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Stephen Winkler, Dan Alter, MD PhD; A Topical Protocol to Minimize Pain Following Intravitreal Injections. Invest. Ophthalmol. Vis. Sci. 2012;53(14):886.
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To devise a standardized protocol for diminishing pain following intravitreal injections.
A retrospective study of 161 eyes that, based on what date they presented to the clinic, received one or four post injection washouts. Initially, all patients received either one drop of tetracaine or lidocaine followed by a single drop of povidone iodine 10%. Following dilation, the patients were given 5 drops of topical anesthetic (tetracaine or lidocaine 2%). A lid speculum was placed and another drop of PI-10% was given. The injection was given and one of four post injection washouts (gatifloxacin, gatifloxacin + prednisolone, eyewash, lidocaine 2% topical solution) was performed. Patients were then asked to rate their pain on a 1-10 scale immediately after washout. Twenty fours hours post injection, patients were asked rate their average pain score over the course of the day on the same scale.
Of the 161 eyes injected, 38 were partitioned into group 1 (gatifloxacin only), 35 into group 2 (gatifloxacin + prednisolone), 38 into group 3 (eyewash) and 50 into group 4 (lidocaine). The average pains scores initially following the washouts were 4.31 (SD 2.63), 4.31 (SD 2.16), 6.54 (SD 1.83), and 2.70 (SD 1.80) for groups 1 through 4 respectively. The average pain scores over 24 hours post injection were 5.54 (SD 2.97), 4.80 (SD 2.42) 2.54 (SD 2.22) for groups 1, 2, and 4 respectively. It is of note that due to the unacceptable pain score reported by group 3 patients immediately following injection a lidocaine 2% washout was initiated for 26 of the patients post eyewash. Their initial pain score was 3.5 (SD 1.6) following lidocaine washout. Wilcoxon rank sum analysis was used to show statistical significance in washout treatment between group 4 and 1 through 3.
The number of intravitreal injections is growing exponentially and will only increase with the advent of new medications, indications for injections, and the aging population. Efficient delivery of anesthesia and effective pain control will become increasingly important to maintain patient comfort and compliance. A simple protocol that maintains efficiency but minimizes pain and post injection complications will be crucial. The protocol involving topical lidocaine along with a lidocaine washout not only avoids a subconjunctival injection but also demonstrates pain control both initially and over the course of 24 hours following the intravitreal injection.
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