Intraocular Pressure Prophylaxis prior to Intravitreal Injection: A Systematic Review and Meta-analysis

benefit from prophylactic topical timolol, topical brimonidine, oral acetazolamide, or intravenous mannitol in controlling acute IOP elevations after intravitreal bevacizumab injections.11,12 A retrospective cohort study by Frenkel et al. found that routine prophylaxis using topical timolol, brimonidine, apraclonidine, dorzolamide, brinzolamide, or oral acetazolamide did not effectively prevent IOP spikes following intravitreal injections of pegaptanib, ranibizumab, or bevacizumab.13 As most healthy eyes can tolerate the IOP spike without issue, there is no universal standard of care for prophylaxis prior to intravitreal injection.2 However, for patients with glaucoma or optic nerve compromise, these acute IOP spikes from intravitreal injections pose a greater concern. 2 There is evidence that IntroductIonIntravitreal injections of antivascular endothelial growth factor (anti-VEGF) agents are essential for the treatment of ocular conditions, including but not limited to age-related macular degeneration, diabetic retinopathy, and retinal vein occlusion.However, these injections can cause intraocular pressure (IOP) elevations, posing significant risks, particularly in patients with preexisting conditions such as glaucoma.For example, one study of 250 intravitreal injections of ranibizumab found that the mean IOP rose to nearly 50 mm Hg at 1 minute after injection.1 Extreme spikes to greater than 60 to 80 mm Hg have also been documented in certain cases.2,3 These acute rises in IOP are thought to be secondary to an increase in vitreous volume.4 In glaucomatous eyes, acute IOP spikes may lead to retinal artery occlusion and irreversible damage to the retinal nerve fiber layer (RNFL).Evidence supporting pretreatment with IOP-lowering medications has so far been equivocal.One randomized trial of 308 eyes comparing different combination drops found that all three tested regimens similarly prevented significant IOP rises in the treatment group.5 Similarly, prophylactic brimonidine, brinzolamide, apraclonidine, acetazolamide, brinzolamidebrimonidine, brinzolamide-timolol, brimonidine-timolol, and dorzolamide-timolol have all been noted to effectively lower IOP elevations within the initial 30 minutes postinjection of bevacizumab, ranibizumab, or aflibercept when compared to patients who received no prophylaxis.1,[6][7][8][9][10] In contrast, two separate randomized clinical trials (RCTs) reported no significant 1,2,