Ronald Gentile, MD: Pain Management and Anti-VEGF Adherence

Investigators at Mount Sinai in New York found that using a topical nonsteroidal anti-inflammatory drug (NSAID) following an intravitreal injection significantly reduced patient pain at 6 hours and 24 hours post-injection compared to control.

One study author, Ronald Gentile, MD, professor of ophthalmology at the Icahn School of Medicine at Mount Sinai in New York, emphasized the effect that pain management can have on adherence for patients who need regular intravitreal injections.

“Patients fear going blind, but they also fear the pain of the treatment,” Gentile told MD Magazine®. “So, let's see if we can do something to decrease their fear of the pain, which will get them to actually potentially show up for their injections and feel better about their care.”

The single-blinded, placebo-controlled study of 56 patients randomized participants to receive either a single drop of nepafenac .3% (n = 19), a pressure patch for two hours (n = 18), or a single drop of preservative-free tears (n = 19) following an injection of bevacizumab, aflibercept, or triamcinolone acetonide. Participants had diabetic macular edema, age-related macular degeneration, retinal vein occlusion, or another diagnosis. Patient pain was assessed using the Numeric Pain Rating Scale and investigators controlled for age, gender, number of prior injections, and administering physician.

Pain scores in patients in the nepafenac group were significantly lower than those in the control group at 6 hours (−1.3 ± .6 less, P = .047) and at 24 hours (−.7 ± .3 less, P= .047).

Participants in the pressure patch group had lower pain scores than those in the control group, but the difference did not reach statistical significance.

The data were presented as a poster titled, “Pain Control Following Intravitreal Injection Using Topical Nepefanac 0.3% or Pressure Patching: A Prospective, Randomized, Placebo Controlled Trial,” at the 2018 American Academy of Ophthalmology Annual Meeting in Chicago, IL.

Why is it important to consider patient pain after intravitreal injections?

What were the study’s top results?

What can we learn from the study results to improve clinical practices?

What’s your advice for colleagues who aren’t using pain reduction methods?

How do pain-reduction efforts like these affect patient adherence/compliance?

Transcript is edited for clarity.It's a pleasure to be able to talk about this study. This is a very important study, I feel, because patient satisfaction—and the patient experience—is something that all ophthalmologists and all doctors need to put on the top of their priority list.What we found is that the nonsteroidal [eye] drop and the pressure patch group decreased patients’ pain after the intravitreal injection. What we found is that the nonsteroidal [eye] drop improved [patient experience] and it was actually statistically significant by decreasing their pain scores 6 hours and 24 hours after the intravitreal injection.So, what we've learned from the study is if we combine [the nonsteroidal eye drop and pressure patch], what we found is that the patient experience is markedly improved. How do we know this? Well patients who did not have this done in the past, who now have that done as our standard procedure, say they feel a lot more comfortable and can get back to work and really get back to their normal daily activities after the injection much faster than they could prior to implementing these procedures.Colleagues that are not using any techniques to improve the patient experience: may I stress to them that the future is going to be in the patient's experience and patient satisfaction. The online reviews, the reviews that patients fill out for Press Ganey scores, are going to be reflected in terms of how they give their individual injections and how much emphasis they put on the patient experience. So, I would tell them to look into this and to take note of the patient experience and try to make the patient's experience as good as possible.So, if the patient experience is poor it doesn't matter how great the medicine works, if the patient doesn't come in for their treatment and we see this all the time. Patients fear going blind, but they also fear the pain of the treatment. So, let's see if we can do something to decrease their fear of the pain, which will get them to actually potentially show up for their injections and feel better about their care. The worst thing we can do is have a patient non-compliant because of something we did or something that we actually have control over in the future to improve their experience.