Overview of Injections for Optometry (Part II)

Dr. Landgraf's FOSD II UMSL School of Optometry

Intradermal

Intradermal

What type of injection used to be done more frequently and is similar to intralesional?

1. Intralesional

2. Local infiltrative

3. Subconjunctival

What are the 3 perioribital types of injections?

Intralesional

What type of injection is performed on chalazions?

intradermal

Out of the following injections (IM, IV, SC, Intradermal), which one is performed most tangential to the skin?

IM

Out of the following injections (IM, IV, SC, Intradermal), which one is performed at 90 degrees from the skin?

1. Anaphylaxis to IV NaFl

2. Pre- or post-IVFA for nausea & vomiting

3. Acute Angle Closure Glaucoma

What are 3 ophthalmic indications for an IM injection?

1. IM Benadryl

2. IM Epinephrine

What 2 medications can be given for anaphylaxis to IV NaFl? Include type of injection before.

IM Promethazine 25 or 50 mg/mL

What medication can be given for pre- & post-IVFA for nausea and vomiting? Include type of injection before the medication as well as dosage.

1. IM Promethazine

2. IV Mannitol

What 2 medications can be given for acute angle closure glaucoma? Include type of injection before the medication.

True

True/False: Epinephrine can be administered intramuscularly through the clothes if necessary.

2-5 cc

What range of syringe volume should be used for epinephrine injection?

20 gauge; 1-2”

What gauge of needle should be used for epinephrine injection? What length?

2-3 finger widths below acromion process of the deltoid

What is the primary site in which epinephrine should be administered if injected with IM epinephrine via syringe?

1. Dorsogluteal

2. Ventrogluteal

3. Rectus femoris

4. Vastus lateralis

Besides the deltoid muscle, what 4 other muscles are a potential site for epinephrine administration IM via syringe?

Dorsogluteal

What injection site do we need to be wary of sciatica when injecting IM epinephrine?

Stretch & Bunch

What technique should be done for IM epinephrine injection into the deltoid?

45-90 degrees; less painful

At what angle range should you attempt to jab the patient with for an IM epinephrine injection? Why?

False—bury the needle

True/False: For an IM epinephrine injection via syringe, it is important to only jab the needle about halfway to avoid hitting a blood vessel.

True—you don’t want blood

True/False: you should aspirate for blood with an IM injection.

Subcutaneous (SQ)

What type of injection is indicated for slow absorption of numerous medications?

3/8 - 5-8”

What needle lengths are used for Subcutaneous injections?

25-27 g

What needle gauges are used for subcutaneous injections?

< 1 mL

What injection volume is often necessary for SQ injections?

To deliver local anesthesia with Xylocaine prior to various procedures

What is an ophthalmic indication for subcutaneous injections?

Subcutaneous

What type of injection is used to deliver local anesthesia prior to an ophthalmic procedure?

1. Local infiltrative

2. Intradermal

What are 2 types of subcutaneous injections?

Local infiltrative

What type of SQ injection is utilized prior to cyst removal or drainage within the eyelid?

Local infiltrative

What type of subcutaneous injection is utilized prior to incision & cutterage of chalazion?

Local infiltrative

What type of SQ injection is utilized prior to eyelid lesion removal or papilloma?

1% Xylocaine with 1:100,000 epinephrine

What medication (include dosage) is used for local infiltrative procedures of the eyelid?

Lidocaine

What is the Brand Name of Xylocaine?

4%; 0.5-2%

What concentration of Xylocaine is utilized when used topically? Injectable?

4-6 minutes; 1 hour (2 hours with epinephrine)

How long does it take for injectable Xylocaine to take effect? How long does it take to wear off?

Liver

Where is Xylocaine metabolized when given as an injectable?

Liver disease

What disease should you ensure patients do not have before injecting Xylocaine SQ?

Xylocaine SQ

What medication reversibly blocks nerve conduction & temporarily paralyzes sensory and motor function with loss of sensation? Include type of injection.

Epinephrine

What medication is a vasoconstrictor to prolong anesthesia, decreases the rate of systemic absorption, and decreases local bleeding?

Epinephrine

What medication keeps Xylocaine in the area?

1. Hypersensitivity to amide anesthetics

2. Sites with active injection, bony prominences, large nerves

3. Peripheral, cerebro- disease

4. Immunocompromised?

5. Nerve Blocks?

What are 5 contraindications of Xylocaine?

1. Keratitis

2. Corneal edema

3. Lacrimation

4. Allergic conjunctivitis

What are the 4 ocular side effects of Xylocaine

1. Tingling

2. Numbness

3. Hypertension

4. Tachycardia

5. CNS Stimulatory effects (early)

6. CNS Depression effects (late)

What are the 6 systemic side effects of Xylocaine?

1. Delayed wound healing

2. Necrosis

3. Vasoconstriction

What are the 3 main side effects of epinephrine?

Vasoconstriction

What side effect of epinephrine can be beneficial when used with anesthesia?

1. Liver disease

2. Cardiovascular disease

Before using injectable Xylocaine + Epinephrine, what 2 systemic conditions are most important to ask about during your history?

27-30 g

What size needle should be used for SQ injections?

20 g; 27-30g

What gauge of needle are you supposed to draw up medication with for subcutaneous injections? What gauge needle are you supposed to switch to for subcutaneous injections for the actual injection?

Jaeger plate

What equipment used for subcutaneous injection is used to prevent injury from going through the lid into the globe?

bevel up

How should the needle be oriented for a subcutaneous injection?

15-30 degrees

What angle should a SQ injection be given?

Intravenous (IV)

What type of injection is indicated for large volumes, meds specified for this type of injection, and medical emergencies?

1. FLAN & ICG —> IV NaFl & ICG

2. Anaphylaxis Treatment (IV epinephrine)

3. Acute Angle Closure Glaucoma (IV Mannitol)

4. Rule-out Myasthenia Gravis (IV Tensilon)

What are 4 ophthalmic indications for IV injection use?

Serious systemic side effect

Why isn’t IV Tensilon administered much anymore via IV to rule out Myasthenia Gravis?

5 mL; 2 mL

What is the dosing of IV NaFl at a concentration of 10%? 25%?

80-90%

What percent of IV NaFl is bound to plasma albumin?

1. Nausea & Vomiting

2. Extravasation (ice packs)

3. Dizziness & fainting

4. Pruritis & Utricaria

What are 4 milder effects of IV NaFl?

1. Anaphylaxis

2. Syncope

3. Myocardial Infarction

What are 3 serious side effects of IV NaFl?

Visualize a hidden subretinal neovasulcar membrane

What is the purpose of performing an IV ICG injection (Indocyanin Green)?

choroid

What retinal structure can be better visualized with IV ICG?

True

True/False: Pigment & hemes fluoresce through Indocyanin Green.

True

True/False: ICG IV is relatively non-toxic and safe.

Intravenous (IV)

What type of injection requires a tourniquet?

25-27 gauge butterfly needle

What type of needle & gauge is often used for IV injections?

1. Epi-Pen

2. IM Benadryl (pre-loaded)

3. Promethazine

4. Supplemental oxygen

5. Defibrillator

What 5 additional equipment must be around when injecting an IV injection?

1. Dorsum of hands

2. Forearm

3. Inner aspect of elbow

What are the 3 main sites of IV injections?

Veins

Which is easier to feel for IVs—arteries or veins?

1. Have patient open & close fist

2. Tap skin overlying vein

3. Stroke the arm below the expected site

4. Apply tourniquet

What are 4 helpful tips to help find vein of choice for IV injection?

20 g

What gauge of needle should be used for IV?

Bevel up

How should the needle be oriented for IV injection?

15-45 degrees

What angle should IV injections be administered?

Extravasation

After removing the tourniquet for an IV injection, what should you check for at the site of injection?

30 minutes after

How long should you observe a patient for following FLAN IV injection?

Chalazion management

What is a major indication for intralesional (IL) injections?

1. Kenalog-10 (10 mg/ml)

2. Kenalog-40 (40 mg/ml)

3. Triamcinolone acetonide suspension

What 3 main steroids are used for intralesional injections, often for chalazions?

40%; 80%; 90%; 100%

What percent of chalazions will treated with hot compresses & digital massage? Injections alone? Injections + massage? Incision + curettage?

Chalazion

Chronic inflammatory bags with steroid-sensitive histiocytes, multinucleate giant cells, lymphocytes, plasma cells, PMNs, eosinophils

True

True/False: Chalazions may require a 2nd injection if > 6mm & takes longer than 6 months to heal.

False—usually steroid injection

True/False: Antibiotic-Steroid Drops are often very effective for chalazion management.

1. Pain on injection

2. Depigmentation of eyelid at injection site

3. Bruising

4. Ptosis (from steroid)

5. Vasovagal syncope

6. Temporary skin atrophy

7. Retinal & Choroidal vascular occlusion

8. Increased IOP

9. Subcutaneous abscess / white steroid deposits

What are 9 complications of intralesional injections?

1. Known hypersensitivity

2. Internal hordeolum

3. Sebaceous cell carcinoma

What are 3 contraindications for intralesional injections?

Use an oral antibiotic first to treat

Why should you avoid intralesional injection for an internal hordeolum?

25-27 g

What gauge needle should be used for intralesional injections?

1 cc syringe

What volume of syringe should be used for intralesional injections?

1. Chalazion clamp

2. Jaeger plate

What 2 pieces of equipment may be used for intralesional injections to better navigate the injection?

True

True/False: You should draw up medication for intralesional injections before applying the injection.

Evert the lid

What should you do prior to the administering an intralesional injection if the chalazion is on the conjunctiva side of the lid?

Bevel Up

How should a needle be oriented for an intralesional injection?

0.1-0.3 cc

What volume of medication should be injected for intralesional injections?

RTC 1 month

How soon should you follow up after an intralesional injection for a chalazion?

1. Delivery of increased concentration vs. topicals

2. Prolonged tissue exposure

3. Avoid adverse systemic effects

4. Eliminate compliance issues

What are 4 considerations of Subconjunctival injections?

1-2 weeks

How long does medication delivery last after subconjunctival injection?

1. Refractory uveitis

2. Cystoid Macular Edema Post-Op

3. Scleritis

4. Corneal Ulcers

5. Trabeculectomy (post and failing)

What are 5 indications of subconjunctival injections?

Methylprednisone or Kenalog; subconjunctival (SC)

What medication should be administered for refractory uveitis? What type of injection?

Subconjunctival (SC)

What type of injection should be administered for corneal ulcers?

Peripheral Corneal Ulcers

What ocular anomaly is shown here?

1. Known hypersensitivity

2. Steroid responders

3. Infectious etiology if using steroids

What are 3 contraindications of Subconjunctival injections?

1. Discomfort

2. Subconjunctival heme

3. Subconjunctival steroid deposits

4. Increased IOP

5. Vasovagal syncope

6. Globe penetration

What are 6 complications of subconjunctival injections?

Bevel down

How should you orient the needle for a subconjunctival injection?

Subconjunctival heme; subconjunctival injection

What ocular complication is shown here? What type of injection has this as a complication?

27-30 g; 1 cc syringe

What diameter of needle is used for subconjunctival injections? What volume of syringe?

Forceps

What equipment should you use to lift the conjunctiva up into a “tent”?