Comparison of 3 different anesthetic approaches for intravitreal injections:
          a prospective randomized trial

Andrade, Gabriel Costa de; Carvalho, André Correa Maia de

doi:10.5935/0004-2749.20150008

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Original Articles • Arq. Bras. Oftalmol. 78 (1) • Jan-Feb 2015 • https://doi.org/10.5935/0004-2749.20150008 copy

Comparison of 3 different anesthetic approaches for intravitreal injections: a prospective randomized trial

Comparação de três abordagens anestésicas diferentes para injeções intravítreas: um estudo prospectivo e randomizado

Authorship SCIMAGO INSTITUTIONS RANKINGS

Purpose:

To compare the anesthetic effectiveness of topical proparacaine drops, subconjunctival lidocaine, and 2% lidocaine gel.

Methods:

Ninety-two patients undergoing intravitreal injections were randomized to 1 of 3 groups: proparacaine 0.5% drops (Group Drops), proparacaine 0.5% drops plus subconjunctival lidocaine (Group SC), or 2% lidocaine gel (Group Gel). Patients were asked to score their pain experience using a visual analog scale of 0 to 10 immediately following the injections and 10 min, 1 h, 6 h, and 24 h after the injections. Patients also graded the overall injection experience as Excellent, Very Good, Fair, Poor, or Awful. The physician evaluated the patients’ eye movement during intravitreal injection on 3 levels: (0) none or minimal, (1) not compromising the injection, and (2) compromising the injection.

Results:

The patients in Group Drops had the worst mean pain scores during the injection and 10 min after, with the highest occurrence of movements compromising the procedure (Grade 2; 38.7%). The patients in Group SC had a higher percentage of good experiences (37.9%) but a higher incidence of chemosis (16.7%). The patients in Group Gel had similar overall pain scores to Group Drops patients but a higher incidence of keratitis (19.4%). There was no statistically significant correlation between the use of aspirin or anticoagulants and the occurrence of hyperemia or hyposphagma.

Conclusion:

Subconjunctival lidocaine was most effective in preventing pain and eye movements during intravitreal injections. Although 2% lidocaine gel produced a good overall experience for the patients, the incidence of keratitis was very high (19.4%). Therefore, we do not recommend 2% lidocaine gel as the first anesthetic choice for intravitreal injections. There is no evidence to suspend the use of aspirin or other anticoagulants drugs prior to intravitreal injections.

Efficacy; Anesthesia; Propoxycaine/administration & dosage; Lidocaine/ administration & dosage; Intravitreal injections; Conjunctiva/drug effects

	Anesthetic approach
	Group Drops		Group SC		Group Gel		Total
	N	%	N	%	N	%	N	%	p value^* * = p value (chi-square test or Fisher's exact test(a));
Sex	31	100.0%	30	100.0%	31	100.0%	92	100.0%	0.715
Female	17	54.8%	14	46.7%	14	45.2%	45	48.9%
Male	14	45.2%	16	53.3%	17	54.8%	47	51.1%
Disease	31	100.0%	30	100.0%	31	100.0%	92	100.0%	0.103^a
Age-related macular degeneration	9	29.0%	11	36.7%	11	35.5%	31	33.7%
Diabetic macular edema	22	71.0%	13	43.3%	15	48.4%	50	54.3%
Branch retinal vein occlusion	0	0.0%	5	16.7%	4	12.9%	9	9.8%
Central retinal vein occlusion	0	0.0%	1	3.3%	1	3.2%	2	2.2%
Sistemic arterial hypertension	31	100.0%	30	100.0%	31	100.0%	92	100.0%	0.409
No	14	45.2%	9	30.0%	10	32.3%	33	35.9%
Yes	17	54.8%	21	70.0%	21	67.7%	59	64.1%
Diabetes mellitus	31	100.0%	30	100.0%	31	100.0%	92	100.0%	0.349
No	12	38.7%	17	56.7%	16	51.6%	45	48.9%
Yes	19	61.3%	13	43.3%	15	48.4%	47	51.1%
Anticoagulant use	31	100.0%	30	100.0%	31	100.0%	92	100.0%	0.417^a * = p value (chi-square test or Fisher's exact test(a));
No	29	93.5%	25	83.3%	29	93.5%	83	90.2%
Yes	2	6.5%	5	16.7%	2	6.5%	9	9.8%
Aspirin use	31	100.0%	30	100.0%	31	100.0%	92	100.0%	0.147
No	26	83.9%	27	90.0%	22	71.0%	75	81.5%
Yes	5	16.1%	3	10.0%	9	29.0%	17	18.5%

	Treatments
	Group Drops		Group SC		Group Gel		Total
	N	%	N	%	N	%	N	%	p value^* * = p value (chi-square test or Fisher's exact test(a));
Experiment procedure as a whole	31	1000%	30	100.0%	31	100.0%	91	100.0%	<0.001^a * = p value (chi-square test or Fisher's exact test(a));
Awful	0	0.0%	0	0.0%	3	9.7%	3	3.3%
Poor	6	19.4%	0	0.0%	1	3.2%	07	7.7%
Fair	19	61.3%	4	13.8%	5	16.1%	28	30.8%
Very good	6	19.4%	14	48.3%	21	67.7%	41	045.1%
Excellent	0	0.0%	11	37.9%	1	3.2%	12	13.2%

	Anesthetic approach
	Group Drops		Group SC		Group Gel		Total
	N	%	N	%	N	%	N	%	p value^* * = p value (chi-square test or Fisher's exact test(a)).
Degree of eye movement	31	100.0%	30	100.0%	31	100.0%	92	100.0%	<0.001^a * = p value (chi-square test or Fisher's exact test(a)).
Minimum or absent	4	12.9%	25	83.3%	16	51.6%	45	48.9%
Not compromising the injection	15	48.4%	4	13.3%	14	45.2%	33	35.9%
Compromising the injection	12	38.7%	1	3.3%	1	3.2%	14	15.2%

	Treatments
	Group Drops		Group SC		Group Gel		Total
	N	%	N	%	N	%	N	%	P^* * p= value (chi-square test or Fisher's exact test(a)).
Hyperemia	31	100.0%	30	100.0%	31	100.0%	92	100.0%	0.326
No	18	58.1%	13	43.3%	19	61.3%	50	54.3%
Yes	13	41.9%	17	56.7%	12	038.7%	42	045.7%
Hyposphagma	31	100.0%	30	100.0%	31	100.0%	92	100.0%	0.190
No	22	71.0%	15	50.09%	21	67.7%	58	63.0%
Yes	9	29.0%	15	050.0%	10	032.3%	34	037.0%
Chemosis	31	100.0%	30	100.0%	31	100.0%	92	100.0%	0.017^a * p= value (chi-square test or Fisher's exact test(a)).
No	30	96.8%	25	83.3%	31	100.0%	86	93.5%
Yes	1	3.2%	5	016.7%	0	0.0%	6	006.5%
Keratitis	31	100.0%	30	100.0%	31	100.0%	92	100.0%	0.003^a * p= value (chi-square test or Fisher's exact test(a)).
No	31	100.0%	30	100.0%	25	80.6%	86	093.5%
Yes	0	0.0%	0	0.0%	6	19.4%	6	6.5%

	Hyposphagma
	No		Yes		Total
	N	%	N	%	N	%	p value^* * = p value (chi-square test or Fisher's exact test(a).
Aspirin	58	100.0%	34	100.0%	92	100.0%	0.339
No	49	84.5%	26	76.5%	75	81.5%
Yes	9	15.5%	8	23.5%	17	18.5%
Anticoagulant	58	100.0%	34	100.0%	92	100.0%	0.721^a * = p value (chi-square test or Fisher's exact test(a).
No	53	91.4%	30	88.2%	83	90.2%
Yes	5	8.6%	4	11.8%	9	9.8%

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[1] Corresponding author: Gabriel Costa de Andrade. Alameda Gabriel Monteiro da Silva, 987 - São Paulo, SP - 01441-000 - Brazil - E-mail: drgabrielandrade@gmail.com