Worldwide variations in the use of anesthesia for cataract surgery are underscored in a Chinese meta-analysis of published randomized clinical trials that did not consider the most popular method applied in the United States. Ophthalmologists at the Shanghai Jiao Tong University School in China evaluated 15 randomized clinical trials comparing the performance of topical and regional anesthesia during phacoemulsification with lens implantation, study published in Ophthalmology.
The study concludes that topical anesthesia falls short of matching the ability of regional anesthesia (including retrobulbar and peribulbar anesthesia) for sparing patients from pain. But overall, the clinical trials indicated the topical approach led to similar clinical outcomes, eliminated injection-related complications, and mitigated patients’ fears about needle injections near the eye and orbit.
Thus, the findings suggested that topical anesthesia before cataract surgery is an inevitable trend for ophthalmology and its use will grow because of improved performance of phacoemulsification machines, better surgical techniques that lead to reduced incision sizes, and effects on the anterior chamber and iris. There were less frequent anesthesia-related complications such as chemosis, periorbital hematoma, and subconjunctival hemorrhage.
By contrast, intraoperative and postoperative pain was higher in the topical anesthesia group, compared with regional anesthesia. Also, inadvertent intraoperative ocular movement was observed significantly more often among patients who received topical anesthesia than among patients in the retrobulbar group and those in the peribulbar group. Those in the topical anesthesia group more often needed an additional intraoperative dose. Still, patients far more often preferred topical anesthesia over other pain-stopping options and the meta-analysis uncovered no significant differences in the surgical complication rate for the topical and injected regional approaches to anesthesia.
These findings do not reflect how phacoemusification is performed in the United States. The standard of care here has involved topical anesthesia supplemented by intracameral lidocaine for more than a decade. The protocol calls for the injection of a slightly dilute solution of nonpreserved lidocaine and epinephrine, which facilitates pupil dilation into the anterior chamber immediately after incision to instantly anestehtize the eye internally.