A randomized clinical trial of combined topical-intracameral anesthesia in cataract surgery

Topical and subconjunctival anesthesia versus topical anesthesia alone in patients with senile cataracts undergoing phacoemulsification: a double-blind randomized controlled trial

BACKGROUND

This study compared topical anesthesia to a combination of topical anesthesia and subconjunctival anesthesia for phacoemulsification.

METHODS

This double-blinded parallel placebo-controlled randomized trial involved senile cataract patients scheduled for phacoemulsification between May and December 2022. Patients were randomly assigned to receive either topical anesthesia with 0.5% tetracaine hydrochloride and subconjunctival balanced salt solution injection (Control group) or topical anesthesia and subconjunctival injection with 2% lidocaine (Lidocaine group). Baseline parameters, cataract grades, and various outcomes were recorded, including pain scores at specific time points, patient cooperation scores, requests for additional anesthesia, and complications. Statistical methods included Fisher's exact test, the t-test, ordinal logistic regression, and linear regression with robust standard errors.

RESULTS

In total, 176 patients were included in the study after excluding 33 patients. A significant reduction in immediate postoperative pain was achieved in the Lidocaine group (p < 0.001) and was maintained for 2 h (p = 0.011). Additionally, better cooperation was observed in this group (p = 0.038). However, patients in the Lidocaine group experienced more pain during the subconjunctival injection (p = 0.001) and a significant increase in subconjunctival hemorrhage related to the injection (p < 0.001). Despite this, the rates of surgical complications were comparable between the groups, and all phacoemulsification procedures were successfully completed using the assigned anesthetic technique.

CONCLUSIONS

The addition of subconjunctival lidocaine injection to topical anesthesia reduced postoperative pain and improved patient cooperation during phacoemulsification. However, the lidocaine injection was painful, and it carried a higher risk of spontaneous-relief subconjunctival hemorrhage.

TRIAL REGISTRATION

Trial Registration Number: TCTR20220804003, date of registration August 4, 2022, retrospectively registered.

Comparative clinical trial of intracameral ropivacaine vs. lignocaine in subjects undergoing phacoemulsification under augmented topical anesthesia

Purpose:

To compare intracameral Ropivacaine to Lignocaine during phacoemulsification under augmented topical anesthesia, in terms of efficacy and safety.

Methods:

This prospective, randomized, double-masked clinical trial included subjects planned for phacoemulsification with posterior chamber intraocular lens implantation for visually significant uncomplicated senile cataract, under augmented topical anesthesia. Cases were randomized into two groups, Group A (Ropivacaine 0.1%) or Group B (Lignocaine 1.0%). The pain experienced by the patients during the surgery, mydriasis, post-op inflammation and endothelial cell change at six weeks after the procedure was evaluated. Surgeon's feedback was recorded to evaluate the cooperation of the patient during surgery.

Results:

A total of 210 subjects were screened and 184 were randomized to have 92 subjects in each group. There was no statistically significant difference seen on comparing Group A and B with respect to Age (P = 0.05), painful surgical steps (P = 0.85), visual analog scale scores (P = 0.65), surgeon's score (P = 0.11), postoperative inflammation (P = 0.90) and average ultrasound time during phacoemulsification (P = 0.10). Subjects in Group A fared better when compared to Group B with respect to endothelial cell loss (P = 0.0008), and augmentation in mydriasis (P < 0.001).

Conclusion:

Intracameral Ropivacaine and Lignocaine, both are equally effective in providing analgesia during phacoemulsification. However, intracameral Ropivacaine is superior to Lignocaine with regards to corneal endothelial cell safety, and augmenting mydriasis.

Topical anaesthesia plus intracameral lidocaine versus topical anaesthesia alone for phacoemulsification cataract surgery in adults

BACKGROUND

Phacoemulsification cataract surgery is usually performed in adults under local anaesthesia. Topical anaesthesia, which involves instilling anaesthetic drops to the ocular surface prior to and during surgery, has found large acceptance internationally. It is safe and allows for rapid patient turnover and visual recovery. Some surgeons have supplemented topical anaesthesia with intracameral lidocaine, reasoning that this may further reduce intraoperative pain, particularly during surgical stages involving manipulation of intraocular structures and rapid changes in fluid dynamics. This review, originally published in 2006 and updated in 2020, explores the efficacy and safety of using supplementary intracameral lidocaine in phacoemulsification cataract surgery.

OBJECTIVES

To assess whether supplementing topical anaesthesia with intracameral lidocaine for phacoemulsification cataract surgery in adults reduces intraoperative and postoperative pain, and to assess differences in participant satisfaction, need for additional intraoperative anaesthesia, surgeon satisfaction, measures of intraocular toxicity, and adverse effects attributable to choice of anaesthesia.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS BIREME iAH, and six trial registries on 4 February 2020. We also searched the reference lists of identified studies. There were no language restrictions.

SELECTION CRITERIA

We included only randomized controlled trials (RCTs) where participants underwent phacoemulsification for age-related cataract under topical anaesthesia with or without intracameral lidocaine either in two eyes of the same participant, or in different participants. We also included studies that used oral or intravenous sedation in addition to local anaesthesia.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial methodological quality using standard Cochrane procedures.

MAIN RESULTS

We identified five new RCTs in this updated review. We included a total of 13 trials in the review, conducted in the UK, the USA, Australia, Italy, Canada, Taiwan, Singapore, India, and Pakistan, and comprising 2388 eyes of 2355 participants (one study was a paired-eye study with each participant acting as their own control). The age range of participants was 34 to 95 years. We excluded studies that only included low-risk participants and excluded more difficult operative cases, for example hard lens nuclei or small pupils. We excluded studies assessing only participants with Fuchs' endothelial dystrophy. We judged one study as at high risk for selection bias. We assessed five studies as having an unclear risk of bias for random sequence generation and seven studies an unclear risk of bias for allocation concealment. We judged three studies as at high risk of performance bias, as the surgeon was not blinded, and two studies as at unclear risk of bias for this domain. No studies were judged as at high risk for detection bias, but five studies were judged to have an unclear risk of bias for this domain. We judged all 13 included studies to have a low risk of attrition bias and an unclear risk of reporting bias. Data from eight RCTs favoured topical anaesthesia plus intracameral lidocaine 0.5% to 1% over topical anaesthesia alone for reducing intraoperative pain when measured using a 10-point visual analogue scale, analysed as a continuous outcome. Mean pain score was 0.26 lower in the supplemental intracameral lidocaine group (95% confidence interval (CI) -0.39 to -0.13, 1692 eyes, moderate-quality evidence). Data from seven RCTs favoured supplemental intracameral lidocaine for reducing intraoperative pain when measured as a dichotomous outcome. The odds ratio of experiencing any pain was 0.40 versus the topical anaesthesia-only group (95% CI 0.29 to 0.57, 1268 eyes, moderate-quality evidence). Data from four RCTs did not show any additional benefit on postoperative pain when measured using a 10-point visual analogue scale (mean difference 0.12 points, 95% CI -0.29 to 0.05, 751 eyes, moderate-quality evidence). The impact on participant satisfaction was uncertain as only one small study investigated this outcome. The study suggested no difference between groups (mean difference 0.1 points, 95% CI -0.47 to 0.27, 60 eyes, low-quality evidence). Data from seven RCTs did not demonstrate a difference between groups in the need for additional intraoperative anaesthesia (odds ratio 0.88, 95% CI 0.56 to 1.39, 1194 eyes of 1161 participants; low-quality evidence), although this result is uncertain. A variety of measures were reported relating to possible intraocular toxicity. Data from four RCTs did not demonstrate a difference between groups in mean percentage corneal endothelial cell count change from pre- to postoperatively (mean difference 0.89%, 95% CI -1.12% to 2.9%, 254 eyes of 221 participants, moderate-quality evidence). Synthesis of the evidence from eight RCTs identified no difference in intraoperative adverse events between groups (odds ratio 1.00, 95% CI 0.32 to 3.16, 1726 eyes, low-quality evidence). This result should be interpreted with caution, mainly due to a lack of clear definitions of adverse events, low numbers of events, heterogeneity between studies, and large confidence intervals. Large observational studies may have been more appropriate for looking at this outcome.

AUTHORS' CONCLUSIONS

There is moderate-quality evidence that supplementation of topical anaesthesia with intracameral lidocaine 0.5% to 1% for phacoemulsification cataract surgery in adults reduces participant perception of intraoperative pain. The odds of experiencing any pain (as opposed to no pain) were 60% less for the topical anaesthesia plus intracameral lidocaine group versus the topical anaesthesia-only group. However, the numerical amplitude of the effect may not be of great clinical significance on the continuous pain score scale. Generally, the pain scores were consistently low for both techniques. We found moderate-quality evidence that there is no additional benefit of intracameral lidocaine on postoperative pain. There is insufficient evidence to determine the impact on participant satisfaction and need for additional intraoperative anaesthesia due to low-quality evidence. There is moderate-quality evidence that intracameral lidocaine supplementation does not increase measures of intraocular toxicity, specifically loss of corneal endothelial cells. There is low-quality evidence that the incidence of intraoperative adverse events is unchanged with intracameral lidocaine supplementation, but as RCTs are not the optimum medium for looking at this, this result should be interpreted with caution. Further research specifically investigating the adverse effects of intracameral anaesthesia might help to better determine its safety profile. Economic evaluations would also be useful for detailing cost implications.

Is Intracameral Lidocaine Really Effective in Cataract Surgery?

PURPOSE

To evaluate the usefulness of intracameral lidocaine in cataract surgery under topical anesthesia and especially if the patient wanted intravenous sedation preoperatively.

METHODS

In this prospective study 96 patients were randomly assigned to receive 0.5 cc of balanced salt solution (Group 1) or 1% unpreserved lidocaine (Group 2). Patients who wanted sedation received intravenous midazolam hydrochloride. All surgery was done by one surgeon using a clear corneal technique.

RESULTS

Mean pain scores were 0.73 (of a maximum 3) in Group 1 and 0.54 in Group 2; the difference between groups was not statistically significant. Forty patients in Group 1 (83%) and 44 patients in Group 2 (92%) reported no discomfort or only mild discomfort. The two study groups were comparable in need for intravenous midazolam. Logistic regression analysis showed a significant relationship between pain scores and intravenous sedation (p=0.02) but not with intracameral lidocaine or other tested variables. However, odds ratio for pain increased to 5.1 (95% CI; 1.29-20.41) in participants without intravenous sedation compared to those with sedation.

CONCLUSIONS

The results of the present study suggest that intravenous sedation preoperatively seems to be an important determinant to relieve the sensation of discomfort/pain during small incision cataract surgery, but intracameral lidocaine was shown not to have a clinically useful role.

A comparison of patient pain and visual outcome using topical anesthesia versus regional anesthesia during cataract surgery

Purpose

The purpose of this study was to compare the level of patient pain during the phacoemulsification and implantation of foldable intraocular lenses while under topical, intracameral, or sub-Tenon lidocaine.

Patients and methods

This was a retrospective study. Three hundred and one eyes subjected to cataract surgery were included in this study. All eyes underwent phacoemulsification surgery and intraocular lens implantation using topical, sub-Tenon, or intracameral anesthesia. The topical group received 4% lidocaine drops, and the intracameral group received a 0.1–0.2 cc infusion of 1% preservative-free lidocaine into the anterior chamber through the side port combined with topical drops of lidocaine. The sub-Tenon group received 2% lidocaine. Best-corrected visual acuity, corneal endothelial cell loss, and intraoperative pain level were evaluated. Pain level was assessed on a visual analog scale (range 0–2).

Results

There were no significant differences in visual outcome and corneal endothelial cell loss between the three groups. The mean pain score in the sub-Tenon group was significantly lower than that in the topical and intracameral groups (P=0.0009 and P=0.0055, respectively). In 250 eyes without high myopia (< −6D), there were no significant differences in mean pain score between the sub-Tenon and intracameral groups (P=0.1417). No additional anesthesia was required in all groups.

Conclusion

Intracameral lidocaine provides sufficient pain suppressive effects in eyes without high myopia, while sub-Tenon anesthesia is better for cataract surgery in eyes with high myopia.

Topical ocular anesthetic abuse among Iranian welders: time for action

Purpose:

The purpose of this study is to estimate the prevalence of topical ocular anesthetic abuse among welders in Iran and suggest public health solutions for this issue.

Methods:

In this cross-sectional study, 390 welders were randomly recruited and queried on the use of anesthetic drops. A questionnaire was administered through structured one-on-one interviews conducted by the first author.

Results:

A total of 314 welders (80.5%) declared that they had used topical anesthetics at least once during their working lives. Almost 90% of them stated a preference for self-treatment over seeking help from a physician due to cultural and financial reasons. The most commonly used topical anesthetic was tetracaine. Most of the subjects (97.4%) had obtained the drugs from pharmacies without a prescription.

Conclusions:

The prevalence of topical ocular anesthetic abuse among welders in Iran is alarmingly high and may partially be due to cultural issues. Although most physicians are aware that topical anesthetics should only be used as a diagnostic tool, there is a crucial need to re-emphasize the ocular risks associated with chronic use of these medications. Educational programs for both physicians and the public are necessary to address the problem.

Satisfaction level with topical versus peribulbar anesthesia experienced by same patient for phacoemulsification

Background:

Various studies have assessed patient satisfaction with topical versus peribulbar anesthesia with conflicting results. Aim of study was to determine satisfaction level in same patient who gets topical anesthesia in one eye and peribulbar block in another eye. We propose that evaluation of various indicators of patient satisfaction will enable better selection of cases for topical anesthesia in the future.

Methods:

Eighty patients scheduled for phacoemulsification were enrolled in prospective, randomized, double-blind study. Each patient scheduled twice for one eye under topical anesthesia and other in peribulbar block. Pain, discomfort and pressure during application of local anesthetic, during phacoemulsification and at 2 hours after procedure were assessed on standard scales. Before discharge patient satisfaction level was checked with Iowa satisfaction with anesthesia scale (ISAS). The Student's t-test was used to determine the significance of IOWA score in both groups. P<0.05 was considered significant.

Results:

Feeling of pain, pressure and discomfort scores during administration of topical anesthesia were all significantly lower compared to peribulbar anesthesia (P=0.004, 0.000, 0.002, respectively). In contrast, intraoperative scores were significantly higher in the topical anesthesia group compared to peribulbar anesthesia (P=0.022, 0.000, 0.000, respectively). Patient satisfaction measured with ISAS shows that peribulbar anesthesia with P=0.000 is strongly significant.

Conclusion:

Peribulbar anesthesia provided significantly better patient satisfaction in comparison with topical anesthesia when used for cataract surgery.

Combined Topical-Intracameral Anesthesia in Manual Small-Incision Cataract Surgery: A Prospective, Randomized, Double-Masked, Placebo-Controlled Trial

PURPOSE

To determine whether intracameral lidocaine plus topical anesthesia could further reduce patients' pain experience during manual small-incision cataract surgery, compared with topical anesthesia alone.

DESIGN

A prospective, randomized, double-masked, placebo-controlled clinical trial was conducted.

METHODS

This research was approved by the institutional review board of the Eye Hospital of Wenzhou Medical College in China. All patients gave written, informed consent, and no untoward pressure or coercion was used for the written informed consent. A total of 300 patients were randomly assigned into the placebo group (topical anesthesia plus intracameral balanced salt solution) or the interventional group (combined topical plus intracameral anesthesia). The pains they experienced during the different stages of the operation were evaluated by a visual analog pain scale. At the end of the surgery, the surgeon was given a questionnaire to evaluate the cooperation of the patient. The endothelial cell count was collected preoperatively and 1 month postoperatively.

RESULTS

The patient-reported pain scores were significantly lower in the interventional group at the following stages of the operation: nucleus rotation (P < 0.001), bisection of the nucleus (P < 0.001), and prolapse of the nucleus (P < 0.001). The surgeon assessment showed better patient cooperation in the lidocaine group (P = 0.04). There was no significant difference in endothelial cell loss between the 2 groups.

CONCLUSIONS

Although topical anesthesia alone provides acceptable anesthesia for manual small-incision cataract surgery, combined topical and intracameral anesthesia decreased patients' discomfort and increased their cooperation during the operation.

Use of viscoelastic substance in ophthalmic surgery - focus on sodium hyaluronate

Among viscoelastic substances, sodium hyaluronate has become the most popular for intraocular surgeries since the introduction of Healon^® (sodium hyaluronate 1%, 4 × 10⁶ daltons) in 1979. This review focuses on the recent development of a new generation of sodium hyaluronate agents with new rheologic properties and the relevant new techniques used in cataract, glaucoma, corneal, and vitreoretinal surgeries. The introduction of sodium hyaluronate agents with different rheologic properties has improved the safety and reliability of intraocular surgeries. Although there have been numerous studies reporting the effectiveness of viscoelastic substances in intraocular surgeries, rigorous validation by multi-center randomized control trials is lacking in many cases. At present, no single viscoelastic agent is most suitable to all of the various intraocular surgical techniques. Therefore, ophthalmologic surgeons should keep up with recent developments of viscoelastic agents and relevant surgical techniques for better patient care.

Cataract surgery under topical anesthesia: Gender-based study of pain experience

Background:

Pain perception, expression, tolerance, and the healthcare provider’s evaluation and management of pain are affected by the gender of the patient. To the best of our knowledge, there is lack of gender-based evaluation of pain during cataract surgery under topical anesthesia.

Aims:

This study has been initiated to evaluate and determine pain experience during cataract surgery under topical anesthesia and to study the gender-based differences of the same.

Settings and Design:

Hospital-based study involving cataract surgery under topical anesthesia using standard cataract surgery. It was an interventional comparative case series.

Materials and Methods:

One hundred and sixty patients were included in four groups, according to the gender and choice of surgery. Patients underwent either phacoemulsification with foldable intra ocular lens (IOL) or manual small incision cataract surgery with rigid IOL under topical anesthesia. Patients ranked their pain experience on VAS scale after the surgery and the surgeon recorded the ease/difficulty accordingly using a questionnaire.

Statistical Analysis Used:

MedCalc version 10.2.0.0 (www.medcalc.be) for windows was used to analyze the results. Analysis of variance (ANOVA) test and Kruskal-Walis test were used to analyze the data.

Results:

The overall visual analog scale (VAS) score was 0.8 (SD 1.3 range 0-8), with no statistical difference among the groups (P=0.5). The average surgeon’s score was 3.3 (SD 0.71 range 3-7), with no statistical difference between the groups (P=0.37).There were no sight threatening complications during the surgery in any group.

Conclusions:

The outcome of the study demonstrates that the patients undergoing cataract surgery under topical anesthesia perceive comparable pain and discomfort irrespective of their gender.

Anesthesiologist intervention during cataract surgery under topical or peribulbar anesthesia: a propensity model comparison

PURPOSE

To compare the incidence and type of anesthesiologist intervention during cataract surgery under peribulbar (PA) or topical (TLA) anesthesia in a day-surgery monitored anesthesia care setting (monitoring provided by nurses with the anesthesiologist available on an on-call basis).

METHODS

From a prospective database of all phacoemulsifications performed in our hospital (January 2008-January 2009), 97 patients submitted to cataract surgery under PA were matched with 97 patients submitted to the same surgery under TA by a propensity model. The resulting groups were homogeneous as to history of antihypertensive therapy administered on the day of surgery and not administered on the day of surgery, cardiologic history, neurologic history, psychiatric history, anxiolytic assumption, and history of diabetes mellitus. We compared the incidence of intervention of the anesthesiologist between groups and the type of adverse event triggering such interventions.

RESULTS

The anesthesiologist was called in 37(38.14%) cases in the PA group and in 27 (27.84%) cases in the TA group (37 [38.14%]) (p = 0.123). Only the occurrence of agitation differed significantly between groups (9 [9.28%] patients in the TA group vs 24 [24.74%] patients in the PA group; p = 0.004).

CONCLUSIONS

Monitored anesthesia care is feasible for cataract surgery both under PA or TA. PA still remains an appealing alternative to TA during cataract surgery for patients incapable of keeping the operating eye in the primary position or with incoercible blinking, photophobia, or phacodonesis. A greater incidence of agitation is to be expected and adequate premedication with anxiolytics should be considered if PA is chosen.

The effect of combined topical-intracameral anaesthesia on neuroleptic requirements during cataract surgery

OBJECTIVE

To evaluate whether the addition of intracameral lidocaine to topical anaesthesia during cataract surgery leads to a decrease in the administration of intraoperative midazolam and fentanyl.

DESIGN

Retrospective case-control study.

PARTICIPANTS

The eyes of 124 patients undergoing phacoemulsification were included in the study, with 62 in the intracameral group and 62 in the control group.

METHODS

A single-centre, retrospective chart review of cases between April and October 2007 in which patients had undergone small-incision phacoemulsification with foldable intraocular lens insertion and received preoperatively either topical tetracaine 0.5% with unpreserved intracameral lidocaine 1% (intracameral group) or topical tetracaine 0.5% alone (control group). Intraoperatively, midazolam and fentanyl were administered as needed based on pain and anxiety.

RESULTS

A total of 124 eyes (124 patients) were included. There was no statistically significant difference between the mean intraoperative midazolam doses given for the 2 groups (p = 0.08). The mean intraoperative dose of fentanyl was lower in the intracameral than in the control group (p < 0.0001). A comparison of intraoperative fentanyl requirements between groups using a multivariate regression analysis for age, gender, surgical time, and preoperative fentanyl levels confirmed the lower need for intraoperative fentanyl in the intracameral compared with the control group (p = 0.0037). There were no anaesthetic complications among any of the study patients.

CONCLUSIONS

Patients receiving topical tetracaine 0.5% with unpreserved intracameral lidocaine 1% during cataract surgery demonstrated a reduction in intraoperative fentanyl requirements. Surgeons performing cataract surgery under topical anaesthesia should consider the addition of intracameral lidocaine 1% to decrease fentanyl requirements and improve patient safety and comfort.

Local anesthesia for cataract surgery

Various aspects of local anesthesia for cataract surgery, such as the anesthetic agents and their interaction with ocular nerve supply, anesthesia requirements, available clinical techniques and their inherent complications are reviewed. A comparative evaluation of clinical techniques in terms of efficacy, akinesia, and patient-perceived pain during both anesthesia administration and intraoperative cataract surgery is presented, along with the prevailing practice patterns of anesthesia techniques among refractive surgeons in the United Kingdom and United States. More randomized clinical trials are needed to facilitate statistical methods of metaanalysis to establish convincingly the overall benefits and efficacy of the various local anesthesia procedures in cataract surgery. The wide scope of the present review is of relevance in structuring ophthalmology and anesthesia specialist training programs for junior staff.

Induction of apoptosis of rabbit corneal endothelial cells by preservative-free lidocaine hydrochloride 2%, ropivacaine 1%, or levobupivacaine 0.75%

PURPOSE

To determine and compare the amount of apoptosis and changes in rabbit corneal endothelial cell morphology after intracameral administration of different anesthetic agents.

SETTING

Department of Ophthalmology, Baskent University Medical Faculty, Ankara, Turkey.

METHODS

Right eyes of 64 Vienna white rabbits were injected intracamerally with preservative-free lidocaine hydrochloride 2%, ropivacaine 1%, levobupivacaine 0.75%, or fortified balanced salt solution (BSS Plus) (control). Animals were humanely killed 1 day or 7 days later. Terminal deoxynucleotidyl transferase deoxy-UTP-nick end labeling was used to detect apoptosis. Corneal endothelial cells and apoptotic cells were counted by light microscopy. The morphologic appearance was determined by transmission electron microscopy (TEM).

RESULTS

Apoptotic cell density was high in the anesthetic groups on day 1 (P<.01); there was no significant difference between groups at 7 days. Apoptotic cell density declined significantly between 1 day and 7 days in the anesthetic groups (P<.05) but not in the control group. There was no difference in endothelial cell density between the 4 groups at 1 or 7 days. All anesthetic groups showed degenerative changes on TEM, with the least change in the preservative-free lidocaine hydrochloride 2% group.

CONCLUSIONS

Intracameral injections of preservative-free lidocaine, ropivacaine, and levobupivacaine induced significantly more apoptotic endothelial cell loss than BSS Plus and led to morphologic changes in the corneal endothelial cells in the early period. This effect was temporary, with recovery by 7 days. Considering the limited proliferative capacity in human eyes, the induced apoptosis might result in the permanent cell loss and enlargement in human corneal endothelium.

Comparative clinical trial of topical anaesthetic agents for cataract surgery with phacoemulsification: lidocaine 2% drops, levobupivacaine 0.75% drops, and ropivacaine 1% drops

PURPOSE

To assess the safety and efficacy of topical lidocaine, levobupivacaine, and ropivacaine in cataract surgery with phacoemulsification.

METHODS

One hundred and five patients scheduled for cataract surgery with topical anaesthesia were randomly allocated into 3 groups of 35 patients each to receive eye drops of lidocaine 2%, levobupivacaine 0.75%, or ropivacaine 1% every 5 min starting 30 min before surgery. Patients graded their pain using a 0-10-point verbal pain score (VPS) at different stages of the procedure. The levels of patient and surgeon satisfaction, the duration of surgery, complications, and the need for supplemental anaesthesia were recorded.

RESULTS

There was no significant difference in duration of surgery and demographic variables among the groups. At the intraoperative period, end of surgery, and postoperative first hour the mean VPS in the lidocaine group was significantly higher than the others (P<0.01), but no significant difference was found between the levobupivacaine and ropivacaine groups. At incision and 24 h after surgery, it was not significantly different among the groups. Surgeon and patient satisfaction scores were significantly better in the levobupivacaine and ropivacaine groups than in the lidocaine group (P<0.01).

CONCLUSIONS

Topical anaesthesia with levobupivacaine and ropivacaine were safe, feasible and more effective than lidocaine in cataract surgery. Levobupivacaine and ropivacaine provided sufficient and long-lasting analgesia without the need of supplemental anaesthesia for each patient.

Topical anaesthesia alone versus topical anaesthesia with intracameral lidocaine for phacoemulsification

BACKGROUND

Cataract is defined as loss of transparency of the natural lens and is usually an age-related phenomenon. The only recognized treatment available for cataract involves surgery. An ideal anaesthetic should allow for pain-free surgery with no systemic or local complications. It should be cost effective and should facilitate a stress-free procedure for surgeon and patient alike. Topical anaesthesia involves applying anaesthetic eye drops to the surface of the eye prior to and during surgery. This has found large acceptance especially in the USA where it is used by 61% of cataract surgeons. Many surgeons who perform cataract surgery under topical anaesthesia also use intraoperative supplementary intracameral lidocaine (injected directly into the anterior chamber of the eye). The benefits and possible risks of intracameral lidocaine have been assessed by a number of randomized controlled trials, but the results have been conflicting and many of the endpoints have been heterogeneous.

OBJECTIVES

The primary objective of this systematic review was to assess pain during surgery and patient satisfaction with topical anaesthesia alone compared to topical anaesthesia with intracameral anaesthesia for phacoemulsification. The secondary objectives were to assess adverse effects and complications attributable to choice of anaesthesia and the need for additional anaesthesia during surgery.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 2), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006) and LILACs (1982 to 3 May 2006). We also searched the reference lists of the identified studies and the Science Citation Index. We did not have any language restriction.

SELECTION CRITERIA

We included only randomized controlled trials (RCTs) comparing topical anaesthesia alone to topical anaesthesia with intracameral lidocaine.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. For dichotomous outcomes data were presented as odds ratios. For continuous outcomes the weighted mean difference was employed. A random-effects model was used unless there were fewer than three trials in a comparison, where a fixed-effect model was used. We explored heterogeneity between trial results using a chi-squared test.

MAIN RESULTS

A total of eight trials comprising of 1281 patients were identified for analysis. Our data comparison showed a significantly lower intraoperative pain perception in patient groups using supplementary intracameral lidocaine, although the difference was small. No significant difference was demonstrated between the groups receiving topical anaesthesia alone and topical combined with intracameral anaesthesia in terms of the need for supplemental anaesthesia, intraoperative adverse events or corneal toxicity.

AUTHORS' CONCLUSIONS

The use of intracameral unpreserved 1% lidocaine is an effective and safe adjunct to topical anaesthesia for phacoemulsification cataract surgery.

Cataract surgery anaesthesia: is topical anaesthesia really better than retrobulbar?

PURPOSE

To compare the effectiveness for the patient of retrobulbar anaesthesia (RBA) and topical anaesthesia (TA) in cataract surgery by phacoemulsification.

METHODS

We performed a prospective, randomized study on 115 patients operated at our clinic using the two anaesthesia techniques. The RBA group comprised 57 patients (20 women, 37 men; age 72 +/- 10 years); the TA group comprised 58 patients (20 women, 38 men; age 74 +/- 10 years). Measured parameters were: blood pressure; heart rate; blood oxygen saturation level; serum adrenaline, noradrenaline and cortisol levels; white blood cell count; indicated pain during the procedure, and pain as reported by the patient afterwards. Two psychological tests were used: the State-Trait Anxiety Inventory (STAI), and the patient-selected face-scale test. Statistical analysis was performed using Student's t-test and the chi-square test. Results were also analysed using a logistic regression model.

RESULTS

Both types of anaesthesia were adequate for the surgical procedure. In the RBA group fewer patients experienced pain during surgery (p < 0.01) and fewer recalled any perioperative discomfort. With RBA the objective parameters were more stable than with TA, and systolic blood pressure was significantly lower (p = 0.01). The logistic model was able to predict perioperative pain with 93% certainty. Pain sensitivity was higher in younger patients and in patients with higher initial cortisol and noradrenaline serum levels.

CONCLUSIONS

Both methods of anaesthesia are appropriate, but phacoemulsification with TA is more painful than with RBA. In hypertonic patients and younger patients who are more susceptible to pain, TA should be avoided or used in combination with individualized sedation.

Ropivacaine versus lidocaine for deep-topical, nerve-block anaesthesia in cataract surgery: a double-blind randomized clinical trial

PURPOSE

To evaluate the safety and efficacy of ropivacaine versus lidocaine for deep-topical, nerve-block anaesthesia in cataract surgery.

METHODS

This prospective controlled randomized double-blind study comprised 64 patients undergoing clear corneal phacoemulsification. Patients were equally divided into two group receiving either deep-topical anaesthesia with 1% ropivacaine-soaked sponge (Group R, n = 32) or 2% lidocaine-soaked sponge (Group L, n = 32). The level of intraoperative and postoperative pain was assessed by patients using a verbal analogue scale from 1 to 10. The duration of surgery, the need for supplemental anaesthesia, surgeon satisfaction, and intraoperative and early postoperative complications were recorded. The patients' heart rate, arterial blood pressure and peripheric oxygen saturation (SpO(2)) were obtained just before the anaesthesia and during the surgery.

RESULTS

The demographic data of the patients and duration of surgery were similar in both groups. No significant difference in the mean pain scores of patients were found in the ropivacaine and lidocaine groups. Surgical satisfaction was also statistically insignificant. None of the patients had significant difference in heart rate, blood pressure or SpO(2) during the surgical procedure.

CONCLUSION

Deep-topical anaesthesia with ropivacaine and lidocaine in cataract surgery is safe and the two anaesthetic agents do not present differences in the degree of analgesia achieved. Deep-topical anaesthesia with ropivacaine or lidocaine was equally effective in providing anaesthesia with sufficient quality for cataract surgery.

Safety and efficacy of topical anesthesia combined with a lower concentration of intracameral lidocaine in phacoemulsification

PURPOSE

To assess the safety and efficacy of phacoemulsification under a topical anesthesia combined with intracameral lidocaine 0.5%.

SETTING

Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan, Taiwan, China.

METHODS

A prospective randomized double-blind study was designed in which patients had phacoemulsification performed under topical anesthesia (4 drops of nonpreserved lidocaine 2%) with 0.15 mL intracameral placebo (balanced salt solution) in 1 eye (Group 1) and topical anesthesia with intracameral nonpreserved lidocaine 0.5% in the other eye (Group 2). Endothelial changes, including cell density, coefficient variation of cell size, and percentage of hexagonal cells, were measured by noncontact specular microscopy. Preoperative and postoperative best corrected visual acuity was also documented. The degree of pain throughout surgery was ranked on a 10-point visual analog pain scale.

RESULTS

Thirty-three patients were recruited. There was no significant difference in preoperative and postoperative mean endothelial parameters between the 2 groups. Furthermore, mean endothelial cell loss was similar. Mild or no pain (score 0 to 1) was reported by 48.5% in Group 1 and 90.9% in Group 2. Patients reported less pain with combined topical and intracameral lidocaine anesthesia (P = .001, Mann-Whitney test). Vision was significantly improved in both groups. However, 1 patient in Group A developed vitreous loss as a result of involuntary eye movement.

CONCLUSION

Combining topical anesthesia with intracameral lidocaine 0.5% [corrected] anesthesia was safe and effective in phacoemulsification with intraocular lens implantation.

Cytotoxicity of Lidocaine or Bupivacaine on Corneal Endothelial Cells in a Rabbit Model

PURPOSE

To investigate the corneal endothelial cytotoxicity of commercial formulations of agents used for intracameral anesthesia in cataract and other ocular surgery.

METHODS

Cultured corneal endothelial cells (CECs) of New Zealand White rabbits were exposed for 1 minute to balanced salt solution (control); Xylocaine (lidocaine) 1% E (with epinephrine), 2% E, 2%, or 4%; or Marcaine (bupivacaine) 0.5% or 0.5% spinal heavy. The degree of cytotoxicity was determined by in vitro staining with trypan blue and light microscopic evaluation of cell morphology. The effect of longer exposure (up to 16 minutes) to lidocaine 1% E was also investigated.

RESULTS

CECs were not significantly damaged by 1-minute exposure to lidocaine 1% E or 2% E; however, significant cytotoxicity was seen after 1-minute exposure to lidocaine 2% or 4% or bupivacaine 0.5% or 0.5% spinal heavy. Exposure to lidocaine 1% E showed a trend toward time-dependent cytotoxicity that reached significance at 16 minutes.

CONCLUSIONS

One-minute exposure to lidocaine 1% E or 2% E appears to be safe for cultured rabbit CECs, although longer exposures could cause time-dependent cytotoxicity, which should be considered in planning cataract or other ocular surgery. Because bupivacaine 0.5% and 0.5% spinal heavy cause cytotoxic effects within the first minute of contact with CECs, they should be used with great caution, if at all, in the anterior chamber of human eyes.

L’anesthésie topique en chirurgie de la cataracte ambulatoire de l’adulte sans anesthésiste présent

To review the local anesthesia environment in France in adult out-patient cataract surgery. The author considers the presence or absence of an anesthesiologist in the operating room. The report shows that in many circumstances there is no need for an anesthesiologist if the following criteria are respected: the adult is fully informed, in rather good health, with no acute risk factors, and surgery is performed by a senior surgeon in a certified operating room. In France, a move toward more flexible regulations is expected, with a new cooperation between ophthalmologists and anesthesiologists that will lead to a new true risk/benefit/obligation ratio. Respect of the individual and safety remain crucial requirements making systematic generalizations impossible.

Topical versus peribulbar anaesthesia for cataract surgery

BACKGROUND

To assess and compare the efficacy and safety of topical versus peribulbar anaesthesia in patients undergoing routine cataract surgery.

METHODS

The unicentre, prospective, randomized, clinical interventional trial included 140 consecutive patients undergoing routine cataract surgery performed by one of two surgeons. The patients were randomly distributed to either peribulbar anaesthesia or topical anaesthesia. To assess intraoperative pain, each patient was asked immediately after surgery to quantitate his/her pain using a 10-point pain rating scale.

RESULTS

The study groups did not differ significantly in pain score (p=0.54), duration of surgery (p=0.52), anaesthesia-related intraoperative difficulties (p=0.17), postoperative visual acuity (p=0.94), overall intraoperative surgical complication rate, blood pressure rise (p=0.16) or blood oxygen saturation (p=0.74)

CONCLUSIONS

Patient comfort and surgery-related complications did not differ between topical anaesthesia and peribulbar anaesthesia. As there are no significant differences between the two techniques in terms of subjective pain experienced by patients, intraoperative complications and postoperative visual outcome, and in view of the minimally invasive character of topical anaesthesia compared to peribulbar anaesthesia, the present study suggests the use of topical anaesthesia for routine cataract surgery.

Topical anaesthesia: a risk factor for post-cataract-extraction endophthalmitis?

PURPOSE

To investigate if the incidence of postoperative endophthalmitis in temporal clear corneal cataract surgery is influenced by the use of topical anaesthesia compared to retrobulbar anaesthesia.

METHODS

A retrospective study was conducted of one surgeon's cataract surgery between October 1997 and October 2001.

RESULTS

Between October 1997 and May 2000, there were 633 cataract extractions performed with 219 patients operated under topical anaesthesia and 414 under retro-bulbar injection. The selection criteria were that surgically easier cases underwent topical anaesthesia. There were five patients who suffered postoperative endophthalmitis in their first week, of which four cases were under topical anaesthesia. This was shown to be borderline significance of P = 0.05 using the Fischer exact 2-tailed test. There was a complicated case, operated under retrobulbar anaesthesia, who had a low-grade endophthalmitis in the second postoperative week. The four topical cases and the case from the second week all grew Staphylococcus epidermidis. The retrobulbar case developing endophthalmitis in the first week grew alpha haemolytic Streptococcus. After May 2000, there was a change to performing all cataract surgery under retrobulbar anaesthesia and the next 453 cases had no incidence of endophthalmitis.

CONCLUSION

Topical anaesthesia techniques in temporal clear corneal cataract extraction may be a factor in endophthalmitis.

Viscoanesthesia. Part I: toxicity to corneal endothelial cells in a rabbit model

PURPOSE

To evaluate the toxicity of a solution combining sodium hyaluronate 1.5% with lidocaine (0.5%, 1.0%, or 1.65%) to the rabbit corneal endothelium.

SETTING

Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA.

METHODS

Each rabbit cornea was excised, and the endothelium was exposed to 1 of the following solutions for 20 minutes: viscoanesthetic solution (0.5%, 1.0%, or 1.65% lidocaine in sodium hyaluronate 1.5%; 5 corneas each), sodium hyaluronate 1.5% (n = 5), balanced salt solution (BSS(R)) (n = 5), mitomycin-C 0.02% (n = 2), dextran 15% (n = 2), or distilled water (n = 2). The endothelium was then stained with trypan blue and alizarin red. Two corneas were stained immediately after excision. Cell morphology and damage to the corneal endothelium were analyzed by microscopic examination.

RESULTS

The endothelium in the corneas of the viscoanesthetic groups was comparable to that in the sodium hyaluronate 1.5% and the BSS groups and to the corneas not exposed to any solution. In some areas of the 1.0% and the 1.65% viscoanesthesia groups, the corneal endothelial cells presented irregular intercellular borders. Staining with trypan blue, which indicates cellular damage, was observed in some linear areas corresponding to corneal folds in all groups. The folds were probably caused during manipulation for corneal excision and staining. The corneal endothelium was destroyed in the mitomycin group. In the dextran and distilled-water groups, morphological alterations probably resulting from osmotic changes were observed.

CONCLUSIONS

The 3 concentrations of viscoanesthetic solutions appeared to be safe to rabbit corneal endothelium.

Viscoanesthesia. Part II: toxicity to intraocular structures after phacoemulsification in a rabbit model

PURPOSE

To investigate the toxicity of a solution that combines sodium hyaluronate 1.5% with lidocaine (0.5%, 1.0%, or 1.65%) to intraocular structures.

SETTING

Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA.

METHODS

Phacoemulsification was performed in both eyes of 29 rabbits. They were divided into 3 groups; in each group (n = 7), 1 viscoanesthetic solution was used before capsulorhexis. After irrigation/aspiration, 0.2 mL of the solution was purposely left in the capsular bag. In 1 rabbit in each group, the solution was injected into the vitreous cavity through a posterior capsulorhexis. In 8 rabbits used as controls, balanced salt solution (BSS(R)) (n = 4) or sodium hyaluronate 1.5% (n = 4) was injected into the vitreous cavity. Enucleations were performed 15, 30, and 60 days postoperatively. Histological sections were cut and stained with hematoxylin-eosin, periodic acid-Schiff, and Masson trichrome stains.

RESULTS

Light microscopic evaluation of the eyes enucleated after 15, 30, and 60 days in the study and control groups showed similar findings in intraocular structures such as the ciliary body and retina. No evidence of an inflammatory reaction, cell necrosis, or cell degeneration was observed in the histological sections.

CONCLUSIONS

The use of viscoanesthesia during phacoemulsification appeared to be safe, with no histologic abnormalities observed with the 3 lidocaine concentrations. The efficacy of the anesthetic effects of these solutions will be addressed in clinical trials.

Lidocaine 2% gel versus lidocaine 4% unpreserved drops for topical anesthesia in cataract surgery: a randomized controlled trial

OBJECTIVE

To compare intracameral levels and clinical efficacy of lidocaine 2% gel with lidocaine 4% unpreserved drops.

DESIGN

Double-blind, randomized, one-surgeon, controlled trial.

PARTICIPANTS

One hundred seven consecutive cataract cases eligible for topical anesthesia.

INTERVENTION

Patients were randomly assigned to receive 20 mg of lidocaine either as lidocaine 2% gel (1 ml) or as lidocaine 4% unpreserved eyedrops (0.5 ml) before clear corneal phacoemulsification.

MAIN OUTCOME MEASURES

Aqueous samples were taken to measure lidocaine intraocular levels. Intraoperative pain was quantified a few minutes after surgery using a 0 to 10 visual analog scale.

SECONDARY OUTCOME MEASURES

Patients were asked to grade the degree to which they were bothered by tissue manipulation. The surgeon graded patients' cooperation. The anesthesiologist recorded any increase in pulse or blood pressure and the need for supplemental topical anesthesia or intravenous sedation. Duration of surgery and intraoperative complications were also recorded.

RESULTS

In the gel group intracameral lidocaine levels were significantly higher (P < 0.001) and patient-reported intraoperative pain scores were significantly lower (P = 0.026). Patients in the gel group were bothered by tissue manipulation to a lesser extent (P = 0.028), and their cooperation was better (P = 0.002). Increases in blood pressure were more frequent in the eyedrops group. Supplemental anesthesia was required in two cases (3.70%) in the gel group versus eight cases in the eyedrops group (15.09%). No correlation between intracameral lidocaine levels and intraoperative pain scores was found (r = -0.026, P = 0.789).

CONCLUSIONS

If administered by means of gel, the same amount of lidocaine gives significantly higher intracameral levels of lidocaine, better analgesia, better patient cooperation, and less need for intraoperative supplemental anesthesia. Lower pain scores do not correlate with intracameral lidocaine levels.

Long-term endothelial cell loss after phacoemulsification: peribulbar anesthesia versus intracameral lidocaine 1%: prospective randomized clinical trial

PURPOSE

To evaluate endothelial cell loss after phacoemulsification with posterior chamber intraocular lens implantation using peribulbar anesthesia or topical anesthesia combined with intracameral unpreserved lidocaine 1%.

SETTING

Department of Ophthalmology, Charité, Humboldt-University of Berlin, Berlin, Germany.

METHODS

Before and 20 months +/- 5.1 (SD) after surgery, specular microscopy was used to evaluate the number and morphology of endothelial cells in 78 eyes having peribulbar anesthesia or topical anesthesia combined with an intracameral injection of 0.15 cc unpreserved lidocaine 1%.

RESULTS

The mean endothelial cell loss was 11.11% in the peribulbar group and 12.55% in the topical/lidocaine group. There was no statistically significant difference in the amount of endothelial cell loss or cell morphology between the 2 groups.

CONCLUSION

The long-term postoperative endothelial cell course showed that topical anesthesia combined with an intracameral injection of 0.15 cc unpreserved lidocaine 1% is a safe alternative to peribulbar anesthesia.

A comparison of cataract surgery under topical anaesthesia with and without intracameral lignocaine

PURPOSE

To compare the efficacy of intracameral unpreserved lignocaine with placebo during cataract surgery under topical anaesthesia.

METHODS

One hundred and thirty-five consecutive cases undergoing clear corneal phacoemulsification were enrolled in this single surgeon, prospective, double-masked, controlled trial. Patients were randomized into two groups, receiving either intracameral unpreserved lignocaine 1% or placebo (balanced salt solution). Systolic and diastolic blood pressure, pulse rate and peripheral oxygen saturation were recorded preoperatively and during phacoemulsification. The level of intraoperative pain was assessed by a numerical analogue scale ranging between 0 (no pain) and 10 (unbearable pain). Data were compared by Student t-test.

RESULTS

Sixty-seven cases received lignocaine (group 1) and 68 received placebo (group 2). Average age was 75 years and 74 years, respectively. Systolic blood pressure, pulse rate, oxygen saturation and pain score showed no statistical difference (P = 0.241, 0.542, 0.712, 0.237, respectively). Diastolic blood pressure showed a weakly significant change (P = 0.023). Patients reported minimal discomfort during surgery in both groups.

CONCLUSION

This study found no additional benefit of intracameral unpreserved lignocaine when performing routine clear corneal phacoemulsification under topical anaesthesia.

Anxiety in cataract surgery: pilot study

PURPOSE

To quantify the anxiety provoked by cataract surgery and establish whether the preoperative stage, the day of surgery, or the outcome was associated with unduly high anxiety.

SETTING

Moorfields Eye Hospital, London, United Kingdom.

METHODS

A cross-sectional survey of adult patients having cataract surgery under local anesthesia was done. The Hospital Anxiety and Depression (HAD) scale and a Visual Analog Scale (VAS) were used to quantify the patients' anxiety. Of the 108 patients enrolled, 38 were surveyed at the preassessment clinic, 36 at the day ward (operation day), and 34 at the postoperative clinic. For each stage, the patients were divided into groups: first-eye cataract surgery, second-eye cataract surgery, and combined (first- and second-surgery patients).

RESULTS

The average patient in the combined group found the preassessment stage to be more anxiety provoking than the operation day or the postoperative visit. The median HAD scale scores were 5, 4, and 2, respectively, and the median VAS anxiety scores, 4, 2, and 1.75. The HAD anxiety scores in the combined group were significantly different between the operation day and the postoperative visit (P <.05, Mann-Whitney U) but not between the preassessment and operation day. The VAS scores showed no significant differences among the 3 stages of treatment in the combined group. Different anxiety trends were found between the first- and second-surgery groups.

CONCLUSION

The average patient was not unduly anxious about cataract surgery.

No-anesthesia clear corneal phacoemulsification versus topical and topical plus intracameral anesthesia. Randomized clinical trial

PURPOSE

To compare the intraoperative pain scores during clear corneal phacoemulsification under no anesthesia, topical anesthesia, and topical plus intracameral anesthesia.

SETTING

Dr. Agarwal's Eye Hospital and Eye Research Center, Chennai, India.

METHODS

Seventy-five patients were randomized to have phacoemulsification under no anesthesia, topical anesthesia, or topical plus intracameral anesthesia. Uncooperative or illiterate patients and those with hard cataract, a shallow anterior chamber, or small pupils were excluded. A protocol was established for supplemental anesthesia in case of breakthrough pain during the surgery. Each patient was asked to grade the overall severity of intraoperative pain immediately after surgery on a 10-point visual analog scale. Also evaluated were the general discomfort during surgery, discomfort from the microscope lights, surgeon stress during surgery, and total surgical time. Comparison among the 3 groups was performed using an analysis of variance.

RESULTS

No supplemental anesthesia was required in any group. No significant difference was noted in the mean scores of the subjective sensation of pain with or without topical anesthesia (P =.610). The mean scores of patient discomfort from the microscope lights and surgical time were also statistically insignificant. Patient discomfort and surgeon stress during surgery were significantly greater in the no-anesthesia group than in the topical and topical plus intracameral groups (P =.0235 and P = 0.0206, respectively).

CONCLUSION

No-anesthesia clear corneal phacoemulsification was performed by a highly experienced, skilled surgeon without causing an unacceptable level of pain. However, this technique is not suitable for every cataract surgeon or patient.

Cataract surgery under topical anesthesia in patients with coexisting glaucoma

PURPOSE

To evaluate and compare levels of patient discomfort and complications during phacoemulsification with implantation of a foldable intraocular lens (IOL) under topical lidocaine hydrochloride in patients with and without various forms of chronic open-angle and chronic angle-closure glaucoma.

SETTING

Two university eye centers in Germany.

METHODS

This prospective nonrandomized comparative study comprised 176 eyes of 176 patients with various forms of chronic open-angle glaucoma and chronic angle-closure glaucoma. Eyes with cataract and without a glaucoma diagnosis or history of intraocular surgery served as a control group (n = 212). All patients received a minimum of 5 doses (2 drops per dose) of topical lidocaine hydrochloride 2% before standard temporal clear corneal phacoemulsification and foldable IOL implantation. No intracameral anesthetic injection was given, and no systemic sedatives were used. The main outcome measures were the number of complications and adverse events.

RESULTS

The intraoperative complication rate in all patients (n = 388) was capsule tear, 1.3%; zonule tear, 1.8%; vitreous loss, 1.0%; iris prolapse, 0.8%. No statistically significant differences in intraoperative or early postoperative complications were found between the glaucoma and control groups. The mean pain scores of patients were 0.38 +/- 1.1 (SD) in the glaucoma group and 0.36 +/- 0.8 in the control group (P =.21) Patient preference for cataract surgery under topical anesthesia was similar in both groups.

CONCLUSIONS

Surgery-related complications and patient discomfort were similar in patients with and without glaucoma who had phacoemulsification and IOL implantation under topical anesthesia. These results indicate that topical anesthesia is safe for routine phacoemulsification with foldable IOL implantation in patients with glaucoma and does not compromise patient comfort.

The methodologic quality of clinical trials on regional anesthesia for cataract surgery

OBJECTIVE

To assess the methodologic quality of published randomized trials of regional anesthesia management strategies for cataract surgery.

DESIGN

Literature review and analysis.

METHOD

We performed a systematic search of the literature to identify all articles pertaining to regional anesthesia for cataract surgery on adults. Overall quality scores and scores for individual methodologic domains were based on the evaluations of two investigators experienced in methodologic research who independently reviewed all relevant articles using a quality abstraction form.

MAIN OUTCOME MEASURES

Study quality in each of five domains: representativeness, bias and confounding, intervention description, outcomes and follow-up, and statistical quality and interpretation.

RESULTS

Eighty-two randomized clinical trials were identified with a mean overall quality score of 44%. The mean domain scores ranged from 37% for representativeness to 58% for outcomes and follow-up. Forty percent or fewer studies received the maximum score for reporting the setting, the population, and the start and end dates; describing the inclusion and exclusion criteria; adequately randomizing subjects; and adequately masking individuals participating in the study. Key outcomes were often inadequately reported, including the distribution of patient-reported pain scores and the mean surgical time.

CONCLUSIONS

Greater attention to methodologic quality and detailed reporting of study results will improve the ability of readers to interpret the results of clinical trials assessing regional anesthesia for cataract surgery.

Synthesis of the literature on the effectiveness of regional anesthesia for cataract surgery

OBJECTIVE

To synthesize the findings of the randomized trials of regional anesthesia management strategies for cataract surgery.

DESIGN

Literature review and analysis.

METHOD

The authors performed a systematic search of the literature to identify all articles pertaining to regional anesthesia during cataract surgery on adults. One investigator abstracted the content of each article onto a custom-designed form. A second investigator corroborated the findings. The evidence supporting the anesthesia approaches was graded by consensus as good, fair, poor, or insufficient.

MAIN OUTCOME MEASURES

Evidence supporting the effectiveness of different forms of regional anesthesia.

RESULTS

There was good evidence that retrobulbar and peribulbar blocks provide equivalent akinesia and pain control during cataract surgery. Additionally, sub-Tenon's blocks were at least as effective as retrobulbar and peribulbar blocks. There was good evidence that retrobulbar block provides better pain control during surgery than topical anesthesia, and there was fair evidence that peribulbar block provides better pain control than topical anesthesia.

CONCLUSIONS

This synthesis of the literature demonstrates that currently used approaches to anesthesia management provide adequate pain control for successful cataract surgery, but there is some variation in the effectiveness of the most commonly used techniques. Data are needed on patient preferences to determine the optimal strategies for anesthesia management during cataract surgery.

Perilimbal topical anesthesia for clear corneal phacoemulsification

PURPOSE

To evaluate the efficacy of perilimbal topical anesthesia for clear corneal cataract surgery.

SETTING

Department of Ophthalmology, University of Udine, Udine, Italy.

METHODS

Seventy-five consecutive patients were studied for perioperative pain, visual outcome, and intraoperative complications. Topical anesthesia was administered with a cellulose sponge soaked in preservative-free lidocaine 2%. The perilimbal area was touched 360 degrees for 30 seconds with the sponge tip under the operating microscope just before surgery. No sedation or adjunctive anesthetic drops were given. Surgery was performed through a temporal corneal tunnel with the easy-chop technique. Pain was scored on a subjective scale from 0 (no pain) to 3 (severe pain). Visual acuity was measured 1 day and 1 week after surgery. Mean operating time was recorded.

RESULTS

Sixty-nine patients (92%) tolerated the procedure well, giving a pain score of 0 or 1. Six (8%) of the 40 patients who had a single stitch at the end of surgery scored 2. No patient reported pain during iris touch, intraocular lens implantation, or conjunctiva manipulation. No intraoperative complications were recorded. Mean operating time was 12.7 minutes +/- 3.7 (SD) (range 7 to 34 minutes). Mean preoperative visual acuity was 0.4 +/- 0.2 (range 0.01 to 0.80). Visual acuity of 0.5 or better was attained in 93.6% of eyes 1 day and in 96% 1 week postoperatively.

CONCLUSIONS

Perilimbal topical anesthesia was an effective and easy-to-administer anesthetic procedure for phacoemulsification, providing good perioperative pain tolerance by patients and rapid visual recovery.

Injectable versus topical anesthesia for cataract surgery: patient perceptions of pain and side effects. The Study of Medical Testing for Cataract Surgery study team

OBJECTIVE

To compare patient reports of intraoperative pain and postoperative side effects by different anesthesia strategies for cataract surgery.

DESIGN

Prospective cohort study.

PARTICIPANTS

Men and women 50 years of age and older undergoing 19,250 cataract surgeries at nine centers in the United States and Canada from June 1995 through June 1997.

INTERVENTION

Topical anesthesia or anesthesia with injection, with or without sedatives, opioid analgesia, hypnotics, and diphenhydramine (Benadryl).

MAIN OUTCOME MEASURES

Patient ratings of intraoperative pain, satisfaction with pain management, and early postoperative side effects (drowsiness, nausea, vomiting, or a combination thereof).

RESULTS

Twenty-six percent of surgeries were performed using topical anesthesia alone, and the remainder were performed with peribulbar, retrobulbar, or facial nerve block, or a combination thereof. Local anesthesia by injection with sedatives and diphenhydramine resulted in the lowest reporting of any intraoperative pain (1.3%), with postoperative drowsiness (9.6%) and nausea, vomiting, or both (1.5%) comparable with those administered topical anesthesia alone. Among those receiving topical anesthesia, use of sedatives and opioids reduced reports of any pain during surgery by 56% (95% confidence interval [CI], 34%, 70%), but increased nausea and vomiting (odds ratio, 2.27; 95% CI, 1.26, 4.09) compared with those administered topical anesthesia alone, after adjusting for age, gender, race, American Society of Anesthesiologists risk class, self-reported health status, and duration of surgery. Among those receiving local injections, use of opioids reduced reports of any pain among those receiving sedatives by 37% (95% CI, 15%, 54%), but did not increase postoperative side effects. The use of diphenhydramine among those receiving sedatives decreased reports of any pain by 59% (95% CI, 33%, 75%) and also reduced drowsiness and nausea and vomiting by 57% (95% CI, 48%, 65%) and by 60% (95% CI, 36%, 75%), respectively. Use of hypnotics with sedatives was associated with increased reports of any pain during surgery and increased nausea and vomiting after surgery.

CONCLUSIONS

Patient reports of any pain during cataract surgery (5%) and postoperative side effects (16% drowsiness and 4% nausea and vomiting) were low, but varied by anesthesia strategy. Patient perceptions of pain and side effects can be helpful in guiding the appropriate choice of anesthesia strategy.

Anesthesia modalities for cataract surgery

Research articles on anesthesia modalities for cataract surgery are reviewed. A growing trend toward the use of topical anesthesia is apparent. Particular emphasis in the literature is given to determining the safety and efficacy of various forms of topical anesthesia using injectable anesthesia as a frame of reference. A consensus of opinion points toward the use of topical application of anesthetic drops plus intracameral unpreserved lidocaine 1% as the anesthesia modality that provides the best level of analgesia and comfort to patients while not compromising ocular safety. Several articles reporting complications of injectable anesthesia are also reviewed.

Pain relief with intracameral mepivacaine during phacoemulsification

AIM

To assess the efficacy and safety of an intraoperative intracameral injection of mepivacaine, administered when patients experienced pain during the course of cataract surgery under topical anaesthesia.

METHODS

This is a prospective placebo controlled double masked randomised clinical trial. 50 eyes were included; 25 receiving the active compound and 25 receiving placebo. Mepivacaine (2%, 0.4 ml) or placebo was administered intraoperatively under the iris of the patients who experienced pain during the course of phacoemulsification in spite of previous topical anaesthesia. Efficacy was evaluated by the patients themselves using a five point subjective pain rating scale, the Keele verbal pain chart. Safety was measured by assessing intraocular inflammation (clinical evaluation and laser flare meter), intraocular pressure, and endothelial cell count.

RESULTS

The pain rating score significantly diminished after intracameral injection in the mepivacaine group (mean 3.0 (95% CI 2.6-3.4) v 0.8 (0.3-1.3), p<10(-4))) while remaining unchanged in the placebo group (2.9 (2.6-3.2) v 2.9 (2.5-3. 3)), the mean reduction in pain score being significantly different between the two groups (p<10(-4)). There was no indication of increased postoperative ocular inflammation, intraocular pressure change, or endothelial cell loss.

CONCLUSIONS

These results suggest that it may not be necessary to systematically add intracameral anaesthesia with topical anaesthesia for cataract surgery. An intraoperative intracameral injection, performed only in patients who happen to suffer during surgery, is safe and effective.