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Vascular Endothelial Growth Factor (anti-VEGF) medicines administered intra-ocularly

1 May 2013

College Statement

This statement refers only to injections of anti –Vascular Endothelial Growth Factor (anti-VEGF) medicines administered intra-ocularly directly through the conjunctiva and sclera using a sharp needle.

This statement is the current College position and supersedes older statements on intraocular injections in the ARMD Guidelines for Management (2009) and Maximising Capacity in AMD Services (2009). These documents will be updated in due course.

Background

Anti-VEGF agents are given for a variety of previously untreatable eye conditions and the indications for their use are increasing. Their use in Age Related Macular Degeneration (ARMD) and in some diabetics with macular oedema is approved by NICE. Most patients require multiple injections. This has resulted in many eye departments administering thousands of injections per annum. To cope with this massive increase in workload, Trusts have appointed more medical retina specialists. The College has published two guidelines an ARMD including one that suggests strategies for  streamlining services (ARMD Guidelines for Management, and Maximising Capacity in AMD Services).

As a treatment evolves from being at the “cutting edge” of practice to the mainstream of practice, it becomes an increasing challenge to ensure that it can be made available in a timely fashion to all those who need it, and the process of meeting this challenge often includes the training of non-medical personnel to undertake tasks that have previously only been undertaken by doctors. There are precedents for this in many areas of health care.

This document outlines the College views on whether intravitreal injections of anti-VEGF agents should be given by appropriately trained HCPs.

College Guidance

The College appreciates that, for many patients, the administration of anti-VEGF agents by intra-ocular injection is far from trivial. The condition for which it is given is extremely worrying as the eyesight is under threat. The procedure itself, though almost painless and short, can be emotive. The College view is that, where circumstances and facilities allow, the injection should be given by a specialist doctor trained in the procedure.

However, the College is aware of the enormous pressure that eye departments are under to deliver this treatment to thousands of new and follow-up patients. The College is also aware that non-medical HCPs are already being used in some parts of the UK to administer intra-ocular injections of anti VEGF agents and that this has been shown in those areas, by those persons, to be safe. The College therefore considers that it is reasonable for non-medical HCPs to administer anti-VEGF agents so long as the following stipulations are met:

  • The patient remains under the care of a named consultant ophthalmic surgeon at all times
  • The HCP is fully trained in the rationale for the treatment, its effects, and possible complications both intra operative and post-operative
  • The HCP is fully trained in the technique of injection by an ophthalmic specialist doctor.
  • The HCP giving the injection has immediate access to advice from an ophthalmic specialist doctor at all times whilst giving injections and that an ophthalmic specialist doctor is immediately available to manage any complications
  • There is a continuous audit of the injection service provided by HCPs). There should also be regular patient feedback. Further training must be available to the HCP if required
  • The hospital Trust management is fully aware of, and supports the initiative, and all personnel are covered by appropriate indemnity
  • Consent. GMC Guidance must be followed. This, including guidance on delegation of consent, and can be found at http://www.gmcuk.org/guidance/ethical_guidance/consent_guidance_index.asp  (accessed 13 March 2013)
  • The training of ophthalmic doctors in the giving of intra-ocular injections is essential. It must not be compromised by the injection service provided by HCPs.

Mr Graham Kirkby FRCOphth

Vice President

Chairman of the Professional Standards Committee April 2013