Patient Anxiety Linked to Pain from Anti-VEGF Injections

June 17, 2020

Gauging patient wellbeing prior to intravitreal injections may help inform clinicians as to who may fare worse with the treatment.

Screening questionnaires based around a patient’s anxiety to intravitreal anti-vascular endothelial growth factor (VEGF) injections may help inform ophthalmologists which patients are most likely to suffer from treatment-related pain.

In a new study planned for presentation at the Association for Research in Vision and Ophthalmology (ARVO) 2020 Annual Meeting prior to its cancellation, a team of New York-based investigators found associations between self-reported anxiety and increased perceptions of pain due to the common intraocular injection therapy.

The team, led by Joyce Mbekeani, MD, of the Albert Einstein College of Medicine, sought to assess patient characteristics that could predict procedural pain. They did so by evaluating patient anxiety levels and sleep patterns.

Mbekeani and colleagues noted that, while intravitreal anti-VEGF injections are the most commonly performed intraocular procedure in the world and are linked to consistent tolerability, patients are susceptible to pain.

Investigators conducted the prospective, non-interventional trial using surveyed, consecutive patients scheduled for intravitreal anti-VEGF injections by 2 experienced retinal surgeons from separate clinical sites. Patients were all administered a standard dose of bevacizumab superotemporally and without subconjunctival anesthesia.

Anxiety and sleep metrics were gauged by patient-response, pre-procedure GAD-7 Anxiety and Pittsburgh Sleep Quality Index (PSQI) questionnaires, respectively. Both questionnaires grade patient anxiety and poor sleep severity on a 0-21 scale, with greater numbers indicating worse signs and symptoms.

The team also assessed patient post-injection pain on a visual analogue 0-10 scale. Considerations were made to patient demographics, diagnoses, laterality, hours of sleep, and rate of previous intravitreal injections.

Statistical analysis was conducted via student’s T and chi-squared tests, as well as Spearman’s rank correlation and regression calculations through a software program. Significance was set at P <.05.

Of the 154 observed patients, 140 were eligible for assessment. Each of the gauged surgeons had conducted 70 intravitreal injections in the remaining patient population. Mean patient age was 72.1 years old, with a majority (56.4%) being female.

Mean patient anxiety score was 4.9; mean PSQI score was 6.3; mean injection pain score was 3.69. Mbekeani and colleagues observed a significant correlation between injection pain and anxiety (rho = 0.25; P = .003).

Investigators also observed a negative correlation between pain and previous night’s sleep—as per hours slept—while PSQI was positively correlated with injection pain (rho = 0.14; P = .11). However, neither correlation had statistical significance.

The only significant predictor of injection pain was patient anxiety (B = .11; P = .0034). Every one-point increase on the anxiety scale was associated with a 0.11-point increase in regression model-predicted injection pain, after controlling for observed patient demographics and treatment history.

Mbekeani and colleagues did not find patient age, gender, laterality, disease diagnosis, and previous injection history to be predictors of injection pain.

The team concluded that the use of anxiety questionnaires prior to anti-VEGF administration may help clinicians identify and aide patients who are at risk for elevated pain from intravitreal injections.

“Anxiety level was the best predictor of perceived intravitreal injection pain,” they wrote. “Future studies of modifications that target anxiety may help address pain perception in this procedure.”

The study, “Impact of Anxiety Levels and Sleep Patterns on Perceived Pain During Intravitreal Injections,” was published online in Investigative Ophthalmology & Visual Science.