Injectable Medications in Primary Eyecare

Transcription

1 Injectable Medications in Primary Eyecare Andrew Rixon OD, FAAO Mike Dorkowski OD,FAAO Scott Ensor OD John Neal OD Jennifer Sanderson OD, FAAO Please silence all mobile devices and remove items from chairs so others can sit. Unauthorized recording of this session is prohibited.

2 Disclosure Statement: Nothing to disclose

3 PRIMARY EYE CARE PROCEDURES. For the purpose of 1993 Public Acts Chapter 295, The performance of primary eye care procedures rational to the treatment of conditions or diseases of the eye or eyelid is determined by the board to be those procedures that could be performed in the optometrist s office or other health care facilities that would require no more than a topical anesthetic. Laser surgery and radial keratotomy are excluded. Authority: T.C.A , , , and Public Chapter 295, Acts of Administrative History: Original rule filed February 14, 1993;; effective April 30, 1994.

4 Standard of Care The courts have ruled that Optometry and Ophthalmology are held to the same Standard of Care. The Optometrist must adhere to the rules governing the practice of Optometry for his/her state.

5 TN Updates 4/8/2014

6 SB 220

7 SB 220

8 Inclusions of Amendment Needle drainage of eyelid abscess, hematoma, bulla and seroma Excision of single epidermal lesion without characteristics of malignancy Incision and curettage on non-recurrent chalazion Simple repair of eyelid laceration no larger than 2.5mm, no deeper than orbicularis, not involving lid margin or lacrimal drainage Removal of foreign bodies similar restrictions as above

9 Prohibitions of Amendment Reconstruction of the eyelid Procedures not approved by board of optometry prior to this bill becoming law No larger than 5 mm No deeper than dermal layer of skin

10 SB 220

11 The Board Giveth

12 The Rules

13 Universal Precautions Universal Precautions is an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.

14 Standard Precautions 1) blood;; 2) all body fluids, secretions, and excretions, except sweat, regardless of whether or not they contain visible blood;; 3) non-intact skin 4) mucous membranes. Includes Hand Washing and appropriate use of PPE = X 2

15 Personal Protective Equipment Determination of PPE based on anticipated exposure to blood or other potentially infectious body fluids during any given procedure Use gloves or masks if warranted Lab coats/surgical gown to protect clothing

16 Gloves Latex? Nitrile? Neoprene? Avoid vinyl;; reduced barrier protection. Use correct size Powdered vs Non Non-sterile vs. sterile? >15% of healthcare workers exhibit latex allergy Amarasekera M, et al. Int J Occup Med Environ Health (4):

17 Glove Selection

18 Proper Glove Removal

19 Universal Precautions Biohazardous Definitions: Any material other than sharps that is contaminated with blood, bodily fluid, or tissue is biomedical waste. Needles and other sharps must be disposed of in proper containers. Drs.RixonDorkowskiEnsorNealSa nderson

20 Sharps and Biohazard Bags

21 Biohazards Waste should be placed in a red bag which has been labeled according to federal, state and local regulations with the biohazard symbol & word BIOHAZARD.

22 Handling Needles/Sharps Do not bend, recap, or remove contaminated needles and other sharps unless such an act is required by a specific procedure or has no feasible alternative Do not shear or break contaminated sharps. (OSHA defines contaminated as the presence or reasonably anticipated presence of blood or other potentially infectious materials on an item or surface)

23 Sharps Any item with corners edges, etc. capable of piercing skin Must be placed in red, OSHA compliant sharps container

24 OSHA Compliant Sharps Closable, puncture-resistant, leak-proof on sides and bottom. Accessible, maintained upright, and not allowed to overfill. Labeled or color coded Colored red/labeled with the biohazard Labeled in fluorescent orange/orangered with lettering and symbols in contrasting color Red bags may be substituted for labels

25 Disposal Care and disposal of waste can be arranged and coordinated through various pathogen control companies in your area They ll supply bags, boxes, etc. and can arrange for pickup on virtually any schedule: Weekly, monthly, quarterly, etc Sharps containers, bags, etc. are also available through retailers of most surgical equipment

26 Medical Supplies Syringes Image courtesy of David K. Talley OD, FAAO Tip, Barrel, Plunger 6 cc/ml 5 cc/ml 1 cc/ml

27 Medical Supplies Hypodermic Needles 20 gauge 27 gauge 1 ½ 30 gauge Image courtesy of David K. Talley OD, FAAO Bevel, Shaft, Hub ½

28 Needle Anatomy

29 Syringe Anatomy

30 Safety Device Designs Self Re-sheathing Needles Winged Steel Needles Syringe with Retractable Needles

31 Syringe Selection

32 Bevel Position Visualization easier with bevel up? Bevel away from globe on true peribulbars? Chamber Tap bevel down? More comfortable for SubQ. Bevel Up

33 Avoiding the Vacuum Ready medication Air In

34 Aspirating Suspension Draw out.1-1cc of medication

35 Periocular Basics

36 Instrumentation Chalazion Clamps Spring Loaded Mechanical O.D. Image courtesy of David K. Talley OD, FAAO

37 Instrumentation Image courtesy of David K. Talley OD, FAAO Forceps Tissue single tooth Jewelers no teeth & with long tip Cilia no teeth & short tip

38 Instrumentation Jaeger Plate Metal or plastic Used to protect globe when giving injection Image courtesy of David K. Talley OD, FAAO

39 Sterilization Systems Autoclave (heat/steam) are required for invasive surgery;; cost~ $ $6000. Ethyl Oxide can also be used to sterilize instruments for intraocular surgery. Chemical (germicide) is an inexpensive way to sterilize hand instruments. O.D. Slide courtesy of David K. Talley OD, FAAO

40 Autoclave Sterilization Sterilization Tray O.D. Statim Autoclave Sterilization Cassette Images courtesy of David K. Talley OD, FAAO

41 Chemical Sterilization Metricide Germicide is an inexpensive way to sterilize instruments for minor surgery Most require 10 minutes for disinfection and 10 hours for sterilization O.D.

42 Chemical Germicide Metricide 28 O.D. C - Tub Activator

43 Informed Consent Elements of: 1) the nature of the decision/procedure 2) reasonable alternatives to the proposed intervention 3) the relevant risks, benefits, and uncertainties related to each alternative including risks of denying procedure 4) assessment of patient understanding 5) the acceptance of the intervention by the patient

44 EHR? What about obtaining e-signature? Physical signature is always preferable Wikipedia.com

45 Sample Informed Consents

46 Intralesional Indications Chalazion/Chalazia Capillary Hemangioma

47 Intralesional Injection Technique-Translesional 1 to 2 gtt Proparacaine Xylocaine to conj optional Apply hemostatic chalazion clamp Use 27 gauge, ½ needle Aspirate vs non aspirate Insert needle and push through entire lesion Slowly remove needle while injecting contents of syringe Remove chalazion clamp

48 Atlas of 1 Eyecare Procedures

49 Intralesional Video

50 Intralesional Complications Pain Depigmentation Ptosis-Temporary Delayed Wound Healing Eyelid Necrosis Globe Perforation Microembolization Always R/O SCC if recalcitrant!

51 11900 and Injection, Intralesional, up to and including 7 lesions *$51.96 PAR non Facility Injection, Intralesional, >7 lesions *65.67 PAR non Facility *Cahaba Medicare TN Allowable 2017

52 Intramuscular Injection Typically reserved for irritating medications Also used for administering larger volumes of medication - Typically 3-5mL. Optometric Use: - Anaphylactic reaction to IVFA - IM benadryl or IM epinephrine 1: IM phenergan for patients with known nausea response to IVFA

53 Intramuscular

54 Recommended Sites-IM

55 Obesity Influence? Johnstone J, et al. Allergy 2015;; 70: Med J Armed Forces India Oct;;70(4):

56 Intramuscular Equipment 1-3 cc syringe gauge needle Depends on viscosity of med 5/8 to 1 ½ inches Under 130lbs 5/ lbs lbs Over Alcohol pad, gauze, band-aid Sharps container, biohazard bag

57 PER CDC For all intramuscular injections, the needle should be long enough to reach the muscle mass and prevent vaccine from seeping into SubQ tissue, but not so long as to involve underlying nerves, blood vessels, or bone Aspiration NOT necessary

58 Procedure 1. Cleanse area with alcohol swab in circular motion. 2. Apply pressure to the skin in a spreading motion in order to make the entry point taut. 3. This ensures the muscle is isolated and prevents injection into the subcutaneous space. 4. Insert the needle fully into the tissue at a 90 angle and inject the bolus. 5. Retract the needle and apply direct pressure to the injection site with a cotton ball or gauze pad. 6. Dispose of needle in sharps container.

59 Intramuscular Injection Botox administered Subcutaneously Injection directly in the affected muscle relieves the muscle spasm. The duration of effect lasts about 3 months. O.D.

60 Botox Coding Chemodenervation of muscle(s): muscle(s) innervated by facial nerve *$ PAR Non Facility J0585 Injection, onabotulinumtoxina per unit Will be 100 Units regardless of waste *Cahaba Medicare Allowable TN 2017

61 Subcutaneous Injection Subcutaneous Shallow injection into loose connective tissue Absorption time about 30 minutes. Used for epinephrine, insulin, tetanus toxoid, vaccine, narcotics, vitamin B gauge needle

62 SubQ Indications Focal SubQ infiltration of the lid Use of local anesthetic to block the nerves traversing the injected area

63 What to Inject

64 Lidocaine Logistics Mechanism: stabilizes the neuronal membrane by inhibiting the ionic fluxes required for the initiation and conduction of impulses, thereby effecting local anesthetic action. Hemodynamics: Excessive blood levels may cause changes in cardiac output, total peripheral resistance, and mean arterial pressure.usually results in moderate hypotension if dosages not exceeded.lowest blood levels p subq

65 Lidocaine Logistics Anesthetic Equivalent concentration Onset (minutes) Duration (hours) Maximal dose (mg per kg) Maximal dose (ml per 70 kg) Lidocaine (Xylocaine) 1 or 2% <2 1.5 to 2 4 mg per kg, not to exceed 280 mg 28 ml (1%); 14 ml (2%) Lidocaine with epinephrine 1 or 2% lidocaine, 1:100,000 or 1:200,000 epinephrine <2 2 to 6 7mg per kg, not to exceed 500mg Based on lidocaine 50mL (1%); 25mL (2%) Based on Table from Achar S and Kundu S. Priniciple of office anesthesia: part I. Infiltrative anesthesia. Am Fam Physician Jul 1;;66(1):91-4.

66 Adverse/Contraindications Less common than with regional blocks or general anesthesia. Severe Hepatic Disease Impaired cardiovascular function

67 Lidocaine Liability LIDOCAINE HYDROCHLORIDE INJECTION, FOR INFILTRATION AND NERVE BLOCK, SHOULD BE EMPLOYED ONLY BY CLINICIANS WHO ARE WELL VERSED IN DIAGNOSIS AND MANAGEMENT OF DOSE- RELATED TOXICITY AND OTHER ACUTE EMERGENCIES THAT MIGHT ARISE FROM THE BLOCK TO BE EMPLOYED AND THEN ONLY AFTER ENSURING THE IMMEDIATE AVAILABILITY OF OXYGEN, OTHER RESUSCITATIVE DRUGS, CARDIOPULMONARY EQUIPMENT AND THE PERSONNEL NEEDED FOR PROPER MANAGEMENT OF TOXIC REACTIONS AND RELATED EMERGENCIES. (See also ADVERSE REACTIONS and PRECAUTIONS.) DELAY IN PROPER MANAGEMENT OF DOSE- RELATED TOXICITY, UNDERVENTILATION FROM ANY CAUSE AND/OR ALTERED SENSITIVITY MAY LEAD TO THE DEVELOPMENT OF ACIDOSIS, CARDIAC ARREST AND, POSSIBLY, DEATH

68 Epinephrine Effects Promotes hemostasis (<1:100,000 no sig ) Decreases rate of systemic absorption by 1/3 Reduces likelihood of systemic side effects Increases analgesia duration by up to 50% Wait at least 7min for vasconstriction to occur

69 Infiltrative Technique 27-30G ½ inch needle, 1.5cc anesthetic in syringe 1-2 gtts topical anesthetic, 1-2gtts optional phenyl/brimonidine (palpebral side) Alcohol prep pad with percutaneous approach Pull skin laterally until slightly taut Introduce needle in SubQ tissue approximately 15 to eyelid surface Inject 0.5cc of solution, distribute using a gentle turning motion Apply pressure to increase diffusion

70 Atlas of 1 Eyecare Procedures

71 Video

72 Post Injection Blanching

73 SUBCONJ INDICATIONS Refractory Uveitis Cystoid Macular Edema Noncompliant patient Failing trabeculectomy (Bleb needling) Recalcitrant pterygium p sx Alternative route of anesthesia in trabeculectomy or cataract surgery Anterior Scleritis

74 Corticosteroids Anterior Seg Posterior Seg

75 Injectable Info Name Trade Name Potency (cortisol equivalents) Duration of Action Triamcinolone Acetonide (10, 20, 40 mg/ml) Kenalog mos IO, >3mos perioc. Methylprednisone Acetate (40, 80, 160 mg/ml) Depo-medrol 1 >3 mos Table based on Cunningham ET, et al. Canadian Journal of Ophthalmology 2010;;45,4:

76 SubConj Technique 25-30G, ½ needle with 1cc syringe Instill topical anesthetic Direct patient s gaze away from site Position needle (technique dependent) Insert needle Inject the desired amount of medication forming a bleb within the subconj space Withdraw the needle May apply pressure

77 Which one?

78 Brimonidine??? Nice job as vasoconstrictor Reduction in SCH?

79 Growing Pains? Video Courtesy of David Talley O.D., FAAO

80 Tent????

81 Inferior Fornix

82 Deep Subconj

83 SubConj Complications Subconjunctival Hemorrhage Pain/irritation during/post injection Increased IOP Secondary ocular infections Chemosis Ecchymosis Perforation of the globe Retained drug deposits

84 SubConj Ca$h SubConjunctival Injection *$39.01 PAR Non Facility *Cahaba Medicare TN Allowable 2017

85 Retinal Realities #1- healthy retinal vessels are not fenestrated and therefore should not leak dye. #2- vessels comprising a non-compromised choriocapillaris are fenestrated and should leak creates the choroidal flush seen in the early phase #3 An intact RPE-Bruch s membrane complex forms a barrier between fluid within the choriocapillaris and sensory retina #4 RPE-Bruch s provides a filter which prevents complete visualization of fluorescence within the underlying choroid. Andrew J. Rixon, O.D, F.A.A.O 85

86 Indocyanine Green (ICG): Properties Water soluble Tricarbocyanine dye Peak absorption at 800 nm Fluoresces in IR spectrum Transmission through pigment,fluid, lipid and hemorrhage more efficient than fluorescein Contains 5% sodium iodide ~98% bound to blood protein Indications: CNV, RAP, PCV, CSCR, intraocular tumors, choroidal inflammation 86

87 Fluorescein Sodium: Properties Biological Dye Water-Soluble Disodium salt Adjusted to ph 8+ Low Molecular weight Up to 80% binds to plasma proteins Max absorption peak 465 to 495nm Emission at 525 to 530nm λ of emitted light blocked by the overlying RPE DrsRixonDorkowskiEnsorNealSanderson 87

88 Hypofluorescence 40 seconds DrsRixonDorkowskiEnsorNealSanderson 88

89 Hypofluorescence DrsRixonDorkowskiEnsorNealSanderson 89

90 Hyperfluorescence DrsRixonDorkowskiEnsorNealSanderson 90

91 Hyperfluorescence 1 min 8 min 91

92 IVFA-Equipment 25% Fluorescein Dye Infusion set-23 or 25g Tourniquet Syringe-3 or 5cc Alcohol prep pads Bandaids Emesis basin ** Angio-Pro-Pak Justiceop.com $30.95/pk

93 IVFA Equipment

94 Stat Kits or Crash Carts StatKit 1000HD StatKit Z

95 Treatment with a STAT Kit Acute Coronary Syndrome Allergy Anesthesia Related Oversedation Asthma Cardiac Arrest Congestive Heart Failure Dysrhythmias GI Distress with Hypotension Hypertension Emergencies Hypoglycemia Pain Management Poison Emergencies Seizures Vasovagal Syncope Statkit 900

96 CPR Updated??? A Tennessee optometrist using local anesthetic in the manner allowed by SB 220 shall provide to the board proof that the he/she has current CPR certification by an organization approved by the board Or providing that another person who has current CPR certification will be present in the office at all times that a local anesthetic is used by the O.D. in conjunction with the treatment of an eyelid lesion Check that card!

97 AED Compliance

98 Emergency University Scenarios Acute Coronary Syndrome Allergy Anesthesia Related Oversedation Asthma Cardiac Arrest Congestive Heart Failure Dysrhythmias GI Distress c Hypotension Hypertensive Emergencies Hypoglycemia Pain Management Poison Emergencies Seizures Vasovagal Syncope

99 IVFA-Practical Considerations Use universal precaution Flashback equal stable venous access Open the cap at end of infusion set to confirm stability May need to keep cap off initially if concern over quality of veins to avoid infiltration Tape site down to stabilize Can reattach cap prior to attaching syringe if hydrostatic pressure too much Remove tourniquet once site is stable

100 IVFA-Practical Considerations Watch for extravasation during push Speed of push has been disproven to increase risk of nausea/vomiting Suggested rates vary from 1-6sec for entire 2cc bolus Phlebotomy requires good tactile sense, use this over what you visualize Control the site to prevent vein from rolling

101 Where? Netter knows..

102 OR...

103 Intravenous Injection Technique Prepare IV tray. Wash hands and Glove. Advance infusion line into vein (bevel up) watching for blood return. Remove tourniquet. Attach syringe. Inject medication. O.D.

104 Intravenous Injection Technique Remove needle and apply gauze. Check vitals on patient. Discard supplies. Inspect injection site and apply bandage. Discard gloves. O.D.

105 IVFA-Procedure Site Selection Alcohol Prep

106 IVFA-Procedure Tourniquet Venipuncture-Shallow

107 IVFA-Procedure Remove infusion set Apply pressure

108 Venous Air Embolism Severity depends on volume, rate of accumulation and body position Small amounts of air are generally broken up in the capillary bed and absorbed from the circulation without complications Ingress of mL of air at a rate of 100mL/sec can be lethal 1 -This involves a 14G needle with pressure gradient of 5cmH2O -Involves central venous catheterization (Large veins i.e Jugular) Symptoms may arise in as little as 20mL/sec 2 1) Respiratory Medicine Case Reports 18 (2016) ) Indian Journal of Anaesth 2010 Jan-Feb;; 54(1): DrsRixonSandersonDorkowskiEnsorNeal 108

109 Closed System

110 Open System

111 FANG-Complications Nausea Vomiting Pruritis Urticaria Anaphylaxis Syncope Tachycardia Extravasation Death-MI

112 Incidence of Complications Yannuzzi et al, Fluorescein Angiography Complication Survey (FACS), Ophthalmology 1986;; 93: responding retinal specialists N=221,781 IVFAs performed in 1984 Moderate adverse reaction 1:63 (transient effect, possible medical intervention) Severe reaction was 1:1900 (prolonged requiring intense Tx) Rate of death 1:222,000.

113 Jennings and Mathews 1st optometric exploration into the adverse reactions of IVFA-1994 N=1, % of patients had adverse effects Nausea 0.8%, Urticaria 0.6%, Emesis 0.2%, Extravasation 0.2% Not one factor existed which served to adequately predict which patients will have an adverse rxn to the NaFl dye J Amer Optom Assoc 1994 Jul;;65(7):465-71

114 Financial Facts R/L Fluorescein Angiography $80.59 TC $ R/L Indocyanine - Green Angiography $ Special Anterior Segment Photography with Angiography $ Fundus Photography $61.24 Cahaba TN 2017 PAR NonFacility

115 Vascular Layers Imaged by OCT-A JAMA Ophthalmol. 2015, 133(1): 45-50

116 IVFA vs OCT-A-Parapapillary JAMA Ophthalmol. 2015, 133(1): 45-50

117 IVFA Inner plexus Deep plexus JAMA Ophthalmol. 2015, 133(1): 45-50

118 BRVO -Depth Enhanced

119 BRVO-Full Thickness Map

120 Twig????

121 Twig on OCT-A

122 SubTenon s Techniques Smith and Nozik Orbital Floor Cannula Method

123 Intravitreal Utilization Based on publically available medicare claims in ,593 patients treated 1 2,869 physicians 1 4,749,026 injections 1 $1,474,501,217 Total Payments 1 Projected over 6 million in )Baisiwala S, et al. Ophthalmic Surg Lasers Imaging Retina. 2016;;47: ) Avery RL, et al Retina :S1-S18

124 Intravitreal Indications Neovascularization Inflammation Infection

125 Intravitreal Guidelines No contraindications exist Use of Antibiotics unsupported Bilateral injections should be treated as separate procedures Gloves/Draping has not been shown to reduce endophthalmitis Minimize speaking/surgical mask Povidone-Iodine 5-10% last agent to be applied pre-injection Avery RL, et al. Retina 2014 Dec;; 34 Suppl 12: S1-S18

126 Intravitreal Guidelines Speculum or manual lid retraction ok If gel anesthetic is used apply povidone-iodine pre and post Deliver injection between horizontal and vertical rectus muscles mm posterior to limbus Use 30G or smaller, 18mm or shorter Post injection need to confirm formed vision prior to pt departure Avery RL, et al. Retina 2014 Dec;; 34 Suppl 12: S1-S18

127 Intravitreal Technique

128 Intravitreal Technique

129 InVitria

130 Intravitreal Complications Endophthalmitis Retinal Detachment Conjunctival Hemorrhage Vitreous Reflux Eye pain Cataract Development Increased IOP RPE tears Hypotony

131 Endophthalmitis Rates Reported ranges from 0.0%-0.36% c and s antibiotic prophylaxis 1,2 Meta-analysis of 16 studies/105,536 injections average 0.049% 3 0 per 15,144 with mask c povidone irrigation 4 Rates comparable amongst bevacizumab, ranibizumab, and aflibercept (0.039%, 0.035%,0.035%) 5 1) Hasler PW, et al Acta Ophthalmol. 2015;;93: ) Cheung CS, et al. Ophthalmology. 2012;;119: ) McCannel CA. Retina. 2011;;31: ) Shimada H, et al. Graefes Arch Clin Exp Ophthalmol. 2013;;251: ) Rayess N, et al. Am J Ophthalmol 2016;; 165:88-93

132 Nurses and Orthoptists?

133 Retrobulbar Indications Globe anesthesia Orbital pain relief

134 Retrobulbar Technique 25 g 1 ½ needle c blunt point Have pt stare superior nasally Insert needle through lower eyelid.5mm medial to lateral canthus Redirect needle into muscle cone Aspirate syringe Inject (2-5mL) Remove needle Apply Pressure to globe

135 Retrobulbar Technique Lange Anesthesiology Fig 38-1

136 Retrobulbar Complications Retrobulbar hemorrhage Globe perforation (>26mm) Optic nerve atrophy Frank convulsions Oculocardiac reflex Acute neurogenic pulmonary edema Respiratory arrest Postretrobulbar apnea syndrome Death

137 Current Injectable Authority D.C. Limited to Treatment of Anaphylaxis Use of Injectables [Including Tx of Anaphylaxis] September 2017 Slide Courtesy of Catherine Hendricks

138 Acknowledgements Owen Bell Erin Jaffe Erin Nosel O.D., FAAO Phil Ridings David K.Talley O.D., FAAO Corrie Wicklund O.D. Drs.RixonDorkowskiEnsorNealSanderso n

139 Thank You! Additional Question;;

140 Please remember to complete your session evaluations online. Tweet about this session using the official meeting hashtag #academy17