This talk was given on December 20th 2016 by Dr. Stephen G. Odaibo as the inaugural Special Guest Lecture in Ophthalmology at the University of Ilorin Teaching Hospital, Ilorin Nigeria. ABSTRACT: Anti-VEGF agents such as Bevacizumab (Avastin), Ranibizumab (Lucentis), and Aflibercept (Eylea) have revolutionized the care of a number of retinal diseases such as diabetic macula edema, proliferative diabetic retinopathy, retinal vein occlusions, and exudative age-related macular degeneration. In this talk, I focus on the practical steps and considerations of administering intravitreal injections, and I show a video of how I perform the procedure in my clinic.

1. Intravitreal Injection of Anti-VEGF
Agents: A Practical Review
Stephen G. Odaibo1,2
M.D., M.S.(Math), M.S.(Comp. Sci.)
Retina Specialist and Board-Certified Ophthalmologist
Medical Associates Clinic, Dubuque IA1
Quantum Lucid Research Laboratories, Dubuque IA2

2. Special Guest Lecture
University of Ilorin, Department
of Ophthalmology, Ilorin Nigeria.
 Dedicated to my dad and mom:
Professor Stephen Kirtsiner Odaibo
and Marie Boyowa Odaibo, on the
occasion of my mom’s 70th birthday
and my parents’ 45th wedding
anniversary.
Dec 20th 2016

4. Stephen G. Odaibo, MD
 Place of Birth: University of Ilorin
Teaching Hospital
 Kindergarten: Saboke Ilorin
 Elementary School: Unilorin Primary
School, Ilorin
 Secondary School: Federal Government
College Ilorin

5. Intravitreal Injection of Anti-
VEGF Agents: A Practical
Review

6. Objectives
 Indications and Cases
 Steps of procedure
 Videos
 Questions

7. Indications
 Diabetic Macula Edema
 Proliferative Diabetic Retinopathy
 Central Retinal Vein Occlusion
 Branch Retinal Vein Occlusion
 Exudative Age-Related Macula Degeneration
 Other Choroidal Neovascular Membranes
 ?Retinopathy of Prematurity

8. Central Retinal Vein Occlusion
with Macula Edema
Bevacizumab
(Avastin)
After (1 month)Before

9. Next Case…

10. CRVO with Edema

11. Monthly Bevacizumab Aflibercept (Eylea)
Month 0
(Bevacizumab #1)
Month 2
(Bevacizumab #3)
Month 4
(Aflibercept #2)
Month 3
(Aflibercept #1)

12. Previous Case:
 Central Retinal Vein Occlusion with
Macula Edema

13. Next Case…

17. Month 0
(Bevacizumab #1)
Month 2
(Bevacizumab #3)
Month 3
(Aflibercept #1)
Month 4
(Aflibercept #2)
Month 5
(Aflibercept #3)
Monthly Bevacizumab Monthly Aflibercept, Treat-and-Extend …
Month 7.5
(Aflibercept #5)
Month 12
(Aflibercept #8)

18. Previous Case:
 Branch Retinal Vein Occlusion with
Macula Edema

19. Next Case…

23. Bevacizumab
Before After (1 month)

25. Previous Case:
 Ectopic Choroidal Neovascular
Membrane
 Peripheral Exudative Hemorrhagic
Choroidopathy
 Serous Retinal Detachment

26. Next Case…

27. Month 0
(Bevacizumab #1)
Month 1
(Bevacizumab #2)
Month 3
(Bevacizumab #4)

28. Previous Case:
 Exudative Age-Related Macular
Degeneration
 Pigment Epithelial Detachment

29. Next Case…

30. Some Patients Require Monthly Aflibercept (or More)
Aflibercept administered 2 months later
Missed 1 month
scheduled injection

31. Previous Case:
 Exudative Age-Related Macular
Degeneration

32. Next Case…

35. Previous Case:
 Myopic Choroidal Neovascular
Membrane
 Degenerative High Myopia

36. Next Case…

40. Previous Case:
 Proliferative Diabetic Retinopathy
 Vitreous hemorrhage
 Diabetic Macula Edema

41. Next Case…

47. Previous Case:
 Peripapillary Choroidal
Neovascular Membrane

48. Next Case…

50. Previous Case:
 Branch Retinal Vein Occlusion
 Retinal Arterial Macroaneurysm

51. Injection Procedure

52. Steps of Procedure (Part 1)
 Obtain informed consent
 Obtain Anti-VEGF medication from Fridge
(4 degrees Celsius or 2-8 degrees C )
 Locally anesthesize the eye with
proparacaine eye drops.
 Insert 5% betadine in the conjunctiva.
 Use Betadine (Povidone-Iodine) 10% to
prep the eye lids.

53. Steps of Procedure (Part 2)
 Insert eyelid speculum.
 Insert another drop of 5% povidone iodine on the
conjunctiva.
 Use caliper to place mark 3.5 mm from the limbus.
 Using a 32 G needle on a 1ml Syringe to Inject 0.05
ml of Anti-VEGF 3.5 mm from the limbus.
 Verify counting fingers vision
 Use Eyewash to rinse out the eye thoroughly
 Insert one drop of topical NSAID

54. Anti-VEGF Fridge

55. Video of Procedure
Watch video in YouTube Link below

56. Potential Complications and Side
Effects
 Endophthalmitis
◦ Rare (0.02 to 0.1%) but can be blinding
 Retinal breaks and detachments
 Traumatic cataracts
 Ocular hypertension or glaucoma
 Transient ocular irritation (most common side
effect)

57. Other practical considerations
 Costs:
◦ Bevacizumab (Avastin -- $60)
 Off-label use. i.e. not approved by U.S. Food and Drug Administration (FDA).
 Requires compounding pharmacy, or intermediate vendor.
◦ Aflibercept (Eylea -- $1850). [Regeneron Pharmaceuticals, Inc.]
◦ Ranibizumab (Lucentis -- $1170). [Genentec, Inc.]
 Storage
◦ Needs 2-8 degree Celcius storage.
 Post-injection irritation
◦ 5% betadine on conjunctiva instead of 10%.
◦ Rinse eye thoroughly post-procedure
◦ Consider applying 1 drop of long-acting topical NSAID e.g. nepafenac
0.3%
 Elevated Intraocular Pressure
◦ IOP rises to high 30-40 range after procedure and normalizes within 2
hrs. Caution required in patients with moderate to severe glaucoma.

58. Acknowledgements
 My dad Prof. Stephen K. Odaibo and my mom Marie Boyowa Odaibo
 My lovely wife Lisa and son Daniel
 My Team:
◦ Amanda Williams
◦ Shannon Walsh
◦ Lizzy Meier
 Ophthalmology Department, Medical Associates Clinic, Dubuque IA
 My Training
◦ Retina Faculty, Kellogg Eye Center Univ. Michigan – Ann Arbor
◦ Ophthalmology Faculty, Howard University Hospital
◦ Duke University Medical Center and Duke University School of Medicine
 Ophthalmogy Department University of Ilorin, Nigeria; for the kind
invitation!

59. My dad and mom at their 45th wedding anniversary and mom’s 70th
birthday celebration

61. The Core Team
F to B: Shannon Walsh, Amanda Williams, Lizzy Meier

62. Exam and Procedure Rooms

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67. QUESTIONS ?