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Attention to pain management critical for cataract surgery
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It is important for all surgeons, including ophthalmic surgeons, to minimize the intraoperative and postoperative pain associated with the procedures they perform. Having undergone two hip replacements, arthroscopic surgery on both knees, a right total knee replacement and right ankle surgery, all associated with my passion for sports, which began at an early age and continues today, I can state with certainty that the level of pain management required in ophthalmology is much lower than in orthopedics. Nonetheless, patient comfort during and after surgery is highly associated with patient satisfaction, and the satisfied patient is the source of most new patients.
I find a topical anesthetic combined with intracameral 1% lidocaine to be the primary element in my intraoperative pain management for routine cataract surgery. Some studies suggest that topical alone is adequate, but I find the intracameral lidocaine enhances intraoperative comfort. The addition of a dilating agent such as phenylephrine or epinephrine also enhances pupillary dilation and makes management of patients with intraoperative floppy iris syndrome easier.
Another useful adjunct is an NSAID. It can be given topically before surgery and/or intracamerally during surgery, and the clinical trials performed by Omeros leading to FDA approval of Omidria (phenylephrine 1% and ketorolac 0.3% injection) are very convincing for reduction of intraoperative and early postoperative pain and enhanced pupillary mydriasis. I am a user of Omidria for all cases today while the drug is well reimbursed. I still find a peribulbar block wise in many younger patients, especially male patients, and in complex procedures in which anterior segment reconstruction will be required. We start an IV and put the patient to sleep with propofol for a few minutes when giving the block to eliminate pain. Our ASCs still all use anesthesia standby, usually with an anesthetist. Our anesthetists work for a large group that does a lot of major surgery cases, and they all still prefer an IV and rely primarily on intravenous Versed (midazolam, Roche) and fentanyl. We have trialed the Imprimis MK Melt with midazolam, ketamine and ondansetron with good results, but our anesthetists still prefer an IV.
I just visited my friends Vance Thompson, MD, and John Berdahl, MD, in Sioux Falls, South Dakota, and watched them do 40 cataract cases with comfortable patients using the MK Melt and no IV. They have their own full-time employee anesthetist, and he is also an advocate. If we move to office surgery with no anesthetist, I see this in our future, and perhaps before.
Topical steroids and topical NSAIDs have both been shown in well-done clinical trials to reduce postoperative pain and inflammation. I find them additive in effect and prefer to start them before surgery when possible. The newer combination drops available from several compounding pharmacies including Imprimis make this a simple and cost-effective regimen. I also protect the ocular surface during surgery with a viscoelastic (For me, Viscoat; sodium chondroitin sulfate-sodium hyaluronate, Alcon) or sterile Goniosol (hydroxypropyl methylcellulose, Novartis) to reduce epithelial toxicity and associated pain.
Finally, starting with a lower microscope light setting at the beginning of the case and using the lowest light needed enhance comfort during surgery. I especially like the “Lumera” setting on the Zeiss microscope.
I do not routinely prescribe any postoperative opioids in my cataract surgery, finding acetaminophen or an oral NSAID adequate. From my orthopedic experience, when needed, celecoxib is a well-tolerated and potent oral NSAID. A medical regimen to reduce the risk for infection and reduce pain and inflammation associated with cataract surgery is an important duty for the ophthalmologist. Fortunately, we have several safe and effective medications. There is no one best protocol, but attention to pain management is critical to maximize the cataract surgery patient experience.
Disclosure: Lindstrom reports he consults for, is on the board of directors of and is an equity owner in Imprimis and Ocular Therapeutix; consults for and is an equity owner in Omeros; and consults for Alcon/Novartis, Bausch + Lomb, Allergan, Sun Pharmaceuticals and Zeiss.