Nurse-administered intravitreal injections: a systematic review

Abstract

Dear Editor: The growing elderly population and prevalence of diabetes mellitus have increased the number of patients with exudative age-related macular degeneration (AMD) and diabetic macular edema (DME) [1–4]. This has created a need to explore more cost-effective methods of delivering anti-vascular endothelial growth factor (VEGF) therapy [5]. One approach is to use nurses instead of physicians to administer the intravitreal injections of anti-VEGF agents. We have systemically reviewed the literature on the safety and efficacy of this treatment model. We searched articles in PubMed, Medscape and Google Scholar for the terms “retina and nurses,” “nurse injection” and “demand for ophthalmologists” from 2006 to 2014. Our inclusion criterion was nurse administration of intravitreal injections. For each paper, we recorded the number of nurses administering the injections, the training received by nurses, the number of injections, and the length of the study. We determined safety through reported vision-threatening complications. We evaluated efficacy through reported measures of patient satisfaction and efficiency. Our search produced 20 publications; four met the inclusion criteria. All four studies described safety audits of nurseadministered intravitreal injections in the United Kingdom (UK); the studies’ salient features are outlined in Table 1. The previous experience and training of the nurse injectors and the number of initial injections they performed under direct supervision by an ophthalmologist varied in each study. In all studies, the ophthalmologists retained responsibility for diagnostic and therapeutic decisions. The study with the highest sample number (10,006 injections) over the longest duration (5.5 years) reported a 0.04 % rate of post-injection endophthalmitis [8]; the other studies reported no major adverse events. The three smaller studies [6, 7, 9] reported positive patient satisfaction surveys; the studies also reported improved clinic efficiency using measures such as increased mean number of injections over fewer injection clinic days, and improved patient access to injections with decreased wait time and increased access to retina specialists. The literature on nurse-administered intravitreal injections has several limitations. The small number of published studies and the localization of research to the UK restricted the generalizability of study findings. Additionally, the variability in nurse training and in measuring clinic efficiency precluded definitive conclusions regarding the most appropriate training for nurse injectors or the efficacy of nurse-versus-physician-administered injections. These limitations notwithstanding, the use of nurses to administer intravitreal injections merits further study, especially in healthcare settings outside the UK. Presentation This work was submitted for presentation at the Association for Research in Vision and Ophthalmology (ARVO) Annual Meeting, 3–7 May 2015, in Denver, Colorado, USA. E. Li : P. B. Greenberg Division of Ophthalmology, The Warren Alpert Medical School of Brown University, Providence, RI, USA