Assessment of Patient Pain Experience During Intravitreal Ranibizumab and Aflibercept Injection

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.

EFFECT OF ANESTHESIA DURATION ON INTRAVITREAL INJECTION PAIN: A double-blinded, randomized, comparative study

PURPOSE

To determine the effect of different durations of topical anesthesia on intravitreal injection (IVI) pain.

METHODS

This was a double-blinded, randomized, comparative study . Three hundred and twelve sequential eyes undergoing IVI were randomized to one of six groups according to the duration of topical anesthesia (from 1 to 30 minutes, one group for every 5-minute range, Groups 1-6). Topical anesthesia before IVI was standardized. Patients graded their pain using the visual analog scale and the Wong-Baker FACES scale at 15 minutes after the procedure.

RESULTS

The pain scores among the six groups were significantly different for the visual analog scale ( P = 0.013) and Wong-Baker FACES scale ( P = 0.024). The mean pain scores for Group 4 were 1.97 ± 1.04 (visual analog scale) and 2.02 ± 1.08 (Wong-Baker FACES scale) and were significantly lower than those of Group 1, 2, 5, or 6.

CONCLUSION

The duration of topical anesthesia significantly correlated with IVI pain. Preoperative 0.5% proparacaine hydrochloride drops were most effective in relieving IVI pain 11 to 20 minutes after topical administration.

A novel, minimally invasive implant to assist in repeated intraocular drug delivery

The standard of care for posterior segment disorders such as wet age-related macular degeneration, diabetic macular oedema and retinal vascular occlusions is pharmacotherapy by intravitreal drug delivery. Since the therapeutic effect of these drugs lasts only around 4 to 8 weeks, repeated intravitreal injections are required. Pain is experienced by the patients during injection as the needle courses through the sclera and choroid. The current work describes the design and development of a novel anodized titanium alloy implant that allows for intravitreal injections through the implant so that the needle transverses only the conjunctiva, thus minimizing discomfort to the patient. Both ex-vivo testing of the implant in enucleated goat's eye as well as in-vivo validation in rabbit eyes was carried out. The implant was placed through pars plana via a minor surgical procedure and was sutured to the sclera and covered with conjunctiva. Subsequent intravitreal injections were administered under topical anaesthesia with a 30-gauge needle through the implant thus delivering the drug into the vitreous cavity. Repeated intravitreal injections were administered every 2 weeks via the implant for 3 months in 4 rabbits. Apart from cataract in 1 rabbit, no complications were observed. There was no evidence of intra-ocular inflammation or infection at final follow-up. Histopathological analysis did not reveal any inflammation or necrosis around the area of implant. The implants were subsequently removed at 5 months and scleral wound was closed with a single suture. The sclera and overlying conjunctiva healed well and no intraocular complications were observed after removal.

Factors Associated with Pain Level in Patients Receiving Intravitreal Injection

Purpose:

To identify the factors associated with the pain level in patients receiving intravitreal injection.

Methods:

A total of 120 patients were prospectively evaluated, and 104 were included in the study. Patients were asked to rate their pain intensity from 0 to 10 on the visual analog scale. Factors that were possibly associated with pain level were evaluated using a sociodemographic data form, state anxiety inventory, and the hospital anxiety and depression scale.

Results:

Of the participants, 54 (51.9%) were female, and 50 (48.1%) were male, with a mean age of 65 ± 9.01 years. There was a positive correlation between pain level and state anxiety scores (r = 0.30; P < 0.001) and a negative correlation between hospital anxiety score (r = −0.23; P = 0.02) and hospital depression score (r = −0.27; P = 0.01). The correlation between pain score and education level was significantly higher in primary and secondary school graduates (P < 0.01). Smokers were observed to have higher pain scores (6.50 ± 2.21 in smokers and 4.87 ± 2.50 in nonsmokers; P = 0.01). Among diagnostic groups, pain scores were found to be significantly lower in the diabetic retinopathy (DR) group (6.82 ± 1.99 in age-related macular degeneration, 5.94 ± 2.27 in retinal vein occlusion, and 3.58 ± 1.97 in DR; P < 0.001). When pain scores were evaluated according to the drug injected, the group receiving bevacizumab injection was observed to have higher pain scores (7.32 ± 1.81 in bevacizumab, 4.00 ± 2.08 in aflibercept, and 3.92 ± 1.96 in ranibizumab; P < 0.001). Based on the multiple regression analysis, the state anxiety score, hospital anxiety score, hospital depression score, and smoking status were observed not to be significant predictors. The level of education, diagnosis, and active substance were found to have a statistically significant effect on pain perception.

Conclusion:

In this study, pain levels have been found to be high in smokers, those with a low educational level, individuals receiving bevacizumab for intravitreal injection, and those having a higher level of state anxiety, whereas patients with DR have lower pain scores.