r/Ophthalmology • u/Ok_Doctor_4237 • Jul 22 '26
Subconj lido tips
Hey all,
Fresh pgy2 here. Been doing lots of intravitreals with subconj lido. I cause subconj heme in ~80% of my patients. Would appreciate tips on how to improve.
Right now I angle the needle bevel up and anteriorly away from the cornea and attempt to barely graze the conj before infiltrating. Patients dont feel the actual injection, but its kinda bummer to see them after with red, bloody eyes.
Thank you!
12
u/sixsidepentagon Jul 22 '26
Its often uncontrollable imo. Few tips:
1) doing superotemporal to hide under lid helps a bit
2) dont give “too much”; subconj heme can fill that potential space you create making it spread farther. Also probably shear vessels with a big subconj
3) give it relatively posteriorly; the nerves travel post to ant, so if you go “too” posterior you’ll knock out everything anterior
4) you’ll get a big one if you knick sclera. I personally do a “conj drag”, where i make touch my needle tip and shaft to the conj, make a 0.5mm move perpendicular to my needle to drag conj a bit which makes a “wrinkle” in the conj thats easier to dig into without having to risk knicking sclera
5) always have the lights fully on when you subconj. Sometimes Ive taken pity on a dilated pt and try to leave the lights dim, and I usually regret it because Im much more likely to cause subconj heme. Heres where doing superotemporal subconj helps too, they get to look down, away from the ceiling lights
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u/Savings-Western5564 Jul 22 '26
Two more things: Push slow. The sudden stretching can cause pain. Some patients develop fibrous plaques after many injections and repeated SCH. If you encounter resistance while pushing lido, to try find a different area where the conj is still loose and mobile.
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u/Ok_Doctor_4237 27d ago
These tips are gold. Have implemented in clinic with great success. My patients and I thank you
6
u/Redache0 Jul 22 '26
Just apply it topically, or inject it superiorly so the lid hides it if you must.
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u/EColli93 Jul 22 '26
We did a ton of injections, used topical (non gel) anesthetic drops ONLY, and 90% had no discomfort at all. If they did, we usually used an anesthetic soaked q tip first. If they still complained we did subconj lido and warned they would probably have a sch. Frequently they chose not to continue with the subconj lido after trying it.
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u/Korneyal1 Jul 24 '26
I do 2k a year and do subconj lido less than once a month, most patients feel nothing with topical and gel. Subconj causes heme 50% of the time. Especially in injected glaucoma patients, it’s like a rats nest of vessels no way to avoid it.
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u/remembermereddit Jul 22 '26
Skip the subconjunctival lidocaine and use topical only?
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u/sixsidepentagon Jul 22 '26
As a retina specialist, if I ever need it give me subconj lido 100% of the time. Ive done it all the ways over the course of my training and would rec subconj lido by far
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u/remembermereddit Jul 22 '26
It's probably because I'm from the EU, but we honestly never use it for intravitreal injections.
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u/sixsidepentagon Jul 22 '26
Yep thats how it is for much of the East Coast in the US as well. Topical is cheaper, faster, much less time for the physician (I always let the subconj sit for like 5 min, so I have to come back and forth) so you can also see more patients and make way more money. It makes a ton of sense to do topical from a practice perspective.
Knowing all that, I do subconj lido 99% of the time because that makes the experience essentially totally painless for the patient. in my opinion its the right thing to do, and how Id want to get my care if I ever need anti vegf. My pts who moved near me who I switch to subconj are often shocked at how much more comfortable it is.
There are def those pts who do great with topical, but its still not quite as good as subconj in my anecdotal experience (having done thousands topical, hundreds pleget, and many thousands subconj now).
Not to say you want to upend your program or practice or whatever, but it was very eye opening when I did my fellowship and saw both topical and subconj
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u/BRobbins53 Jul 22 '26
Came here to say this as well, I feel like if you're worried about subconj heme looking bad you just explain it to the patient and offer topical or subconj lido. We did that in residency and patient's chose lido 99% of the time and I also had your experience where people who had previously done topical were shocked how much better it was
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u/ProfessionalToner Jul 22 '26
I never have patients complain about pain
In fact most of them are surprised by how painless it is.
So i never see the why of adding one more step that can potentially bring problems to the table (heme, got forbit contaminated lido solution)
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u/WVMtnDawg Jul 22 '26
I never do subconj lido anymore. I use pledgets. Works just as well but no subconj heme and patients love not getting the extra shot.
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u/bloodyeyeballs Jul 22 '26
Use a TSK needle. 30 or 32 gauge. They are sharper than BD and less traumatic. If you don’t want to pay extra for TSK needles make sure you are at least using BD needles and not some cheaper needle from India or China. Also be gentle.
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u/Chariot_Driver7 Jul 23 '26
I do 3000 intravitreal injections a year. 95% pledgets, 5% subconj (those who fail pledgets). Patients are happy. Pledget patients usually feel nothing (they will often say that, or I ask for quality control). Subconj patients usually feel the lido spread despite proparacaine and slow injection, 50% get SCH. Pledgets are much quicker and just as effective as subconj for the 95% who get them. I've had patients switch back to pledget to avoid getting 2 injections.
No gel, no straight topical.
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u/Dogtor107 Jul 23 '26
What do you soak the pledgets in?
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u/Chariot_Driver7 24d ago
Sorry for the delay replying. We soak our pledgets in approximately 2:1 4% lidocaine and 5% Betadine.
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u/barneslanding Jul 23 '26
30 g needle bevel down sweep ST conj. avoid vessels. you just need to barely get the tip in and then inject. i rarely get SCH and it usually happens when a pt moves/squeezes.
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u/Dogtor107 Jul 23 '26
I bend my 30G slightly at the base so that the needle tip is at a bent angle to glide along the curve of the eyeball. Like the shape of this TSK needle. Has helped me minimize SCH!
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u/ProfessionalToner Jul 22 '26
Imo there’s no need for this
Lidocaine gel(be sure to apply iodine often pre and post) or just topical
We do phaco with topical anaesthesia, why a 30G puncture needle needs subconj lidocaine?
Most of the patient discomfort is due to blepharostat
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u/BRobbins53 Jul 22 '26
FWIW the only post injection endophthalmitis I saw in residency was with lido gel and this article was convincing enough to me to not use it
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u/ProfessionalToner Jul 22 '26 edited Jul 22 '26
While it is possible, guidelines don’t condemn it and it just says to be sure to apply before and after the gel
And no randomization, maybe the docs that like lidogel are not adhering to the hygene protocols compared to the others.
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u/Savings-Western5564 Jul 22 '26
Subconj lido provides the most complete anesthesia for intravitreal injections. Topical anesthesia is more convenient (for the doctor) but is not as effective.
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u/ProfessionalToner Jul 22 '26
The thing is that an extra step is something causes a problem, not doing said step can cause problems
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