# Comparison of intravitreal injection techniques with and without a speculum using eyelid retraction with a cotton-tipped applicator

## TL;DR

This study compares two methods for eye injections and finds that using a cotton swab instead of a speculum reduces patient pain without increasing complications.

## Contribution

The study introduces a novel eyelid retraction method using a cotton-tipped applicator to reduce pain during intravitreal injections.

## Key findings

- Patients reported significantly lower pain scores with cotton-swab retraction compared to speculum use.
- Subconjunctival hemorrhage was the most common complication, but no serious complications occurred in either group.
- The cotton-swab method showed comparable safety and better patient comfort for repeated injections.

## Abstract

Intravitreal injection (IVI) is a widely performed ophthalmic procedure with generally low complication rates, but repeated applications are often required due to the short half-life of anti-VEGF agents. Pain management during IVI is critical for patient quality of life and adherence to treatment (Andrade and Carvalho in Arq Bras Oftalmol 2015;78:27–31). Prior studies have suggested that eyelid specula may increase discomfort, while alternative retraction methods could improve patient tolerance.

In this prospective, randomized clinical trial, 106 patients were assigned to receive IVI either with an eyelid speculum or with cotton-swab–assisted eyelid retraction. Immediately after the procedure, patients rated pain using a 10-cm visual analog scale (VAS). Complications were also recorded. The mean VAS pain score was 2.34 ± 1.83 (95% CI: 1.83–2.85) in the speculum group and 1.37 ± 1.58 (95% CI: 0.93–1.80) in the cotton-swab group. The mean difference of 0.97 points was statistically significant (ANOVA, p = 0.0041). The most frequent complication was subconjunctival hemorrhage (9.4%), with no cases of endophthalmitis, retinal detachment, or lens touch.

Under the conditions of this study, IVI performed without a speculum using cotton-swab eyelid retraction was associated with lower reported pain and comparable complication rates. This technique may enhance patient comfort and treatment adherence, particularly for those requiring multiple injections each year, although further validation is warranted.