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Emily Li, Paul B Greenberg, Magdalena G Krzystolik; Nurse-administered intravitreal injections: a systematic review. Invest. Ophthalmol. Vis. Sci. 2015;56(7 ):4180.
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The growing elderly population and prevalence of diabetes mellitus have increased incidences of exudative age-related macular degeneration and diabetic macular edema. This has created a need for more cost-effective methods of delivering anti-vascular endothelial growth factor intravitreal injections. One approach is to employ nurses instead of physicians to administer injections. We systemically reviewed the literature on the safety and efficacy of this treatment model.
We searched PubMed, Medscape and Google Scholar under 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 nurse injectors, the training--if any--received by the nurses, the number of the injections and the length of the study. We evaluated safety through vision-threatening complications. We evaluated efficacy through reported measures of patient satisfaction and efficiency.
Our search produced 20 publications; four met inclusion criteria. All four described safety audits (one retrospective, three prospective) of nurse-administered intravitreal injections in the United Kingdom (UK). The number of nurse injectors in the studies ranged from two to four. Injection training ranged from none (one study) to one full day of didactics and wet lab demonstration (two studies). In all reports, the nurses initially performed a number of injections (ranging from 20 to 200) under direct supervision by an ophthalmologist; subsequently, an ophthalmologist was always on site. The studies reported 1,400 to 10,006 injections over 5 months to 5.5 years. The study with the highest number of injections (10,006) over the longest duration (5.5 years) reported a 0.04% rate of post-injection endophthalmitis; the other studies reported no major adverse events. Three studies measured patient satisfaction using surveys and all reported positive results; they also cumulatively reported increased mean number of injections over fewer injection clinic days, improved patient access to injections with decreased wait time in clinic and increased access to retina specialists.
Preliminary UK studies suggest that nurse-administered intravitreal injections may provide a safe and effective therapeutic option for retina care.
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