Intravitreal Injection Informed Consent

# Intravitreal Injection Informed Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Date:** ___________ **Physician / Retina Specialist:** ___________ **Practice / Clinic:** ___________ **Patient Name:** ___________ ("Patient") **Date of Birth:** ___________ **Medical Record Number (if applicable):** ___________ **Eye to Be Injected:** ___________ **Planned Injection Agent:** ___________ --- ## 1. Description of the Procedure (a) An **intravitreal injection** is a procedure in which medication is injected directly into the vitreous cavity of the eye — the gel-filled space between the lens and the retina. This route of administration achieves high local drug concentrations in the retina and choroid with minimal systemic exposure. (b) **Technique:** The procedure is performed in the clinic or office setting. The Patient reclines in an examination or procedure chair. The eye is anesthetized with topical eye drops, a gel anesthetic, or a subconjunctival anesthetic injection. The eyelids are held open with a speculum, and the eye surface is sterilized with povidone-iodine antiseptic. The physician uses a fine-gauge needle (typically 30-gauge) to inject the medication through the white of the eye (sclera/pars plana, approximately 3.5–4 mm posterior to the corneal limbus) into the vitreous cavity. The procedure takes approximately 5–10 minutes per eye. No surgical incision is required. (c) **Treatment frequency:** Most anti-VEGF agents require a loading phase (commonly 3 monthly injections) followed by a maintenance phase. The interval between injections during maintenance is adjusted based on the patient's treatment response, as determined by visual acuity measurements and optical coherence tomography (OCT) imaging of the retina. The physician will discuss the planned treatment protocol. **Planned Treatment Protocol:** ___________ --- ## 2. Indications Intravitreal injection is recommended for this Patient for the following reason(s): **Primary Indication(s):** ___________