Preventing Adverse Events in Cataract Surgery: Recommendations From a Massachusetts Expert Panel

Predictors of pain during phacoemulsification under local sedation: A multicentric study

PURPOSE

To assess the risk factors for pain during cataract surgery under local anesthesia.

METHODS

This multicentric observational study assessed risk factors for pain during cataract surgery from June to November 2020 in a private clinic and two university hospitals (France). Adults who underwent cataract surgery under local anesthesia with conscious sedation were consecutively included. Exclusion criteria were locoregional anesthesia and an inability to communicate. Once the surgical drape was removed, patients rated the pain on a numerical rating scale (NRS) from 0 to 10, after the surgical drape was removed. Clinical and biometric parameter data were retrieved from medical records. Multivariate logistic regression was used to determine factors associated with pain during cataract surgery.

RESULTS

Among the 387 eyes (330 patients), 53 (13.7%) were classified by patients as painful (numerical rating scale [NRS] score≥4). An intraoperative painful eye (NRS score≥4) was associated with intraocular lens (IOL) power<19 D (OR=2.78, P=0.005), chronic analgesic use (OR=4.34, P=0.011), and brown or white type of cataract (OR=5.68, P=0.008).

CONCLUSION

In conclusion, anesthesia should be adapted for myopic eyes with IOL power<19 D, chronic analgesic use, and brown or white cataract. A larger study may help develop a predictive score for pain that could, for example, be integrated into a biometer.

Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: report 11, techniques and complications of local anesthesia for cataract surgery in the United Kingdom

PURPOSE

To describe variation in local anesthesia techniques and complications over a 10-year period for cataract surgery in the United Kingdom.

SETTING

Reporting centers to the Royal College of Ophthalmologists (RCOphth) National Ophthalmology Database (NOD).

DESIGN

Retrospective cross-sectional register-based study.

METHODS

Data from the RCOphth NOD were used. Eligible for analysis were 1 195 882 cataract operations performed using local anesthesia between April 1, 2010, and March 31, 2020, in 80 centers.

RESULTS

Overall, topical anesthesia alone was used in 152 321 operations (12.7%), combined topical and intracameral in 522 849 (43.7%), sub-Tenon in 461 175 (38.6%), and peribulbar/retrobulbar in 59 537 (5.0%). In National Health Service (NHS) institutions, 48.3% of operations were topical with/without intracameral vs 88.7% in independent sector treatment centers (ISTCs). 45.9% were sub-Tenon in NHS vs 9.6% in ISTCs. 5.8% were peribulbar/retrobulbar in NHS vs 1.7% in ISTCs. Anesthetic complication rates decreased from 2.7% in the 2010 NHS year to 1.5% in the 2019 NHS year (overall, 2.1% for NHS; 0.2% for ISTCs). Overall anesthetic complication rates were 0.3%, 0.3%, 3.5%, and 3.1% for topical alone, combined topical/intracameral, sub-Tenon, and peribulbar/retrobulbar, respectively. Complication rates were higher for sharp-needle anesthesia (peribulbar/retrobulbar) in patients taking warfarin rather than direct oral anticoagulants (4.8% vs 3.1%; P = .024). Considerable variation was observed between centers on anesthetic choices and anesthetic complication rates.

CONCLUSIONS

Combined topical and intracameral is the most common choice of anesthesia for cataract surgery in the United Kingdom and is associated with lower anesthetic-related complication rates than sub-Tenon and peribulbar/retrobulbar anesthesia. Variation in the anesthetic choice exists between centers and between NHS and ISTC sectors.

Anaesthetic considerations for the surgical management of ocular hypotony in adults

Ocular hypotony can occur from many causes, including eye trauma, ophthalmic surgery and ophthalmic regional anaesthesia-related complications. Some of these patients require surgical intervention(s) necessitating repeat anaesthesia. While surgical management of these patients is well described in the literature, the anaesthetic management is seldom discussed. The hypotonous eye may also have altered globe anatomy, meaning that the usual ocular proprioceptive feedbacks during regional ophthalmic block may be altered or lost, leading to higher risk of inadvertent globe injury. In an 'open globe' there is a risk of sight-threatening expulsive choroidal haemorrhage as a consequence of ophthalmic block or general anaesthesia. This narrative review describes the physiology of aqueous humour, the risk factors associated with ophthalmic regional anaesthesia-related ocular hypotony, the surgical management, and a special emphasis on anaesthetic management. Traumatic hypotony usually requires urgent surgical repair, whereas iatrogenic hypotony may be less urgent, with many cases scheduled as elective procedures. There is no universal best anaesthetic technique. Topical anaesthesia and regional ophthalmic block, with some technique modifications, are suitable in many mild-to-moderate cases, whilst general anaesthesia may be required for complex and longer procedures, and severely distorted globes.

Effect of adding clonidine to lidocaine on ocular hemodynamics during sub-Tenon's anesthesia: randomized double-blind study

INTRODUCTION AND OBJECTIVES

Different regional anesthesia techniques for ophthalmology can have hemodynamic effects on the eye. We assessed the effects of adding clonidine to lidocaine on Intraocular Pressure (IOP), Ocular Pulse Amplitude (OPA), and Ocular Perfusion Pressure (OPP) after the sub-Tenon's technique for cataract surgery.

METHODS

The study included 40 patients randomly allocated into two groups: sub-Tenon's blockade with Lidocaine plus Saline Solution (LS) or Lidocaine plus Clonidine (LC). IOP, OPA and OPP were measured before anesthesia, and 1, 5 and 10 minutes after the injection of anesthetic solution.

RESULTS

There was no difference between the groups in IOP, OPA, and OPP baseline values. After the injection of the anesthetic solution, the IOP increased in both groups at minute one, with a mean difference of +4.67 mmHg (p = 0.001) and +2.15 mmHg (p = 0.013) at 5 minutes. The increase was lower in the LC group when compared to LS (p = 0.027). OPA decreased in both groups, with a baseline difference, after 1 minute, of -0.85 mmHg (p =  -0.85 mmHg (p = 0.001), and at 5 and 10 minutes with differences of -1.17 (p = 0.001) and -0.89 mmHg (p = 0.001), respectively. The highest decrease was observed in group LC in relation to group LS (p = 0.03). There was no difference in OPP in relation to baseline measurements.

CONCLUSIONS

Adding clonidine to lidocaine for sub-Tenon's anesthesia reduced IOP and OPA without significant changes in OPP.

Comparative study of silicone membrane simulator and animal eye models for sub-Tenon's block

To compare and assess silicone membrane-based sub-Tenon's block (STB) simulator and animal eye model (goat's eye) for practicing STB in terms of anatomical similarity and feel of texture of eye layers. The study included 34 participants (26 learners and 8 consultants) from tertiary ophthalmic centres. The participants were divided into groups A and B. Group A performed STB on the goat's eyes before using the silicone membrane simulator. Group B performed STB on the simulator and further proceeded to the goat's eye. Participants had to rate the anatomical similarity and feel of the texture for the simulator model on a scale of 0-10 and share their preference between the two models. In group A, the scores given to the simulator model and the feel of texture of layers were 8.05 ± 0.88 and 7.97 ± 1.07, respectively, and the scores given to the animal model and the feel of texture of layers were 8.11 ± 0.97 and 8.21 ± 0.88, respectively. Group B participants scored the simulator model and feel of texture of layers with 8.13 ± 0.95 and 8.25 ± 0.99, respectively. Overall, 89% participants preferred the simulator; the reasons included ease of usage, helpful warning system, absence of biological waste, and facility for repeatable training. The study validated anatomical accuracy, preference, and ability of usage of the STB simulator. For broader usage, further study involving higher number of participants is recommended.

Conducting Safety Research Safely: A Policy-Based Approach for Conducting Research with Peer Review Protected Material

A multidisciplinary team developed a policy-based approach that provides guidance for using peer review protected information for safety research while maintaining peer review privilege. The approach includes project approval by an ad hoc review committee, signed confidentiality agreements by investigators and study staff, early removal of case identification numbers, standards for maintaining data security, and publication of aggregate data without data set sharing. By describing this procedure and embedding into an institutional policy on Data for Performance Improvement, the team encourages other institutions to develop similar policies consistent with their state regulations.

The effect of retrobulbar anesthesia for cataract surgery on the retinal nerve fiber layer thickness

OBJECTIVE

The aim of this study was to evaluate the effect retrobulbar and topical anesthesia on optic nerve by measuring retinal nerve fiber layer (RNFL) thickness before and after phacoemulsification cataract surgery using optical coherence tomography (OCT).

METHODS

A total of 126 eyes of 108 patients were included in the study. Retrobulbar anesthesia was used in 61 eyes of 53 patients, and topical anesthesia was used in 65 eyes of 55 patients. OCT scans were done 1 week before the surgery and 4 weeks after surgery, and the results were evaluated.

RESULTS

The average RNFL thickness increased postoperatively in both groups (p < 0.001 for topical anesthesia group and p = 0.001 for retrobulbar anesthesia group). The preoperative and postoperative average and quadrant RNFL thickness and the change in RNFL thickness were not significantly different between the two anesthesia groups (p > 0.05).

CONCLUSION

Our results suggest that retrobulbar anesthesia has no unfavorable effect on the retinal nerve fiber layer.

Ocular Anesthesia-Related Closed Claims from Ophthalmic Mutual Insurance Company 2008-2018

PURPOSE

To evaluate the types of anesthesia-related closed claims and their contributing factors, using data from the Ophthalmic Mutual Insurance Company (OMIC).

DESIGN

Retrospective analysis of preexisting data.

PARTICIPANTS

Plaintiffs who filed a professional liability claim or suit (written demand for money) against OMIC-insured ophthalmologists, ophthalmic practices, or surgicenters in which the surgical case occurred.

METHODS

Plaintiff claims were collected from the OMIC database from 2008 to 2018 using search queries for terms associated with known complications of ophthalmic anesthesia.

MAIN OUTCOME MEASURES

Number and types of anesthesia-related injuries and claims, who administered the anesthesia, the outcomes of the claim or suit, cost to defend, and payments made to plaintiffs.

RESULTS

Sixty-three anesthesia-related claims or suits were filed by 50 plaintiffs. Anesthesia-related injuries included globe perforation (n = 17), death (n = 13), retrobulbar hemorrhage (n = 7), optic nerve damage (n = 4), vascular occlusions (n = 2), pain (n = 2), eye or head movement resulting in injury (n = 2), and 1 case each for numbness, diplopia, and tooth loss during intubation. All but 1 patient who died had preexisting, significant comorbidities. Two deaths were related to brainstem anesthesia. Regarding the type of anesthesia in the closed claims, retrobulbar and peribulbar anesthesia were the most common types (n = 16 each), followed by local infiltration around the lids and facial nerve (n = 6), topical anesthesia (n = 5), and general anesthesia (n = 5). In 2 cases, the exact type of anesthesia was unknown but not general. The 5 topical with sedation anesthesia-related claims were due to inadequate pain control (n = 2), ocular movement resulting in capsular rupture (n = 2), or death (n = 1) allegedly related to excessive or inadequate monitoring of sedation. There were 5 claims related to general anesthesia including 4 deaths and 1 tooth loss during intubation. Sedation was alleged to be a factor in 5 cases resulting in death. Anticoagulants were a factor in 3 retrobulbar hemorrhage cases.

CONCLUSIONS

Although claims and suits were infrequent given the large number of insured ophthalmologists and the large number of surgical cases requiring various types of anesthesia performed over the 10.5-year study period, severe injuries can occur.

Patient Harm in Cataract Surgery: A Series of Adverse Events in Massachusetts

Massachusetts state agencies received reports of 37 adverse events (AEs) involving cataract surgery from 2011 to 2015. Fifteen were anesthesia related, including 5 wrong eye blocks, 3 cases of hemodynamic instability, 2 retrobulbar hematoma/hemorrhages, and 5 globe perforations resulting in permanent loss of vision. While Massachusetts' reported AEs likely underrepresent the true number of AEs that occur during cataract surgery, they do offer useful signal data to indicate the types of patient harm occurring during these procedures.

Hypnosis intervention for the management of pain perception during cataract surgery

Objective

To investigate the effectiveness of hypnosis in pain management during cataract surgery.

Methods

Male or female patients with bilateral age-related cataract who wished to have both eyes subjected to phacoemulsification surgery were preliminarily admitted. Immediately after the first-eye surgery, each patient was evaluated for pain using the visual analog scale (VAS), and patients with a VAS score >1 were enrolled. By using block randomization, the enrolled patients were allocated to either the treatment group, which received a hypnosis intervention before the scheduled second-eye surgery, or the control group, which did not undergo hypnosis. The levels of anxiety, pain, and cooperation were evaluated independently by the patients and the surgeon.

Results

During the intraoperative pain assessment, 5%, 34%, 38%, and 23% of patients in the control group reported experiencing no pain, mild pain, moderate pain, and severe pain, respectively. In contrast, in the hypnosis group, 18%, 56%, 15%, and 11% of patients reported experiencing no pain, mild pain, moderate pain, and severe pain, respectively, which showed significant differences between the groups (P<0.005). The evaluation of anxiety level showed that the mean score in the control group and hypnosis group was 11.77±0.32 and 6.64±0.21, respectively, revealing a highly significant difference between the two groups (P<0.005). The assessment of patient cooperation showed that only 5% and 18% of patients in the control group and 18% and 36% of patients in the hypnosis group showed excellent and good cooperation, respectively, while 47% of patients in the control group and only 24% of patients in the hypnosis group exhibited poor cooperation, revealing significant differences between the groups (P<0.005).

Conclusion

Hypnosis may be considered as an auxiliary measure in cataract surgery, especially for patients who experienced obvious pain during the first-eye surgery.