Anterior chamber paracentesis during intravitreal injections in observational trials: effectiveness and safety and effects
International Journal of Retina and Vitreous volume 5, Article number: 8 (2019)
A paracentesis prior to an intravitreal injection is a very safe procedure and can prevent IOP-spikes after injections. As these spikes pose the risk of inducing glaucomatous changes particularly in patients with frequent injections and/or with a risk profile, a regular paracentesis prior to an injection may be considered and discussed with the patient.
Intravitreal injections and acute increase of intra-ocular pressure
For decades, anterior chamber (AC) paracentesis has been a well-established, safe and cost-effective procedure to immediately reduce pathological elevation of intraocular pressure (IOP). The importance of AC paracentesis has regained attention with the widespread use of intravitreal injections after the approval of anti-vascular endothelial growth factor (VEGF) medications for the treatment of age-related macular degeneration (AMD) and retinal vascular diseases more than a decade ago . It is evident that any injection of fluid into the vitreous cavity induces acute IOP increase, which is usually physiologically compensated within minutes to hours in the majority of patients . However, in some patients, even the typically prescribed volume of 50 µl intra-vitreal anti-VEGF injection can cause acute vision loss and ocular pain secondary to acute IOP increase immediately after the injection . When this happens, in many cases AC paracentesis is necessary to avoid permanent damage to the optic nerve. Persistent IOP increase may be present in some eyes and may cause acute angle closure attack .
There is some controversy about the clinical management of IOP increase in the post-intravitreal injection period : while some reports showed a rapid IOP spike  and speculated that this might cause damage to the optic nerve, other authors believe this is negligible as IOP usually returns to normal within 15–30 min . Nevertheless, there are patients with considerable IOP spikes of more than 80 mmHg post intravitreal injection that might be asymptomatic and therefore undetected after the injection or at the next day clinical check-up , which might result in serious and irreversible damage to the optic nerve and should have been treated immediately. One study indicated AC paracentesis in 33% (n = 87) out of 230 intravitreal injections and advocates on the benefits of such procedure . All patients should be considered for AC paracentesis in the management of post-injection IOP spike regardless of injection volume, previous diagnosis of ocular hypertension or ocular globe size.
Chronic intravitreal therapy and potential long-term side effects
Treatment algorithms for AMD with anti-VEGF injections have changed considerably over the past decade. “Real world” data showed that patients often received less than 5 injections per year  with suboptimal outcomes due to under-treatment. While treatment algorithms such as “pro re nata” or “treat and extend” aim to reduce the burden of monthly anti-VEGF injections, optimal outcomes such as those observed in clinical trials can only be achieved with more frequent treatments. At the other hand, long-term follow up in successfully treated neovascular AMD cases shows other causes of visual decline, such as geographic atrophy  or optic nerve atrophy . In one study, Pershing et al.  observed that 4 years after anti-VEGF therapy, 81% of treated eyes developed unilateral glaucoma requiring IOP-lowering medication. Eyes treated with intravitreal injections showed significantly loss in the retinal ganglion cell layer (RGCL) compared to the untreated fellow eye over a period of 2–4 years [13, 14].
These can be found regardless of age and disease: the same effects of RNFL decrease were found in older patients treated with intravitreal injections for AMD and in younger patients treated for diabetic macular edema . There seems to be no difference in risk of RNFL damage between intravitreal triamcinolone or anti-VEGF drugs, suggesting that increased IOP and not a drug-specific mechanism may be the underlying cause .
Therapy options and paracentesis risk assessment
European retina specialists, through the EURETINA expert’s consensus recommendations of 2018, reported that 89% of patients submitted to intravitreal injections experienced IOP increase above 30 mmHg 5 s after the procedure, and in approximately one third of these patients the IOP remained high during the first 5 min . A pre-treatment AC paracentesis or tap can reduce the impact of transient IOP elevation and was lately conformed in a 2018 literature searches of the PubMed and Cochrane databases by the American Academy of Ophthalmology . Some authors believe that frequent IOP spikes after intravitreal injections can lead to unilateral glaucoma of difficult clinical management, which then might require a surgical procedure to prevent further progression. Meyer et al. postulated that the problem might be related to injection volumes greater than 50 µl due to an improper calibration and preparation of intravitreal syringes. These authors measured a range of injection volumes in a clinical routine setting: from 0.24 to 0.65 μl observed for an intended 50 μl injection volume .
The IOP increase associated with intravitreal injection has also been explained by a biomechanical model, in which an injection volume of 100 µl resulted in IOP increase up to 40.6 mmHg. Eyes with shorter axis length showed greater response in one study . Injection volumes greater than 50 µl were previously thought to be more commonly associated with IOP spike, as shown after the administration of 90 µl pegaptanib (Macugen, Pfitzer) inducing IOP spike greater than 50 mmHg in 45% of patients, which motivated some physicians to consider prophylactic AC paracentesis . However, more recent studies did not find a clear association between intravitreal injection of 100 µl and increased risk of clinically significant IOP spike, in comparison to the previous literature.
Some authors have recommended prophylactic paracentesis prior to intravitreal bevacizumab injections based on two arguments: first, the immediate IOP spike may damage the retinal microcirculation, potentially aggravating an already impaired blood-retinal barrier in diabetic or venous occlusive eye disease; second, AC paracentesis would prevent drug reflux, resulting in more medication entering the vitreous cavity. The pre-injection paracentesis can prevent the reflux ensuring the complete dose in the vitreous cavity. The incidence of complications is low when caution is maintained [22, 23].
Risks of AC paracentesis
The incidence of complications related to AC paracentesis may be low when caution is exercised [24, 25]. Numerous reports evaluated the risk of AC paracentesis in vast experience for more than 20 years [24,25,26,27]. Potential complications could include pain, traumatic injuries of the iris, occurrence of AC fibrin, hyphema, severe inflammation, infection or persistent leakage with hypotension or endophthalmitis. Decades before the introduction of frequent VEGF-injections, Helbig et al.  reported a single case of bacterial endophthalmitis after the AC-paracentesis in an eye with a central arterial occlusion. Although disinfection and paracentesis were performed in an operating room, no eyelid speculum or drape was mentioned in the article. This preventive measure is today an essential part of the guidelines for intravitreal injections set up by the national and international ophthalmological societies. Helbig stated when questioned on personal request, that he assumed the use a lid speculum. However, he has observed no further infections ever since after any paracentesis during an intravitreal injection period for the last 30 years (personal communication by Prof. Horst Helbig, August 2018). Of course, this procedure remains not completely free of possible injuries: Meyer et al.  reported as complications only two posterior lens and one anterior lens injuries after the AC paracentesis in 32,318 cases. This favorable risk profile is further confirmed by the authors who did not experience any injury or infection in thousands of patients with AC-samples.
Effectiveness of protective effect of paracentesis in intravitreal injections
Several studies demonstrated the effectiveness of prophylactic AC paracentesis in the prevention of immediate or long-term IOP increase associated with intravitreal injections [30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46]. Ichiyami et al.  studied 111 patients who received AC paracentesis prior to each intravitreal injection over a period of 12 months. No IOP increase was observed, defined as a change of more than 6 mmHg or IOP > 22 mmHg. Bach et al. demonstrated the effectiveness of paracentesis following intravitreal drug injections into maintain the physiologic ocular perfusion in 1681 cases. A median (SD) of 210 µl (40 µl) of aqueous was removed during each paracentesis and there were no reported incidences of endophthalmitis, capsular rupture, wound leak, AC collapse or any other negative outcome . Soheilian et al.  monitored IOP values in 90 eyes 2 min, 30 min, 24 h, and 3 months post-injection. In group A, only the intravitreal injection was administered, in group B, an intravitreal injection was combined with AC puncture. In Group A, the IOP increase was 26.4 mmHg, 6.5 mmHg, 0.2 mmHg, and 0.5 mmHg in each time point respectively. In Group B, the relative IOP increase was − 1.3 mmHg, − 3.2 mmHg, 3.1 mmHg, and − 1.8 mmHg. The RNFL thickness was also measured in both groups at the same time points. The RNFL baseline values did not differ significantly (85.3 μm and 85.6 μm in groups A and B, respectively). However, after 3 months the RNFL loss in group A was − 2.0 μm and in group B only 0.2 μm. Enders et al.  evaluated 76 AMD patients without glaucoma treated by intravitreal injection with and without AC paracentesis. Again, there was a significant difference in RNFL decrease in treated eyes with and without paracentesis. The RNFL remained unaffected in patients with unilateral AC paracentesis after intravitreal injection compared to the untreated fellow eye.
Take home message
AC paracentesis is a safe and effective option to manage acute IOP increase secondary to intravitreal pharmacotherapy. In addition, prophylactic AC paracentesis immediately before intravitreal injection is a safe procedure and prevent IOP spikes associated with this common treatment modality. As IOP spikes pose the risk of inducing glaucomatous changes in the optic nerve head, particularly in patients receiving frequent intravitreal injections, the option of prophylactic AC paracentesis and its risk/benefit profile should be considered and discussed with the patient.
Rosenfeld PJ, Brown DM, Heier JS, Boyer DS, Kaiser PK, Chung CY, Kim RY, MARINA Study Group. Ranibizumab for neovascular age-related macular degeneration. N Engl J Med. 2006;355:1419–31.
Bracha P, Moore NA, Ciulla TA, WuDunn D, Cantor LB. The acute and chronic effects of intravitreal anti-vascular endothelial growth factor injections on intraocular pressure: a review. Surv Ophthalmol. 2018;63:281–95. https://doi.org/10.1016/j.survophthal.2017.08.008.
El Chehab H, Agard E, Russo A, Boujnah Y, Dot C. Intraocular Pressure Spikes after Aflibercept Intravitreal Injections. Ophthalmologica. 2016;236:43–7.
Jeong S, Sagong M, Chang W. Acute angle closure attack after an intravitreal bevacizumab injection for branch retinal vein occlusion: a case report. BMC Ophthalmol. 2017;17:25.
Hollands H, Wong J, Bruen R, Campbell RJ, Sharma S, Gale J. Short-term intraocular pressure changes after intravitreal injection of bevacizumab. Can J Ophthalmol. 2007;42:807–11.
Gismondi M, Salati C, Salvetat ML, Zeppieri M, Brusini P. Short-term effect of intravitreal injection of ranibizumab (Lucentis) on intraocular pressure. J Glaucoma. 2009;18:658–61.
Sharei V, Höhn F, Köhler T, Hattenbach LO, Mirshahi A. Course of intraocular pressure after intravitreal injection of 0.05 mL ranibizumab (Lucentis). Eur J Ophthalmol. 2010;20:174–9.
Lorenz K, Zwiener I, Mirshahi A. Subconjunctival reflux and need for paracentesis after intravitreal injection of 0.1 ml bevacizumab: comparison between 27-gauge and 30-gauge needle. Graefes Arch Clin Exp Ophthalmol. 2010;248:1573–7.
Holz FG, Tadayoni R, Beatty S, Berger A, Cereda MG, Cortez R, Hoyng CB, Hykin P, Staurenghi G, Heldner S, Bogumil T, Heah T, Sivaprasad S. Multi-country real-life experience of anti-vascular endothelial growth factor therapy for wet age-related macular degeneration. Br J Ophthalmol. 2015;99:220–6. https://doi.org/10.1136/bjophthalmol-2014-305327.
Munk MR, Ceklic L, Ebneter A, Huf W, Wolf S, Zinkernagel MS. Macular atrophy in patients with long-term anti-VEGF treatment for neovascular age-related macular degeneration. Acta Ophthalmol. 2016;94:e757–64.
Horsley MB, Mandava N, Maycotte MA, Kahook MY. Retinal nerve fiber layer thickness in patients receiving chronic anti-vascular endothelial growth factor therapy. Am J Ophthalmol. 2010;150:558–61.e1.
Pershing S, Bakri SJ, Moshfeghi DM. Ocular hypertension and intraocular pressure asymmetry after intravitreal injection of anti-vascular endothelial growth factor agents. Ophthalmic Surg Lasers Imaging Retina. 2013;44:460–4.
Beck M, Munk MR, Ebneter A, Wolf S, Zinkernagel MS. Retinal ganglion cell layer change in patients treated with anti-vascular endothelial growth factor for neovascular age-related macular degeneration. Am J Ophthalmol. 2016;167:10–7.
Saleh R, Karpe A, Zinkernagel MS, Munk MR. Inner retinal layer change in glaucoma patients receiving anti-VEGF for neovascular age related macular degeneration. Graefes Arch Clin Exp Ophthalmol. 2017;255(4):817–24. https://doi.org/10.1007/s00417-017-3590-4.
Kopić A, Biuk D, Barać J, Vinković M, Benašić T, Kopić V. Retinal nerve fiber layer thickness in glaucoma patients treated with multiple intravitreal Anti-VEGF (Bevacizumab) injections. Acta Clin Croat. 2017;56:406–14.
Prager SG, Lammer J, Mitsch C, Hafner J, Pemp B, Scholda C, Kundi M, Schmidt-Erfurth U, Kriechbaum K. Analysis of retinal layer thickness in diabetic macular oedema treated with ranibizumab or triamcinolone. Acta Ophthalmol. 2018;96:e195–200.
Grzybowski A, Told R, Sacu S, Bandello F, Moisseiev E, Loewenstein A, Schmidt-Erfurth U, Board Euretina. Update on intravitreal injections: euretina expert consensus recommendations. Ophthalmologica. 2018;2018(239):181–93.
Hoguet A, Chen PP, Junk AK, Mruthyunjaya P, Nouri-Mahdavi K, Radhakrishnan S, Takusagawa HL, Chen TC. The effect of anti-vascular endothelial growth factor agents on intraocular pressure and glaucoma—a report by the american academy of ophthalmology. Ophthalmology. 2018. https://doi.org/10.1016/j.ophtha.2018.11.019.
Meyer CH, Liu Z, Brinkmann C, Rodrigues EB, Helb HM. Accuracy, precision and repeatability in preparing the intravitreal dose with a 1.0-cc syringe. Acta Ophthalmol. 2012;90:e165–6.
Kotliar K, Maier M, Bauer S, Feucht N, Lohmann C, Lanzl I. Effect of intravitreal injections and volume changes on intraocular pressure: clinical results and biomechanical model. Acta Ophthalmol Scand. 2007;85:777–81.
Knip MM, Välimäki J. Effects of pegaptanib injections on intraocular pressure with and without anterior chamber paracentesis: a prospective study. Acta Ophthalmol. 2012;90:254–8.
Tsui YP, Chiang CC, Tsai YY. Paracentesis before intravitreal injection of bevacizumab. Can J Ophthalmol. 2008;43:239.
Huang WC, Lin JM, Chiang CC, Tsai YY. Necessity of paracentesis before or after intravitreal injection of bevacizumab. Arch Ophthalmol. 2008;126:1314–5.
Van der Lelij A, Rothova A. Diagnostic anterior chamber paracentesis in uveitis: a safe procedure? Br J Ophthalmol. 1997;81:976–9.
Cheung CM, Durrani OM, Murray PI. The safety of anterior chamber paracentesis in patients with uveitis. Br J Ophthalmol. 2004;88:582–3.
Trivedi D, Denniston AK, Murray PI. Safety profile of anterior chamber paracentesis performed at the slit lamp. Clin Exp Ophthalmol. 2011;39:725–8.
Kitazawa K, Sotozono C, Koizumi N, Nagata K, Inatomi T, Sasaki H, Kinoshita S. Safety of anterior chamber paracentesis using a 30-gauge needle integrated with a specially designed disposable pipette. Br J Ophthalmol. 2017;101:548–50.
Helbig H, Noske W, Kleineidam M, Kellner U, Foerster MH. Bacterial endophthalmitis after anterior chamber paracentesis. Br J Ophthalmol. 1995;79:866.
Meyer CH, Rodrigues EB, Michels S, Mennel S, Schmidt JC, Helb HM, Hager A, Martinazzo M, Farah ME. Incidence of damage to the crystalline lens during intravitreal injections. J Ocul Pharmacol Ther. 2010;26:491–5.
Muether PS, Hermann MM, Dröge K, Kirchhof B, Fauser S. Long-term stability of vascular endothelial growth factor suppression time under ranibizumab treatment in age-related macular degeneration. Am J Ophthalmol. 2013;156:989–93.e2.
dell’Omo R, Cassetta M, dell’Omo E, di Salvatore A, Hughes JM, Aceto F, Porcellini A, Costagliola C. Aqueous humor levels of vascular endothelial growth factor before and after intravitreal bevacizumab in type 3 versus type 1 and 2 neovascularization. A prospective, case-control study. Am J Ophthalmol. 2012;153:155–61.e2.
Wang JW, Zhou MW, Zhang X, Huang WB, Gao XB, Wang W, Chen S, Zhang XY, Ding XY, Jonas JB. Short-term effect of intravitreal ranibizumab on intraocular concentrations of vascular endothelial growth factor-A and pigment epithelium-derived factor in neovascular glaucoma. Clin Exp Ophthalmol. 2015;43:415–21. https://doi.org/10.1111/ceo.12477 (Epub 2015 Jan 14).
Balaiya S, Grover S, Murthy RK, Chalam KV. Freezing adversely affects measurement of vascular endothelial growth factor levels in human aqueous samples. Clin Ophthalmol. 2011;11(5):81–5. https://doi.org/10.2147/OPTH.S15837.
Jampol LM, Diabetic Retinopathy Clinical Research Network. Anti-vascular endothelial growth factor comparative effectiveness trial for diabetic macular edema: additional efficacy post hoc analyses of a randomized clinical trial. JAMA Ophthalmol. 2016;1:134. https://doi.org/10.1001/jamaophthalmol.2016.3698.
Hillier RJ, Ojaimi E, Wong DT, Mak MYK, Berger AR, Kohly RP, Kertes PJ, Forooghian F, Boyd SR, Eng K, Altomare F, Giavedoni LR, Nisenbaum R, Muni RH. Aqueous humor cytokine levels and anatomic response to intravitreal ranibizumab in diabetic macular edema. JAMA Ophthalmol. 2018;136(4):382–8.
Kim JH, Shin JP, Kim IT, Park DH. Aqueous angiopoietin-like 4 levels correlate with nonperfusion area and macular edema in branch retinal vein occlusion. Invest Ophthalmol Vis Sci. 2016;57:6–11.
Kim JH, Shin JP, Kim IT, Park DH. Angiopoietin-like 4 correlates with responds to intravitreal ranibizumab injections in neovascular age-related macular degeneration. Retina. 2018;38:523–30.
Jung SH, Kim KA, Sohn SW, Yang SJ. Association of aqueous humor cytokines with the development of retinal ischemia and recurrent macular edema in retinal vein occlusion. Invest Ophthalmol Vis Sci. 2014;55:2290–6. https://doi.org/10.1167/iovs.13-13587.
Sato T, Takeuchi M, Karasawa Y, Enoki T, Ito M. Intraocular inflammatory cytokines in patients with neovascular age-related macular degeneration before and after initiation of intravitreal injection of anti-VEGF inhibitor. Sci Rep. 2018;18(8):1098. https://doi.org/10.1038/s41598-018-19594-6.
Terao N, Koizumi H, Kojima K, Yamagishi T, Yamamoto Y, Yoshii K, Kitazawa K, Hiraga A, Toda M, Kinoshita S, Sotozono C, Hamuro J. Distinct aqueous humour cytokine profiles of patients with pachychoroid neovasculopathy and neovascular age-related macular degeneration. Sci Rep. 2018;8:10520. https://doi.org/10.1038/s41598-018-28484-w.
Ichiyama Y, Sawada T, Kakinoki M, Sawada O, Nakashima T, Saishin Y, Kawamura H, Ohji M. Anterior chamber paracentesis might prevent sustained intraocular pressure elevation after intravitreal injections of ranibizumab for age-related macular degeneration. Ophthalmic Res. 2014;52:234–8.
Liu F, Ding X, Yang Y, Li J, Tang M, Yuan M, Hu A, Zhan Z, Li Z, Lu L. Aqueous humor cytokine profiling in patients with wet AMD. Mol Vis. 2016;22(22):352–61.
Zhang Y, Liang Q, Liu Y, Pan Z, Baudouin C, Labbé A, Lu Q. Expression of cytokines in aqueous humor from fungal keratitis patients. BMC Ophthalmol. 2018;18(1):105. https://doi.org/10.1186/s12886-018-0754-x.
Hernández Garfella ML, Palomares Fort P, Román Ivorra JA, Cervera Taulet E. Aqueous humor levels of different interleukins 1-β, 2, 6 and 10, tumor necrosis factor-α and vascular endothelial growth factor in uveitis treated with adalimumab. J Ophthalmic Vis Res. 2015;10:49–54.
Lee WJ, Kim YK, Kim YW, Jeoung JW, Kim SH, Heo JW, Yu HG, Park KH. Rate of macular ganglion cell-inner plexiform layer thinning in glaucomatous eyes with vascular endothelial growth factor inhibition. Glaucoma. 2017;26:980–6. https://doi.org/10.1097/IJG.0000000000000776.
Sisk RA, Rusia D, Zamora BG, Kuley A, Toussaint BW. Effect of serial anterior chamber paracentesis on sustained intraocular pressure elevation in patients receiving intravitreal anti-vascular endothelial growth factor therapy. Retina. 2018. https://doi.org/10.1097/iae.0000000000002314.
Bach A, Filipowicz A, Gold AS, Latiff A, Murray TG. Paracentesis following intravitreal drug injections in maintaining physiologic ocular perfusion pressure. Int J Ophthalmol. 2017;10:1925–7.
Soheilian M, Karimi S, Montahae T, Nikkhah H, Mosavi SA. Effects of intravitreal injection of bevacizumab with or without anterior chamber paracentesis on intraocular pressure and peripapillary retinal nerve fiber layer thickness: a prospective study. Graefes Arch Clin Exp Ophthalmol. 2017;255:1705–12.
Enders P, Sitnilska V, Altay L, Schaub F, Muether PS, Fauser S. Retinal nerve fiber loss in anti-VEGF therapy for age-related macular degeneration can be decreased by anterior chamber paracentesis. Ophthalmologica. 2017;237:111–8.
DF, MK and CHM conceived and planned the manuscript. All authors contributed in an extensive exchange. SS and CHM took the lead in writing the manuscript. All authors read and approved the final manuscript.
The international pharmacokinetic collaboration in alphabetical order: Gabriel Andrade, Clement K. Chan, Sandeep Grover, Michel E. Farah, Sascha Fauser, Daniela Ferrara, Vincenco Ferrara, Roxane J. Hiller, Yusuke Ichiyama, Makoto Inoue, Marisa Hernandez Garfella, Saeed Karimi, Hideki Koizumi, Michael Koss, Timothy Y. Lai, Fung Liu, Carsten H. Meyer, Rajeev Muni, Timothy Murray, Sundaram Natarajan, Piergiorgio Neri, Masahito Ohji, Dong Ho Park, David Pelayes, Nelson A Sabrosa, Christopher Riemann, Yoichi Sakurada, Tomohito Sato, Sandeep Saxena, Massaru Takeuchi, Sung Jae Yang, Han Zhang, Yingnan Zhang.
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Saxena, S., Lai, T.Y., Koizumi, H. et al. Anterior chamber paracentesis during intravitreal injections in observational trials: effectiveness and safety and effects. Int J Retin Vitr 5, 8 (2019). https://doi.org/10.1186/s40942-019-0157-z