Assessment of patient pain experience during intravitreal 27-gauge bevacizumab and 30-gauge ranibizumab injection

Effect of Needle Gauge Size on Pain During Intravitreal Anti-VEGF Injection: A Systematic Review and Network Meta-Analysis

INTRODUCTION

Concerns related to pain from intravitreal injections are one of the key factors mentioned by patients when asked about therapy. In this systematic review and network meta-analysis, we evaluate the literature of comparative clinical trials on the relationship between needle gauge size and pain experience during intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy.

METHODS

We searched 12 literature databases on 14 October 2023 for comparative studies of gauge sizes for intravitreal anti-VEGF injections. The primary outcome of interest was the reported pain experience immediately after the injection. All outcomes of pain were transformed into standardized effect sizes using Cohen's d. Using a network meta-analysis approach, we were able to compare all gauge sizes and rank them according to the reported pain experience.

RESULTS

We identified nine eligible studies with data on a total of 998 patients and 1004 eyes. Needle sizes studied were 26-gauge, 27-gauge, 29-gauge, 30-gauge, 32-gauge, 33-gauge, and 34-gauge. A complete network was present, which allowed for a network meta-analysis. We used the thickest (26-gauge) needle as the reference group and observed a clear trend of lower pain experience with thinner gauge sizes (d: -0.4, d: -2.7, d: -3.8, d: -4.8, d: -4.5, and d: -5.3; respectively, for 27-gauge, 29-gauge, 30-gauge, 32-gauge, 33-gauge, and 34-gauge).

CONCLUSION

A gauge size of 30 or thinner may minimize patient discomfort related to intravitreal anti-VEGF therapy.

Post-Intravitreal injection pain reduction using topical NSAIDS: A comparative study

PURPOSE

To compare the efficacy of two different topical non-steroidal anti-inflammatory drugs (NSAIDs) drops with versus without conservatives after intravitreal injections (IVIs).

DESIGN

Prospective, randomized, placebo-controlled, single-blinded comparative study.

PARTICIPANTS AND METHOD

A total of 308 eyes of 252 patients receiving an IVI of anti-vascular endothelial growth factor (anti-VEGF) were randomly assigned to receive either a single drop of nepafenac 0.1%, preservative-free diclofenac 0.1%, or artificial tears (control group) immediately after IVI. Primary outcome measure was pain scores immediately, six hours and twenty-four hours post- injection.

RESULTS

166 patients received one topical drop of NSAIDS, of which 90 in the diclofenac group and 76 in the nepafenac group. Additional 86 patients were included in the control group. Mean reported pain score was significantly lower at six hours after IVI in the preservative-free diclofenac group (17.1 ± 23.0) than in the nepafenac group (26.2 ± 31.9) and the control group (27.5 ± 29.2) (p = 0.03). At twenty-four hours post-injection there was no statistically significant difference between the groups. Patients reported less pain compared to previous IVIs and none referred to urgent health care, but these findings were not statistically significant.

CONCLUSIONS

The use of topical preservative-free NSAIDs may be superior to preservative- containing NSAIDs in pain relief after IVIs and may be considered as part of the treatment protocol of this population.

The Effect of Dorzolamide-timolol Eye drop on Intraocular Pressure Change in Intravitreal Ranibizumab Injected Patients

PURPOSE

The objective of the study was to examine the effect of dorzolamide-timolol (DT) eye drop used before intravitreal ranibizumab (IVR) injection on intraocular pressure (IOP) change.

METHODS

50 eyes of 50 patients who received DT eye drops 1 h before IVR injection due to diabetic retinopathy and macular edema were considered Group 1, and 50 eyes of 50 patients who did not receive DT eye drops were considered Group 2. Those patients who had previously undergone intravitreal injection had intraocular surgery, and used any eye drops were not included in the study. Before the injection, IOP values were measured with a Tonopen contact handheld tonometer before the blepharostat was placed (BIOP), after the blepharostat was placed (AIOP), and at the 1st min after the injection (IIOP).

RESULTS

There were 25 males and 25 females in Group 1 and 25 males and 25 females in Group 2; the mean age was 65.66 ± 9.94 years in Group 1 and 65.54 ± 7.43 years in Group 2 (P = 0.98). In Group 1, BIOP was 18.91 ± 18.91, AIOP was 21.62 ± 6.16 mmHg, and IIOP was 49.21 ± 10.95 mmHg. In Group 2, BIOP was 20.18 ± 4.19 mmHg, AIOP was 24.60 ± 4.90 mmHg, and IIOP was 49.96 ± 9.72 mmHg. IIOP-BIOP difference was 30.30 ± 9.85 mmHg in Group 1 and 29.78 ± 9.33 mmHg in Group 2 and the difference was not statistically significant (P = 0.78). In Group 1, the IIOP-AIOP difference was 27.58 ± 10.60 mmHg and in Group 2, 25.36 ± 10.46 mmHg. The difference between IIOP and AIOP was not statistically significant (P = 0.27).

CONCLUSION

The use of topical DT eye drops before IVR injection does not affect the intraocular pressure change.

Anterior Chamber Paracentesis Offers a Less Painful Experience During Intravitreal Anti-vascular Endothelial Growth Factor Administration: An Intraindividual Study

Introduction: In order to improve comfort and compliance to treatment of the patient during the intravitreal injections (IVIs), relieving pain may help and provide getting better results. The purpose of the study was to evaluate the efficacy of anterior chamber paracentesis on pain perception and the factors related to pain perception during intravitreal injection procedures.

Material and methods: This prospective randomized study includes 212 eyes of 106 patients scheduled for bilateral IVI of ranibizumab 0.5 mg/0.05 cc under topical anesthesia. All patients underwent full ophthalmologic examination, including intraocular pressure (IOP), anterior chamber depth (ACD), and axial length (AL) measurements. Group 1 received IVI following anterior chamber paracentesis (ACP) and group 2 received IVI without ACP. Intraocular pressure was measured five minutes and 30 minutes after the procedure. Pain perception was assessed by visual analogue scale (VAS) grading from 0 to 10.

Results: Mean VAS score for groups 1 and 2 was recorded as 0.51±1.00 and 1.32±1.50, respectively. Correlation analysis revealed a positive correlation between VAS score and history of previous IVI, preinjection IOP values, and an inverse correlation with the presence of reflux in both groups, in addition to inverse correlation with ACD in group 2.

Conclusions: ACP may offer a comfortable, effective, and less painful alternative to prevent the acute rise in IOP after IVI, especially in patients with small anterior chambers, small vitreous volumes, with a history of multiple injections, and in patients with advanced glaucomatous optic neuropathy.

Impact of Anxiety Levels and Sleep Patterns on Perceived Pain During Intravitreal Bevacizumab Injections

BACKGROUND AND OBJECTIVE

To evaluate the impact of anxiety and sleep patterns on intravitreal injection pain.

PATIENTS AND METHODS

This prospective, noninterventional study surveyed patients scheduled for intravitreal injection by two retinal surgeons. A standard intravitreal injection technique was used. Patients filled out pre-procedure General Anxiety Disorder-7 (GAD-7) and Pittsburgh Sleep Quality Index (PSQI) questionnaires. Post-procedural pain was assessed with a visual analogue scale. Quality and hours of sleep and anxiety levels were correlated with perceived intravitreal injection pain.

RESULTS

A total of 140 patients met inclusion criteria. Mean ± standard deviation scores were 4.9 ± 5.6 for the GAD-7, 6.3 ± 4.1 for the PSQI, and 3.69 ± 2.64 for intravitreal injection pain. Anxiety correlated with intravitreal injection pain (rho = 0.25; P = .003). Previous night's sleep (rho = -0.16; P = .057) and poor sleep quality (rho = 0.14; P = .11) were weakly correlated. Regression analysis revealed anxiety was the only significant predictor of intravitreal injection pain. A 1-point increase in anxiety predicted a 0.10-point increase in intravitreal injection pain (B = 0.10, P = .032).

CONCLUSIONS

Anxiety level was the best predictor of perceived pain. This has implications for pre-procedural anxiety screening. [Ophthalmic Surgery Lasers Imaging Retina. 2021;52:498-504.].

Subjective and objective measures of the patient experience before, during, and after intravitreal anti-vascular endothelial growth factor injections

Purpose

To assess patient experience of intravitreal injections using vital-signs, visual-experience, pain-rating and emotional response during intravitreal anti-VEGF injections.

Methods

A prospective observational study of patient experience of intravitreal anti-VEGF injections done following metrics were collected pre-injection, during injection, and post-injection: pain assessment using visual analog score, fear-response rating, visual-experience questionnaire, and vital-signs.

Results

A total of one-hundred-and-seventy-four patients undergoing intravitreal anti-VEGF injections for retinal pathologies were included in the study. Mean age was 58.8 ± 10.4 years in <5 injection group (n = 133) and 59.02 ± 9.0 years in ≥5 injection group (n = 41) (P = 0.90).During injection, 90.2% of patients in <5 injection group reported moderate or severe pain compared to 78% of patients in ≥5 injection group. In pre and post-injection phases, mild-to-moderate pain was reported in both groups (P = <0.001). Ninety-two (52.9%) patients reported having a mild frightening experience. There was no statistical significance in patients assessment of fear with respect to age, sex, or number of injections. The Systolic Blood Pressure (SBP) during and following injection ((SBP 171.7 ± 21.1,150.8 ± 16.2) procedures was significantly higher in cases with <5 injections when comparing to cases with >5 injections (SBP 159.7 ± 26.4, 143.2 ± 17.0) (P = 0.003), (P = 0.011). DBP, heart rate, pulse rate measurements were similar among patients in all phases of the study.

Conclusion

We report a large sample size with comprehensive assessments of the patient experience. Higher pain ratings in the <5 injection group, the increase in the SBP in the pre-and during injection phases, and the overall rating of mild-to-moderate fear during the procedure.

Reflux, Intraocular Pressure Variation and Pain Following Intravitreal Ranibizumab Injections Using 30-Gauge or 32-Gauge Needles for Patients With Retinal Pathologies: A Randomized Clinical Trial

PURPOSE

To compare reflux, intraocular pressure (IOP) variation and pain following intravitreal (IV) injections using 30-gauge and 32-gauge needles in patients with retinal pathologies in Saudi Arabia.

METHODS

A double-blind randomized clinical trial was conducted in 2018. Participants were randomized to receive IV injections of Ranibizumab using 30-gauge (Gr₁) or 32-gauge (Gr₂) needles. The amount of reflux of injected material, IOP before (IOP₁) and five minutes after injection (IOP₂) were measured. The patient-perceived pain score was assessed using a visual analogue score (VAS). Outcome variables were compared.

RESULTS

The study sample was comprised of 86 eyes (86 patients) in each group. Gender (P=0.76), laterality (P=0.55) and age (P=1.0) were not different between groups. The reflux in Gr₁ [34.9% (95% confidence interval {CI}, 24.8; 45.0)] was significantly higher compared to Gr₂ [22.1% (95% CI, 13.3; 30.9)] (P=0.007). The median pain score was 1 in both Gr₁ [interquartile range (IQR) 1.0: 3.0] and Gr₂ (IQR 0.0; 2.0) (P=0.04). Among 56 eyes without reflux in Gr₁, the IOP₁ and IOP₂ were 13.6±2.7 mmHg and 16.4±5.0 mmHg, respectively. Among 67 eyes without reflux in Gr₂, the IOP₁ and IOP2 were 13.6±2.9 mmHg and 17.0±5.2 mmHg, respectively. The change in percentage in IOP in Gr₁ and Gr₂ was not significantly different (Mann Whiney P=0.3).

CONCLUSIONS

IV injection given by 30-gauge needle compared to 32-gauge needle resulted in greater patient-perceived pain and more reflux of injected material from the injection site. An increase in IOP was not associated with the gauge of the needle used for IV injection.

Needle Gauge Influences Pain Perception During Intrapulpal Anaesthesia - A Randomized Clinical Trial

OBJECTIVE

The purpose of this randomized trial was to assess the pain perception during intrapulpal anesthesia (IP) using thinner gauge needles and syringes with or without topical anaesthesia as an adjunct.

METHODS

One hundred patients, on whom the inferior alveolar nerve block and intraligamentary injections failed, were recruited for the trial. Block randomization was performed and the patients were allocated into 4 groups based on the needle gauge and topical application of anaesthesia prior to IP injection. In two groups (27GN, 31GN) the patients received IP injection with 27 gauge or 31 gauge needles. The patients of other two groups received topical lignocaine-prilocaine mixture prior to the IP injection with 27 or 31 gauge needles, respectively (27GT, 31GT). The visual analogue scale (VAS) was used to assess the pain immediately after IP injection and after cleaning and shaping by a blinded outcome assessor. The Kruskal-Wallis test for overall comparisons followed by the post-hoc analysis using the Conover's test (P<0.05) was done. Chi-square and Fischer exact test was used to assess the proportion of patients who were comfortable during IP anaesthesia.

RESULTS

The intensity of pain during IP administration with 31GN and 31GT (3.7 and 2.3 respectively) was significantly less in comparison to 27GN and 27GT (5.6 and 5.7 respectively). The proportion of patients who were significantly comfortable with IP injections in the groups 31GN and 31GT (52% and 80% respectively) were more (VAS<4) when compared to 27GN and 27GT (12% and 8% respectively). Topical application of lignocaine-prilocaine reduced the pain on IP injection significantly when used as an adjunct with 31 gauge needles. The anaesthetic success of IP anaesthesia was comparable and 100% (VAS scoring <4) in all the groups.

CONCLUSION

Thinner gauge needles (31 gauge) significantly reduce pain perceived during IP anaesthesia. Topical anaesthesia with lignocaine-prilocaine acts as an effective adjunct only with 31gauge needle.

A Comparison of Conventional Intravitreal Injection Method vs InVitria Intravitreal Injection Method

Purpose

To compare use of the conventional intravitreal injection method to the InVitria intravitreal injection device. Three outcome measures were studied: patient comfort, speed of injection and cost-effectiveness.

Patients and Methods

A prospective review of 58 patients was undertaken. Patients scored their perceived pain for each part of the conventional injection method using visual analogue scales (VAS), which allows pain to be scored from 0 (no pain) to 100. The same 58 patients scored their perceived pain for each part of the injection process with the InVitria on their follow-up visit. The procedure was timed in both settings and cost to the Trust was analysed.

Results

Pain scores when the InVitria was used were lower than when the conventional method was used for all aspects of the intravitreal injection procedure, in particular, when comparing insertion of drape/speculum (mean score 57.56) to insertion the InVitria (mean score 16.50), needle entry (mean score 37.76 to 27.86) and removal of the drape/speculum (mean score 38.72) to removal of the InVitria (11.07). The reduction in pain scores was statistically significant for all aspects of the procedure, except the initial instillation of drops. The InVitria was an average of 1 minute and 32 seconds faster than the conventional method. Use of the InVitria in place of the conventional method provides an annual saving of £24,300 to the Trust based on the number of injections currently performed.

Conclusion

The introduction of the InVitria in the Newcastle Eye Centre has had a positive impact on patient comfort, time and cost to the Trust.

Systematic review: non-adherence and non-persistence in intravitreal treatment

Purpose

Intravitreal injection of VEGF inhibitors has become the standard of care for different macular diseases within the last years resulting in improved visual outcomes. Under real-life conditions, however, the necessity for frequent retreatments and reexaminations poses a burden for patients and treatment centers. Non-adherence and non-persistence to intravitreal treatment may lead to inferior clinical outcomes, and knowledge of contributing factors is crucial to improve adherence. This systematic review analyzes current literature for potential factors involved in non-adherence and non-persistence.

Methods

A systematic search was conducted in PubMed and Embase including three different aspects of intravitreal injection therapy: (1) diseases with intravitreal injections as treatment, (2) intravitreal injection, and (3) aspects of therapy adherence or therapy persistence. Data from identified quantitative studies were further extracted and grouped according to WHO criteria (condition, socio-economy, therapy, patient, and health system). The methodological quality of identified studies was graded. Identified qualitative studies (i.e., interviews) were descriptively analyzed and their findings narratively reported.

Results

Twenty-four publications were included. In 16 of those publications, a quantitative data analysis was conducted, analyzing factors associated with non-adherence. Worse visual acuity at baseline and unfavorable development of visual acuity, higher age, and greater distance to the treatment center were associated with non-adherence, while there was inconsistent evidence for an association of comorbidity. In qualitative studies, high follow-up/treatment burden, fear and anxiety, disappointed patient expectations, and lack of motivation to continue treatment were reported as reasons for non-persistence.

Conclusions

Knowledge of potential barriers in IVT treatment may improve adherence and potentially clinical results. Improvements can be achieved particularly in the healthcare complex (organizational improvements) and the “patient” complex by establishing realistic expectations. Recurrent education of the patient may be necessary.

Electronic supplementary material

The online version of this article (10.1007/s00417-020-04798-2) contains supplementary material, which is available to authorized users.

Critical analysis of techniques and materials used in devices, syringes, and needles used for intravitreal injections

Intravitreal injections have become the most commonly performed intraocular treatments worldwide. Because intravitreal injections may induce severe adverse events, such as infectious and noninfectious endophthalmitis, cataract, ocular hypertension, vitreous hemorrhage, or retinal detachment, appropriate awareness of the materials and techniques used are essential to reduce these sight-threatening complications. This review provides insights into the needles, syringes, silicone oil coating, sterilization methods, devices to assist intravitreal injections, scleral piercing techniques using needles, syringe handling, anesthesia, and safety issues related to materials and techniques. It is paramount that physicians be aware of every step involved in intravitreal injections and consider the roles and implications of all materials and techniques used. The ability to understand the theoretical and practical circumstances may definitely lead to state-of-the-art treatments delivered to patients. The most important practical recommendations are: choosing syringes with as little silicone oil as possible, or, preferably, none; avoiding agitation of syringes; awareness that most biologics (e.g., antiangiogenic proteins) are susceptible to changes in molecular properties under some conditions, such as agitation and temperature variation; understanding that improper materials and techniques may lead to complications after intravitreal injections, e.g., inflammation; and recognizing that some devices may contribute to an enhanced, safer, and faster intravitreal injection technique.

Comparison of pain during intravitreal dexamethasone, ranibizumab and aflibercept injection

BACKGROUND

This study aimed to compare pain scores of patients during intravitreal aflibercept, ranibizumab or dexamethasone implant injection procedures.

METHODS

This study included 162 eyes of 162 patients, who received intravitreal ranibizumab, aflibercept or dexamethasone implant injections at our clinic. Following the injection, patients were asked to rate their pain from 0 (no pain) to 10 (worst pain) using a visual analogue pain score survey (VAS). VAS was evaluated according to age, sex, indication for the injection, number of previous intravitreal injections, and lens status in the study eye.

RESULTS

The mean VAS in the ranibizumab, aflibercept or dexamethasone implant groups was 3.38 ± 2.31, 3.82 ± 2.46, and 3.61 ± 2.94, respectively. Female patients reported a higher average pain score than male patients (p = 0.02). Also, phakic patients reported a higher average pain score than pseudophakic patients (p = 0.01). Pain did not significantly correlate with indication for the injection, number of injections, and injection drugs (p > 0.05).

CONCLUSION

Pain associated with intravitreal injection is generally mild and associated with sex, age, and lens status. There was no significant difference in pain between intravitreal injections of dexamethasone implant, ranibizumab or aflibercept.

Assessment of Patient Pain Experience During Intravitreal Ranibizumab and Aflibercept Injection

PURPOSE:

The aim of this study was to compare the pain scores of the patients during intravitreal injection of ranibizumab and aflibercept based on patient feedback.

MATERIALS AND METHODS:

Seventy-two eyes of 72 patients, who had not previously undergone any intravitreal injection procedures, were included in this study. Thirty-eight patients received ranibizumab, and 34 patients received aflibercept injections. The pain was measured by visual analog scale (VAS). Patients were asked to rate their pain experienced during the injection between 0 (no pain) and 10 (worst pain ever felt) on VAS just after the injection.

RESULTS:

VAS pain scores in ranibizumab and aflibercept groups were 3.28 ± 2.45 and 4.20 ± 2.30, respectively. There was a significant difference in average VAS pain scores between groups (P = 0.04).

CONCLUSION:

VAS pain scores in aflibercept group were found to be significantly higher than the scores in the ranibizumab group.

Real-World Trends in Intravitreal Injection Practices among American Retina Specialists

PURPOSE

To analyze practice patterns used for intravitreal injections (IVIs) by retinal specialists in the United States.

DESIGN

Cross-sectional online survey.

PARTICIPANTS

Retina specialists in the United States who responded to a web-based survey.

METHODS

Retinal specialists in the United States were contacted via e-mail to complete a web-based, anonymous, 24-question survey. Multivariate analysis was performed on a selected question of interest focused on choice of anesthetic used for IVI.

MAIN OUTCOME MEASURES

Differences in IVI practices, such as antibiotic preferences, and different odds of anesthetic use by demographic variables with 95% confidence intervals.

RESULTS

A total of 281 retinal specialists responded to the survey (17% response rate). Respondents' average age was 53 years, with an average of 20 years in practice. Respondents practiced in 42 states, with 90% practicing in an urban or suburban area. For anesthesia, 14% used a topical anesthetic with cotton swab compression, 27% used a subconjunctival anesthetic, and 31% used an anesthetic gel. Age, gender, geographic location, and practice setting did not seem to impact choice of anesthetic for IVI significantly. Sixty-six percent of respondents always use a lid speculum, 21% administer topical antibiotics before injection, 36% wear a mask, 73% wear gloves, and 45% always dilate the eyes before injection. Most respondents use a 30-gauge needle and inject in the inferior temporal quadrant (70%). Forty-five percent always perform bilateral injections the same day if indicated. After the injection, 14% administer post operative nonsteroidal anti-inflammatory drugs, 28% administer postoperative antibiotics, and 31% routinely check intraocular pressure after injection.

CONCLUSIONS

This study provided real-world trends in practices for IVI among retina specialists in the United States. In addition, age, gender, practice type, and geographic location did not influence anesthetic choice for IVI.

Intravitreal Injections of Bevacizumab: The Impact of Needle Size in Intraocular Pressure and Pain

Aim

To compare the effect of 30-gauge vs 27-gauge needle size on intraocular pressure (IOP) rise and patients’ pain experience after intravitreal injection (IVI) of bevacizumab.

Materials and methods

Cross-sectional, randomized, double-armed study. Patients were randomized to IVI with 30-gauge or 27-gauge needle. The IOP was measured pre and post IVI. Patients’ pain was graded using the visual analog scale (VAS).

Results

A total of 54 eyes were included. The IVI caused a significant IOP rise in both groups (p < 0.001). In the 30-gauge group, the mean pre- and postinjection IOP was 16.3 ± 3.6 mm Hg and 24.1 ± 9.0 mm Hg. The corresponding figures in the 27-gauge group were 18.0 ± 2.54 (p = 0.26) and 23.1 ± 7.5 mm Hg (p = 0.66). In the 30-gauge group, the mean VAS pain score was 3.2 ± 2.6 compared to 3.0 ± 2.5 in the 27-gauge group (p = 0.78).

Conclusion

The IVI caused a significant rise in IOP after the injection, independently of the needle size used. The 27-gauge needle coursed with lower postinjection IOP without prejudice of the patient comfort.

Clinical significance

The IVI with 27-gauge may be considered for glaucomatous eyes (higher risk eyes), for which IOP spikes are not recommended.

How to cite this article

Loureiro M, Matos R, Sepulveda P, Meira D. Intravitreal Injections of Bevacizumab: The Impact of Needle Size in Intraocular Pressure and Pain. J Curr Glaucoma Pract 2017;11(2):38-41.

Evaluation of pain during intravitreal aflibercept injections

Purpose:

To evaluate the pain associated with intravitreal aflibercept injections.

Methods:

The study included 119 patients who received intravitreal aflibercept injection at a single institution. Pain was evaluated by visual analog scale (VAS) immediately after the injection of 2 mg/0.05 mL aflibercept into the vitreous cavity using a 27-G needle. Additional variables including age, sex, indication for the injection, injection site by quadrant (superotemporal or inferotemporal), position during injection (sitting or supine), number of previous intravitreal injections in the study eye, presence of diabetes mellitus or hypertension, and lens status (phakic or pseudophakic) were recorded and assessed with self-reported pain scores.

Results:

Pain scores on the VAS ranged from 9 to 70, with a median of 18. Indications for injection included diabetic macular edema (21.0%), macular edema secondary to central retinal vein occlusion (12.6%), and neovascular age-related macular degeneration (66.38%). Pain did not significantly correlate with any of the recorded variables.

Conclusions:

This is the first series evaluating the pain associated with intravitreal aflibercept injections. We demonstrated that pain associated with intravitreal aflibercept injection is generally mild with low pain scores.

Strategies for Improving Patient Comfort During Intravitreal Injections: Results from a Survey-Based Study

Introduction

Many ocular diseases require intravitreal injections of pharmacological agents. Optimizing patients’ experiences during injections is important to ensure compliance and maintenance of quality of life. The objective of this study was to identify strategies to help alleviate discomfort during intravitreal injections.

Methods

A cross-sectional study surveying 128 patients during clinic visits between 2014 and 2015 in two outpatient Retina Clinics (one academic and one private). Patients receiving an intravitreal injection(s) for any retinal disorder were given a questionnaire with 10-yes/no responses for various potential strategies. Responses were stratified by sex, age (<30 years, 30–60 years, and >60 years) and total number of prior injections (0–9 injections, 10–20 injections and >20 injections).

Results

A total of 128 patients were surveyed: 59 males, 41 females and 28 with no sex specified. Our results identified four favorable strategies as those receiving more than 50% “yes” votes. These included the presence of technician/staff during the procedure, the use of a neck pillow, a verbal warning before the injection and performing injections in both eyes on the same day. Other specific strategies were identified for females, younger patients and those with greatest experience. These included: females preferred having their hand held during injections (P = 0.001) and using a stress ball (P = 0.000) when compared to males. Stratifying by age, patients 30–60 years old preferred having their hand held (P = 0.008) and background music (P = 0.007). Stratifying by prior injections, patients with >20 prior injections preferred having their hand held (P = 0.001), using a stress ball (P = 0.021) and, if necessary, having bilateral injections performed the same day to improve comfort (P = 0.037).

Conclusions

Having an extra staff member present during the injection, having a neck pillow, having a verbal warning prior to injection and having both eyes injected on the same day were indicated as favorable strategies by over half of those surveyed. Further, specific strategies were identified for females, younger patients (30–60 years old) and those with greatest experience (>20 injections).