This document sets out the guideline and pathway for competency development for specialised ophthalmic nurses, optometrists and orthoptists at band 6 and above to perform intravitreal injections to treat ophthalmic patients in the Eye Treatment Centre (Eye TC) at Frimley Park hospital.

Over the last five years there have been major developments in medical retina and we have seen the introduction of intravitreal injections of anti-vascular endothelial growth factor medications (Anti-VEGFs), such as Avastin, Eylea and Lucentis, for patients with AMD and other macular disease.

As a consequence of this development, outpatient attendances within the Medical Retina Service have increased significantly. This is due to the rapid expansion of this new treatment and the associated increase in regular follow-up care required by patients.

Patients are seen at the Eye TC or MMU every 4 weeks causing tremendous burden on the service and medical staff.

Results of clinical trials have demonstrated the benefits of anti-VEGF therapy for many other indications, especially in the management of diabetic macular oedema and vein occlusions.

The Royal College of Ophthalmologists acknowledged these challenges related to staffing levels.

The Royal College issued a statement that supersedes previous documents. The following statement has been published:

The College considers that it is reasonable for non-medical Health Care practitioners (HCPs) to administer anti-VEGF agents so long as the following stipulations are met:

• The patient remains under the care of a named consultant ophthalmic surgeon at all times

• The HCP is fully trained in the rationale for the treatment, its effects, and possible complications both intra operative and post-operative.

• The HCP is fully trained in the technique of injection by an ophthalmic specialist doctor.

• The HCP giving the injection has immediate access to advice from an ophthalmic specialist doctor at all times whilst giving injections and that an ophthalmic specialist doctor is immediately available to manage any complications.

• There is a continuous audit of the injection service (provided by HCPs). There should also be regular patient feedback. Further training must be available to the HCP if required.

• The hospital trust management is fully aware of, and supports the initiative, and all personnel are covered by appropriate indemnity.

• Consent. GMC Guidance must be followed. This, including guidance on delegation of consent, and can be found at https://www.gmc-uk.org/professional-standards (December 2024)

• The training of ophthalmic doctors in the giving of intra-ocular injections is essential. It must not be compromised by the injection service provided by HCPs

This guidance is relevant to:

• Specialist ophthalmic nurses (band 6 and above)

• Orthoptists (band 6 and above)

• Optometrists (band 6 and above)

Enabling band 6 and above ophthalmic trained nurses, Orthoptists and optometrists to be trained to perform intravitreal injections will contribute to the efficient delivery of the ophthalmology clinic services within Frimley Park Hospital and on the Macular Mobile Unit. This will enhance and develop patient-centred care through a process of enabling nurses / Orthoptists / optometrists to perform functions also performed by medical staff. In addition, service provision will be more flexible and less reliant on the availability of doctors with the potential for increased capacity for treatment.

It will also enable National guidelines and service delivery targets to be met.

4.1 This guideline should be read in conjunction with:

 Standard Operational Procedures,

 Patient Group Directions (PGD)

 Consent policy

 Trust Infection Control manual – Hand Hygiene Policy

4.2 This guideline outlines:

 This guideline covers the treatment of adult patients undergoing an intravitreal injection by a member of nursing/orthoptic staff.

 Standard Operational Procedures (SOP) Intravitreal Injections for TC and MMU,

 Patient Group Directions

 Consent policy

 Tonometry SOP

 VA LogMAR SOP

 Trust Infection Control manual – Hand Hygiene Policy, Aseptic Technique policy, Sharps Management Policy, Glove Usage, Standard Precautions, Decontamination Policy, Major Outbreak Protocol, Endophthalmitis protocol

 This guideline provides details of minimum qualifications and training in order to carrying out this procedure.

 Consent, prescribing and documentation required.

 The required procedural steps, including equipment required and the management of complications.

 Contraindications to nurses / orthoptists / optometrists carrying out this treatment.

4.3 It is essential that this guideline is followed, as failure could result in the loss of the trust’s indemnity and could result in investigation and management action being taken as considered appropriate. This could include formal action in line with the trust’s disciplinary procedures for trust employees and/or other action in relation to other workers, which may result in the termination of an assignment, placement, secondment or honorary contract.

4.4 Consent, prescribing and documentation

• The nurse, Orthoptist, optometrist must ensure written consent for the procedure has been taken prior to the procedure taking place in line with the trust’s consent policy. This process will ensure that the patient is aware of the rationale for the procedure and of all potential complications.

• The patient must have been given a copy of the relevant patient information leaflet prior to signing the consent form.

• A copy of the consent form must be filed in the patient’s clinical record.

• All eye drops must be instilled in accordance with the guideline and procedure and the relevant patient group directions (PGD’s) or prescription.

• In the case of Avastin this must be prescribed by an ophthalmologist indicating the use for the eye as an off-licence medication.

• Any complications or untoward incidents must be reported via the trusts incident reporting system and to the medical retinal team.

4.5 Exemptions to treatment by the Practitioner

The procedure should not be performed by the nurse, Orthoptist, optometrist if:

• Informed consent is not obtained

• The patient refuses treatment by the Practitioner

4.6 Patients should be referred on to a member of the medical team in the following situations:

• The patient has an underlying condition which will make it difficult for them to keep still – e.g., Parkinson’s disease – or if there are any concerns that the patient will be unable to fixate; for example, patients with nystagmus should be referred on to the supervising consultant.

• The patient has had previous retinal comorbidity, e.g., retinal detachment, allergy related reaction

• There is not an ophthalmologist in clinic

From the point of registration, each practitioner must adhere to their code of professional conduct (Nursing and Midwifery Council, 2015 Health and Care Professions Council Health (2016)/BIOS guidelines and is accountable for his / her practice.

Practitioners working within Frimley Health NHS Foundation Trust must be aware that:

• Additional education and training are necessary for all practice not covered in previous training and education;

• They assume full accountability for their actions/omissions;

• They should maintain and improve professional knowledge;

• They should acknowledge limitations in knowledge and competency and decline any duties or responsibilities unless able to perform them in a safe competent manner;

• They must adhere to current policies and guidelines for practice;

• Delegation of work to other staff must be within their level of competence and to a degree appropriate to their role

• Where appropriate, patients and informal carers must have sufficient knowledge and understanding to participate safely in the patient’s care;

• Any proposed expansion of practice must not compromise policies and procedures ratified by the trust.

The trust will provide Trust indemnity for the nurse / Orthoptist / optometrist providing they adhere to the guideline and procedure document.

NB: All eye drops must have their expiry dates checked before use

• Lidocaine and fluorescein eye drops

• Tropicamide 1%

• Chloramphenicol 0.5%

• Levofloxacin eye drops (if allergy to Chloramphenicol)

• Phenylephrine 2.5 %

• Proxymetacaine Hydrochloride 0.5%

• Iodine skin scrub (10% aqueous solution) or Tisept solution (Chlorhexidine gluconate 0.015%) if patient is allergic to Iodine

• Povidone Iodine 5% eye drops

• Soft neutral detergent wipes (see Decontamination Policy) for use on slit lamp between patients

• Tissues

• Slit lamp

• Disposable tonometer head

• AMD injection pack (including drape)

• Injection drug

• Dressing trolley cleaned thoroughly at the start of the clinic with detergent followed by 70% isopropyl alcohol.

• Sterile gloves, hat, mask and green aprons

• Hand antiseptic (4% Chlorhexidine Gluconate or 7.5% Iodine)

• Sharps container

• Clinical Waste bin

Preparation of AMD pack

• The user must decontaminate hands prior to opening out the pack

• A strict aseptic technique must be used to prevent potential contamination of the sterile field and equipment

• Once opened and prepared the pack must be covered with a sterile drape unless it is to be used immediately

Prior to intravitreal injection session commencing

• Ensure that a fundus examination has taken place by a doctor, Orthoptist or optometrist and details of the examination are recorded in the patient’s notes. Ensure appropriate gap since last injection and the eye is clearly marked.

• Check that the consultant or fellow in charge of the clinic is available in clinic. The Clinic must not commence until the doctor in charge of the clinic is available.

• Check all equipment ready for session

• Ensure that a designated practitioner is present in the treatment room to assist with the procedure in accordance with the Standard Operation Procedure for intravitreal injection administration

• The nurse / Orthoptist / optometrist who is to carry out the injection must ensure that their assistant has followed the correct hygiene precautions and aseptic technique in preparing for the injection

Preparation of the patient

• Introduce yourself to the patient and confirm patient’s identity, (ensuring that the patient tells you their name and date of birth)’ this will ensure that the patient is treated with dignity and respect and minimise the risk of misidentification.

• Explain to the patient that you are a nurse / Orthoptist / optometrist and that you will be administering the intravitreal injection.

• Confirm the patient’s allergy status and past medical history (especially whether they have suffered a recent heart attack or stroke or attended hospital since their last injection), ask about blood pressure control. This will prevent any untoward side effects from medications used during this procedure.

• Check the hospital notes and confirm with the patient which eye is to be treated. Check which eye is marked and if there is a discrepancy between the notes and patient confirm with the consultant or fellow in charge in clinic.

• Check if the eye to be treated is phakic or pseudophakic. Document this in the patient’s clinical record

• Explain the procedure, allowing time to answer any queries that the patient may have.

• Confirm the patient’s identity as specified in trust’s Patient Identification Policy

• Ensure that the patient is positioned comfortably on the examination couch.

• Ensure that the patient knows how to inform you if suffering any discomfort

• Nurse, optometrist or orthoptist must not inject the patient with anti- VEGF therapy if the patient is suffering from:

• Unstable angina

• Uncontrolled hypertension

• Any evidence of infection

• Ocular infection

PROCEDURE

• Nurse / Orthoptist / optometrist to decontaminate hands following hand hygiene policy and using chosen antiseptic (4%Chlorhexidine gluconate or 7.5% Povidone iodine) perform aseptic hand wash

• Dry hands thoroughly and apply sterile gloves

• Assistant to insert x1 drop 0.5% proxymethacaine eye drops and then

1 drop of 5% povidone iodine eye drops into eye for injection and repeats this once more as per PGD.

• Clean the eye with 10% iodine aqueous solution skin scrub as PGD

• Apply sterile drape over patient’s eye

• Insert lid speculum

• Mark the injection site by measuring 4.0mm from limbus for phakic eyes and 3.5mm from the limbus in pseudophakic eyes

• Insert additional drop of 1 drop of 5% povidone iodine eye drops into eye for injection

• Inject as per PGD or prescribed

• Instil stat dose of Chloramphenicol drop (use levofloxacin if chloramphenicol allergy)

• Check patient hand movement vision to ensure no significant change in vision.

• Remove eyelid speculum and skin drape and wash off iodine from skin with sterile saline solution

• Remove used AMD pack and ensures that the needle and any other sharps are disposed of directly in to the sharps container.

• Ensure any sterile instruments are correctly packaged and then stored in a designated area for collection and processing

• Used sterile gloves and if applicable surgical mask to be discarded in clinical waste bag together with all other clinical waste.

• Hand decontamination to be undertaken prior to continued patient care and documentation of procedure

• Dressing trolley to be wiped down with detergent between patients

• Complete GP letter and patients’ note and input on Epic

• Give patient written aftercare advice and a contact telephone number in case they have any cause for concern, such as severe pain, dramatic drop in visual acuity. Inform patient they can contact on-call ophthalmologist at Frimley Park hospital if they experience any problems.

• Ensure patient has follow up appointment.

• Give TTO’s

DOCUMENTATION

• Complete pathway /procedure sign off on Epic

• Record treatment clearly in the patient’s health records on the pathway – amount of the drug injected, date, signature and designation should all be clearly recorded.

• If an unexpected event occurs, document and complete and report the incident as necessary on Epic and on the pathway

• This procedure is necessary to facilitate communication within the team, meet legal requirements of practice and enable monitoring over a time period.

• Inform patient of treatment outcomes and discuss further appointments if required in order to facilitate good communication and a partnership approach to care.

Tropicamide 1% Eye drops

Legal status: Prescription only medicine. **Dose: **Once only Method and route of administration: Standard eye drop instillation procedure. Instil ONE drop to the outer aspect of the lower fornix of the eye to be treated. For supply of treatment: see medicines from policy on patient group directions on the intranet.

Advice to patients

• Drop may sting

• Patient should not drive for 1-2 hours following dilatation of pupils

• Patient should not operate machinery unless vision is clear

• Patient should advise the hospital of any untoward effects. Adverse drug reactions

• Transient stinging, local irritation

• Hyperaemia

• Oedema

• Conjunctivitis

Record keeping The administration of Tropicamide 1% eye drops will be recorded in the patient’s case notes, recording date, time and signature of nurse / Orthoptist / optometrist.

Proxymetacaine hydrochloride 0.5% eye drops minims.

Legal status: Prescription only medicine. Dose: Once only Method and route of administration: Standard eye drop instillation procedure. Instil ONE drop to the outer aspect of the lower fornix of the affected eye. For supply of treatment: see medicines from policy on patient group directions.

Advice to patients

• Drop may sting

• Patients should refrain from touching or rubbing their eyes due to loss of corneal sensation

• Advise the hospital of any unwanted effects. Adverse drug reactions

• transient stinging, local irritation

• Hyperaemia

• Oedema

The administration of Proxymetacaine hydrochloride 0.5% eye drops will be recorded in the patient’s case notes, recording date, time and signature of nurse / Orthoptist / optometrist.

Information to be documented:

• Name, form and strength of medicine to be documented in full

• Date, time and dosage administered

• Signature of registered nurse / Orthoptist / optometrist

Povidone Iodine 5% Eye Drops

Legal status: Prescription only medicine. Dose: One drop into the lower conjunctival sac and onto lid margins prior to administration of intravitreal injection, to be repeated after a 5 minute interval if 2 drops are required. Method and route of administration: One drop into the lower conjunctival sac. For supply of treatment: see medicines from policy on patient group directions.

Advice to patient

• Drop may sting

Route of administration Topically to the lower conjunctival sac and lid margin

Record keeping The administration of Povidone iodine 5% eye drops will be recorded in the patient’s case notes, recording date, time and signature of nurse / Orthoptist / optometrist following prescription by a doctor.

Information to be documented:

• Name, form and strength of medicine to be prescribed in full

• Date, time and dosage administered

• Signature of registered nurse / Orthoptist / optometrist

Ranibizumab 10mg/ml Injection or a biosimilar

Legal status: Prescription only medicine. Dose: Supplied in a vial or pre-filled syringe containing 0.05 ml, dose is once only 0.5mg in 0.05 ml once a month for three months with further injections as needed Method and route of administration: by intravitreal injection. For supply of treatment: see medicines from policy on patient group directions.

Advice to patient

• Advise if any loss of vision immediately

• Advise the hospital of any unwanted effects. Adverse drug reactions

• Nausea

• Headache

• Eye pain

• Conjunctival and retinal haemorrhage

• Oedema

• Vitreous detachment

• Back pain

• Blindness

• Hypopyon Supporting facilities Medical staff Record keeping

The administration of Lucentis or other ranibizumab biosimilar 0.05ml will be recorded in the patient’s Epic record, recording date, time and signature of nurse / Orthoptist / optometrist

Information to be documented:

• Name, form and strength of medicine to be documented in full

• Date, time and dosage administered

• Signature of registered nurse / Orthoptist / optometrist

Faricimab (Vabysmo) 120 mg/mL solution for injection

Legal status: Prescription only medicine.

Dose: Each vial contains 28.8 mg faricimab in 0.24 mL solution. This provides a usable amount to deliver a single dose of 0.05 mL solution containing 6 mg of faricimab. Vabysmo is indicated for the treatment of adult patients with:

• neovascular (wet) age-related macular degeneration (nAMD)

• visual impairment due to diabetic macular oedema (DMO)

Method and route of administration: By intravitreal injection, for supply of treatment: see medicines from policy on patient group directions. Advice to patient Most of the side effects are mild to moderate and will generally disappear within a week after each injection.

Very common (may affect more than 1 in 10 people):

• Cloudy lens in the eye (cataract) Common (may affect up to 1 in 10 people):

• Tearing of the retina (the layer at the back of the eye that detects light) or one of its layers

• Detachment of the gel-like substance inside the eye (vitreous detachment)

• Increase in pressure inside the eye (increased intraocular pressure)

• Bleeding from small blood vessels in the outer layer of the eye (conjunctival haemorrhage)

• Moving spots or dark shapes in your vision (vitreous floaters)

• Eye pain

• Increased tear production (increased lacrimation)

• Scratched cornea, damage to the clear layer of the eyeball that covers the iris (corneal abrasion)

• Eye irritation

Uncommon (may affect up to 1 in 100 people):

• Serious inflammation or infection inside the eye (endophthalmitis)

• Inflammation of the gel-like substance inside the eye (vitritis)

• Inflammation in the iris and its adjacent tissue in the eye (iritis, iridocyclitis, uveitis)

• Bleeding in the eye (vitreous haemorrhage)

• Eye discomfort

• Itching (eye pruritus)

• Red eye (ocular/conjunctival hyperaemia)

• A feeling of having something in the eye

• Blurred vision

• Decreased sharpness of vision (visual acuity reduced)

• Pain during the procedure (procedural pain)

• Detachment of the retina  Rare (may affect up to 1 in 1,000 people):

• Temporary decreased sharpness of vision (visual acuity reduced transiently)

• Clouding of the lens due to injury (traumatic cataract)

Record keeping

• The administration will be recorded in the patient’s record on Epic, recording date, time and signature of nurse / Orthoptist / optometrist

• Information to be documented:

• Name, form and strength of medicine to be documented in full Date, time and dosage administered

• Signature of registered nurse / Orthoptist / optometrist

Aflibercept 40mg/ml Injection

Legal status: Prescription only medicine. Dose: Supplied in a vial, each vial contains 100 microlitres, equivalent to 4mg of Aflibercept. 2 mg (0.05 mL) administered by intravitreal injection every 4 weeks (monthly) for the first 3 months, followed by 2 mg (0.05 mL) via intravitreal injection once every month or 8 weeks (2 months).

Method and route of administration:

By intravitreal injection, for supply of treatment: see medicines from policy on patient group directions.

Advice to patient

• Advise if any loss of vision immediately

• Advise the hospital of any unwanted effects. Adverse drug reactions

• More common

• Blindness

• bloody eye

• blurred vision

• eye or eyelid redness

• eye pain

• seeing flashes, sparks of light, or a veil or curtain

• seeing floating spots before the eyes

• vision changes

• Less common

• Bleeding or pain at the injection site

• swelling of the eyelid

○ Rare

• Fast heartbeat

• fever

• headache

• hives

• hoarseness

• itching

• joint pain, stiffness, or swelling

• rash or skin redness

• swelling of the face, lips, hands, or feet

• troubled breathing or swallowing

○ Incidence not known

• Pain in the chest, groin, or legs, especially the calves

• severe, sudden headache

• slurred speech

• sudden loss of coordination

• sudden, severe weakness or numbness in the arm or leg

• sudden, unexplained shortness of breath

Record keeping The administration of Eylea 0.05ml will be recorded in the patient’s record on Epic, recording date, time and signature of nurse / Orthoptist / optometrist

Information to be documented: Name, form and strength of medicine to be documented in full Date, time and dosage administered Signature of registered nurse / Orthoptist / optometrist

Intravitreal use of Avastin – off label Must be prescribed by an ophthalmologist Avastin is not formulated for intravitreal use.

Legal Category

POM: Prescription only medicine Intravitreal injection (Unlicensed Product) 1.25mg in 0.05mL or 625micrograms in 0.025mL Restricted for;

1. age related macular degeneration

2. Diabetic maculopathy and/or proliferative diabetic retinopathy, unresponsive to conventional treatments such as laser, vitrectomy or intravitreal Triamcinolone

3. Retinal vein occlusions

4. Retinopathy of prematurity only where treatment is required and laser is not a suitable option

Eye disorders

Individual cases and clusters of serious ocular adverse reactions have been reported following unapproved intravitreal use of Avastin compounded from vials approved for intravenous administration in cancer patients. These reactions included infectious endophthalmitis, intraocular inflammation such as sterile endophthalmitis, uveitis and vitritis, retinal detachment, retinal pigment epithelial tear, intraocular pressure increased, intraocular haemorrhage such as vitreous haemorrhage or retinal haemorrhage and conjunctival haemorrhage. Some of these reactions have resulted in various degrees of visual loss, including permanent blindness.

Systemic effects following intravitreal use

A reduction of circulating VEGF concentration has been demonstrated following intravitreal anti-VEGF therapy. Systemic adverse reactions including non-ocular haemorrhages and arterial thromboembolic reactions have been reported following intravitreal injection of VEGF inhibitors.

Ovarian failure/fertility

Avastin may impair female fertility (see sections 4.6 and 4.8). Therefore, fertility preservation strategies should be discussed with women of child-bearing potential prior to starting treatment with Avastin.

Chloramphenicol 0.5% drops POM =Prescription only medicine

Route of administration Topically to the lower conjunctival sac unless Doctor requests otherwise

Frequency of administration and maximum dosage One drop into designated eye on completion of the Intravitreal injection

Contraindications Pregnant or lactating women Children under 16 years of age Patient refuses consent Known allergy to Chloramphenicol

Levofloxacin multi dose 5mg/1ml Eye drops

POM = Prescription only medicine

Route of administration Topically to the lower conjunctival sac unless Doctor requests otherwise

Frequency of administration and maximum dosage Levofloxacin 5mg/ml multi dose eye drops One drop into designated eye on completion of the Intravitreal injection

Contraindications Pregnant or lactating women Children under 16 years of age Patient refuses consent Known allergy to levofloxacin, fluoroquinolone antibiotics or the preservative Benzalkonium chloride.

Record keeping The administration of Levofloxacin eye drops will be recorded in the patient’s case notes, recording date, time and signature of nurse / Orthoptist / optometrist.

Information to be documented: Name, form and strength of medicine to be documented in full Date, time and dosage administered Signature of registered nurse / Orthoptist / optometrist

10.1 Patients

The RISKS of intravitreal injections include:

• Pain

• Bleeding (subconjunctival, vitreous haemorrhage)

• Retinal tear / detachment

• Cataract (from inadvertently hitting the lens)

• Infection (Endophthalmitis)

• Loss of vision (from any of above)

• Loss of the eye (from a severe infection)

• Raised intra ocular eye pressure

10.2 Staff

• Needle stick injury

11.1 Practitioners responsibilities (Nurse, optometrist or Orthoptist)

• Practitioners undertaking the training are responsible for keeping up to date, accurate training records as required by this guideline. They are also required to audit their patient records on a quarterly basis reporting on outcomes to the supervising consultant or designated senior clinician.

• Practitioners administering the injection have a duty of care to ensure that the patient that is being treated is fully informed of the risks and benefits of the injection.

11.2 Consultant ophthalmologist’s responsibilities to the practitioner

• To ensure the practitioner has achieved a satisfactory knowledge base from which to perform this enhanced role

• The consultant will formally examine the nurse / Orthoptist / optometrist to ensure she/he has the knowledge base required prior to being deemed competent. The nurse / Orthoptist / optometrist will only progress to each stage of training once the consultant has assessed that competency has been achieved. The consultant or deputy will through formal assessment will assess the individual competent to carry out the procedure.

• To provide adequate time for the nurse / Orthoptist / optometrist to observe intravitreal injection technique and to subsequently supervise or designate a suitable experienced clinician to supervise and assess the nurse / Orthoptist / optometrist procedural skills.

• To be available or designate a suitable experienced clinician to support the nurse / Orthoptist / optometrist during an intravitreal injection clinic.

11.3 Employer’s responsibilities

• To provide trust indemnity for the nurse / Orthoptist / optometrist providing they adhere to the guideline and procedure document.

• To provide the clinical personnel to train the designated nurse / Orthoptist / optometrist ensuring that training lists are not oversubscribed. To provide sufficient time and support for the nurse / Orthoptist / optometrist to achieve the requirements of the individualised learning programme prior to them expanding their sphere of practice. This means that the trainee will have a dedicated training role and staff in training will be in addition to normal staffing levels and will not be expected to carry out additional roles during training

• The training manual and protocol must be accessible at all times and updated as required and published to the intranet.

• The Trust must ensure documented evidence is maintained to ensure evidence is available of competency of practice through audit for the nurse / Orthoptist / optometrist performing the procedure.  

11.4 Trust Management’s responsibility

• Advising and overseeing the implementation and evaluation of the service delivery.

• Giving support to the practitioner ensuring that he / she has regular support meetings to discuss any issues with the training.

• This procedure must be performed by a registered nurse (RN) level 1, (band 6 or above) who must hold an ophthalmic nursing qualification or be a registered orthoptist or optometrist Band 6 and above. The member of staff must have completed the intravitreal training course and have been assessed as competent by their supervising consultant/or designated deputy. This process must have included a series of formal lectures on intravitreal injections, consenting, complications and personal study into risks and complications from intravitreal injections. (See Appendix 1 for detailed information regarding the theoretical and practical training)

• The Practitioner must have been trained in consenting and signed off as competent

• The Practitioner must be satisfied with his/her own level of competence in accordance with the Nursing and Midwifery Council’s guidelines, Health Professions Council and BIOS.

• The Practitioner must undertake a period of observation of the procedure before practical training commences

• The Practitioner can proceed to practical training only if their supervising consultant considers he /she is ready.

• The practitioner will remain under close supervision from her supervising consultant/Senior clinician for at least 50 cases once deemed competent to practice independently.

• The Practitioner must not be signed of as a competent practitioner unless the supervising consultant/designated Senior clinician is 100% confident in the practitioner’s ability.

• The Practitioner will have their competency assessed every three months in the first year to safeguard patient safety and monitor safe practice.

• The Practitioner will undertake a quarterly audit of outcomes related to the patients that they have treated over the previous 3 months and be assessed as competent by his/her supervising consultant on an annual basis once unsupervised practice has begun.

This guideline was developed by the Medical Retina team both medical, non- medical and management.

Stakeholder engagement with consultants and other relevant staff via appropriate meetings and email communication.

This guideline will be implemented and disseminated immediately following ratification to all staff involved with the administration of intravitreal injections and will be communicated to key stakeholders and guideline users via email and highlighted at Macular service meetings. This guideline will be published on the internet guideline platform.

This document will initially be reviewed every 3 years by the Guideline Owner/Authors

Changes to the legislation of the administration of intravitreal injections by non-medical personal will trigger a review of this guideline.

The Trust will use a variety of methods to monitor compliance with the processes in this document, including the following methods:

In addition to the monitoring arrangements described above, the Trust may undertake additional monitoring of this guideline as a response to the identification of any gaps, or as a result of the identification of risks arising from the guideline prompted by incident review, external reviews or other sources of information and advice.

This monitoring may include commissioned audits and reviews, detailed data analysis or another focussed study, for example. Results of this monitoring will be reported to the Clinical and Education Audit committee and/or individual responsible for the review of the process and/or the risks identified.

Monitoring at any point may trigger a guideline review if there is evidence that the guideline is unable to meet its stated objectives.

Moorfields Eye Hospital IVT Policy 2011

British Medical Association (2023 British National Formulary, British Medical Association and the Royal Pharmaceutical Society of Great Britain. Available online at: https://bnf.nice.org.uk/

Nursing and Midwifery Council (2015) code of professional conduct Available at: https://www.nmc.org.uk/standards/code/, NMC London British and Irish Orthoptic Society Professional Development Committee

National Institute of Clinical Excellence (2012) Ranibizumab and Peganptanib for the treatment of age-related macular degeneration. NICE Technology Appraisal Guidance 155 Available at: https://www.nice.org.uk/guidance/ta155

Royal College of Ophthalmologists (2018) Intravitreal injection therapy. Available at: https://www.rcophth.ac.uk/resources-listing/intravitreal-injection-therapy/ (Accessed: 27 May 2022).

General Optical Council (2020) Code of conduct for members. Available at: https://optical.org/media/ynlhrzxy/code_of_conduct_pdf.pdf (Accessed: 27 May 2022).

The following topics will be covered in a theory training day prior to the practitioner being allowed to proceed to the next level of training. Mandatory attendance is required.

Observation of practice

On completion of theory day, practitioners can commence their period of observation whereby they shadow their assigned training consultant and follow each patient from assessment through to discharge. Once twenty patient’s treatment has been observed the next stage can begin.

Preparation of the patient The next step of the training pathway is to prepare the patient for the intravitreal injection. The practitioner will need to be able to demonstrate the following:

• Explanation of the procedure to the patient

• Positioning of the patient

• Skin cleansing

• Draping of the patient

• Insertion of the speculum

On Completion of twenty preparations the training consultant/clinician will decide if the practitioner can proceed to the next stage or whether further practice is required.

Administration of the injection

The final step of the training Pathway will be for the practitioner to administer the intravitreal injection. The practitioner will under strict supervision administer the injection, at least 50 injections under supervision must be administered by the practitioner prior to the training consultant or assigned senior clinician assessing whether the practitioner is safe to proceed independently.

All the paperwork must be signed and audit of practice must occur at this stage. NB. If at this stage the practitioner is not yet ready to practise unsupervised they must continue supervised practice until the consultant or senior clinician feels they are ready for a further assessment

Intravitreal injections Competency training for………………………….

The nurse / Orthoptist / optometrist must achieve these competencies with each patient to decide when nurse / Orthoptist / optometrist is competent to practise independently and have a three monthly review by lead consultant in the first year then an annual review thereafter.

Nurse / Orthoptist / optometrist signature Date

Lead Consultant’s

Signature Date

Comments for final assessment confirming if safe to practise independently or further training required

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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