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Neovascular Age-Related Macular Degeneration (nAMD)IVI-RETRACTNCT07481500

Speculum-Free Intravitreal Injection Using Cotton-Tipped Applicator Retraction: Pain, Procedure Time, Patient Satisfaction, and Safety

A study testing Eyelid Speculum Retraction and Cotton-Tipped Applicator Retraction in people with Neovascular Age-Related Macular Degeneration (nAMD) and Diabetic Macular Edema, run by Jakkrit Juhong at 1 site in Thailand.

Active, not recruiting

Under way, not looking for participants. Everyone needed has enrolled. The study is still running.

Official record
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Trial summary

This randomized controlled trial compares two techniques for eyelid retraction during intravitreal injection (IVI): an adjustable solid-blade eyelid speculum (Group A) and single-hand retraction of the upper eyelid with one cotton-tipped applicator (Group B), in patients with neovascular age-related macular… Read more about this study

Who is it for?
Ages 18 years and older
What is being tested?
Eyelid Speculum Retraction and Cotton-Tipped Applicator Retraction
Could I receive a placebo?
No, everyone receives an active treatment
How many people
129 participants
Where
1 siteThailand
Study dates
9 Sep 2026to 7 Oct 2026
Phase
Interventional
Are there results?
Not yet: the study is under way

Key requirements

Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.

  • Ages 18 years and older
  • All sexes
  • No healthy volunteers
  • Adult, Older adult

Who may be able to join

  • Age 18 years or older
  • Diagnosed with neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), or retinal vein occlusion (RVO)
  • Scheduled for intravitreal anti-VEGF injection (bevacizumab, aflibercept, or faricimab)
  • Able to provide written informed consent

Who cannot join

  • Active ocular infection or inflammation
  • Known allergy to povidone-iodine, tetracaine, or levofloxacin
  • Inability to cooperate with the injection procedure
  • Concurrent participation in another interventional clinical trial
  • Anatomical eyelid abnormality precluding use of either retraction technique

Trial locations and contacts

1 site in 1 country.

Thailand1 site
  • Walailak University Hospital

    Tha Sala, Changwat Nakhon Si Thammarat, 80160

Other trials in Thailand

About this study

Official title: Speculum-Free Intravitreal Injection Using Cotton-Tipped Applicator Retraction: A Randomized Controlled Trial Comparing Pain Perception, Procedure Duration, Patient Satisfaction, and Safety Between Eyelid Speculum and Cotton-Tipped Applicator Retraction Techniques

This randomized controlled trial compares two techniques for eyelid retraction during intravitreal injection (IVI): an adjustable solid-blade eyelid speculum (Group A) and single-hand retraction of the upper eyelid with one cotton-tipped applicator (Group B), in patients with neovascular age-related macular degeneration (including polypoidal choroidal vasculopathy), diabetic macular edema, or retinal vein occlusion treated at Walailak University Hospital, Nakhon Si Thammarat, Thailand.

The study evaluates four outcomes: (1) pain on a 0-10 numbered pain scale with a faces pictogram, 1-5 minutes after injection; (2) procedure duration from the first contact of the retraction device with the eyelid to its removal; (3) patient satisfaction on a 5-item Likert questionnaire; and (4) safety, including subconjunctival hemorrhage, corneal abrasion, lens touch, vitreous hemorrhage, endophthalmitis, retinal detachment, and intraocular pressure elevation.

In both groups, the cap of the insulin syringe is used as an injection-site marker instead of a caliper. Randomization was stratified by diagnosis and prior injection history using permuted blocks of 4 and 6. All 129 participants were randomized and injected on September 9, 2026.

Read the detailed description

Background:

Intravitreal injection is one of the most frequently performed ophthalmic procedures. Eyelid specula are widely used to keep the eye open but may cause discomfort. Cotton-tipped applicator retraction is an alternative that may reduce pain, and when a single applicator is held in one hand, the other hand remains free for injection-site marking and injection, so that one surgeon can complete the procedure without an assistant. Randomized data on procedure duration and satisfaction are limited.

Study Design:

Single-center, prospective, parallel-group randomized controlled trial with 1:1 allocation to an eyelid speculum (Group A) or cotton-tipped applicator retraction (Group B). The principal investigator generated stratified permuted-block sequences (block sizes 4 and 6) with Study Randomizer software; there were six strata: diagnosis (nAMD / DME / RVO) x prior injection history (injection-naive / previously injected). A research assistant placed the assignments in sequentially numbered, opaque, sealed envelopes, which another research assistant opened immediately before each procedure.

Interventions:

One vitreoretinal surgeon performed all injections without an assistant. Injections were given in the superotemporal quadrant in right eyes and the superonasal quadrant in left eyes (surgeon preference, same in both groups). All participants received tetracaine 0.5% and povidone-iodine 5% drops in the waiting area (contact time of at least 5 minutes), povidone-iodine 10% periocular skin preparation, a second instillation of tetracaine, and a fenestrated cloth drape. Anti-VEGF agents (bevacizumab, aflibercept, or faricimab) were prepared by the hospital pharmacy in 1-mL insulin syringes with a fixed 31G needle (Terumo). Group A: adjustable solid-blade eyelid speculum with a screw lock (PMS) retracting the upper and lower eyelids. Group B: one sterile cotton-tipped applicator held in the left hand to retract the upper eyelid; conversion to the speculum if retraction failed after 2 attempts. If the first attempt failed because of forceful eyelid squeezing or a marked Bell phenomenon, the participant was asked to close the eye, the applicator was used to retract the lower eyelid, and the injection was given in the inferotemporal or inferonasal quadrant. The injection site was marked with the povidone-iodine-dipped cap of the insulin syringe. Levofloxacin 0.5% was instilled after injection.

Outcome Measures:

All four outcomes are primary. Pain (0-10 numbered pain scale with faces), procedure duration (seconds), and satisfaction (5-item Likert questionnaire, total 5-25) were assessed on Day 0, 1-5 minutes after injection. Safety outcomes were assessed on Day 0, Day 1 (telephone), and Week 4 (clinic visit). Pain, procedure duration, and satisfaction are tested at a Bonferroni-adjusted alpha of 0.0167; safety is summarized descriptively (statistical analysis plan version 1.0, locked September 21, 2026).

Masking:

Open label. Participants, the surgeon, and the research assistants who timed the procedure and assessed the outcomes were aware of group assignment.

Sample Size:

Based on Chen et al. (2025) (pooled SD 1.71 for pain; Cohen's d = 0.57), with alpha = 0.025 (Bonferroni correction for 2 outcomes) and 80% power, 60 patients per group are required for pain (the earlier version of this record reported 52 per group because of a calculation error) and 46 per group for procedure duration. The enrollment target was 60 per group (120 total). All eligible patients who attended the injection session and gave consent were randomized (actual enrollment, 129).

Being tested
Eyelid Speculum Retraction, Cotton-Tipped Applicator Retraction
Keywords
intravitreal injection, eyelid speculum, cotton-tipped applicator, injection pain, procedure time, patient satisfaction, anti-VEGF, randomized controlled trial
Medical subject headings
Retinal Vein Occlusion, Polypoidal Choroidal Vasculopathy, Patient Satisfaction

What participants receive

What participants receive. In a randomised study each person is assigned to one group by chance.

  • Eyelid Speculum RetractionProcedure or surgery

    An adjustable solid-blade eyelid speculum with a screw lock (PMS) is inserted to retract the upper and lower eyelids before intravitreal injection (bevacizumab, aflibercept, or faricimab) with a Terumo 31G insulin syringe in the superotemporal quadrant in right eyes or the superonasal quadrant in left eyes (surgeon preference, same in both groups). The speculum is removed immediately after needle withdrawal.

  • Cotton-Tipped Applicator RetractionProcedure or surgery

    One sterile cotton-tipped applicator, held in the surgeon's left hand, is used to retract the upper eyelid (speculum-free) before intravitreal anti-VEGF injection (bevacizumab, aflibercept, or faricimab) with a Terumo 31G insulin syringe in the superotemporal quadrant in right eyes or the superonasal quadrant in left eyes (surgeon preference, same in both groups). The right hand marks the injection site and injects. If the first attempt fails because of forceful eyelid squeezing or a marked Bell phenomenon, the participant is asked to close the eye, the applicator is used to retract the lower eyelid, and the injection is given in the inferotemporal or inferonasal quadrant. The eyelid speculum is used if retraction fails after 2 attempts. The applicator is removed immediately after needle withdrawal.

Study groups in NCT07481500
Study groupRoleWhat they receive
Eyelid Speculum (Group A)Active comparatorIntravitreal injection performed with an adjustable solid-blade eyelid speculum with a screw lock (PMS) retracting the upper and lower eyelids. The speculum is inserted immediately before injection-site marking and injection and removed immediately after needle withdrawal.
Receives: Procedure: Eyelid Speculum Retraction
Cotton-Tipped Applicator (Group B)ExperimentalA single sterile cotton-tipped applicator, held in the surgeon's left hand, retracts the upper eyelid (speculum-free) before intravitreal injection (bevacizumab, aflibercept, or faricimab) with a Terumo 31G insulin syringe in the superotemporal quadrant in right eyes or the superonasal quadrant in left eyes (surgeon preference, same in both groups). If the first attempt fails because of forceful eyelid squeezing or a marked Bell phenomenon, the participant is asked to close the eye, the applicator is used to retract the lower eyelid, and the injection is given in the inferotemporal or inferonasal quadrant. The eyelid speculum is used if retraction fails after 2 attempts. The applicator is removed immediately after needle withdrawal.
Receives: Procedure: Cotton-Tipped Applicator Retraction

What is being measured

The primary outcome is the main question the study is designed to answer.

  1. Pain Perception

    Patient-reported pain score on a 0-10 numbered pain scale with a faces pictogram and verbal categories (0 = no pain; 10 = worst pain). The participant pointed to or stated a level, and a research assistant recorded the score after the participant had left the injection room.

    Measured: 1-5 minutes after intravitreal injection (Day 0)

  2. Procedure Duration

    Time in seconds from the first contact of the retraction device (speculum or cotton-tipped applicator) with the eyelid to its complete removal after needle withdrawal, measured by a research assistant with a stopwatch.

    Measured: During intravitreal injection procedure (Day 0)

  3. Patient Satisfaction

    Total score on a 5-item Likert satisfaction questionnaire in Thai (item 3, squeezing or pressure on the eyelid, reverse-scored; total 5-25; higher scores indicate greater satisfaction), administered at the same assessment as the pain score.

    Measured: 1-5 minutes after intravitreal injection (Day 0)

  4. Procedure-Related Complications

    Incidence of ocular complications, including subconjunctival hemorrhage, corneal abrasion, lens touch, vitreous hemorrhage, endophthalmitis, rhegmatogenous retinal detachment, and intraocular pressure greater than 25 mmHg, assessed on Day 0 (clinic), Day 1 (telephone call), and Week 4 (clinic visit).

    Measured: Day 0, Day 1, and Week 4 post-injection

Timeline

From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.

  1. First posted18 Mar 2026
  2. Study start9 Sep 2026
  3. Primary completion7 Oct 2026 (estimated)
  4. Study completion7 Oct 2026 (estimated)

Resources

More details

For doctors and researchers: how the study is designed, who runs it, and its registry IDs.

Study design
Study type
Interventional
Phase
Phase N/A
Primary purpose
Supportive care
Allocation
Randomised
Intervention model
Parallel groups
Model description
Patients are randomized 1:1 to either eyelid speculum retraction (Group A) or cotton-tipped applicator retraction (Group B) for intravitreal injection. Stratified by diagnosis (nAMD, DME, RVO) and prior injection history (naive, previously injected) using permuted block randomization with variable block sizes of 4 and 6.
Masking
None (open label)
Enrolment
129 participants (actual)
IDs, dates and publications
ClinicalTrials.gov ID
NCT07481500
Sponsor's protocol ID
WURCT5954
Acronym
IVI-RETRACT
Status last verified
Sep 2026
First submitted
13 Mar 2026
Last updated
25 Sep 2026
Results posted
No
Data monitoring committee
No
FDA-regulated drug
No
FDA-regulated device
No
Individual data sharing
Yes: De-identified individual participant data underlying the results reported in the article (baseline characteristics, pain, procedure duration, satisfaction, and adverse events), with a data dictionary, will be shared on reasonable request to the principal investigator.

Publications

  • Chen HRQ, de Andrade GC, Arimori LK, Lerner FK. Comparison of intravitreal injection techniques with and without a speculum using eyelid retraction with a cotton-tipped applicator. Int J Retina Vitreous. 2025 Oct 29;11(1):119. doi: 10.1186/s40942-025-00739-5.

    PubMed 41163036

Questions about this trial

What is this clinical trial studying?

A study testing Eyelid Speculum Retraction and Cotton-Tipped Applicator Retraction in people with Neovascular Age-Related Macular Degeneration (nAMD) and Diabetic Macular Edema, run by Jakkrit Juhong at 1 site in Thailand.

The full registered description is in the About this study section and the official record.

Who may be eligible to take part?

The sponsor lists 4 inclusion and 5 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.

Is this clinical trial currently recruiting?

The record says: under way, not looking for participants, as of the sponsor's last update on 25 Sep 2026. Status can change between updates, so confirm with the study contact before making plans.

Where is the study taking place?

The record lists 1 site in Thailand. Whether a site is taking part right now should be confirmed with that site. See every site.

What are the possible benefits and risks?

They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.

Are results available for this study?

This study is still under way. Results are not available in the source record yet.

How can a doctor refer a patient or contact the research team?

The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.

What does the primary outcome measure?

Pain Perception (time frame: 1-5 minutes after intravitreal injection (Day 0)). The study lists 4 primary outcomes in all. It is what the study was designed to measure, not a finding.

Where can I read the original study information?

On the ClinicalTrials.gov record for NCT07481500, which also lists 1 linked publication.

Does a listing mean the treatment is approved or proven to work?

No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.

How often is this information updated?

AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 25 Sep 2026.

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