Publication Exclusive: Extra steps should be taken to make surgery patients comfortable

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.

• Click here to read the full publication exclusive, Lindstrom's Perspective, published in Ocular Surgery News U.S. Edition, September 25, 2016.