Emotional and physical experiences of people with neovascular age-related macular degeneration during the injection process in Germany: a qualitative study.

OBJECTIVES: In order to better understand the continued barriers to the provision of vascular endothelial inhibitor therapy, this study aims to investigate patients' experiences with neovascular age-related macular degeneration (nvAMD) in Germany during the injection process and how they deal with it. DESIGN AND PARTICIPANTS: This analysis is part of the qualitative arm of a wider mixed-methods study. We recruited participants all over Germany via ophthalmologists, eye clinics, general practitioners, care bases and support groups between June 2018 and December 2020 and selected a subsample of study participants with nvAMD who were either undergoing or had previously undergone vascular endothelial growth factor inhibitor therapy. We conducted narrative, semistructured, face-to-face interviews at the participants' homes, which were audio-recorded. The interviews were thematically analysed. RESULTS: Twenty-two participants were included in this analysis. Experiencing neovascular macular degeneration was dominated by the injection experience. Study participants perceived the treatment with vascular endothelial inhibitor injections as uncomfortable, and they described undergoing varying levels of anxiety during the whole injection process. After some years of receiving multiple injections, the pain and not experiencing any positive effects made participants with significant vision loss want to discontinue therapy. Furthermore, they narrated negative injection experiences in association with their interactions with medical staff and doctors. CONCLUSION: Although time in the medical setting is limited, efficient and good doctor-patient relationships seem crucial for satisfying care experiences. A respectful and humane relationship may be one key to achieving treatment adherence.

Patient experience of anti-vegf intravitreal injection.

Intravitreal anti-vascular epithelial growth factor (anti-VEGF) injections have revolutionised the treatment of macular diseases, but can be stressful for the patient. We surveyed 904 patients receiving injections at 5 centres in France regarding their feelings toward anti-VEGF injections. The mean age was 77.4 years, and the injections were performed mostly for age related macular degeneration (72%). Half of the patients had previously received>10 injections, 35.6% had received 3-10 injections, and 14.2% had received<3 injections. The mean (SD) stress score was 4.2 [on a scale from 1-10 (0=least stressful, 10=extremely stressful)]. Most patients (70%) reported low to moderate stress (score ≤5). The number of previous injections did not influence stress scores. Paradoxically, 61.2% of patients reported finding injections to be less stressful over time. Most patients found injections to be less traumatic than expected (64%) or just as they had anticipated (25%). Most patients (88%) were not bothered by the presence of other patients in the waiting room. Most patients (78.8%) preferred to be injected quickly before they had time to feel stressed about the procedure. Injections were generally well accepted; most patients would prefer to maintain their current schedule of injections and their current vision (55.7%), or would be willing to have more frequent injections for better vision (39.5%). Our results suggest that stress appears to be more related to the patient's psychological make-up than to the treatment experience or the number of injections received.

Association of Intravitreal Injections With Blood Pressure Increase: The Following Excitement and Anxiety Response Under Intravitreal Injection Study.

Importance: Despite the unquestionable effectiveness of anti-vascular endothelial growth factor therapy (VEGF), there is ongoing controversy about potential systemic adverse effects. Besides the direct adverse effects of anti-VEGF agents, other factors associated with the injection itself, such as perioperative blood pressure fluctuations, may contribute to adverse events. Objective: To determine blood pressure fluctuations during intravitreal injections. Design, Setting, and Participants: Prospective observational study at a tertiary referral center (Department of Ophthalmology, University Hospital Bern, Bern, Switzerland). Consecutive patients scheduled for intravitreal injections were recruited. Data were analyzed between October 2017 and January 2018. Main Outcomes and Measures: Systolic and diastolic blood pressure, pulse rate, and oxygen saturation were recorded before, during, and after the intravitreal injection. An anxiety questionnaire was completed by all participants. Multivariate regression analysis was used to investigate potential factors associated with blood pressure rise during injections. Results: Two hundred one patients (92 women and 109 men) were included in this study, with a mean age of 68 years (range, 18-93 years). Mean (SD) systolic blood pressure increased from a baseline of 150 (20) mm Hg to 162 (24) mm Hg following the preparation procedure to 168 (24) mm Hg during the injection (P < .001). Mean (SD) diastolic blood pressure increased from 78 (14) mm Hg to 83 (37) mm Hg to 83 (16) mm Hg, respectively (P = .009). Mean (SD) pulse frequency increased from 76 (13) bpm to 80 (13) bpm (P = .005). In total, 23 patients (11%) had a systolic blood pressure greater than 200 mm Hg. This subgroup of patients had a mean (SD) perioperative systolic blood pressure increase from 182 (19) mm Hg to 214 (12) mm Hg, resulting in an increase of 32 (20) mm Hg (P < .001). Age and anxiety were to be next associated with systolic blood pressure rise. Conclusions and Relevance: The intravitreal injection process is associated with a transient increase in blood pressure. Most of the increase occurs following the preparation before the injection itself. This may constitute a risk factor for cardiovascular or cerebrovascular complications during treatment and could be of particular relevance in patients at high risk for such events and those receiving frequent injections. Future work may be needed to determine whether, in patients at risk for cardiovascular or cerebrovascular events, perioperative blood pressure monitoring or antihypertensive therapy needs to be considered.

Experiences of patients undergoing repeated intravitreal anti-vascular endothelial growth factor injections for neovascular age-related macular degeneration.

Current therapy to slow disease progression in patients with neovascular age-related macular degeneration (AMD) entails regular intravitreal anti-vascular endothelial growth factor (VEGF) injections, often indefinitely. Little is known about the burden imposed on patients by this repetitive treatment schedule and how this can be best managed. The aim of this study was to explore the psychosocial impact of repeated intravitreal injections on patients with neovascular AMD. Forty patients (16 males, 24 females) with neovascular AMD undergoing anti-VEGF treatment were recruited using purposive sampling from a private ophthalmology practice and public hospital in Melbourne. Patients were surveyed using the Macular Disease Treatment Satisfaction Questionnaire (MacTSQ; Bradley, Health Psychology Research Unit, Surrey, England) and underwent semi-structured, one-on-one interviews. Interview topics were: treatment burden and satisfaction; tolerability; barriers to adherence; treatment motivation; and patient education. Interviews were audio recorded and thematic analysis performed using NVivo 10 (QSR International, Doncaster, Australia). Patients recognised the importance of treatment to preserve eyesight, yet experienced significant psychosocial and practical burden from the treatment schedule. Important issues included treatment-related anxiety, financial considerations and transport burden placed on relatives or carers. Many patients were restricted to sedentary activities post-injection owing to treatment side effects. Patients prioritised treatment, often sacrificing family, travel and social commitments owing to a fear of losing eyesight if treatment was not received. Whilst anti-VEGF injections represent the current mainstay of treatment for neovascular AMD, the ongoing treatment protocol imposes significant burden on patients. An understanding of the factors that contribute to the burden of treatment may help inform strategies to lessen its impact and assist patients to better manage the challenges of treatment.

Intravitreal injections service: a patient experience evaluation.

INTRODUCTION: This survey has been conducted following the introduction of nurse-led intravitreal injections clinics at the Great Western Hospital. A team of 5 nurses regularly carry out an average of 90 injections per week. METHODS: A series of 169 consecutive injection patients have been offered the study questionnaire between 28 January 2016 and 28 February 2016; patients with no previous experience with a nurse injector were excluded. RESULTS: 76.9% strongly agree that the nurse is more friendly and sensitive to their needs. Only 12.4% strongly agree that a doctor will be more suitable to deliver the injections. Seventy-five percent stated that they were very happy with the care, while 0.4% thought a nurse would be unsafe; 69.2% feel more comfortable asking questions when with a nurse injector. Anxiety and nervousness were found to be the main two symptoms experienced by patients around the time of injections (27.8% and 34.9%, respectively). DISCUSSION: The questionnaire was designed based on the feedback from the local friends and family test. A clear majority of patients gave highly positive feedback about nurse injectors. Considering patients' individual needs at the time of injections, such as allergies or points that needs clarification, helps in overcoming some of the psychological complications of treatment.

Experience of Anti-VEGF Treatment and Clinical Levels of Depression and Anxiety in Patients With Wet Age-Related Macular Degeneration.

PURPOSE: To investigate detailed patient experiences specific to receiving vascular endothelial growth factor inhibitors (anti-VEGF) for wet age-related macular degeneration (wAMD), and to acquire a snapshot of the frequency of clinically significant levels of depression, anxiety, and posttraumatic stress among patients and levels of burden in patients' carers. DESIGN: Observational cross-sectional mixed-methods study. METHODS: Three hundred patients with wAMD receiving anti-VEGF treatment and 100 patient carers were recruited. Qualitative data on patients' experience of treatment were collected using a structured survey. Standardized validated questionnaires were used to quantify clinically significant levels of anxiety, depression, and posttraumatic stress, as well as cognitive function and carers' burden. RESULTS: Qualitative data showed that 56% of patients (n = 132) reported anxiety related to anti-VEGF treatment. The main sources of anxiety were fear of going blind owing to intravitreal injections and concerns about treatment effectiveness, rather than around pain. From validated questionnaires, 17% of patients (n = 52) showed clinical levels of anxiety and 12% (n = 36) showed clinical levels of depression. Depression levels, but not anxiety, were significantly higher in patients who received up to 3 injections compared with patients who received from 4 to 12 injections (analysis of variance [ANOVA] P = .027) and compared with patients who received more than 12 injections (ANOVA P = .001). CONCLUSIONS: Anti-VEGF treatment is often experienced with some anxiety related to treatment, regardless of the number of injections received. Clinical levels of depression seem to be more frequent in patients at early stages of anti-VEGF treatment. Strategies to improve patient experience of treatment and minimize morbidity are suggested.

Waiting room educational media effect on preinjection anxiety for initial intravitreal injections.

OBJECTIVE: To ascertain the effectiveness of an educational web page in reducing anxiety associated with initial intravitreal anti-vascular endothelial growth factor injections. DESIGN: Single-centred, observation-enriched, randomized controlled trial. PARTICIPANTS: Ninety-six patients receiving intravitreal injections at the Hamilton Regional Eye Institute. METHODS: Patients aged 18 years or older scheduled to receive their first intravitreal injection were randomized to either view an educational web page pertaining to the injection procedure or wait 30 minutes. Both groups then completed the State-Trait Anxiety Inventory (STAI). A third cohort of patients who previously had intravitreal injections waited 30 minutes before completing the STAI. The difference between STAI anxiety scores across cohorts 1 through 3 was assessed using analysis of variance and independent t tests where applicable. RESULTS: Ninety-six patients completed the STAI questionnaires, of which 55 (57.3%) were female and 86 (89.6%) were Caucasian. The mean age of participants was 68.5 ± 14.2 years, 72.7 ± 12.9 years, and 70.4 ± 11.7 years for control, intervention, and treatment-experienced cohorts, respectively. The mean STAI score was 40.3 ± 12.0 for the control cohort, 39.3 ± 11.1 for the intervention cohort, and 30.2 ± 9.9 for the treatment-experienced cohort. No significant difference in STAI scores was observed between intervention and control cohorts (p = 0.716). The effect size between treatment-naïve and treatment-experienced cohorts was high, ranging from 0.862 and 0.919, and the mean difference in STAI scores was significant. CONCLUSIONS: Compared to treatment-experienced patients, treatment-naïve patients are more anxious. Electronic educational information about the intravitreal injection process may be ineffective at reducing procedure-induced anxiety.