injection of Avastin®. I think all patients should have an OCT to make sure there is no residual fluid because it can be missed on the examination. The goal of treatment is to get rid of all of the fluid. Often the best acuity is gained only after multiple injections. The exception to this rule may be if the eye already has a lot of scarring and the doctor doesn’t think additional injections are going to help.

So, I would take your father to another doctor and get an OCT. If it shows no fluid, then the first doctor was right and I apologize for doubting him. If it shows residual fluid, I would give your father another injection of Avastin® or maybe Lucentis®. He should be given a subconjunctival injection of anesthetic first and the doctor should wait five minutes before giving the intraocular injection. I predict your father will be very pleased.

related posting: Pain after Avastin injection (May 26, 2006)

related posting: Pain with Intraocular Injection (February 26, 2007)