Randomised Controlled Trial: Influence of Subconjunctival Anaesthesia Duration on Pain Perception During Intravitreal Injections: Comment.
We read with great interest the study by Kim et al. [1] regarding the influence of subconjunctival anaesthesia duration on pain perception during intravitreal injections (IVIs). Their proposed 3-min waiting period presents a compelling solution for balancing effective analgesia with clinical efficiency. Although these findings are indeed insightful, a more granular examination of certain details within the study's design and data analysis is warranted to fully appraise the robustness of their conclusions. Firstly, the study's discussion on limitations correctly notes its single-blind design but overlooks a more critical potential confounder: performance bias from the unblinded injectors [2]. An injector's awareness of a shorter, theoretically more painful wait time could inadvertently alter their technique or communication. This performance bias, if present, could systematically inflate the reported pain scores in the 2-min group, potentially overstating the magnitude of the therapeutic effect observed when extending the wait time to 3 min. This prompts a question regarding the study's protocol: were measures implemented to standardise the injectors' technique and communication, such as mandating a fixed injection speed or using scripted reassurances, to mitigate this potential bias? For future research, a rigorous double-blind protocol is essential to validate these findings. A design where wait times are managed by a third party who activates a pre-set, patient-inaudible timer to signal the injector would be invaluable for eliminating this confounder and strengthening the study's evidentiary rigour. Secondly, a review of baseline characteristics reveals a notable imbalance in the number of prior injections, which serves as a key confounder. This imbalance is particularly concerning as prior injection experience can significantly modulate pain perception through mechanisms such as pain habituation or anticipatory anxiety, leading to potential residual confounding [3]. Although the authors report a non-significant p-value (p = 0.42) for this variable, this statistical finding does not fully mitigate the risk of clinically relevant bias. To transparently assess this impact, we suggest the authors present the unadjusted and ANCOVA-adjusted mean visual analogue pain scale scores side-by-side. Furthermore, reporting the effect size of the adjustment would allow readers to precisely quantify the impact of this baseline imbalance. As a further step to bolster confidence, a sensitivity analysis, such as stratifying results by high versus low prior injection experience (e.g., > 15 vs. ≤ 15 injections), could validate whether the effect of wait time is consistent across these clinically distinct subgroups, thereby greatly enhancing the study's robustness. Lastly, a notable inconsistency emerges in the study's findings, where univariate analysis identified laterality as a significant pain predictor (p = 0.03), yet its influence was dismissed based on a ‘cursory examination’ claiming that exclusion did not alter conclusions. This non-standard terminology is perplexing: does ‘exclusion’ imply variable removal from a model, or a sensitivity analysis on a patient subset? Such ambiguity hinders rigorous validation, especially given the substantial baseline imbalance, where right-eye injections constituted 55% of the 3-min group versus only 38.3% of the 5-min group. Since the authors themselves hypothesise heightened pain in right eyes due to ocular dominance, the superior analgesia in the 5-min group risks being confounded by its lower prevalence of inherently more painful right-eye procedures [4]. To resolve this uncertainty, we urge the authors to present a subgroup analysis stratified by laterality. Demonstrating the pain score trends specifically within ‘right-eye only’ or ‘left-eye only’ cohorts would most effectively verify whether the extended wait time confers an independent clinical benefit, unconfounded by this significant baseline asymmetry. In summary, the constructive points we have raised are intended to foster a more profound and rigorous examination of the study's key findings. By highlighting potential sources of bias and suggesting supplementary analyses, we aim to stimulate a productive academic dialogue, with the ultimate goal of collaboratively refining pain management strategies for IVIs. The authors have nothing to report. The authors declare no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
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