Sir,
The frequency of intravitreal injections is increasing after landmark age-related macular degeneration studies,1, 2 and to a lesser extent evidence for the efficacy of intravitreal triamcinolone for diabetic maculopathy.3 Several uncommon complications are described, namely infectious and non-infectious endophthalmitis, iatrogenic lesions to the intraocular structures leading to retinal detachment or cataract and steroid-induced glaucoma.4
Two patients receiving intravitreal ranibizumab (Lucentis) for wet age-related macular degeneration complained immediately after their injection of unusual visual symptoms, ‘like looking through an hour glass,’ particularly when looking down. Ocular examination revealed multiple small intravitreal air bubbles with no entry site breaks or vitreous floaters.
This is an important observation for several reasons. Most importantly, these bubbles produced disturbing symptoms in the patients that they were not expecting. Air within the syringe could also alter the administered dose of the drug. Finally, it is well documented that intravitreal gas presents a risk during air flight.5 The volume involved here is low, but we should be aware that this is a potential complication of intravitreal injections and should take appropriate measures to avoid these symptoms and potential complications by actively checking the syringe and needle before injection to ensure that no air has been drawn up when preparing the drug for injection.
References
Rosenfeld PJ, Brown DM, Heier JS, Boyer DS, Kaiser PK, Chung CY et al., MARINA Study Group. Ranibizumab for neovascular age-related macular degeneration. N Engl J Med 2006; 355 (14): 1419–1431.
Brown DM, Kaiser PK, Michels M, Soubrane G, Heier JS, Kim RY et al., ANCHOR Study Group. Ranibizumab versus verteporfin for neovascular age-related macular degeneration. N Engl J Med 2006; 355 (14): 1432–1444.
Grover D, Li TJ, Chong CC . Intravitreal steroids for macular edema in diabetes. Cochrane Database Syst Rev 2008; (1): CD005656.
Jonas JB, Spandau UH, Schlichtenbrede F . Short-term complications of intravitreal injections of triamcinolone and bevacizumab. Eye 2008; 22 (4): 590–591.
Mills MD, Devenyi RG, Lam WC, Berger AR, Beijer CD, Lam SR . An assessment of intraocular pressure rise in patients with gas-filled eyes during simulated air flight. Ophthalmology 2001; 108 (1): 40–44.
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Somner, J., Mansfield, D. Inadvertent injection of intravitreal air during intravitreal Lucentis injection for wet age-related macular degeneration: an undescribed complication. Eye 23, 1744 (2009). https://doi.org/10.1038/eye.2008.297
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DOI: https://doi.org/10.1038/eye.2008.297
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