This article is more than 5 years old. Information may no longer be current.
Extra steps should be taken to make surgery patients comfortable
Click Here to Manage Email Alerts
While most ophthalmic surgeons consider cataract surgery a relatively painless experience for the patient, controlled studies confirm that about one in three patients experience moderate to severe pain during the procedure. In addition, the fact that select topical steroids, topical NSAIDs and intraoperative delivery of Omidria, which contains ketorolac, have achieved an FDA label for the reduction of postoperative pain when compared with placebo confirms that there is measurable perceived discomfort by the patient during surgery and in the first 24 hours after the surgery is completed.
We all know the cornea is an extremely sensitive and heavily innervated structure. In addition, patients can perceive pressure, heat and cold, which are also usually interpreted as pain. We are all aware that starting an IV can generate mild to severe pain depending on the individual, their anatomy and the individual starting the IV. In addition, the application of anesthetics, especially a facial nerve, peribulbar or retrobulbar block can be extremely painful. As much as possible, all patients want a pain-free and anxiety-free experience when they have any surgery performed. In my opinion, this is an often neglected dimension in ocular surgery. We all know that patient word of mouth is a powerful driver of new patients, and the cataract surgeon who neglects pain and anxiety management is not going to be highly recommended.
A few thoughts on methods that I find useful in reducing intraoperative and early postoperative pain. First, both steroids and NSAIDs have been proven in well-controlled clinical trials to reduce intraoperative and postoperative pain. To be most effective, they need to be given before surgery, during surgery and after surgery. While regimens vary, if one uses a topical steroid and NSAID routinely, I believe both should be started before surgery. Omidria from Omeros, which contains phenylephrine and ketorolac and is delivered in the irrigating solution during cataract surgery, effectively reduced pain associated with cataract surgery in well-controlled studies. While study outcomes vary, I am impressed that intracameral non-preserved lidocaine enhances the anesthesia obtained with topical anesthetics and use it in all my topical cases. A mydriatic agent such as epinephrine or phenylephrine can be added to lidocaine, and I use this combination routinely in addition to a topical anesthetic. Besides reducing discomfort, I find it is a big help in cases of small pupils and intraoperative floppy iris syndrome along with Omidria.
The ocular surface is significantly stressed during surgery, and I personally recommend ocular surface protection with an ophthalmic viscosurgical device. While many surgeons suffer over endothelial trauma, ocular surface trauma is also an issue. For me, Viscoat (Alcon) warmed slightly is an excellent agent for both endothelial and epithelial protection. I basically operate in a “sea” of viscoelastic both in the eye and on the eye. A secondary benefit of this approach is that visualization is enhanced and no one needs to squirt balanced salt solution on the eye during surgery to clear the view. Alternatives include the other dispersive OVDs such as OcuCoat (Bausch + Lomb) and EndoCoat (Abbott Medical Optics). A few of my partners cover the ocular surface with Goniosol (Novartis), which is 2.5% hydroxypropyl methylcellulose, and it is quite inexpensive. They just have the circulating nurse, using a new sterile bottle for each patient, drench the eye with Goniosol.
Ocular surface preparation before surgery in dry eye patients along with ocular surface protection during surgery and ocular surface rehabilitation after surgery can significantly reduce postoperative discomfort and enhance visual recovery. High myopes with low scleral rigidity are more sensitive to a pressure sensation during surgery. In these patients, I reduce the forced infusion setting or lower the bottle. These are large eyes and rarely demonstrate a crowded anterior chamber or positive pressure. Younger male patients are often for me the most sensitive, and either a good anesthetist or a block is occasionally wise in these patients. When using drops for inflammation management, I place a topical steroid and NSAID on the eye immediately after surgery and again in the postoperative recovery room before the patient leaves. Intraocular steroid in my experience, whether intracameral using dexamethasone solution or intravitreal using triamcinolone suspension, is also effective, and I always squirt some on the ocular surface as well.
Our practice uses an anesthetist routinely in cataract surgery, and anesthetists are, in my opinion, invaluable. They are usually very expert at starting an IV and can make it a less stressful and painful experience. If I am doing a block, I like having the patient put to sleep with propofol. We are investigating MKO Melt from Imprimis, but none of our surgeons have adopted it for the majority of their cases. Intraoperative sedation is delegated to the anesthetist, but I like my patients to stay awake and cooperative but have some amnesia. Just like with surgeons, there is definitely a difference in the skills of our anesthetists. We use a large group of anesthetists because we operate at five different ASCs. The surgeon with a dedicated employed anesthetist who becomes expert in eye cases is fortunate indeed.
I am also a quiet reassuring talker during my surgery, and “vocal local” has value. Studies suggest that the proper “relaxing” music in the background and surrounding the patient with appropriate colors such as blue and green rather than, for example, red can also help create a relaxing environment. I try to keep operating room “chatter” and any loud noises to a minimum when operating.
There are many effective approaches to achieve a good outcome and a comfortable, highly satisfied patient. All of the methods above, other than the last few, do carry some cost to the surgeon or facility, but a patient with a painless intraoperative and postoperative experience is worth the extra expense. No pain and good vision on day 1 are, for me, priceless.