Intravitreal Injection Procedure Note

Patient: [Patient full name] | DOB: [Date of birth] | MRN: [Medical record number] | Date of Service: [Date] | Performing Clinician: [Clinician name and credentials] | Location: [Clinic/facility name]

Procedure Performed: [Intravitreal injection / Bilateral intravitreal injections] — [Right / Left / Bilateral]; [Medication name] [Concentration], [Dose] in [Volume]; [Indication] (If bilateral with differing medications or doses, specify each eye separately.)

Indication

[Primary indication for injection] (If indications differ between eyes, specify per eye. If off-label use, note that off-label status was discussed.)

Informed Consent

[Consent obtained statement] (Attest that informed consent was obtained, risks/benefits/alternatives were discussed, and patient elected to proceed. If off-label medication, note that off-label status was disclosed. Material risks discussed include endophthalmitis, retinal tear/detachment, intraocular hemorrhage, lens injury, inflammation, IOP elevation, and need for additional procedures.)

Pre-procedure Verification (Time-out)

• [Time-out performed] (Include time if recorded.)
• [Patient identity confirmed with two identifiers]
• [Correct eye laterality confirmed and marked per protocol] (For bilateral, note separate verification for each eye.)
• [Correct medication and dose verified against order and label]
• [Allergies reviewed]

Pre-injection Assessment

Right Eye (include only if treated)

• Baseline VA: [Visual acuity]
• Baseline IOP: [IOP value] (If not obtained, state reason.)
• Lens status: [phakic / pseudophakic]
• Anterior segment: [Assessment findings] (Confirm no active infection, discharge, or corneal defect.)
• Contraindications/risk factors: [None identified / Finding and decision to proceed or defer] (Document if active infection, relevant allergy, significant ocular hypertension, or anticoagulation present.)

Left Eye (include only if treated)

• Baseline VA: [Visual acuity]
• Baseline IOP: [IOP value] (If not obtained, state reason.)
• Lens status: [phakic / pseudophakic]
• Anterior segment: [Assessment findings] (Confirm no active infection, discharge, or corneal defect.)
• Contraindications/risk factors: [None identified / Finding and decision to proceed or defer] (Document if active infection, relevant allergy, significant ocular hypertension, or anticoagulation present.)

Medication

(Document each eye separately. If any identifier is unavailable, explicitly state "not recorded.")

Right Eye (include only if treated)

• Medication: [Generic and brand name]
• Concentration: [Concentration]
• Dose administered: [Dose in mg]
• Volume administered: [Volume in mL]
• Route: Intravitreal — Right eye
• Manufacturer: [Manufacturer]
• NDC: [NDC number]
• Lot number: [Lot number]
• Expiration date: [Expiration date]
• Compounding pharmacy and beyond-use date: [Pharmacy name, beyond-use date] (Include only if compounded product.)
• Wastage: [Total amount available] → [Amount administered] → [Amount discarded] (Include for single-dose containers.)

Left Eye (include only if treated)

• Medication: [Generic and brand name]
• Concentration: [Concentration]
• Dose administered: [Dose in mg]
• Volume administered: [Volume in mL]
• Route: Intravitreal — Left eye
• Manufacturer: [Manufacturer]
• NDC: [NDC number]
• Lot number: [Lot number]
• Expiration date: [Expiration date]
• Compounding pharmacy and beyond-use date: [Pharmacy name, beyond-use date] (Include only if compounded product.)
• Wastage: [Total amount available] → [Amount administered] → [Amount discarded] (Include for single-dose containers.)

Anesthesia

Topical: [Agent] | Additional anesthesia: [Subconjunctival or gel anesthetic with concentration/volume, or "none"] | Tolerance: [Patient tolerance]

Antisepsis and Setup

• Ocular surface antisepsis: [Agent and concentration] (If alternative agent used due to intolerance, note reason.)
• Lid/lash antisepsis: [Agent or "not performed"]
• Eyelid retraction: [speculum / manual technique]
• Mask/no-talking protocol: [Yes / No]
• Injection site confirmed free of contamination after antisepsis

Procedure Technique

(Document each eye separately. If technique deviated from standard approach, document the reason.)

Right Eye (include only if treated)

• Patient positioning: [Position]
• Injection site: [superotemporal / inferotemporal / superonasal / inferonasal] quadrant, [distance] mm posterior to limbus
• Needle: [Gauge and length]
• Conjunctival displacement: [performed / not performed]
• Injection confirmed into vitreous cavity
• Tamponade at site: [Yes / No] | Reflux: [Yes / No]
• Paracentesis: [Not performed / Performed with details]
• Deviations from standard technique: [None / Deviation and rationale]

Left Eye (include only if treated)

• Patient positioning: [Position]
• Injection site: [superotemporal / inferotemporal / superonasal / inferonasal] quadrant, [distance] mm posterior to limbus
• Needle: [Gauge and length]
• Conjunctival displacement: [performed / not performed]
• Injection confirmed into vitreous cavity
• Tamponade at site: [Yes / No] | Reflux: [Yes / No]
• Paracentesis: [Not performed / Performed with details]
• Deviations from standard technique: [None / Deviation and rationale]

Immediate Post-procedure Assessment

Right Eye (include only if treated)

• Patient tolerance: [Tolerance]
• Vision check: [formed vision present / count fingers / hand motion / light perception]
• Perfusion assessment: [Optic nerve and retinal perfusion intact / Findings] (Include if performed.)
• Post-injection IOP: [IOP value / Clinical assessment method if not measured]

Left Eye (include only if treated)

• Patient tolerance: [Tolerance]
• Vision check: [formed vision present / count fingers / hand motion / light perception]
• Perfusion assessment: [Optic nerve and retinal perfusion intact / Findings] (Include if performed.)
• Post-injection IOP: [IOP value / Clinical assessment method if not measured]

Complications

[No immediate complications] (If complication occurred, document below.)

• Complication: [Event] (e.g., subconjunctival hemorrhage, reflux, corneal abrasion, lens touch, vitreous hemorrhage, IOP spike, vasovagal reaction)
• Management: [Intervention provided]
• Outcome: [Resolution and disposition]

Post-procedure Instructions and Follow-up

• Post-procedure medications: [Agent, frequency, duration / None prescribed]
• Return precautions provided: Worsening pain, decreasing vision, increasing redness, discharge, new floaters/flashes, curtain or shadow in vision; after-hours contact instructions given
• Follow-up: [Planned interval]
• Next injection: [Scheduled date or interval, if applicable]

(If any critical field—laterality, medication, dose, lot, expiration, or wastage—cannot be documented, explicitly note the information is unavailable. Omit eye-specific sections only if that eye was not treated.)