The conventional technique for administering intravitreal injections into the eye uses an eyelid speculum to keep the eye open and stationary, but techniques that do not use the lid speculum have the potential to improve patient comfort, lower cost, and reduce injection times, a new analysis of the various approaches found.

The meta-analysis compared two different non-speculum techniques — manual eyelid retraction with a cotton-tip swab and device-assisted retraction using an injection assistant or an injection guide — with the traditional approach of holding the eyelids open with a speculum, Abdulwahab Alomar, a medical student at the University of Aberdeen in Aberdeen, Scotland, reported at European Society of Retina Specialists (EURETINA) 2026 in Vienna. The meta-analysis included 11 studies and 713 patients who received intravitreal injections.

Less Pain With Manual Technique

“The clearest finding was that manual non-speculum techniques were associated with significantly less patient-reported pain than conventional speculum-based injections,” Alomar told Medscape Medical News. The pooled standardized mean difference was -0.78 (95% CI, -1.22 to -0.34; P < .001).

The difference in the rate of complications between the techniques was not significant, Alomar said. The speculum technique had an 82% greater risk for complications; the CI was so wide (0.6-5.54) that the researchers could not draw any conclusion, he said.

Device-assisted non-speculum techniques showed no clear difference in pain compared with the use of a speculum but did have about half the rate of complications (risk ratio, 0.51; 95% CI, 0.32-0.82), Alomar said.

Alomar cited a study in the UK from 2020 — which was not included in the analysis — that reported less pain in the device-assisted non-speculum group and that the technique resulted in an annual saving of £24,300 (about USD $31,100) for the study institution compared with the conventional speculum-based approach. That estimate was based on 18,000 injections a year.

A 2021 study in Eye found the number of eye injections at one major UK center, Moorfields Eye Hospital, London, England, rose 11-fold between 2009 and 2019, from about 4100 injections to nearly 45,000. The number is predicted to reach 83,000 per year by 2029.

“Intravitreal injections are being performed on an enormous and growing scale, with many patients receiving repeated injections over months or years,” Alomar said. “If a simpler technique can reduce discomfort while maintaining appropriate procedural safety, even a relatively small improvement could have a meaningful impact across a large number of patients.”

Patients also appeared to favor non-speculum techniques, Alomar told Medscape Medical News. “For device-assisted approaches, the evidence was more limited, but these techniques showed a significant reduction in reported complications compared with the conventional speculum techniques.”

The meta-analysis has multiple limitations in addition to its relatively small patient population, Alomar said. The techniques and outcomes varied widely between studies, and safety data were limited, as were subgroup analyses. Some studies had methodological concerns, and there were few studies for each outcome.

“The most important point is not to interpret our findings as proving that non-speculum injections are definitively safer or equivalent in safety to speculum-based injections,” he said. Non-speculum injection is a “reasonable alternative” in the appropriate setting and in experienced hands, he said.

To further evaluate non-speculum and speculum-based intravitreal injection techniques, larger prospective multicenter studies using a standardized non-speculum technique would be needed, Alomar said. Those studies should evaluate pain, patient preference, procedure time, and minor complications and be large enough to provide meaningful information about rare complications.

The study did not measure the comparative environmental impact of the techniques, but reducing equipment and material use “is an interesting area for future research, particularly given the very high volume of intravitreal injections performed worldwide,” he added.

Basics of Technique Apply

The new study provides “useful evidence” supporting non-speculum techniques for intravitreal injections, said Alaa AlAli, MD, MHPE, head of the Vitreo-Retinal division at AlBahar Eye Center in Kuwait City, Kuwait. “However, I would be cautious about recommending their routine use based on the currently available evidence,” she said.

Regardless of technique, the basics apply, AlAli said: adequate antisepsis and proper isolation of the eyelids and eyelashes from the injection site.

The non-speculum techniques “may offer an alternative in appropriately selected patients,” she said. The difference the study found between the two non-speculum techniques, manual eyelid retraction and device-assisted techniques, was “particularly interesting,” AlAli said.

“Manual retraction appeared to provide a more consistent reduction in patient-reported pain, whereas device-assisted approaches showed a significant reduction in subconjunctival hemorrhage without a statistically significant improvement in pain scores,” she said.

“This highlights an important point: Eliminating the speculum does not automatically guarantee a more comfortable injection experience,” AlAli added. “The way the eyelids are retracted and the technique used may be equally important.”

The patient preference for non-speculum approaches in some of the included studies may be relevant for patients who require frequent injections over many years, she said.

Alomar and AlAli reported no relevant financial conflicts of interest.

Richard Mark Kirkner is a medical journalist based in the Philadelphia area.