Table 3.

Variability in pain experience during treatment

Themes/subthemes	Illustrative quotations of patients (PA) and healthcare practitioners (HP)
Preparation steps
Instillation of anaesthetic eye drops	‘When they put the drops on, the second one I think it is, makes it burn a little bit.’ (PA04)
Application of chlorhexidine/povidone-iodine	‘It stings for a second but then when they start putting the other injections…you don't know it’s there.’ (PA03)
	‘I am allergic to the iodine. It burnt my eyes. I couldn't see and it was painful…It took a long time to wear off.’ (PA12)
	‘The iodine makes the surface of the eye very fragile.’ (HP6)
Placement of eyelid speculum	‘It wasn't painful it was just part of the routine of giving enough space to put the needle in.’ (PA13)
	‘…some nurses have more difficulty than others getting it in correctly, so that you can't blink. But they eventually get it right and that’s fine.’ (PA14)
Placement of surgical drape	‘The thing that goes over your face [the drape] that’s not very nice… I was scared when I went the first couple of times, but now I got used to it.’ (PA09)
Intravitreal injection: expecting versus experiencing
Pressure	‘But it’s all of a sudden having a pressure on the eye as the needle tries to break through the surface.’ (PA08)
Stress and tension	‘And because it hurts, I tend to hold my breath and tense up.’ (PA07)
Pain	‘But sometimes I just feel like the injection you get when you're having your tooth out. Very mild pain.’ (PA05)
	‘The pain is only instant… As soon as they pull the needle out, the pain is gone.’ (PA08)
	‘And to tell you the truth, it’s over in a second.’ (PA03)
	‘I don't think pain is static. I think pain threshold varies depending on what patient’s like on that day.’ (HP4)
	‘I didn't have enough anaesthetic. It was quite sharp.’ (PA12)
	‘It is just like a pinprick only a bit harder.’ (PA10)
Injection technique	‘Have you hold the bevel horizontally, obviously it will hurt cause you're cutting like two or three fibres. As if you hold it parallel to the sclera fibres, then you squeeze it between two sclera fibres without cutting any… That’s something that you learn from your knowledge of anatomy, also from experience.’ (HP6)
	‘The injections vary. It’s like anything that involves a technique. Some nurses and doctors have a better technique than others.’ (PA14)
‘Better than anticipated’	‘And the first one, I must say, I came out and said, well, that’s certainly wasn't as bad as it sounded.’ (PA06)
	‘It’s bearable. I'm sure there are much worse things than having this done…It’s painful, but over very quickly.’ (PA06)
Impact of quality of care delivery on patient experience
Observation and reflective practice	‘One patient would come and say, oh I felt that…Of course you would reflect…What could have I done better? It’s constantly improving your practice based on what the patient has told you.’ (HP7)
	‘If patients have blepharitis…I put an extra bit of iodine, rub the iodine closely around the eyelids and the eyelashes.’ (HP6)
	‘I was doing two eyes, so I did the right eye and if that was a little bit painful, I would probably put a little bit more anaesthetic in the other eye just to see if that helps, you know, to try and combat that.’ (HP2)
	‘What I do is when they had a drop of iodine in after the anaesthetic, I ask if it stings. If it stings, then maybe they need more anaesthetic.’ (HP3)
Respectful and acting professionally	‘We try to be very professional. We will not show that we feel like that [fatigue].’ (HP5)
	‘You can feel that towards the end you might be tired…My principle is how I treat my first patient that would be the same quality that I treat my last patient.’ (HP7)
Individualised patient care	‘…the InVitria [assisting injection device] might not be a good idea, so I put a drape for anxious patients. Because you need patients’ cooperation when you want to put the InVitria.’ (HP6)
	‘But if my patients are uncomfortable, sometimes, they can't move from the wheelchair to the chair. We still do our best to give them injection while they are in the wheelchair which is a really difficult situation.’ (HP5)
	‘We adjust to the patient. Let’s say we have a little old lady who cannot stretch herself at the chair, we offer to give her the pillow.’ (HP7)
Making decision and clinical judgement	‘Make sure that you're injecting in the area that there’s no vessels, because you don't want to cause any bleeding afterwards.’ (HP2)
Lack of assessment tools to evaluate pain	‘We don’t use any tools, but we provide psychological support. For example, we talk to them…How was your weekend? How was your holiday?’ (HP5)
	‘…we don't have a way of measuring pain threshold.’ (HP4)