Category Archives: Resident Physician Education

Educational material for physicians

Eye Injections: Finer Needle = Less Discomfort

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Eye Injections: Finer Needle = Less Discomfort

What is the finest needle available to date for intravitreal injection?

Ocuject, LLC engineered the VitreJect needle for intravitreal injections.  Several features make this a popular needle among ophthalmologists and patients.  First, it is supplied in various small-caliber needle sizes.  For most injections, the 33G needle is preferred by patients for improved comfort over standard 30G needles.  The smaller 33G caliber reduces the rate of vitreous prolapse from the injection site following injection.  Hopefully, this may reduce the risk of endophthalmitis.  However, the larger caliber 30G VitreJect needle is preferred for more viscous medications such as pegcetacoplan (Syfovre). 

What about persistent floaters after eye injections?

Ocuject reports 70% less silicone content in their 33G needles compared with standard 30G needles.  This feature may reduce the incidence of persistent symptomatic floaters in the vision following injections. 

Can we eliminate the eyelid speculum? 

The VitreJect needle features a sliding shield that protects the needle from contact with the lids and lashes during the injection.  This feature obviates the need for an eyelid speculum, with which many patients report discomfort.  The sliding shield is secured in place by a twist-lock in order to avoid unintentional retraction of the shield and exposure of the needle.

Can we eliminate the extra caliper?

The VitreJect needle has an integrated caliper in the form of three nubs or studs that project from the end of the sliding shield that rests against the conjunctiva during injection (see image below).  When the edge of one nub is placed at the limbus, the needle will insert 4mm from the limbus.  When the edge of two contiguous nubs are placed at the limbus, the needle will inset 3.5mm from the limbus.  A choice of three nubs are located on the shield for convenience of positioning. 

What are the potential pitfalls?

If a technician opens the plastic wrapper part-way to place the needle on a syringe in preparation for injection, the twist-lock may be unintentionally unlocked.  The sliding sleeve may then be accidentally retracted causing the needle to be exposed.  The needle may be bent or contaminated in this situation.  Technician training avoids this issue.  Or, alternatively, I usually have the needle opened onto a sterile field in the exam room.  I place the needle on the syringe myself.  

Note: During actual injections, I wear sterile gloves.

By Scott E. Pautler, MD

Copyright  © 2023 Designs Unlimited of Florida.  All Rights Reserved.

The Use of Steroids in Endophthalmitis

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the use of steroids in endophthalmitis

Why use steroids in endophthalmitis?

Ophthalmologists often consider the use of steroids in endophthalmitis treatment. Steroids reduce inflammation in endophthalmitis.  The decrease in inflammation helps improve comfort and potentially reduces inflammatory tissue damage, such as scarring.  Although it is key to treat with appropriate antibiotics for infectious endophthalmitis, topical steroids (steroid eye drops) are included in the therapeutic regimen. The physician orders the steroid eye drops frequently at the onset and monitors inflammation and eye pressure to determine the best treatment schedule. 

What is the role of intravitreal steroid injections?

The role of intravitreal steroids (dexamethasone) is controversial.  In a recent review and meta-analysis of endophthalmitis, there was no added benefit with the use of intravitreal dexamethasone.  The reason for lack of benefit may include the short half-life of intravitreal dexamethasone (<3 hours).  Nonetheless, there may be benefit derived from the use of intravitreal dexamethasone in severe bacterial infections such as those caused by Bacillus species.  

What about other ways to give steroids?

In select cases there may also be a role for periocular or systemic steroids for a more prolonged steroid effect. Periocular steroids require an injection next to the eye. My preferred technique is a subtenant’s injection as described by Nozik because it is fairly pain-free. Systemic steroids are given as a pill. There are potential side-effects to the use of steroids. With steroid injections come the risk of elevation of eye pressure, which may cause glaucoma. Many side effects may occur with steroid pills including depression, high blood sugar, weight gain, brittle bones, acne, stomach ulcers, and others. Usually side-effects are preventable or treatable. The final decision of how and when to use steroids lies with the treating physician based on the circumstances of the case.   

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright 2023. Designs Unlimited of Florida. All Rights Reserved.

Physician Alert: DEA Phishing Scam

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A warning to all physicians! There is a fraudulent telephone scheme in progress in which an “agent from the DEA” calls doctors at their offices claiming that the doctor’s medical license is at risk of being frozen due to drug trafficking performed with the doctor’s medical credentials. They provide and verify your medical license number and NPI (easily obtainable information). After describing the drug trafficking incident, you are asked to cooperate to “clear your name” and bring the criminals to justice. Legal statutes are repeatedly referenced to enforce “confidentiality.” The scammers do not want you to consult with anyone. Of course, in order to avoid having your personal bank accounts frozen, they want to collect information. The Drug Enforcement Administration has issued a warning regarding scammers impersonating DEA agents. The person who called my office was “Agent Michael A. Davis” (the name was verified by my administrator as an employee of DEA) calling from 571-454-9198. When I refused to give my banking information, veiled threats were made. No information was disclosed.

I called the real Drug Enforcement Administration at 202-307-1000 to confirm the fraudulent nature of the call. Please beware of this elaborate scheme and save yourself time and potential financial loss.

This scam capitalizes on the integrity of the doctor, the respect for the DEA, and the fear of interruption of patient care. The scammer presents an elaborate background story to gain credibility. References are given to governmental agencies such as the FBI and FTC. Governmental statutes are cited to support the investigation and need for confidentiality (“you may tell no one about this investigation”). No probing for banking information occurs until very late in the conversation…about 45 minutes into the interrogation.

The DEA will never contact a physician by telephone and request personal or sensitive information. They present information about legal actions or legitimate investigations in person and/or by mail on official letterhead.