Intravitreal injections consent and checklist recommendations

  • 05 Mar 2024
  • Quality and Standards Committee

Recommendations on informed consent for intravitreal injections updated to reference new drug options (as of Autumn 2023). This guidance with the aims of to support a robust consent process whilst also ensuring safe clinical practice.

Intravitral injections_consent and checklist recommendations

The supporting documents are editable to allow digital completion and facilitate variation based on local practice. These are best accessed in Adobe Acrobat format to use the interactive features.

1) Patient Agreement for Investigation or Treatment

This does not specify the drug used or the eye treated but ensures all the material risks associated with the injection procedure are documented. The content primarily relates to anti-VEGF drugs. Consent may be taken by any healthcare professional with training in the principles of consent and who has sufficient understanding of the procedure to ensure informed consent.  In patients who lack capacity to consent, local protocols need to be followed for capacity assessment, best interests meeting and consent form according to NHS standard consent form. This guidance does not replace the option of bespoke consent forms for each individual drug if that is a local preference but it offers a pragmatic alternative option which may assist with managing capacity in busy clinics.

2) Checklist on day of treatment and Intravitreal injection checklist on the day of treatment example

A separate checklist document is advised for use on the day of the treatment which references the consent and drug list. The sample attached may be adapted to local drop preferences and reference any relevant local clinical guidelines. Some departments have electronic methods for consent and checklist. The principles of these documents may also be applied in this setting.

3) Site-and-Drug-Record-Intravitreal-Injections

The specific drug used and discussion related to it may be recorded on the accompanying sheet. If a drug treatment is changed, this may be recorded on this sheet including the rationale and patient discussion without requiring a patient signature. By retaining these on a single document the treatment history is clear reducing the risk of incorrect drug administration. It also simplifies the process of switching treatments. A new sheet is only needed if the eye or eyes treated changes.