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What are the differences between pain management protocols for first and second eye cataract surgeries?
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Discuss strategies with patients
Ophthalmologists value surgical procedures and Snellen visual acuity while patients value quality of vision and the surgical experience. There is nothing that will ruin the patient impression of their cataract surgery more than having to deal with pain, which can unfortunately be quite common. There are multiple techniques to prevent and deal with pain and cataract surgery. Topical and intracameral anesthesia and NSAIDs play a key role in reducing discomfort. IV, oral and sublingual pain medications and sedation are also very important. Finally, peribulbar anesthesia may be needed in some very sensitive individuals.
Pain management often differs greatly between the first and second eye surgeries. Quite often after uneventful sequential bilateral cataract surgery, the patient will ask if the second procedure was completely different from the first procedure. Often, these same patients will complain of more discomfort during the second surgery. Perhaps their minds are in a different receptive state for pain or they are squeezing on the lid speculum.
To prevent pain in the second eye cataract surgery with the concern that it is often much more common, I will inquire after the first surgery how much discomfort the patient experienced with their topical anesthesia. For patients who state they were displeased with the level of discomfort, I discuss the possibility of peribulbar anesthesia or make a note to ask the anesthesiologist to be available with an IV solution to help their discomfort. We often use propofol and/or Versed for these patients. Preoperative NSAIDs also play a crucial role in reducing pain, and I will begin their use 3 days before surgery to exhaust the supply of endogenous prostaglandins. On the day of surgery, I make certain the patient not only receives topical proparacaine but viscous lidocaine for at least 10 minutes before surgery. Intraoperatively, I strongly recommend intracameral ketorolac (Omidria, Omeros), which has been shown to significantly reduce the pain associated with cataract surgery. Finally, verbal reassurance and asking the patient not to squeeze on the lid speculum plays a very important role in reducing the pain associated with cataract surgery that should not be underestimated.
Eric D. Donnenfeld, MD, is an OSN Cornea/External Disease Board Member. Disclosure: Donnenfeld reports he is a consultant for Allergan, Alcon, Bausch + Lomb and Omeros.
Details matter
The short answer: none. But the details matter.
I have always had the privilege of a dedicated anesthesiologist for my cataract surgery patients. Our protocol for all topical anesthesia patients includes a minimal IV dose of Versed (short-acting anxiolytic) and Alfenta (short-acting analgesic) just before draping. Although we are prepared with more doses and propofol as a last resort, “vocal local” is all that is usually required. I do believe it is essential to explain to the patient, “You will be aware of my presence, of course, but should feel no pain. If anything bothers you, tell us and we will do something about it right away.” Then we must be prepared to be true to our word. I am a believer in intracameral preservative-free lidocaine, in addition to topical anesthetic, and I tell patients as I instill it to expect a brief stinging sensation, which numbs the eye further, adding to their comfort. I tell patients to enjoy the light show, that there will be nothing distinct or disturbing to see. I prevent reverse pupillary block and minimize anterior chamber collapse, which can painfully stress zonules. I use an ultrasound sparing vertical chop technique at the iris plane or below and keep endothelium protected with a soft shell of a dispersive ophthalmic viscosurgical device. I am thorough in aspirating the posterior as well as the anterior chamber and leave the globe pressurized to just above normal. I practice a no-touch technique and keep the epithelium protected with OVDs intraoperatively. The eye is allowed to blink freely following drape removal. We offer preservative-free tears as needed. I prophylactically treat postoperative pressure rise selectively in at-risk patients. For years I have been a believer in preoperative (2 days prior) as well as postoperative topical NSAIDs, which I believe block prostaglandins and have a minor anesthetic effect. I add topical steroid as well as antibiotic drops (no ointment) and no patch or shield immediately postoperatively.
I call all my patients the night after surgery. They very rarely have any complaint of pain, first or second eye.
I always warn people at the preoperative second eye visit that, in general, patients have the impression the first eye went better. I want them to know it is only because with the first they are comparing to the fellow eye’s cataract but the second time they are comparing to a nearly healed eye.
Effective communication is the best medicine.
Lisa B. Arbisser, MD, is an adjunct professor at Moran Eye Center, University of Utah, and co-founder and emeritus at Eye Surgeons Associates in the Iowa and Illinois Quad Cities. Disclosure: Arbisser reports no relevant financial disclosures.