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    Bimanual Lid Retraction Is a Comfortable Choice

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    As the number of intravitreal (IVT) injections has skyrocketed over the past decade, the retina community has continued to refine injection protocols to increase safety and efficiency and reduce treatment burden on patients. A group of retina specialists at Wills Eye Hospital recently reported on an eyelid retraction technique that appears to increase patient comfort without compromising safety.1

    Genesis of study. An earlier study had described this bimanual technique of lid retraction and also observed that it was not associated with an increased endophthalmitis rate.2 According to Allen Chiang, MD, an attending retina surgeon at Wills Eye Hospital and Mid Atlantic Retina, a number of patients informally expressed their discontentment with the speculum, “so we set out to analyze their experience more formally.”

    Eye-to-eye comparison. In this prospective study of 36 patients (72 eyes) undergoing bilateral IVT injections, 22 patients received an injection in the first eye with use of the speculum, while the other 14 had bimanual retraction for the first-eye injection. The retraction technique was switched for the second eye. All other aspects of the procedure—including antisepsis with povidone-iodine and use of topical anesthetic—were identical for both eyes.

    Patients completed a pain survey immediately after both injections, and had a telephone interview two hours later. The responses bore out earlier anecdotal observations: 30 patients (83.3 percent) preferred bimanual retraction, six had no preference (16.7 percent), and none preferred the speculum. Each patient served as his or her own comparator, thus avoiding the problem of differing levels of pain perception between individuals.

    Speculum Alternative

    SPECULUM ALTERNATIVE. With this bimanual technique, care should be taken to avoid pressure on the globe or eyelid glands.

    Implementing the technique. Dr. Chiang noted that the technique is easy to learn, but implementing it depends on having a trained technician available to lend a hand—or, in this case, both hands. At Wills, the technician in charge of prepping the patient for IVT injection is the one who performs the lid retraction.

    Dr. Chiang sees this in the context of ongoing “tinkering” in the retina community in developing nuances in the IVT injection procedure. “While this may not be a huge game-changer,” he said, “we wanted to show an alternative method of retraction that allows one less manipulation with a foreign object and that was preferred by patients in this study with regard to pain and discomfort.”

    —Peggy Denny


    1 Rahimy E et al. Ophthalmology. 2015 Feb. 26. [Epub ahead of print.]

    2 Fineman MS et al. Retina. 2013;33(9):1968-1970.


    Dr. Chiang reports no related financial interests.


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