Patient pain during intravitreal injections under topical anesthesia: a systematic review

Abstract

BackgroundIntravitreal injection (IVI) is a very common vitreoretinal procedure, and multiple injections are often required per patient. This systematic review was conducted to evaluate the effectiveness of various local anesthetic techniques in reducing pain during injection.MethodsA systematic review was conducted based on searches of Cochrane, LILACS, PubMed, Scopus, Web of Science, and the gray literature (Google Scholar). The end search date was February 19, 2016, across all databases. We classified pain by converting visual analog scale (VAS) scores (0–100 mm) into Jensen’s classification levels: 0–4, no pain; 5–44, mild pain; 45–74, moderate pain; and 75–100, severe pain. An intervention was considered clinically significant when pain score change was >12 mm on a 100-mm scale.ResultsEight studies out of 23 met the eligibility criteria. The total number of patients was 847. Most studies (5/8 [62.5%]) were at unclear risk of bias because of unclear randomization, thus providing only moderate evidence to this review. The anesthetic techniques included eye drops with proparacaine, tetracaine or cocaine, a lidocaine pledget or gel, and subconjunctival injection of 2% lidocaine or 0.75% levobupivacaine. No study comprised all of the techniques. Pain was mild (VAS scores, 5–44 mm) regardless of anesthetic technique. A clinically significant intervention (pain score change >12 mm) was found for only one study comparing proparacaine drops, lidocaine gel, and subconjunctival lidocaine; in that study, a subconjunctival injection of 2% lidocaine provided the greatest pain reduction. A meta-analysis was not possible due to study heterogeneity.ConclusionsPatient pain during IVI under topical anesthesia is mild regardless of anesthetic technique. A subconjunctival injection of 2% lidocaine could be an option for highly sensitive patients. However, with moderate level of evidence, no single anesthetic technique could be defined as the best option for IVI.Electronic supplementary materialThe online version of this article (doi:10.1186/s40942-017-0076-9) contains supplementary material, which is available to authorized users.

Which quadrant is less painful for intravitreal injection? A prospective study

“…The higher VAS scores may be due to the method of anesthesia -only two drops of tetracaine. In our study, perceived pain during intravitreal injection was mild (VAS scores between 5 and 44 mm, on a 0-100 mm scale) similar to that observed in a previous study [31], Blaha et al [19] reported a mean pain score of 2.8 in a topical tetracaine group. Andrade et al [35] reported a pain score of 3.2 ± 1.7 for topical proparacaine patients.…”

“…Several factors have been reported to be associated with pain during intravitreal injections, such as anxiety [29], sex, number of previous injections, age [30], ketorolac eye drops [26], needle size [20], and anesthetic technique [31].…”

The intravitreal injection pain study: a randomized control study comparing subjective pain with injection technique

“…As patients were not re-examined at 24 hr, other complications such as subconjunctival haemorrhage were not recorded. Compared to previous studies, a systematic review concluded that there is no sufficient evidence comparing the different anaesthetic techniques and a formal meta-analysis was not possible due to study heterogeneity, but a SCI of 2% lignocaine could be a better option for highly painsensitive patients (Shiroma et al 2017). This study suggests that SCI may be a better option than TP anaesthetic for intravitreal injections given lower pain scores and patient preference.…”

“…Further research is warranted to estimate the incidence and costs associated with the complications of the Nd:YAG laser capsulotomy procedure (Billotte & Berdeaux 2004). The intravitreal injection pain study: a randomized control study comparing subjective pain with injection technique I ncreasing numbers of people require prolonged intravitreal anti-vascular endothelial growth factor (anti-VEGF) for retinal conditions (Stewart 2012), but the most effective peri-procedural analgesia is uncertain (Shiroma et al 2017). We compared the efficacy of two popular techniques, subconjunctival injection (SCI) with 2% lignocaine and topical pledget (TP) with 0.5% amethocaine hydrochloride, through a prospective, randomized control trial.…”

<p>Anesthesia for Intravitreal Injection: A Systematic Review</p>

“…In a review article titled "Patient pain during intravitreal injections under topical anesthesia", Shiroma et al examined eight studies with 847 total subjects through metaanalysis which compared various methods of local anesthesia for intravitreal injection of anti-VEGF or steroids. 25 All reported pain was converted to a 0-100 scale and the investigators decided that a difference in pain of 12 or greater was considered clinically significant. Of the original eight, three studies presented with statistically different levels of pain between anesthetic agents.…”