01Purpose and principlesWhat the treatment does and how it fits into care.
VEGF is a signalling protein involved in vascular growth and permeability. In neovascular AMD and several retinal vascular disorders, excessive or misdirected signalling contributes to leakage, abnormal vessels and visual damage. Giving an inhibitor into the vitreous places treatment near the retina while using much smaller quantities than systemic oncology regimens. This anatomical route does not abolish all systemic exposure or every vascular safety concern.
The same pharmacological family is used in different diseases, but the clinical purpose varies. In wet AMD the aim is to control macular neovascular activity; in diabetic or vein-occlusion macular oedema it includes reducing leakage that impairs central vision. In selected proliferative disease it can suppress new vessels, but this does not remove the need to consider retinal laser, traction and reliable follow-up. Indication-specific guidance and the exact product information must accompany any treatment plan.
Explain the likely benefit in functional terms. Maintaining the ability to read, recognise faces or use an aid may be an important success even when chart acuity does not improve. Existing macular scarring, atrophy or ischaemia limits recovery. Shared decisions should include expected attendance, discomfort, rare serious complications, alternatives and the circumstances in which continuing treatment may no longer help.
Key points
- Anti-VEGF medicines suppress pathological vascular leakage and neovascular activity; they do not restore every previously damaged retinal cell.
- The diagnosis, the licensed product and current disease activity determine the injection schedule.
- A dry optical coherence tomography scan may show treatment success rather than permanent elimination of the underlying disease.
- Check the prescribed medicine, concentration, dose, volume and eye; a vial's total contents are not the injection dose.
- Ocular or periocular infection and severe active intraocular inflammation can make injection unsafe.
- Keep an accessible emergency contact and distinguish mild transient irritation from increasing pain or loss of sight.
- Discuss practical attendance barriers early because missed treatment may allow recurrent disease activity.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
Link symptoms and visual measurements to clinical examination and retinal imaging. Fluid alone is not a complete diagnosis: postoperative inflammation, traction and other causes can require different treatment. Document which eye and which disease the proposed injection addresses.
Record monocular acuity and the patient's experience of reading, distortion and daily tasks. Compare scans over time using a reliable acquisition and segmentation. A small anatomical change can matter greatly in an only functional eye.
Ask about eye discharge, lid infection, increasing redness, previous injection reactions, glaucoma, recent intraocular surgery and vascular events. Establish relevant pregnancy or breastfeeding circumstances. These findings may alter timing or product choice rather than simply adding a note to consent.
Ask how the patient will travel, understand appointments and report deterioration. Provide large print, interpretation or carer involvement with consent. A treatment that depends on repeated visits requires an achievable arrangement, including a route to rearrange missed appointments promptly.
Mild grittiness, a small conjunctival bleed or transient floaters can follow treatment. Increasing pain, worsening vision, marked photophobia or spreading redness is a different trajectory and needs urgent assessment; an apparently minor external bleed does not explain substantial visual loss.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Visual acuity and functional historyFirst step - Why
- Establish benefit, deterioration and the patient's treatment priorities.
- Interpretation and limitations
- Use comparable monocular measurements and account for refraction, cataract and other ocular disease. A fall in vision should trigger examination rather than an automatic assumption that the anti-VEGF interval is too long.
- 02
Macular optical coherence tomography - Why
- Measure and characterise retinal activity during follow-up.
- Interpretation and limitations
- Assess intraretinal and subretinal fluid, structural damage and segmentation reliability. Interpret persistent cavities in their clinical context rather than repeatedly escalating treatment solely to normalise an automated thickness number.
- 03
Slit-lamp examination and intraocular pressure - Why
- Detect contraindications and treatment-related anterior segment problems.
- Interpretation and limitations
- Active infection or severe inflammation can preclude injection. Pressure assessment matters particularly in glaucoma and after injection because an acute rise can compromise perfusion or require treatment.
- 04
Additional retinal imaging when diagnosis is uncertain - Why
- Clarify neovascular activity, leakage, perfusion or an alternative diagnosis.
- Interpretation and limitations
- Use angiography or other specialist imaging where it will change a decision. In suspected wet AMD, NICE recommends fluorescein angiography to confirm the diagnosis when OCT does not exclude neovascularisation; do not offer it when clinical examination and OCT already exclude neovascular disease.
04Treatment approachPreparation, options, escalation and aftercare.
01Before treatmentMake the first injection decisionFirst stepRetinal assessment identifies active disease for which an anti-VEGF treatment is appropriate.+
- 1Confirm diagnosis, laterality, visual potential and the reason for preferring the proposed medicine over other appropriate options.
- 2Discuss realistic benefit, repeated attendance, procedure risks and an individual plan for monitoring and urgent advice.
- 3Check the current product indication, exact formulation, dose, contraindications and relevant recent medical events before prescribing.
- 4Arrange timely treatment and the next assessment, addressing transport or communication needs before the patient leaves.
02At each injectionUse a consistent safety processA patient attends an injection appointment within an established retinal treatment plan.+
- 1Reconfirm identity, eye, medicine, dose and consent, including any change in symptoms or systemic health since the last visit.
- 2Review treatment activity and the intended interval; an appointment booking alone does not override a new contraindication.
- 3Use the trained service's aseptic procedure, appropriate anaesthesia and ocular antisepsis, preserving medicine and batch traceability.
- 4Assess immediate vision or perfusion and pressure as indicated, and give clear written instructions for deterioration and follow-up.
03Longitudinal careAdjust frequency using disease activityInitial treatment has been delivered and the response can be assessed clinically and on imaging.+
- 1Compare visual function and retinal activity with the pretreatment state and previous visits, including missed or delayed doses.
- 2Choose continued loading, an individual maintenance schedule or a treatment change using indication-specific guidance and the product regimen.
- 3In treat-and-extend care, lengthen or shorten intervals within the selected medicine's rules rather than applying another product's schedule.
- 4If benefit is inadequate, reconsider diagnosis, structural damage and alternatives before deciding collaboratively whether to switch, pause or stop.
04AftercareRespond to possible complicationsThe patient develops new ocular symptoms following an intravitreal injection.+
- 1Establish when symptoms started, whether sight is worsening and whether pain, photophobia, redness or a field defect is present.
- 2Arrange immediate ophthalmic assessment for concerning deterioration; mild initial symptoms do not make later progression safe to observe.
- 3Provide the injecting team with the product, treated eye, date and relevant reaction history when these details are available.
- 4Let specialist examination guide treatment of infection, inflammation, retinal injury or pressure elevation rather than assuming all reactions have the same cause.
05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.
Ranibizumab, Lucentis 10 mg/mL, adult intravitreal regimen
Give 0.5 mg in 0.05 mL into the vitreous of the affected eye; allow at least four weeks between doses in that eye. Begin monthly until maximal acuity and/or absence of disease activity, then individualise according to the indication and response.Administration requires an appropriately qualified ophthalmic service. Do not use with ocular or periocular infection or severe intraocular inflammation. Monitor injection complications and pressure; review pregnancy, breastfeeding and recent vascular events. Product-specific treat-and-extend increments differ by indication.
Bevacizumab gamma, Lytenava 25 mg/mL, wet AMD
Give 1.25 mg in 0.05 mL intravitreally into the affected eye every four weeks initially until maximal visual acuity and/or inactivity; three or more consecutive monthly injections may be required, followed by an individualised schedule.Do not substitute the whole vial volume or assume oncology bevacizumab preparations have the same licence. Withhold for pressure at least 30 mmHg, retinal breaks, thromboembolic events or intraocular surgery in the preceding or planned next 28 days, alongside the other product criteria. Do not resume before the next scheduled treatment; discontinue for rhegmatogenous detachment or stage 3 or 4 macular holes. Each vial serves one eye only.
06Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- Record the treated eye, product name and batch, dose, date, clinical activity, complications and next planned review so care can be reconstructed across services.
- Interpret response using acuity, symptoms and retinal structure together; improved dryness with persistent visual loss may reflect irreversible damage rather than ongoing leakage.
- Review attendance after a missed visit and contact patients through the service pathway; repeated non-attendance should prompt practical support and reassessment of the plan.
- Continue disease-specific surveillance even when macular fluid is controlled, including neovascular surveillance in ischaemic vein occlusion and traction assessment where relevant.
- For Lucentis treat-and-extend care, the SmPC allows wet-AMD extension by up to two weeks at a time and diabetic macular oedema by up to one month; do not transfer these increments automatically to every indication or product.
- Ensure the patient knows whom to contact out of hours and understands that rapidly worsening symptoms take priority over a previously booked routine review.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Loading is a response-based phase
Three injections are often discussed in patient information, but they do not establish a universal completed course. The Lucentis and Lytenava regimens describe monthly initiation until a defined clinical response, which may require more than three injections.
Anticoagulants belong in the medication review
Ask about warfarin, antiplatelets and other medicines, and record changes before treatment. Do not advise patients to stop prescribed antithrombotic treatment themselves because of a small conjunctival bruise; any modification requires an explicit clinical plan.
Antisepsis and antibiotics are different interventions
Ocular antisepsis is a core part of injection safety. Moorfields advises that routine antibiotic drops after its anti-VEGF injections provide no benefit and uses lubricants for irritation. Do not extend this instruction to every other intravitreal product or surgical procedure.
Product names carry clinical information
A medicine family name does not establish a concentration, approved indication or dose volume. Lytenava is a licensed ophthalmic bevacizumab product for wet AMD; an older blanket statement that every ocular bevacizumab use is unlicensed is therefore inaccurate.
Pregnancy advice is product specific
VEGF has physiological roles in fetal development. Discuss planned conception before treatment: Lucentis advises waiting at least three months after the last dose before conceiving, and breastfeeding is not recommended during its use. Check the selected product rather than assuming interchangeable advice.
A treatment pause needs ownership
A pause may be reasonable when disease is inactive, benefit is absent or the person's priorities change. Record who monitors, what symptoms prompt re-entry and how quickly the service can reassess; an unexplained gap in bookings is not a considered stopping decision.
08Common pitfallsFrequent interpretation and management errors.
- 01
Using one anti-VEGF schedule for all medicines and indications without checking the exact product information.
- 02
Mistaking a successful dry scan for a guarantee that recurrence or another complication cannot occur.
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Attributing increasing post-injection pain and reduced vision to expected antiseptic irritation without examination.
- 04
Assuming an intravitreal dose has no systemic relevance when reviewing pregnancy or recent arterial thromboembolism.
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Switching or repeatedly injecting a poorly responsive eye without reconsidering the diagnosis, traction, ischaemia or established scarring.