Easing patient comfort, pain perception of intravitreal injections

September 24, 2020

Study points to the possible role of addressing preprocedural anxiety

This article was reviewed by Matthew S. Wieder, MD

Use of anxiety-screening questionnaires in patients needing intravitreal anti-vascular endothelial growth factor (VEGF) injections may help to identify individuals at risk for elevated pain during the procedure, according to the results of a study.

The 2-center, noninterventional, prospective study was designed to evaluate anxiety levels and sleep patterns as predictors of patient perceptions of pain following intravitreal bevacizumab injection. In a regression analysis that controlled for potential confounders, the anxiety score measured with the General Anxiety Disorder-7 (GAD-7) questionnaire was the only variable examined that independently predicted pain.

There were no statistically significant associations between intravitreal anti-VEGF injection pain and measured sleep parameters, age, gender, laterality, diagnosis, previous injections, or surgeon/site.

Intravitreal anti-VEGF injections are the most commonly performed in-office intraocular procedure, according to Matthew S. Wieder, MD

“Although generally well tolerated, some patients experience pain, and because many patients undergo these treatments on a regular basis for treatment of a chronic condition, pain during the injection could result in poor adherence to future treatment,” he said. “To identify strategies to combat the pain experienced by some patients, several studies have evaluated different techniques to decrease the pain, including changes in anesthesia and injection site.”

According to Wieder, a resident in the Department of Ophthalmology and Visual Sciences at the Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York: “The findings of our study support future research of modifications that target anxiety to help address pain perception of intravitreal anti-VEGF injections.”

Wieder presented the study at the Association for Research in Vision and Ophthalmology (ARVO) 2020 virtual annual meeting.

Moshe Szlechter, MD, and Irene Rusu, MD, performed the injections. Szlechter is a retina specialist at KLM Eye Care, Brooklyn, New York, and Rusu is a retina specialist at Brooklyn Eye Center, also in Brooklyn. Both are assistant professors of ophthalmology and visual sciences at Albert Einstein College of Medicine, Bronx, New York.

Szlechter said the idea for the study occurred to him while he was lecturing in his community about ophthalmology procedures.

“I wound up speaking from the hip and said that I can predict based on a patient’s level of stress who will feel pain before I even administer the injection,” he noted. “I researched the idea after my lecture and found no good data to support my assertion.”

Szlechter added that it can be interesting to see how a psychological state influences a very physiological reaction.

“A patient’s heightened anticipation and anxiety of future pain will actually make the procedure more painful,” he said.

Study design

A standard technique was used at the two participating sites to control for potential confounding variables. Patients were given the GAD-7 (possible range 0-21) and Pittsburgh Sleep Quality Index (PSQI; possible range 0-21) to complete prior to their injection.

After the procedure, they were asked to rate the severity of pain after intravitreal injection as 0 to 10 with a visual analog scale.

A total of 154 patients were recruited, of which 140 met the inclusion criteria for analysis. The total cohort was equally distributed between the 2 sites. The patients included in the analysis had a mean age of approximately 72 years and 56% were women.

The 2 most common indications for the injections were wet age-related macular degeneration (40%) and diabetic macular edema (29%). 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 pain. Mean ± standard deviation for overnight sleep was 6.7 ± 2.0 hours and was 7.6 ± 2.6 hours for sleep more than 24 hours.

“Anxiety scores on the GAD-7 ranged from 0 to 21 and postprocedure pain scores ranged from 0 to 10, but most patients had low scores indicating mild to no anxiety and most experienced no or mild pain,” Wieder said.

A statistically significant positive correlation was found between the GAD-7 score and pain.

For the sleep measures, both previous night’s sleep and sleep over the previous 24 hours negatively correlated with pain, and there was a positive correlation between PSQI and pain scores (higher PSQI score indicates poorer sleep quality), although none of the correlations achieved statistical significance. In the regression analysis that controlled for confounding variables, each point increase in the GAD-7 score predicted a 0.11-point increase in procedural pain score, according to Wieder.

Matthew S. Wieder, MD
e: mwieder28@gmail.com
Wieder has no relevant financial interest to declare.
Moshe Szlechter, MD
e: kjandmo@yahoo.com
Szlechter has no relevant financial interest to declare.
Joyce N. Mbekeani, MD
e: jnanjinga888@gmail.com
Mbekeani has no relevant financial interest to declare.