Second cataract extraction may be associated with subtle increase in pain

Surgeons should consider preoperative counseling to alert patients to higher pain perception after second surgery.

Roxana Ursea

A patient’s second cataract extraction may be associated with a slight increase in pain resulting from decreased preoperative anxiety, a study found.

“Having enjoyed a successful first cataract extraction, a portion of patients may subsequently approach their second cataract extraction with less trepidation but also an expectation of less pain. Any pain they experience is then perceived as significant,” the study authors wrote.

The prospective, single-masked, longitudinal study found relatively no pain overall for bilateral cataract surgery and only a minimal experience of discomfort for a second extraction. This outcome was paired with a recommendation for preoperative counseling.

“When you prepare patients for the second eye surgery, you should not expect that they already know everything about the procedure,” Roxana Ursea, MD, first author of the study, said in an interview with Ocular Surgery News. “The surgeon should take extra time to inform patients that they might be more aware during the second cataract extraction or might experience more discomfort.”

Many surgeons have observed this phenomenon in clinical practice, but Dr. Ursea and colleagues may be the first to study it in the same group of patients undergoing sequential cataract surgery, in a prospective fashion and an objective research setting.

Perioperative surveys

Sixty-five participants underwent bilateral sequential clear corneal cataract extraction using phacoemulsification under topical anesthesia and completed four perioperative surveys. The surveys analyzed anxiety and pain levels and included the preoperatively administered State-Trait Anxiety Scale and Amsterdam Preoperative Anxiety and Information Scale that patients completed before the surgery, in the immediate postoperative period and again on the first postoperative day. A numeric 0-to-10 visual analogue scale pain survey was given twice, once immediately after surgery and once on postoperative day 1.

“Objective pain assessment might be a challenge, as subjective perception may play a role, so we selected objective tools — tests and scales already established in the literature as best assessors — to quantitate the pain experience of patients,” Dr. Ursea said.

The patients underwent both cataract extractions by the same surgeon in the same fashion, clear cornea incision and phacoemulsification in a “divide and conquer” fashion, and had the same type of IOL implanted in both eyes, Dr. Ursea said. The duration of the surgical procedures and the doses of anesthesia received were also similar for both eyes.

Outcomes, potential explanations

Forty percent of patients reported a higher visual analogue pain score for their second cataract extraction, but the median pain score for the first extraction was 0. While a median score of 1 was reported for the second extraction, this increase did not persist to postoperative day 1.

On average, patients’ anxiety levels decreased in the interval between the two surgeries. Increases in pain for the second procedure were associated with a lower level of preoperative anxiety.

Moreover, while there was insufficient power to perform a sub-analysis of all races represented, Hispanics reported a significantly more painful second cataract extraction than did patients of other races, consistent with reports of increased pain perception in Hispanics in the non-ophthalmic literature, Dr. Ursea said. There was no statistically significant difference between men and women.

Dr. Ursea said she hopes to extend her research in the future to include a higher number of patients, of various ethnicities, receiving the exact same anesthesia for both first and second cataract surgeries.

The study authors suggested numerous explanations for the observed increase in pain, noting that a psychological effect is most probable.

“Patients who are cataract extraction-naïve are initially anxious and expect substantial pain. When the amount of pain they experience fails to meet this expectation, they perceive it as relatively minimal or negligible,” they said. This may cause patients to anticipate no discomfort during the second procedure.

The authors further highlighted the potential effects of sedatives.

“Patients who receive benzodiazepines during the first operation often have no recollection, or only vague memories, of the intraoperative period of that procedure. … When they present for the second operation, they have the expectation that they will be heavily sedated for that procedure,” the study authors wrote. “When their experience … does not meet their expectation, they naturally report more awareness and pain than they did the first time.”

Adding to a patient’s total sedative and analgesic dose for the second extraction may help counter the effect, they said, but further studies are needed to affirm this recommendation.

In the meantime, they advocate preoperative counseling. – by Michelle Pagnani

Reference:

• Ursea R, Feng MT, Zhou M, Lien V, Loeb R. Pain perception in sequential cataract surgery: Comparison of first and second procedures. J Cataract Refract Surg. 2011;37(6):1009-1014.

• Roxana Ursea, MD, can be reached at the Department of Ophthalmology, University of Arizona, 655 North Alvernon Way, Suite 108, Tucson, AZ 85711, U.S.A.; +1-520-322-3800 ext. 204; fax: +1-520-321-3665; email: rursea@eyes.arizona.edu.
• Disclosure: No products or companies are mentioned that would require financial disclosure.