“An intravitreal injection is a shot of medicine into the vitreous, near the retina at the back of eye.”[1] The procedure of intravitreal injection of air was first described in the early 20th century. Subsequently, antibiotics intravitreal therapy was introduced for endophthalmitis. The rapid increase in clinical use of intravitreal injections has largely been due to new pharmacological agent in particular drugs such as

• Ranibizumab and Bevacizumab directed against vascular endothelial growth factor (VEGF).
• Steroids including Triamcinolone

These agents most commonly used to treat choroidal neovascularisation (CNV) due to age-related macular degeneration (AMD), retinal vein occlusion (RVO), diabetic macular oedema (DMO) and proliferative diabetic retinopathy (PDR), neovascular glaucoma, uveitis and cytomegalovirus retinitis.

According to medical records, there has been a marked increase in the use of intravitreal injections in treatment of Neovascular ARMD Since 2001. Use of intravitreal injections has increased 193- fold from 4215 injections in 2001 to 812413 injections in 2007. Despite encouraging results in halting the disease and improving the vision, intravitreal injection of above agents may be associated with systemic adverse events and devasting ocular complications. This Prospective study of 100 consecutive cases of intravitreal injections was done in tertiary hospital to analyse indications, complication and outcome in phakic and pseudophakic patients.

Prospective

Sample Size with Justification

100 cases: - Sample size was calculated based on previous study which included in bibliography & using following assumption.

a) 95% level of significance

b) Power of 0.8

c) Allowable error on either side 8%

1. Compare pre injection and post injection (at 4weeks and 12 weeks) best corrected visual acuity in both phakics and pseudophakics by using paired t test.
2. To determine percentage of indications & complications in both phakis and pseudophakics.

Figure 1: Fundus for IV antivegf.

Figure 2: Graph showing gender distribution with male predominance.

Figure 3: Intravitreal drug distribution.

Selection criteria

Inclusion criteria: All patients with choroidal neovascularisation due to age related macular degeneration, Proliferative diabetic Retinopathy, Diabetic Macular Edema, Retinal vein occlusion above 18 years of age.

Exclusion criteria:

i) Previous ocular surgery apart from cataract surgery.

ii) Cataract surgery within 6 months or laser photocoagulation within 3 months before entry to study.

iii) Significant media opacities.

Type of sampling

Simple random sampling

Technique: Intravitreal Bevacizumab (1.25mg) or Ranibizumab (0.5mg) or Triamcinolone (4mg) was given under standard protocol.

• 100 eyes of 100 patients treated with intravitreal anti VEGF and steroid.
• Male predominance (60%), M: F ratio 3:2.
• 50 pseudophakic & 50 phakic eyes.
• 60% Bevacizumab, 20% Ranibizumab and 20% Triamcinolone.
• Indications: CSME 36% (most common), RVO 30%, PDR 20% and CNVM 14%.
• Complications were noticed in 16% patients. [2]

Subconjunctival Haemorrhage (SCH) was most common complication found in 7(5 after Bevacizumab, 1 after Ranibizumab and 1 after Triamcinolone), Temporary elevated IOP>22 mmHg in 3(1 after Bevacizumab, and 2 after Triamcinolone), Cataract progression in 3(7(1 after Bevacizumab, 1 after Ranibizumab and 1 after Triamcinolone), Mild transient uveitis in 1, corneal abrasion in 1 & VH (vitros haemorrhage) in 1 patient. Complications rate higher in phakics than pseudophakics (10 phakic and 6 pseudophakics).

• At final visit mean BCVA improved from 20/88(median 20/80) to 20/50(median 20/60) & BCVA improved in 42, remain stable in 50 & worse in 8 eyes (Paired-t test p<.001).
• No difference in VA response with different drug.
• At final visit BCVA Improvement rate(gain two or more line higher in pseudophakic, stable rate higher in phakic and worse rate (lost 2 or more line) equal in both [3,4].
• Improvement of mean BVCA at 4 week slightly higher than at 4 week.

Figure 4: Pie chart of indications.

Figure 5: Percentage of complications.

• In our study subconjunctival haemorrhage (SCH) was 7% as compared Jamrozy Witkowaska et al reported 36%.
  SCH higher in Bevacizumab, IOP elevation higher in Triamcinolone and cataract progression higher in Ranibizumab and in Triamcinolone.
• Transient mild uveitis, corneal abrasion and vitreous haemorrhage associated only with Bevacizumab.
• Serious complications like endophthalmitis and retinal detachment not reported in our study.
• Complication rate higher in phakic but IOP elevation rate higher in pseudophakic.
• The mean BCVA from base line to at 4week and at 12 week was not statistically significant different in all three group of drug.
• The higher no of improved BCVA patients in pseudophakic group and stable BCVA patients in phakic group (Figures 1-5).

The most common indication of intravitreal injection is clinically significant macular edema and least common is choroidal neovascular membrane in aged patients. The procedure of intravitreal injection is generally safe but some procedure related and some drug related adverse event occur but almost all of it is not serious. BCVA improvement rate higher in pseudophakic but complications rate higher in phakic patient.

1. Ramulu PY, Do DV, Corcoran KJ. Use of retinal procedures in medicare beneficiaries from 1997 to 2007. Arch Ophthalmic 2010; 128: 1335-1340.
2. Jamrozy-Witkowska A, Kowalska K, Jankowska-Lech, Terelak-Borys B, Nowosielska A. Grabska-iberek: Complication of intravitreal injections. klin oczna. 2011; 114:127-131.
3. Ozkaya A, Alkin Z, Yilmaz I, Yazici AT. Comparison of intravitreal Ranibizumab between phakic and pseudophakic neovascular age-related macular degeneration patients: Two-year results. Saudi J Ophthalmol. 2015; 29: 182-186.
4. Mandal S, Garg S, Venkatesh P, Mithal C, Vohra R, Mehrotra A. Intravitreal Bevacizumab for subfoveal ICNV. Arch ophthalmol. 2007; 125: 1487-1492.