Accepted Manuscript Sub-Conjunctival Lidocaine Injection before Intravitreal Injection Jonathan Hernandez, BS Kyle Marra, BS Jorge Arroyo, MD, MPH
PII:
S0039-6257(14)00041-1
DOI:
10.1016/j.survophthal.2014.01.008
Reference:
SOP 6507
To appear in:
Survey of Ophthalmology
Received Date: 23 January 2014 Accepted Date: 23 January 2014
Please cite this article as: Hernandez J, Marra K, Arroyo J, Sub-Conjunctival Lidocaine Injection before Intravitreal Injection, Survey of Ophthalmology (2014), doi: 10.1016/j.survophthal.2014.01.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Sub-Conjunctival Lidocaine Injection before Intravitreal Injection Blaha GR, Tilton EP, Barouch FC, et al. Randomized Trial of Anesthetic Methods for Intravitreal Injections. Retina. 2011;31(3):535-539.
M AN U
SC
RI PT
Purpose: To compare the effectiveness of four different anesthetic methods for intravitreal injection. Methods: Twenty-four patients each received four intravitreal injections using each of four types of anesthesia (proparacaine, tetracaine, lidocaine pledget, and subconjunctival injection of lidocaine) in a prospective, masked, randomized block design. Pain was graded by the patient on a 0 to 10 scale for both the anesthesia and the injection. Results: The average combined pain scores for both the anesthesia and the intravitreal injection were 4.4 for the lidocaine pledget, 3.5 for topical proparacaine, 3.8 for the subconjunctival lidocaine injection, and 4.1 for topical tetracaine. The differences were not significant (P = 0.65). There were also no statistical differences in the individual anesthesia or injection pain scores. Subconjunctival lidocaine injection had the most side effects. Conclusion: Topical anesthesia is an effective method for limiting pain associated with intravitreal injections. Comment
Intravitreal injections are the most common procedure performed in ophthalmology practices. Our retina service, like many across the country, sets aside weekly injection clinics to accommodate for the high volume of injections delivered. Even though this procedure is commonplace, however,there is a lack of consensus regarding what type of anesthesia to employ before the intravitreal injection.
AC C
EP
TE D
Blaha et al. addressed this question by conducting a prospective study in a randomized block design that asked 24 masked patients to rate four anesthetic techniques – topical proparacaine, topical tetracaine, 4% lidocaine pledget, and subconjuctival injection of 2% lidocaine.1 Patients rated both the pain of the injection and the pain of the anesthesia on a scale from zero to ten. Proparacaine received the lowest pain score for the anesthesia while subconjunctival lidocane trended towards the highest anesthesia pain. There was, however, no statistically significant difference for the pain score associated with the application of the four anesthetic interventions. Pain due to the intravitreal injection itself was lowest after subconjunctival anesthesia, but there was also no statistical significant difference between the pain scores reported for the intravitreal injection. The authors conclude that topical anesthesia is the most reasonable choice of anesthesia because its pain scores were not significantly different from the more invasive methods and it has minimal side effects. They cite that 54% of patients receiving the subconjunctival injection developed a subconjunctival hemorrhage from the anesthesia, while none of the patients receiving topical drops did. Prenner subsequently presented an editorial where he discusses the merits of the study.2 He notes that the study is the best designed in the literature and that the results echo previous less robust studies that have found that the overall pain experience is equivalent for the most commonly used anesthetic practices. In our practice, we have tried different anesthetic regimens over time and currently use proparacaine drops and 3.5% lidocaine gel (Akten) before a subconjunctival 2% lidocaine
ACCEPTED MANUSCRIPT
RI PT
injection. In recognition of the subconjunctival hemorrhages and possible discomfort associated with subconjuctival lidocaine injections, we recently tried lidocaine pledgets for three months. Many patients qualitatively reported that the cumulative discomfort of the pledget was greater than that of the subconjunctival injection. Based partially on the results from the Blaha et al. paper, we then tried using only 0.5% topical tetracaine drops and lidocaine gel prior to intravitreal injection; however, this was not effective in reducing pain from the intravitreal injection in all of patients. After multiple patient requests, we returned to using subconjunctival lidocaine injections in all of our patients prior to intravitreal injection.
M AN U
SC
Importantly, we find that the more complete local anesthesia produced by subconjunctival lidocaine injection is particularly effective in reducing overall patient anxiety and discomfort in a teaching hospital setting, where rotating residents and fellows perform most of the injections. Of note, we wait at least 5 minutes between the subconjunction injection and the intravitreal injection, while Blaha et al waited only one minute in their study. We believe it is important to tailor the intravitreal injection anesthetic regimen using the results from the Blaha et al study in the context of one’s specific practice setting. Jonathan Hernandez, BS Kyle Marra, BS Jorge Arroyo, MD, MPH Boston, Massachusetts
References
TE D
EP
2.
Blaha GR, Tilton EP, Barouch FC, Marx JL. Randomized trial of anesthetic methods for intravitreal injections. Retina. Mar 2011;31(3):535-539. Prenner JL. Anesthesia for intravitreal injection. Retina. Mar 2011;31(3):433-434.
AC C
1.
PII:
S0039-6257(14)00041-1
DOI:
10.1016/j.survophthal.2014.01.008
Reference:
SOP 6507
To appear in:
Survey of Ophthalmology
Received Date: 23 January 2014 Accepted Date: 23 January 2014
Please cite this article as: Hernandez J, Marra K, Arroyo J, Sub-Conjunctival Lidocaine Injection before Intravitreal Injection, Survey of Ophthalmology (2014), doi: 10.1016/j.survophthal.2014.01.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Sub-Conjunctival Lidocaine Injection before Intravitreal Injection Blaha GR, Tilton EP, Barouch FC, et al. Randomized Trial of Anesthetic Methods for Intravitreal Injections. Retina. 2011;31(3):535-539.
M AN U
SC
RI PT
Purpose: To compare the effectiveness of four different anesthetic methods for intravitreal injection. Methods: Twenty-four patients each received four intravitreal injections using each of four types of anesthesia (proparacaine, tetracaine, lidocaine pledget, and subconjunctival injection of lidocaine) in a prospective, masked, randomized block design. Pain was graded by the patient on a 0 to 10 scale for both the anesthesia and the injection. Results: The average combined pain scores for both the anesthesia and the intravitreal injection were 4.4 for the lidocaine pledget, 3.5 for topical proparacaine, 3.8 for the subconjunctival lidocaine injection, and 4.1 for topical tetracaine. The differences were not significant (P = 0.65). There were also no statistical differences in the individual anesthesia or injection pain scores. Subconjunctival lidocaine injection had the most side effects. Conclusion: Topical anesthesia is an effective method for limiting pain associated with intravitreal injections. Comment
Intravitreal injections are the most common procedure performed in ophthalmology practices. Our retina service, like many across the country, sets aside weekly injection clinics to accommodate for the high volume of injections delivered. Even though this procedure is commonplace, however,there is a lack of consensus regarding what type of anesthesia to employ before the intravitreal injection.
AC C
EP
TE D
Blaha et al. addressed this question by conducting a prospective study in a randomized block design that asked 24 masked patients to rate four anesthetic techniques – topical proparacaine, topical tetracaine, 4% lidocaine pledget, and subconjuctival injection of 2% lidocaine.1 Patients rated both the pain of the injection and the pain of the anesthesia on a scale from zero to ten. Proparacaine received the lowest pain score for the anesthesia while subconjunctival lidocane trended towards the highest anesthesia pain. There was, however, no statistically significant difference for the pain score associated with the application of the four anesthetic interventions. Pain due to the intravitreal injection itself was lowest after subconjunctival anesthesia, but there was also no statistical significant difference between the pain scores reported for the intravitreal injection. The authors conclude that topical anesthesia is the most reasonable choice of anesthesia because its pain scores were not significantly different from the more invasive methods and it has minimal side effects. They cite that 54% of patients receiving the subconjunctival injection developed a subconjunctival hemorrhage from the anesthesia, while none of the patients receiving topical drops did. Prenner subsequently presented an editorial where he discusses the merits of the study.2 He notes that the study is the best designed in the literature and that the results echo previous less robust studies that have found that the overall pain experience is equivalent for the most commonly used anesthetic practices. In our practice, we have tried different anesthetic regimens over time and currently use proparacaine drops and 3.5% lidocaine gel (Akten) before a subconjunctival 2% lidocaine
ACCEPTED MANUSCRIPT
RI PT
injection. In recognition of the subconjunctival hemorrhages and possible discomfort associated with subconjuctival lidocaine injections, we recently tried lidocaine pledgets for three months. Many patients qualitatively reported that the cumulative discomfort of the pledget was greater than that of the subconjunctival injection. Based partially on the results from the Blaha et al. paper, we then tried using only 0.5% topical tetracaine drops and lidocaine gel prior to intravitreal injection; however, this was not effective in reducing pain from the intravitreal injection in all of patients. After multiple patient requests, we returned to using subconjunctival lidocaine injections in all of our patients prior to intravitreal injection.
M AN U
SC
Importantly, we find that the more complete local anesthesia produced by subconjunctival lidocaine injection is particularly effective in reducing overall patient anxiety and discomfort in a teaching hospital setting, where rotating residents and fellows perform most of the injections. Of note, we wait at least 5 minutes between the subconjunction injection and the intravitreal injection, while Blaha et al waited only one minute in their study. We believe it is important to tailor the intravitreal injection anesthetic regimen using the results from the Blaha et al study in the context of one’s specific practice setting. Jonathan Hernandez, BS Kyle Marra, BS Jorge Arroyo, MD, MPH Boston, Massachusetts
References
TE D
EP
2.
Blaha GR, Tilton EP, Barouch FC, Marx JL. Randomized trial of anesthetic methods for intravitreal injections. Retina. Mar 2011;31(3):535-539. Prenner JL. Anesthesia for intravitreal injection. Retina. Mar 2011;31(3):433-434.
AC C
1.
