Anti-VEGF intravitreal injections: indications and procedure

An intravitreal injection (IVT) is often a source of anxiety before the first session. In practice, it is a quick procedure, performed under anesthetic eye drops, that takes less than 5 minutes. Here is what you will actually experience, from the hours beforehand to the 24 hours that follow, so you can approach the day fully informed. For the technical aspects (molecules, indications, protocols), see the page dedicated to intravitreal injections.

BEFORE

The days before: planning ahead with peace of mind

The most common fear before a first IVT is that of “a needle in the eye.” It is understandable and often out of proportion with the reality of the procedure. The brain anticipates a sharp pain that local anesthesia (eye drops) almost entirely eliminates. This apprehension drops noticeably from the second injection onward, once you have been through the experience.

In the days beforehand, a few practical points to plan for:

• Prescription — check that it is up to date (some centers require a recent named prescription for the molecule).
• Administrative documents — health insurance card, supplementary insurance, and any long-term illness (ALD) coverage if you have diabetes or wet AMD.
• Transport — your vision will be blurred for a few hours. Arrange for a companion or a taxi for the trip home, especially for your first IVT. Driving on the same day is not advised.
• Current treatments — continue your usual medications, including anticoagulants (unless your cardiologist has specifically advised otherwise). An IVT does not require stopping a well-balanced anticoagulant.

Many patients tell me that knowing exactly what is going to happen is the best emotional preparation. That is what this article aims to give you.

THE DAY ITSELF

The morning of the injection: what to do, what to avoid

Unlike surgery, you do not need to fast. Have a normal breakfast, take your usual medications, have your coffee. The IVT is performed under local anesthesia with eye drops: no sedation, so no dietary restrictions.

• Current eye drops — continue your glaucoma or ocular surface treatments in the morning as usual, unless told otherwise.
• Makeup and contact lenses — avoid eye makeup on the day of the IVT. If you wear contact lenses, bring your glasses for the day.
• Shower and hygiene — shower as usual, with no particular precautions regarding hygiene. Asepsis will be ensured at the practice just before the injection.
• Arriving at the practice — allow 15 to 30 minutes early for check-in, any preliminary dilating eye drops, and to let the local anesthetic take full effect.

DURING

In the room: the exact sensations, minute by minute

You are settled in a semi-reclined position. Here is the full sequence, just as you will experience it:

• 1 — Anesthetic eye drops (repeated 2 to 3 times a few minutes apart). You first feel a slight sting, then the eye becomes numb. The dominant sensation: “the eye feels numb.”
• 2 — Antiseptic cleaning with povidone-iodine (Betadine®). A brown solution applied around and in the eye. Slight transient stinging. This is the most unpleasant step for many people — it is well managed.
• 3 — Eyelid speculum — a small plastic retainer that holds the eyelids open so you do not have to “force” your eye to stay open. The pressure is not painful, just bothersome for a few seconds while you get used to it.
• 4 — The injection itself — I ask you to look toward a specific target. You feel a brief pressure for about 5 seconds. No sharp pain — thanks to the anesthetic. You do not see the needle coming: your line of sight is directed elsewhere.
• 5 — Removal of the speculum, rinsing with saline solution. Immediate relief.
• 6 — Checking the intraocular pressure and your perception of light for 5 minutes. You can then leave.

Total duration: 5 to 10 minutes from entering the room to leaving. The injection itself lasts a few seconds. Most of the time is devoted to asepsis — this is what underpins the documented safety of the procedure.

RIGHT AFTER

Right after: the first two hours

Your vision is blurred and hazy — a sensation often described as “looking through fog” or “through a filter.” This is normal and temporary, related to the mixing of the injected molecule (aflibercept, faricimab, ranibizumab, etc.) with the vitreous humor, as well as to any pupil dilation.

Other common, benign sensations within 2 to 24 hours:

• A “bubble” or dark spot in the center of the field, sometimes moving — this is the small air bubble injected with the molecule, or a small drop of anti-VEGF. It rises within a few hours and disappears within 24 h.
• A gritty, sand-like sensation in the eye — related to the antiseptic cleaning and the needle passing through the conjunctiva. Artificial tears can relieve it if needed.
• Slight redness at the injection site (outer corner of the eye), sometimes with a bright-red subconjunctival hemorrhage. Dramatic in appearance but harmless, it fades within 7 to 10 days.
• Photophobia — light feels harsh. Sunglasses recommended.

To avoid in the first few hours: rubbing the eye, applying makeup, wearing contact lenses, swimming, or going to a pool or jacuzzi. Resume your usual eye drops according to your post-injection prescription.

THE FIRST 24 H

The following 24 hours: normal vs. warning signs

Normal signs (common)

• Vision gradually clearing over 6 to 12 hours.
• Slight surface discomfort, a gritty, sand-like sensation.
• Localized redness at the injection site, sometimes with a small, harmless subconjunctival hemorrhage.
• The presence of small mobile floaters in the visual field (molecule dispersing in the vitreous).
• Slight photophobia that resolves within 24 h.

Warning signs: get in touch immediately

RECOVERY

Returning to normal life: when?

• Driving — not on the same day (blurred vision, possibly dilated pupil). You can resume the next morning if your vision has cleared.
• Office work — possible from the next day. No routine sick leave needed.
• Physical or outdoor work — 24 to 48 h to avoid any direct trauma.
• Light exercise — from the next day (walking, cycling).
• Intense sport, contact sports — 48 h.
• Pool, jacuzzi, sauna — 7 days (risk of infection of the conjunctival surface through contact).
• Flying and altitude — no contraindication for an IVT alone (unlike vitrectomy with gas tamponade).

Most patients are back to normal comfort within 24 to 48 h. Diabetic patients with regular blood-sugar monitoring continue their usual treatment and follow-up. For wet AMD and diabetic retinopathy, IVTs are part of a protocol spanning several months.

FAQ

Frequently asked questions: the experience in practice

Sources

• Rifkin L, Schaal S. Factors affecting patients’ pain intensity during in office intravitreal injection procedure. Retina. 2012;32(4):696-700. PMID 22082694. Prospective study on pain tolerance during IVTs (VAS score) — perception generally low under anesthetic eye drops.
• Fileta JB, Scott IU, Flynn HW Jr. Meta-analysis of infectious endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents. Ophthalmic Surg Lasers Imaging Retina. 2014;45(2):143-9. PMID 24635156. Meta-analysis of the incidence of post-IVT endophthalmitis — estimated at 1 in 2,000 to 5,000 injections depending on the asepsis protocols.
• Grzybowski A, Told R, Sacu S, et al. 2018 Update on Intravitreal Injections: Euretina Expert Consensus Recommendations. Ophthalmologica. 2018;239(4):181-193. PMID 29393226. European (Euretina) recommendations on the safe practice of IVTs.

This content describes the usual experience of an IVT, as I explain it during the preparatory consultation. Every situation is individual and must be assessed with your ophthalmologist.