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T. L. Seid, J. S. Nielsen; Anesthesia Type and Needle Gauge Impact Discomfort Associated With Intravitreal Injection. Invest. Ophthalmol. Vis. Sci. 2009;50(13):5017.
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Intravitreal injection [IVI] of pharmacologic agents is an increasingly common procedure. Patient discomfort associated with IVI can be a barrier to receiving proper care. At present the literature guiding clinical practice toward decreasing IVI associated discomfort is sparse. Our goal was to determine whether subconjunctival lidocaine [SL] injection is superior to topical lidocaine gel [TLG] in limiting IVI pain. We also examined the affect needle gauge had on IVI discomfort.
We conducted a retrospective chart review of 253 patients that had recieved 456 IVIs for adminstration of either bevacizumab, ranibizumab, or triamcinolone. Either SL or TLG were used as anesthesia and a 32g or 30g needle were used as dictated by surgeon preference at the time. After the IVI patients were asked to give an analog pain score [0= no pain - 10=worst pain ever] for the discomfort associated with the entire procedure. Other factors considered included: age, sex, diagnosis, medication administered, and the distance of IVI from the limbus. The data were analyzed with SPSS statistical software.
The mean pain scores were: SL =0.49 [SD±1.188, n=132] and TLG=1.50 [SD±1.802, n=324]. Mann-Whitney U test demonstrated a statistically significant difference in pain scores between the two anesthesia groups independent of other variables (p<0.001). For TLG IVI 139 were performed with a 30g needle, and 175 were performed with a 32g needle. Mean reported pain scores were: 30g =1.35 [SD±1.922], and 32g =1.60 [SD±1.692]. Mann-Whitney U test demonstrated a statistically significant difference in pain scores between the two needle groups independent of other variables (p=.008). Controlling for needle gauge and anesthesia type still demonstrated independent significance for both variables. The SL group had only seven 32g IVIs, too few to merit an analysis Sex, age, diagnosis, medication administered, and injection distance from the limbus were not found to impact pain scores.
Subconjunctival lidocaine provides superior anesthesia compared to topical lidocaine gel for IVI. Among patients that had topical lidocaine anesthesia higher pain scores were reported for the smaller 32g needle injections than those performed with a 30g needle. The difference in pain scores between the two groups is small and the clinical relevance is unknown. Reducing patient discomfort is an important issue in the care of IVI patients.
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