Impact of Anxiety Levels and Sleep Patterns on Perceived Pain During Intravitreal Injections

Abstract

Purpose : Intravitreal anti-VEGF injections (IVA) are the most commonly performed intraocular procedure worldwide. Although generally well tolerated, patients may experience pain. Several studies have evaluated pain modifying techniques, including anesthesia or changing injection site. We sought to evaluate patient characteristics that might be predictive of procedural pain, using anxiety levels and sleep patterns.

Methods : This prospective non interventional study surveyed consecutive patients, scheduled for IVA by two experienced retinal surgeons at separate sites. They employed the same IVA technique, using a standard dose of Bevacizumab, delivered superotemporally and without subconjunctival anesthesia. Patients filled out pre-procedure GAD-7 Anxiety (0-21) and Pittsburgh Sleep Quality Index (PSQI) questionnaires (0-21). Higher PSQI indicate poor sleep quality. Post IVA pain was assessed with a visual analogue scale (0-10). Patient demographics, diagnoses, laterality, hours of sleep and number of previous IVA were documented. Statistical analysis was conducted using student’s t and chi-squared tests and Spearman’s rank correlation and regression calculations with RStudio software. Significance was set at p<0.05.

Results : 140 out of 154 patients who participated in the study met inclusion criteria for analysis. Each surgeon performed 70 IVA. Mean (SD) age was 72.1(14.2) yrs and male:female ratio was 61:79. Mean (SD) anxiety score was 4.9 (5.6), PSQI, 6.3 (4.1) and IVA pain 3.69 (2.64). Anxiety was significantly correlated with IVA pain (rho=0.25; p=0.003). Previous night’s sleep (hours) was negatively correlated with pain (rho=-0.16; p-0.057) while PSQI was positively correlated with IVA pain (rho=0.14; p=0.11) but both, without significance. Regression indicated that the only significant predictor of IVA pain was anxiety (B=0.11, p=0.0034). For every point increase on the anxiety scale, the regression model predicted a 0.11-point increase in IVA pain, after controlling for confounding variables. Age, gender, laterality, diagnosis, previous injections and surgeon/site were not predictors of IVA pain.

Conclusions : Anxiety level was the best predictor of perceived intravitreal injection pain. Anxiety screening questionnaires may help practitioners identify patients at risk for elevated pain. Future studies of modifications that target anxiety may help address pain perception in this procedure.

This is a 2020 ARVO Annual Meeting abstract.