Pain after Intravitreal Injections

Eye injections (intravitreal injections) can be uncomfortable. What should you do if you are having discomfort? What are the warning signs of an eye-threatening infection?

How They Work

Intravitreal injections are most commonly used for the treatment of age-related macular degeneration, diabetic macular edema, and retinal vein occlusions. Intravitreal agents include Eylea® (Aflibercept), Lucentis® (Ranibizumab), Avastin® (Bevacizumab), Ozurdex® (dexamethasone intravitreal implant), Iluvein® (Fluocinolone acetone intravitreal implant), and Triesense® (triamcinolone).

          Intravitreal Injection Models

Types of Pain

While the majority of patients do not report significant discomfort following intravitreal injections, many will occasionally report burning, foreign body sensation, pain with eye movement, tearing, or the inability to open the eye. Other non-emergent signs such as a spot of blood on the eye or bubbles may occur following injection. These signs and symptoms may be quite intense and patients are often very concerned that they need emergent intervention by a medical professional.

Burning

The intravitreal injection procedure necessitates the use of Betadine (povidone-iodine) to decrease the risk of a severe, eye-threatening condition called Endophthalmitis. Betadine  is very irritating to the surface of the eye. It may cause the eye to become red and uncomfortable due to generalized irritation, focal areas of dryness on the cornea, or even a scratch on the cornea. The eye will typically produce a significant amount of tears, especially when opened. The eye will heal without any intervention within 12-24 hours.

There are several treatment options for the burning sensation. The first option is to instill preservative free artificial tears. Instill 1 drop into the affected eye every 1 hour as needed for discomfort. The second option is to wash the eye out with eye wash. This is performed by looking upwards and instilling a generous amount of eye wash into the inferior fornix of the eye. If possible, it may be beneficial to try moving your eyes left, right, and down to wash out any remaining Betadine from the ocular surface. The third option is to use lubricating ophthalmic ointment. An approximately 1/2 inch of lubricating ophthalmic ointment is instilled into the inferior conjunctival fornix. It will blur your vision temporarily, but will likely provide significant relief.

It is also recommended to use Tylenol® as needed for discomfort.

Foreign Body Sensation

Many people complain of feeling like there is an eyelash, piece of sand, or “rock in their eye” following an intravitreal injection. The eye may or may not profusely as well. These symptoms are a sign that the Betadine has caused irritation to the cornea. Fortunately, these symptoms will resolve over 12-24 hours without intervention.

There are several treatment options for the foreign body sensation. These treatment options are aimed towards lubricating the front surface of the eye. The first option is to instill preservative free artificial tears. Instill 1 drop into the affected eye every 1 hour as needed for discomfort. The second option is to use lubricating ophthalmic ointment. An approximately 1/2 inch of lubricating ophthalmic ointment is instilled into the inferior conjunctival fornix. It will blur your vision temporarily, but will likely provide significant relief.  It is also recommended to use Tylenol® as needed for discomfort.

Tearing

Many of people complaining of tearing after an intravitreal injection. This is the eyes way of responding to irritation, and helping to wash out any remaining Betadine from the eye. This may also be a sign of irritation to the cornea, including a corneal abrasion. Fortunately, these symptoms will resolve over 12-24 hours without intervention.

No treatment needs to be undertaken unless there is underlying discomfort such as burning, foreign body sensation, or the inability to open your eye.

Pain with Eye Movement/Inability to Open Eye

Occasionally, people will complain of the inability to open their eye following an intravitreal injection. This is almost always due to a superficial scratch on the front of the eye which causes intense foreign body sensation, tearing, and pain. Typically, the discomfort becomes much worse upon trying to open the eye or moving the eye under your closed eyelid. These symptoms typically resolve in 12-36 hours without treatment.

Fortunately, there are treatments which can relieve your discomfort and speed up your recovery. The first option is to instill preservative free artificial tears. Instill 1 drop into the affected eye every 1 hour as needed for discomfort. The second option is to use lubricating ophthalmic ointment. An approximately 1/2 inch of lubricating ophthalmic ointment is instilled into the inferior conjunctival fornix. It will blur your vision temporarily, but will likely provide significant relief.  It is also recommended to use Tylenol® as needed for discomfort.

It is recommended to call the physician who administered your intravitreal injection during business hours to schedule follow-up if the discomfort has not almost completely resolved.

Blood Spots on Eye

Very small conjunctival vessels on the surface of the eye (which cannot be seen by your physician) may be punctured by the intravitreal injection and subsequently bleed. This is called a subconjunctival hemorrhage and will resolve completely on its own without any intervention over approximately 7-10 days (just like a bruise elsewhere on your body).

Bubbles

Air bubbles may exist within the intravitreal injection. The physician will always try to remove all air bubbles prior to the injection, but some bubbles may persist within the medication. If this occurs, you will notice small bubbles in the lower part of your visual field while you are upright. These bubbles will not cause any damage to your vision and will completely absorb within approximately 12-36 hours.
     

Endopthalmitis

Endophthalmitis is a site threatening infection of the eye that occurs in approximately 0.05% of eyes following an intravitreal injection. Classically, the patient has recovered completely from the discomfort following the injection during the first 1-2 days, but then 3-5 days after the injection begins to decline rapidly.

The symptoms of endophthalmitis are a triad of worsening pain, severe sensitivity to light, and redness around the entire eye. The pain is typically localized to the eye and the area around the eye. Light sensitivity may be severe causing the patient to want to keep 1, or both eyes closed. Redness will occur around the entire eye and the eyelids may also become swollen.

Endophthalmitis is an emergency. If you have the above symptoms, you need to call the physician who administered your injection immediately! If you are unable to reach the physician, you need to go to the emergency room immediately for treatment (injection of antibiotics into the eye).