Rethinking the IVT Patient Experience

At the moment of injection, Intravitreal Therapy (IVT) may take only seconds to deliver the drug and withdraw the needle. But for the patient, the procedure can cast a much longer shadow, lasting well beyond this moment and even their time within the clinic.

During our recent research into ocular drug delivery we were shocked to discover that, according to data on 409,215 IVT patients, about 30% drop out of anti-VEGF therapy within the very first year of treatment [1]. In other words, about one third of patients would rather suffer the consequences of their condition than endure their monthly treatments. 

So what are the driving factors behind these figures for non-persistence?

The paper from which this data was drawn would suggest that chief among them is a broad patient dissatisfaction with the treatment results. However, by reviewing the published literature and conducting our own interviews with patients, clinicians and key opinion leaders, we uncovered a more nuanced story: a range of factors that collectively tip the 'burden–reward' scale towards a decision to discontinue treatment.

Anxiety, both in the acute and chronic sense, is a key driver with many contributing factors.

At a basic level, most of us are fairly attached to our eyes. That is to say, despite sometimes taking them for granted, they are a sensitive and critical part of our body that we instinctively want to protect. So the idea of someone sticking a needle into them and injecting fluid is a little unnerving at best.

And this is before we even get to the other invasive aspects of the procedure, such as the metal speculum that is used to force the eyelids open, whilst the patent fixes their gaze and tries hard not to flinch as the needle goes in. Or the strong burning or gritty sensations that many patients report as a result of the generous use of povidone-iodine as a sterilant.

For many, even the anticipation of this clinical experience is enough to induce an anxiety-filled, monthly countdown to their next treatment. Meanwhile they may still be recovering from the side effects of their previous treatment — bloodshot eyes, floaters, and headaches are commonplace. And, although largely benign and rarely requiring intervention, these side effects only serve to add to the total anxiety burden.

“1 in 10 patients leave with a subconjunctival hemorrhage. They feel bad, I feel bad. I’m like: 'Oh sorry, you’re going to have a red eye for 3 weeks' "

Source: Interview conducted by Fearsome with Ophthalmology KOL (2026)

Some of the patients we interviewed also highlighted the travel and time burden involved in their monthly visits to the clinic. When we consider that many IVT drugs are targeted at age-related diseases such as Wet AMD and that, with advancing age, patients are more likely to have comorbid conditions affecting mobility, energy levels, and general independence, then it stands to reason that this routine trip becomes a bit of a rigmarole.

In the short term at least, it would seem that this need to deliver drugs into the vitreous is not going away. Demand for intravitreal therapy continues to grow as populations age and the availability of anti-VEGF treatments expands. One UK hospital, for example, reported an 11-fold increase between 2009 and 2019 and projected demand to almost double again by 2029 [2].

And no alternative delivery platform has yet achieved widespread clinical adoption. Perhaps due to the low-tech, cost-effective nature of the current solution — a drug-filled syringe, carefully aimed and injected at the pars plana (the 'safe zone' for delivering into the vitreous, 3.5-4.0 mm from the limbus).

What we can begin to explore seriously in the short term, however, is solutions that will soften the physical and psychological impacts of the treatment — striking at the root causes of the anxiety cycle. Solutions to reduce the scare factor and the mechanical and chemical invasiveness of the clinical experience. Solutions to minimise the common side-effects, whilst maximising the safety and efficacy of the procedure. And solutions that simplify the seemingly complex workflow and fluid mess that is often involved in IVT — a development that we think would be welcomed by patient and clinician alike.

Toward a longer-term vision, perhaps we should start exploring options that would bring about a more wholesale change — not just for the patient, but for the (often oversubscribed) healthcare systems. Maybe we need to learn from parallel drug delivery sectors, such as insulin for diabetics, where the de-skilling of self-administration has subsequently led to wearable and now implantable devices that are self-monitoring and self-regulating. What might this look like for retinal drug delivery?

Looking further ahead, there is reason to be optimistic about more transformative approaches such as slow-release drug implants, subretinal microchips, gene therapy and stem cell therapies. Each of these could become a game changer for both the patient and the healthcare professionals as they become widely adopted. Ultimately bringing us to a future where treatment becomes a one-and-done intervention, leaving the monthly cycle of anxiety firmly in the past.

References:

[1] Shahzad H, et al. Non-adherence and non-persistence to intravitreal anti‑VEGF treatment: systematic review. Systematic Reviews. 2023.  

[2] Chopra et al. Intravitreal injections: past trends and future projections within a UK tertiary hospital, Eye, 2022