AMD Injection Procedure

[Engineer46]

This is based on a response I gave to a regular poster that I think may be of more general interest, especially to those who have not yet had an injection or who are experiencing post injection discomfort. Note that the following applies to wet AMD only.

I’ve been having injections for wet AMD for over ten years and think that I’m lucky to be treated at the Western Eye Hospital on the Euston-Marylebone Road in London. Here’s how the process works there:

Soon after you arrive for your appointment your eye pressures are checked, then you have a sight test to check your “best corrected” visual acuity, including using a pinhole (if you can see more letters with the pinhole it means that your glasses are not as good as they could be - but remember that with AMD your prescription will often change slightly because the fluid leakage moves your retina fractionally.

. Next you have dilating drops and a retinal scan and then you see a doctor who examines your eyes and discusses the scans with you, showing you where the fluid is and comparing it with the previous scans, generally four to six weeks apart. If an injection is recommended, you then receive anaesthetic eye drops three times, at intervals of around 5-10 minutes.

You then go in to the injection room. There you are prepped and more anaesthetic drops are given, together with iodine drops (as long as you aren’t allergic to iodine). The eyelid is then clipped open. You shouldn’t find that at all painful. If it is, ask for more anaesthetic. When the doctor is ready you are told to look in a particular direction and keep your eye still. The doctor then selects the injection site and marks it on your eye. You feel some pressure but no pain. The injection is then given quite quickly. Again you should feel pressure but no pain. You will see the fluid swirl into the eye and your vision will be cloudy, but you should be able to see how many fingers the doctor is holding up in front of you! Then it’s just the clean up. Some doctors use a lot of saline wash to clear out the iodine, but others don’t. 

For 24 hours the eye may feel uncomfortable but not really painful. To me, it sometimes feels as if I have grit in my eye and I use the “Viscotears” gel drops to relieve the symptoms, but often I don’t need to use them at all. My worst recent experience was when a new doctor used a great deal of saline wash after the injection and my eye felt uncomfortable for 36 hours, but that’s unusual.

You may sometimes get one or more air bubbles along with the injected fluid. These will appear as small black circular blobs or rings on the floor, that move around when you move your eyes. Being air bubbles they are actually floating at the top of your eyeball, but as the image on the retina is inverted we see them on the floor. They are of no significance and will disappear within 24-48 hours.

I have had injections of all the drugs used for AMD: Lucentis, Avastin and Eyelea. Of the three, my experience after more than 40 injections is that Eyelea was the least effective. At present I’m having Lucentis in the left eye and Avastin in the right eye, for reasons that only NICE can explain!

I hope that this may help you to spot any procedural differences in how you are treated, because the injections shouldn’t be painful (although some doctors are better at doing the injecting than others!).

One last thought if you haven't been diagnosed with AMD. If you find that you have to clean your glasses more frequently, check that you don't have a small, very slightly dim patch in your central vision area: look at a bright area briefly (eg sky) close one eye and blink the other eye while looking at a white or light coloured plain surface (eg a wall or ceiling). If you see a consistent patch of dimness (it looks like a shadow) then you may have AMD. Go to an optician for a sight test as soon as you can, because the sooner that AMD treatment is started, the better the outcome. Another diagnostic check is to look with each eye in turn at straight vertical and horizontal lines such as lamp posts, TV screen frames, etc. Look for small areas in your central vision where the lines aren't quite straight - if this is the case then go to the optician.

Best wishes to all,

Paul

[springcross]

Hi Paul and thanks for your detailed post on the wet AMD injection procedure.

I wish all hospital staff were the same as in your hospital. I certainly don’t get and never have had a pressure test at my eye clinic or in the main eye hospital prior to the injections. I’ve been having injections for wet AMD for four years now (47 injections) and also have never been shown my scans – I am just told whether there is any change in the fluid behind the macula.

With regard to the anaesthetic drops, I envy you. I don’t have any drops before I go into the injection room. I am given the drops (normally several in a short space of time and I always ask for extra when I enter the room). I have the eye cleanse and then the injection which happens about ten minutes or so from entering the room, then a little flush out, depending on who the injector is, (some are better than others), but the more it’s flushed for me, the less bad after-effects I get. The injections are not always painless – no doubt because the anaesthetic hasn’t had time to work properly. It’s such a shame that not all hospitals are equal in their procedures and also the quality of their staff – some of the injectors I’ve had have been excellent but one or two others have not been so. On saying that, patients are not all the same and some are more sensitive to treatment than others.

One of the reasons I get problems is the iodine. Too much is used on some occasions which causes no end of misery for me and others too, particularly if it’s not flushed out properly afterwards. I find the little vials of iodine don’t give me the same problems as the iodine from the eyewash which sometimes is used instead of the vials and in excess, in my opinion.

Thanks for the tip about having to clean the glasses more frequently, I will keep that in mind for the future. Long may you continue to be happy with your treatment and the procedures.

[magicman229 in reply to springcross]

Be proactive! Tell the medical personnel involved with your injections that you wish to have more anesthetic drops, a longer than normal wait time between the drops and the injection, the least amount of antiseptic that they can ethically apply, and a thorough flush afterwards.

It's your eyes, and if you don't speak up, no one will know of the problems that you encounter post-injection. And if you must, climb the ladder of authority with your concerns.

Good luck.

[springcross in reply to magicman229]

Thanks for your reply magicman. I have told them time and time again, it's on my notes about the iodine and has been since 2018. I had gotten to a reasonable place but the last three injections I've had have been done by the consultant. The after-effects of the first were really miserable (due to the iodine, as she likes to overdose), the second were great after I had a word with her pre injection and she used hardly any, but she'd forgotten by the third and it was the same, if not worse that the first and caused a lot of misery. I will be having words at my next injection if it's her again. By the way, I always request extra anaesthetic drops as soon as I'm in the room but thanks for your advice. I hope your first injection went/will go well and that you don't experience any problems, as so many don't.

[magicman229 in reply to springcross]

I hope my advice to you was not off-putting. I didn't mean it to be. But in matters of healthcare, my experience is that you must "trust, but verify". I've gotten into the habit of reminding the prep tech about the extra time and extra drops, and then when the doc comes in for the injection, I remind him/her to flush my eyes after the injection. I live in the USA, so things may be different across the pond. We don't have consultants here that inject, only Medical Doctors (ophthalmologists) who perhaps receive more training? I'm on my 30th injection and the eyelea seems to help, although frequency has increased recently from 16 weeks to 4-5. I wish you the best, my friend, because I know how frustrating it can be when nobody is seeming to listen to you . Good luck!

[springcross in reply to magicman229]

Hi magicman. No, it wasn't off-putting at all. My problem is that the consultant (who doesn't usually do the injections) has given me my last three injections so that means they must be short-staffed. It is different here in the UK and speaking for myself, some of the staff don't like being asked to do extra to what they normally do. One injector looked at me as if I'd asked him to get me the Crown Jewels when I asked him to flush my eye out, but that was a couple of years ago and things improved after that. I do really wish though that they would check the notes on the files, as if they did, it could save a lot of misery for a lot of people. I hope you benefit from the frequency increase in injections and thank you for your good wishes and the same to you.

By the way, I mistook what you said to Paul about his post being excellent for a person soon to have their first injection as meaning that you were about to, but I realise now that you meant others - sorry about that. All the best. x

[magicman229]

Hi Paul. Excellent information especially for a person soon to have their first injection, or even for those who have had a couple. Brief and to the point. Thank you for posting.

[RP1944]

Hi Paul, that was a very interesting post, thank you. I wish I went to your eye clinic as I only get anesthetic drops just before the Eyelea injection and they never work. Every jab hurts, so I hate going. It’s surprising that you have Lucentis in one eye and avastin in the other, hopefully they both work. Best wishes, Ros.

[fed13]

Liked your post: especially appreciate comment about problems with iodine. Solved in my case by using diluted iodine.

[Shimano]

Great information. Like others I wish I was lucky enough to attend your clinic. Never shown the scAns and don’t have pupil enlarging drops prior to having them. Anaethestic drops don’t work for me but, after arguing my case for ages, now get aneAsthetic injection of lidocaine which works only if left for 5 minutes prior to the jag. Otherwise very painful. Pain after injections now resolved by having an alternative to iodine which had left me going nuts for 24 hours. Information from studies at the San Paulo university in Mexico, a centre of excellence, is worth looking up. Helped me a lot. All the best to you engineer and to all of us with MD.

[Engineer46 in reply to Shimano]

Shimano, thanks for the information on your experience. While OCT scans can often be taken without dilation, the eye examination by the doctor post scan requires dilation, which is why I am dilated pre-scan and am then ready to see the doctor. I'm surprised that you aren't shown the scans, because the comparison of scans over time shows you what effect the injections are (or aren't) having on the fluid build up affecting the macula.

I'd not heard of subconjuctival lidocaine injections being used at our clinic, but we get three lots of topical anaesthetic over a period of 15-20 minutes prior to the injection and this, plus the additional topical anaesthetic given just before the injection seems to work. I rarely hear anyone complaining of having experienced pain during the injections.

Could you please post a link to the Sao Paulo University studies that you mentiioned?

Best wishes,

Paul

[Shimano]

Never got the amount of drops or at the intervals you mention. Will try and refind and post the san paulo studies though my computing skills are pretty Stone Age. Cheers.

[Fuzzbox100]

This is great Paul.

My experience of the procedure (at the Stratford u Avon eye clinic) is very similar to yours. From a personal prespective, no it doesn't hurt as such, more uncomfortable e.g. pressing of the eyeball to check for 'pressure or pain' and then the 'feel' of the needle going in.

In my case, what I find is that I'm quite stressed / nervous beforehand and this gets worse especially as clinic proceeds - initial sight test, drops, scanning, injection prep. and then the injection itself.

After the event, I'm quite 'washed out' for the rest of the day. So I need to spend several hours lying down in a dark room after an injection.

My 'other half' has always said "just think of your happy place" and that will get you through. and she's right, it does help. But note that my "happy place" these days is anywhere other than "eye injection clinic"!😀

I'm not compalining about any of this as I truly believe that my sight in the affected eye has been saved by the initial quick actions of my optician, the follow-up triage and the subsequent work of the injection clinic. Heaven knows what my series of Lucentis injections has cost but thank you NHS!

[Engineer46 in reply to Fuzzbox100]

It's good to hear that there are other good NHS eye clinics.

For anxiety I find that asking lots of questions and making sure that everything is always done to the same standard keeps my mind off the final phase. Good luck with your treatment.

Paul

[tallyho]

A good piece, thanks for taking the time to write it. there are some things that are different here for different hospitals and if your having IVT for other conditions the procedure would be the same. You are attending a hospital that operates a ‘one stop clinic ‘ some don’t have that at the moment and so patients come back for their injection another day. My eye drops are put in in the clean room where the injection is done and not before.

I have my 97 th injection in my right eye on Friday ( smiley face)

[Hrosie]

Thank you Paul for detailed description of your treatment. I am treated at the London Road eye clinic in Derby, part of Derby & Burton Hospital Trust. Over past 5 years I have had 36 injections in my left eye, originally Avastin & latterly Lucentis which has maintained the sight in that eye. I lost central vision in my right eye well before that, purely because my optician at the time said it was dry and couldn't be treated so didn't refer me to a hospital. My treatment is very similar to what you describe except I don't get an eye pressure test. I went a whole year without an injection but the fluid came back recently so I'm back on injections. The most recent injection, in June, cleared up the leak quickly but I am monitored every 4 weeks to make sure it hasn't returned. Once again, thank you so much for sharing details of your experience. R.

[Hrosie]

I would like to add that my allergies are permanently recorded in my case notes + the fact that I have stronger anaesthetic drops, and the nurse checks this with me every time before my injection.