injection and previous injections in both eyes. Repeated injections Treatments administered via intravitreal injection are not cures and therefore repeated injections are necessary for managing conditions. For example, anti-VEGF therapies must be injected monthly or bi-monthly for the rest of their lives in order to treat wet age related macular degeneration. A growing body of evidence has shown repeat intravitreal injections have their own increased risks and complications. A 3x rise in intraocular pressure after an intravitreal injection is expected and usually only lasts a few minutes. Studies have shown an increased risk of sustained elevated intraocular pressure due to repeated intravitreal injections. Elevated intraocular pressure leads to tissue damage, this is how glaucoma damages the eye. Many theories as to why this is have been postulated however many focus on the effect of the repeated eye trauma. The risk of elevated intraocular pressure is so great that it is recommended clinicians monitor intraocular pressure before and after intravitreal injection. Mount Sinai researchers have developed a method to measure retina damage from long term intravitreal injection using optimal coherence tomography angiography (OCTA). OCTA captures the motion of red blood cells in blood vessels noninvasively allowing researchers to measure blood flow in the macula and optic nerve. From this data they were able to show areas of cumulative damage. Procedure and guidelines In 2004 with the rise of intravitreal injections, a group of experts established the first general guidelines for administering intravitreal injections. Until an update in 2014 these were consensus guidelines in the US. In 2014 a panel of 16 health professionals with expertise in different aspects of the injection reviewed and revised the original guidelines. Together they released areas of general agreement, areas with no clear consensus, and recommended sequence of steps for intravitreal injection. Changes from 2004 Guidance Dropped Recommendations from 2004 Use of a lid speculum is no longer essential. Now a lid speculum, manual lid retraction or a similar maneuver can be used to keep the eyelids out of the way during the procedure. The strong 2004 consensus that the pupil should be routinely dilated to examine the posterior segment of the eye post injection was dropped. Some of the 2014 panelists did not dilate the pupil for routine injections while others found this examination to be highly important. As no consensus was reached this recommendation was dropped from the 2014 guidance. New Recommendations in 2014