Improving patient comfort with intravitreal injections

July 1, 2020

Use of anxiety-screening questionnaires in patients needing intravitreal anti-VEGF injections may help to identify individuals at risk for elevated pain during the procedure, according to research presented at ARVO 2020.

This article was reviewed by Joyce N. Mbekeani, MD, Moshe Szlechter, MD, and Matthew S. Wieder, MD.

Use of anxiety-screening questionnaires in patients needing intravitreal anti-VEGF injections may help to identify individuals at risk for elevated pain during the procedure, according to research presented at ARVO 2020.

The two-center, non-interventional, prospective study was designed to evaluate anxiety levels and sleep patterns as predictors of patient perceptions of pain following intravitreal injection. In a regression analysis that controlled for potential confounders, 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. 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,” said Matthew S. Wieder, MD.

“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," Wieder said. "The findings of our study support future research of modifications that target anxiety to help address pain perception of intravitreal anti-VEGF injections.”

Dr Wieder, resident, Department of Ophthalmology and Visual Sciences, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, presented the study for the Virtual ARVO meeting.

Moshe Szlechter, MD, and Irene Rusu MD performed the injections. Dr Szlechter is a retina specialist at KLM Eye Care, Brooklyn, NY, and Dr Rusu is a retina specialist at Brooklyn Eye Center, Brooklyn, NY. Both are Assistant Professors of Ophthalmology and Visual Sciences at Albert Einstein College of Medicine, Bronx, NY.

Dr Szlechter explained 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. I researched the idea after my lecture, and found no good data to support my assertion,” he said.

“It is interesting how a pre-existing psychological state influences a very physiological reaction. A patient's heightened anticipation and anxiety of future pain will actually make the procedure more painful.”

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 (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 analogue 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 two sites. The patients included in the analysis had a mean age of approximately 72 years and 56% were female.

The two 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 over 24 hours.

“Anxiety scores on the GAD-7 ranged from 0 to 21 and post-procedure 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,” Dr Wieder said.

A statistically significant positive correlation was found between the GAD-7 score and pain (P = .003).

For the sleep measures, both previous night’s sleep and sleep over the last 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.

Matthew S. Wieder, MD
E: mwieder28@gmail.com
Moshe Szlechter, MD
E: kjandmo@yahoo.com
Joyce N. Mbekeani, MD
E: jnanjinga888@gmail.com
This article was adapted from a presentation at the 2020 virtual meeting of the Association for Research in Vision and Ophthalmology. None of the investigators has any relevant financial interest to declare.