Retinal diseases including neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), and retinal vein occlusion (RVO) represent leading causes of vision loss globally, significantly impacting quality of life and imposing substantial socioeconomic burdens on healthcare systems [1]. The World Health Organization estimates that approximately 285 million people worldwide suffer from visual impairment, with retinal diseases contributing disproportionately to irreversible blindness in developed and developing nations alike [2].

The introduction of intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy has fundamentally transformed the therapeutic landscape for these conditions. Randomized controlled trials have demonstrated that agents such as ranibizumab, bevacizumab, and aflibercept effectively stabilize or improve visual acuity in nAMD, DME, and RVO [3,4]. Bevacizumab, a humanized monoclonal antibody against VEGF-A, gained widespread ophthalmic use following the seminal work by Rosenfeld et al. in 2006, despite being off-label for ocular indications [5]. Ranibizumab and aflibercept subsequently received regulatory approval, with comparative effectiveness studies suggesting similar visual outcomes across agents, though with varying dosing regimens and treatment burdens [6,7].

Despite robust clinical efficacy data, the patient experience of receiving intravitreal injections remains complex and multifaceted. The procedure involves repeated periocular anesthesia, antiseptic preparation, and needle penetration of the sclera into the vitreous cavity—an experience that generates anxiety and discomfort for many patients [8]. Qualitative research has identified significant psychological impacts including pre-procedural anxiety (reported in 17.3–85% of patients), concerns about pain, and existential fears regarding vision loss [9]. Physical discomfort varies by technique, with studies demonstrating that anesthesia methods, lid retraction devices, and antiseptic application significantly influence patient comfort [10].

Treatment burden extends beyond the procedure itself to encompass travel requirements, waiting times, and the need for frequent clinic visits—factors particularly relevant in resource-limited settings. The Questionnaire to Assess Life Impact of Treatment by Intravitreal Injections (QUALITII) study reported that 64% of patients required caregiver assistance, with clinic visits lasting 1–3 hours for the majority [11]. Despite these burdens, overall satisfaction remains high, with mean satisfaction ratings of 5.46 on a 0–6 scale reported in multinational cohorts [11].

In South Asia, the epidemiology of retinal diseases presents unique challenges. Pakistan faces a growing diabetes epidemic, with an estimated 33 million adults living with diabetes and a reported diabetic retinopathy prevalence of 56.9% among diabetic patients—substantially higher than global averages [12]. A systematic review of task-sharing for diabetic retinopathy management in Pakistan highlighted critical gaps in screening infrastructure, workforce capacity, and patient access to tertiary care [13]. The Khyber Pakhtunkhwa province, with Peshawar as its capital, serves as a referral hub for ophthalmic care but faces resource constraints typical of low-to-middle income healthcare systems.

Patient satisfaction research in ophthalmology has historically focused on cataract surgery outcomes, with validated instruments such as the Catquest-9SF and National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) widely employed [14,15]. However, satisfaction with intravitreal injection services specifically has received limited attention in South Asian contexts. A study from Iran demonstrated high satisfaction (mean PSQ-18 score: 90.8) among patients receiving intravitreal bevacizumab, though financial barriers and appointment scheduling emerged as significant concerns [16]. The Patient Satisfaction Questionnaire Short Form (PSQ-18), developed by Marshall and Hays, offers a validated, multidimensional tool assessing general satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with physician, and accessibility/convenience [17].

The present study addresses a critical research gap by evaluating patient satisfaction with intravitreal injection services in Bannu, Khyber Pakhtunkhwa—a region characterized by high disease burden, resource constraints, and limited patient-centered outcome data. We hypothesized that satisfaction levels would be high overall but variably influenced by demographic factors, clinical characteristics, and systemic healthcare access barriers.

Study Design and Setting

This cross-sectional study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [18]. The study setting was the Department of Ophthalmology, Khyber Teaching Hospital (KGNTH), Bannu, Khyber Pakhtunkhwa, Pakistan—a 1200-bed tertiary care teaching hospital serving as a major referral center for adjacent regions.

Study Population and Sampling

The target population comprised all adult patients receiving intravitreal anti-VEGF injections for nAMD, DME, or RVO at the study site during the recruitment period.

Inclusion criteria were:

(1) age ≥18 years;

(2) diagnosis of nAMD, DME, or RVO requiring intravitreal therapy; (3) receipt of at least one prior intravitreal injection (to ensure procedure familiarity);

(4) ability to communicate in Urdu or Pashto

(5) provision of informed consent.

Exclusion criteria included:

(1) active intraocular infection or inflammation

(2) history of vitrectomy surgery

(3) cognitive impairment precluding questionnaire completion

(4) receipt of intravitreal corticosteroid-only therapy

(5) refusal to participate.

Sample Size

Sample size was calculated using the formula for cross-sectional prevalence studies: n = Z² × P(1-P) / d² [19],

where Z = 1.96 (95% confidence level),

P = 0.80 (expected satisfaction proportion based on prior literature [16]), and d = 0.04 (precision/margin of error). This yielded a minimum sample size of 384.

Systematic random sampling was employed: every third eligible patient presenting for intravitreal injection during the study period was invited to participate until the target sample size was achieved.

Variables and Data Collection

Independent variables included: demographic characteristics (age, gender, education level, occupation, monthly income); clinical characteristics (diagnosis, duration of disease, number of previous injections, injected agent, laterality of treatment, best-corrected visual acuity [BCVA]); and healthcare access factors (travel distance, mode of transport, waiting time, out-of-pocket expenditure).

Dependent variables comprised overall satisfaction (PSQ-18 total score and subscale scores) and procedure-specific satisfaction (pain score, anxiety level, willingness to continue treatment).

Potential confounders included disease severity (BCVA), comorbid diabetes mellitus, hypertension, and provider characteristics (senior vs. trainee ophthalmologist performing injection).

Data collection occurred immediately following the intravitreal injection procedure during scheduled follow-up visits. A trained research assistant administered structured questionnaires in the patient's preferred language (Urdu or Pashto). The PSQ-18 was translated into Urdu using standard forward-backward translation methodology and pilot-tested for cultural appropriateness.

Measurement Instruments

Patient Satisfaction Questionnaire Short Form (PSQ-18): This 18-item instrument measures seven dimensions: general satisfaction (items 3, 17), technical quality (items 2, 4, 6, 14), interpersonal manner (items 10, 11, 12), communication (items 1, 7, 18), financial aspects (items 5, 8), time spent with doctor (items 15, 16), and accessibility/convenience (items 9, 13). Responses utilize a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Total scores range 18–90, converted to 0–100 scale for interpretability [17].

Procedure-Specific Assessment: Visual Analog Scale (VAS) for pain (0–10, where 0 = no pain, 10 = worst possible pain) during injection; State-Trait Anxiety Inventory (STAI) short-form adapted for procedural anxiety; and single-item willingness to continue treatment (5-point scale).

Clinical Data: BCVA measured using Snellen chart and converted to logMAR; intraocular pressure (IOP) via Goldmann applanation tonometry; central retinal thickness (CRT) via spectral-domain optical coherence tomography (SD-OCT).

Bias Control

Selection bias was minimized through systematic random sampling and explicit inclusion/exclusion criteria. Information bias was reduced by using validated, pre-tested questionnaires administered by trained personnel blinded to study hypotheses. Recall bias was mitigated by assessing satisfaction immediately post-procedure. Confounding was addressed through multivariable regression adjusting for age, gender, education, disease duration, visual acuity, and injection history.

Statistical Analysis

Data were analyzed using IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY). Normality was assessed using Shapiro-Wilk tests and Q-Q plots. Descriptive statistics included means with standard deviations (continuous variables) and frequencies with percentages (categorical variables).

Inferential statistics comprised: independent samples t-tests and one-way ANOVA for group comparisons; Pearson or Spearman correlations for continuous associations; and chi-square tests for categorical associations. Multivariable analysis used binary logistic regression to identify independent predictors of high satisfaction (defined as PSQ-18 score ≥75th percentile), entering variables with p < 0.20 in univariate analysis.

Missing data were handled using complete case analysis (<5% missingness anticipated). Statistical significance was set at p < 0.05 (two-tailed). Confidence intervals (95%) were reported for all effect estimates.

Participant Characteristics

Of 423 eligible patients approached, 384 (90.8%) consented and completed the study. Non-participants (n = 39) cited time constraints (n = 22), lack of interest (n = 12), and illness (n = 5). The final sample comprised 384 participants with complete data.

Table 1 presents demographic and clinical characteristics. Mean age was 62.4 ± 9.8 years (range: 28–84 years), with 217 (56.5%) male and 167 (43.5%) female participants. The majority (n = 248, 64.6%) had completed primary education or less, and 45.3% reported monthly income below Pakistani Rupees (PKR) 30,000 (approximately USD 107).

Table 1. Demographic and Clinical Characteristics of Study Participants (n = 384)

DME was the most common indication (42.2%), followed by nAMD (35.4%) and RVO (22.4%). Participants had received a mean of 8.4 ± 6.7 previous injections (range: 1–34). Bevacizumab was the most frequently used agent (51.6%), reflecting cost considerations in this setting. Bilateral treatment was required in 59.4% of cases. Mean waiting time was 142.6 ± 56.4 minutes, and average travel distance was 42.3 ± 38.6 kilometers.

Patient Satisfaction Scores

Table 2 presents PSQ-18 domain scores and total satisfaction. The mean total PSQ-18 score was 78.6 ± 12.4 (range: 42–100), indicating high overall satisfaction. Technical quality (82.1 ± 14.2) and interpersonal manner (80.3 ± 13.8) were highest-rated domains, while financial aspects (65.4 ± 18.6) and accessibility/convenience (68.2 ± 16.4) scored lowest.

TABLE 2: Patient Satisfaction Questionnaire (PSQ-18) Domain Scores (n = 384)

Procedure-specific assessments revealed mean pain VAS score of 2.8 ± 2.1 (range: 0–8), with 68.2% reporting pain scores ≤3. Procedural anxiety was reported by 42.4% of participants (n = 163), though 89.6% (n = 344) expressed willingness to continue treatment indefinitely if clinically indicated.

Factors Associated with Satisfaction

Table 3 presents bivariate associations with total PSQ-18 scores. Higher satisfaction was significantly associated with: younger age (r = -0.18, p = 0.001), higher education level (p < 0.001), higher income (p = 0.002), greater number of previous injections (r = 0.22, p < 0.001), better visual acuity (r = -0.15, p = 0.004), use of private transport (p = 0.032), shorter waiting times (r = -0.24, p < 0.001), and lower pain scores (r = -0.31, p < 0.001). No significant differences were observed by gender, diagnosis, injected agent, or laterality.

TABLE 3: Bivariate Associations with Patient Satisfaction (PSQ‑18 Total Score)

Multivariable Analysis

Binary logistic regression was performed with high satisfaction (PSQ-18 ≥83, 75^th percentile) as the dependent variable. Independent variables included age, education, income, number of previous injections, BCVA, waiting time, and pain score (all p < 0.20 in univariate analysis).

Table 4 presents adjusted odds ratios. Higher education (OR: 2.34; 95% CI: 1.42–3.86; p = 0.001), greater injection experience (OR: 1.89; 95% CI: 1.23–2.91; p = 0.004), and lower pain scores (OR: 0.76; 95% CI: 0.64–0.91; p = 0.002) remained significant independent predictors. Each 1-point increase in pain VAS reduced the odds of high satisfaction by 24%.

TABLE 4: Multivariable Logistic Regression: Predictors of High Patient Satisfaction

Model fit: Nagelkerke R² = 0.24; Hosmer-Lemeshow test p = 0.342.

Satisfaction by Anti-VEGF Agent

Subgroup analysis revealed comparable satisfaction across agents: bevacizumab (77.8 ± 12.6), ranibizumab (79.4 ± 11.8), and aflibercept (80.1 ± 12.9) (p = 0.412). Financial satisfaction was significantly lower among bevacizumab users (62.3 ± 19.1 vs. 68.7 ± 17.4 for ranibizumab/aflibercept; p = 0.002), likely reflecting out-of-pocket costs for off-label medication.

This cross-sectional study of 384 patients at a tertiary care center in Khalifa Gul Nawaz Teaching Hospital Bannu, Khyber Pakhtunkhwa, demonstrates high overall satisfaction (mean PSQ-18: 78.6/100) with intravitreal injection services for retinal diseases. These findings align with international literature reporting satisfaction levels of 81.9–90.8 in comparable populations [5,16], while identifying specific domains—particularly financial aspects and accessibility—where healthcare system constraints impact patient experience.

The highest satisfaction scores observed for technical quality (82.1) and interpersonal manner (80.3) reflect positively on clinical competence and physician-patient relationships at the study site. This is consistent with qualitative research emphasizing that positive interactions with healthcare providers are crucial for improving patient experiences and treatment adherence [9]. The lower scores for financial aspects (65.4) and accessibility/convenience (68.2) highlight systemic challenges characteristic of resource-limited settings. The Iranian study by Ziaei et al. similarly identified financial problems and appointment scheduling as primary sources of dissatisfaction [16], suggesting these concerns transcend national boundaries in low-to-middle income contexts.

Our finding that bevacizumab, ranibizumab, and aflibercept produced comparable overall satisfaction supports the pragmatic use of cost-effective alternatives where resources are constrained. While financial satisfaction was lower with bevacizumab—likely due to lack of insurance coverage for off-label use—this did not translate to reduced overall satisfaction or treatment willingness. This has important policy implications for Pakistan, where bevacizumab remains the most accessible anti-VEGF agent for the majority of patients.

The identification of education level, injection experience, and pain as independent predictors of satisfaction offers actionable insights. The positive association between education and satisfaction may reflect greater health literacy, realistic expectation-setting, or enhanced communication with providers. The "habituation effect" observed with increasing injection numbers aligns with Thetford et al.'s finding that anxiety often diminishes after the first injection as the procedure becomes familiar [9]. Pain emerged as the strongest modifiable predictor, with each 1-point VAS increase reducing high-satisfaction odds by 24%. This underscores the importance of optimizing anesthesia protocols—a finding supported by research demonstrating that lidocaine gel and subconjunctival injection produce superior comfort compared to pledgets [10].

The mean pain score of 2.8/10 and the fact that 68.2% reported minimal pain (≤3) suggest generally adequate analgesia, yet there remains room for improvement. The 42.4% reporting procedural anxiety, despite high overall satisfaction, indicates that psychological support and patient education warrant attention. Burton et al. emphasized that time spent alleviating concerns is vital for emotional well-being and may prevent treatment discontinuation [9].

From a health systems perspective, the mean waiting time of 142 minutes and average travel distance of 42 kilometers represent significant access barriers. These findings are particularly relevant given that 59.4% of participants required bilateral treatment, necessitating frequent return visits. The treat-and-extend regimen employed at our center aims to minimize injection burden while maintaining visual outcomes [20], though implementation challenges remain in high-volume public sector settings.

Strengths and Limitations

Strengths include the use of validated instruments (PSQ-18), systematic sampling, adequate sample size, and high response rate (90.8%). The study provides the first published data on intravitreal injection satisfaction from Khyber Pakhtunkhwa, addressing an important evidence gap for South Asia.

Limitations include the cross-sectional design, which precludes assessment of satisfaction trends over time or causal inference. Single-center recruitment may limit generalizability to other Pakistani settings, particularly private sector facilities. The exclusion of treatment-naïve patients means satisfaction with initial experiences remains uncharacterized. Self-reported data may be subject to social desirability bias, though the anonymous questionnaire format and absence of provider involvement in data collection mitigate this. Finally, we did not capture objective clinical outcomes (e.g., CRT change) to correlate with satisfaction.

Implications for Practice and Policy

Findings suggest several interventions to enhance patient-centered care: (1) implementation of standardized pain management protocols favoring subconjunctival anesthesia or topical gel; (2) targeted education and counseling for less-educated patients and those receiving initial injections; (3) streamlined appointment systems to reduce waiting times; and (4) advocacy for insurance coverage or subsidies to address financial barriers, particularly for off-label bevacizumab use. Task-sharing strategies involving trained ophthalmic assistants for pre-injection counseling and post-injection monitoring could address workforce constraints while maintaining satisfaction [13].

Future Research

Longitudinal studies are needed to characterize satisfaction trajectories from treatment initiation through maintenance phases. Qualitative research would provide deeper understanding of cultural factors influencing satisfaction in Pakistani contexts. Comparative studies across public and private sectors could identify health system determinants of patient experience. Finally, intervention studies testing specific satisfaction-enhancing strategies (e.g., music therapy, virtual reality distraction, enhanced counseling) would advance evidence-based practice.

Patients with retinal diseases receiving intravitreal injections at a tertiary care center in Bannu, Khyber Pakhtunkhwa, report high overall satisfaction (78.6/100) with services, despite significant financial and accessibility challenges. Technical quality and interpersonal manner are particular strengths, while financial burden and waiting times require system-level attention. Education level, injection experience, and procedural pain are key modifiable predictors of satisfaction. These findings support the continued use of intravitreal anti-VEGF therapy in resource-limited settings while highlighting opportunities for patient-centered quality improvement.

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