1. Purpose
Intravitreal injections, most often anti-VEGF drugs for age-related macular degeneration and diabetic macular oedema, are among the highest-volume procedures an independent eye clinic performs. The most serious complication is endophthalmitis, a sight-threatening infection inside the eye. This policy sets out how the Service gives intravitreal injections safely: the right drug in the right eye, a clean aseptic technique that lowers the risk of infection, and clear advice and follow-up so that infection is caught and treated early.
The Service must verify this policy against current Royal College of Ophthalmologists guidance on intravitreal injection and the drug manufacturers' instructions before adoption.
2. Sources to verify before adoption
- Royal College of Ophthalmologists, intravitreal injection guidance and Ophthalmic Services Guidance: https://www.rcophth.ac.uk/
- The Summary of Product Characteristics for each anti-VEGF or steroid agent used (dose, preparation, storage)
- MHRA Yellow Card scheme for adverse drug and device reactions: https://yellowcard.mhra.gov.uk/
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12 (safe care and treatment): https://www.legislation.gov.uk/uksi/2014/2936/regulation/12
- The Service's correct patient, correct eye, correct lens policy (for the eye and drug confirmation)
3. Scope
This policy applies to:
- every intravitreal injection the Service gives, whatever the drug
- the preparation, the injection, and the aftercare
- the clinicians who inject, the nurses and staff who prepare and assist, and the staff who give and record safety-netting advice
4. The right drug, dose and eye
Before any injection the team confirms, against the clinical record and the treatment plan:
- the patient's identity, using at least three identifiers
- the eye to be injected (per the correct patient, correct eye, correct lens policy)
- the drug, the dose and the strength, checked against the prescription or protocol
- the drug's expiry, storage history and, where relevant, that it has reached the correct temperature for use
The eye, the drug and the dose are confirmed aloud immediately before injection.
5. Aseptic technique and infection prevention
The Service follows an aseptic, no-touch technique designed to lower the risk of endophthalmitis:
- the injection is given in a clean, suitable room kept for the purpose, not in a busy general area
- hand hygiene and sterile or clean gloves are used per the technique the Service adopts
- the ocular surface and lids are prepared with povidone-iodine (or an agreed alternative where the patient is allergic), left in contact for the time the evidence supports, as the single most important step in preventing infection
- a sterile lid speculum keeps the lashes and lid margin away from the needle
- single-use sterile equipment and a single-use needle are used for each injection, and the injection site avoids the patient talking or coughing directly over the field; some services use a face mask or a no-talking rule to reduce this risk
- the drug is drawn up and the injection given without the needle touching the lids, lashes or any non-sterile surface
The Service confirms its exact technique against current Royal College of Ophthalmologists guidance.
6. After the injection
- the eye is checked, and intraocular pressure is assessed or monitored where the Service's protocol requires it
- the patient is given clear safety-netting advice, in a form they can keep, on the symptoms of endophthalmitis (increasing pain, increasing redness, falling vision, increasing floaters or light sensitivity) and told to seek urgent help the same day if any occur
- the patient is told exactly how to reach urgent help, including out of hours, and that route is one that can actually assess an injected eye quickly
- the drug, dose, eye, batch or lot number, and the person who injected are recorded
7. Suspected endophthalmitis
A patient reporting pain or falling vision after an injection is treated as possible endophthalmitis until proven otherwise. The Service:
- arranges urgent same-day assessment by an ophthalmologist who can examine the eye
- has a clear, tested pathway to a vitreoretinal service for the urgent treatment endophthalmitis needs, because delay costs sight
- records the event, manages it as a serious patient-safety incident, and opens the duty of candour where the threshold is met
8. Recording and reporting
- every injection is recorded with the drug, dose, eye, batch or lot number and injector
- suspected drug or device reactions are reported through the MHRA Yellow Card scheme
- endophthalmitis cases and injection-related harm are logged, investigated and reviewed for patterns (for example a cluster pointing to a batch, a room or a technique)
9. Training and competency
A clinician gives intravitreal injections only after training and a check that they can do it safely, and the Service repeats the competency check on a stated cadence. Staff who prepare drugs or assist are trained in the aseptic technique and the safety-netting advice. The Service records who is competent and the next refresher date.
10. Audit cadence
The Service checks, on a stated cadence, that:
- the eye, drug and dose were confirmed and recorded for every injection
- povidone-iodine antisepsis and the aseptic technique were applied
- safety-netting advice and a working urgent route were given and recorded
- endophthalmitis cases and rates are tracked, reported and reviewed, with improvement actions completed
The Registered Manager and the clinical lead review the results and record the improvement actions that follow.