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.
Highlights
Intravitreal injection (IVI) is a very common vitreoretinal procedure, and multiple injections are often required per patient
Antibiotics, and antiviral drugs have been injected into the vitreous humor for many years, but the use of IVI has increased dramatically only recently after the introduction of anti-vascular endothelial growth factor (VEGF) therapy for neovascular age-related macular degeneration [2]
Other techniques include the use of an anesthetic gel, peribulbar block, subconjunctival injection, and a pledget soaked in anesthetic [3]
Summary
Intravitreal 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. Intravitreal injection (IVI) is one of the most common vitreoretinal procedures performed nowadays [1]. Antibiotics, and antiviral drugs have been injected into the vitreous humor for many years, but the use of IVI has increased dramatically only recently after the introduction of anti-vascular endothelial growth factor (VEGF) therapy for neovascular age-related macular degeneration [2]. Patients may experience pain during IVI [3], especially if multiple injections are required. The use of local anesthetics minimizes pain and avoids intraocular complications caused by pain-induced rapid, uncontrolled movements of the eye [4]. Most ophthalmologists (65–90%) perform IVI using local anesthetic eye drops [5]. There is no consensus on the best anesthetic option [6]
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