The procedure of IVTA should be carried out with meticulous aseptic precaution, preferably in the operating room. It is very easily carried out under topical anesthesia. A pre-injection single drop of Povidone-Iodine (5%) solution is applied to the eye followed by thorough cleaning of the eyelashes and application of a lid speculum.
0.5% proparacaine hydrochloride drops are applied topically. Alternatively, one could also apply cotton tip pledgets soaked in lignocaine hydrochloride (4%) to the injection site for a couple of minutes prior to the injection to decrease the discomfort.
Preservative free triamcinolone acetonide in a single-use bottle (40 mg/ml, 1ml bottle, Aurocort, Aurolab, Madurai, India), is drawn into a 1-cc tuberculin syringe after cleansing the top of the bottle with an alcohol wipe. A separate 27 or 26 gauge needle is placed onto the syringe, which is then inverted to remove air bubbles. The excess triamcinolone is discarded till 0.1 ml (4 mg) remains in the syringe. The injection site is usually the inferotemporal quadrant to avoid drug deposition in front of the visual axis. The stab is given 3 mm from the limbus (in aphakic and pseudophakic patients) and 3.5 mm from the limbus in phakic patients to ensure against passage of the needle through the vitreous base. The needle is usually not introduced all the way to the hub. Using a single, purposeful continuous maneuver, the steroid is injected into the eye. The needle is removed simultaneously with the application of a cotton tipped applicator over its entry site to prevent regurgitation of the injected material. Indirect ophthalmoscopy to check for central retinal artery (CRA) pulsation and paracentesis (if CRA pulsation is present or the globe feels very tense) are carried out, a drop of topical antibiotic solution is administered and the eye is patched. The patient is usually put on a post-injection course of topical antibiotic eye drops for a week.
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use of IVTA in glaucoma suspects
1. Ozurdex is preferable if possible. If not possible, can consider 1mg with close follow-up. Why not anti-VEGF?
Dont hav ozurdex here. Pt already received 3 avastin with recurrent cme with nsd in brvo. Hav seen such cases responding well to tricot.
Dilemma is pt doesnt hav field defects now , but wil steroid treatment in glaucoma suspect can lead to glaucoma in pt with cdr 0.7 and AT 17 with CCT 449?
2. You could give avastin with triamcinolone 0.05 ml each and start him on antiglaucoma medication for 3 months.
3. It is definitely possible. Alternate option is laser- grid and sectoral. Only that it will take time to show resolution.