I wish I could promise completely pain-free surgery for all of my patients.  Fortunately, at the Duke Eye Center, the vast majority of my patients undergoing routine cataract surgery seldom remember the surgery or any discomfort during or after the surgery.  My “recipe” for success in this regard includes meeting each patient and sensing their level of anxiety and tolerance for any discomfort and their level of squeamishness related to any work near their eye.   Each patient is different in this regard.  Fortunately at Duke, we obtain consultation with anesthesia prior to surgery.  Just prior to surgery, a small amount of IV Versed (0.5-1.0 mg) and Fentanyl (50-100 mcg) (both titrated for size and anxiety) are given.  All medications are adjusted for allergies and other medical problems.  Topical tetracaine 0.5% is instilled after dilating and NSAID drops.  After prep and drape another drop of Tetracaine is given.  At the outset of surgery, intra-op Epi-Shugarcaine consisting of  buffered, preservative free Lidocaine 0.75% and preservative free epinephrine 1:4000 is given and allowed to work for 15-20 seconds.  Patient satisfaction has been overwhelmingly positive with this recipe allowing for even complex cataracts to be treated without a block.  In rare cases, an intraoperative peri-bulbar block is given.  A comfortable patient with excellent recovery of vision is a happy patient!

The article below supports my clinical impression based on thousands of cases.

Br J Ophthalmol :12011;95:837-841 doi:10.1136/bjo.2010.188003

Analgesic effect of supplemental intracameral lidocaine during phacoemulsification under topical anaesthesia: a randomised controlled trial

  1. Colin S H Tan1,2,
  2. Han-Bor Fam1,2,
  3. Wee-Jin Heng1,2,
  4. Hung-Ming Lee1,2,
  5. Seang-Mei Saw3,
  6. Kah-Guan Au Eong4

+ Author Affiliations

  1. 1Department of Ophthalmology, Tan Tock Seng Hospital, Singapore
  2. 2National Healthcare Group Eye Institute, Singapore
  3. 3Department of Epidemiology and Public Health, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
  4. 4Singapore International Eye Cataract Retina Center, Singapore
  • Correspondence to Dr Colin S H Tan, Department of Opthalmology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; colintan_eye@yahoo.com.sg
  • Accepted 9 September 2010 Published Online First 22 December 2010
  • Abstract

    Aims To determine the analgesic effect of supplemental intracameral lidocaine 1% during phacoemulsification under topical anaesthesia, and to assess the risk factors associated with pain.

    Methods In a double-masked, randomised, clinical trial, 506 patients undergoing phacoemulsification under topical anaesthesia were randomised to receive a supplemental intracameral injection of either 0.5 cc of 1% lidocaine (277 patients, 54.7%) or balanced salt solution (BSS) (229 patients, 45.3%). Patients were interviewed by a trained interviewer using a standardised questionnaire. The main outcome measure was intraoperative pain, scored on a visual analogue scale of 0–10. Logistic regression was performed to assess ORs.

    Results 125 of 277 patients (45.1%) experienced pain in the lidocaine group, compared with 123 of 229 patients (53.7%) in the BSS group. The proportion of patients who experienced pain was significantly lower in the intracameral lidocaine group compared with the BSS group (multivariate OR 0.68, 95% CI 0.47 to 0.97; p=0.034). The median pain score (range) was 0.0 for intracameral lidocaine group compared with 1.0 for BSS group (p=0.039). Pain was more common in females (54.3% vs 43.6%; OR 1.56), non-Chinese (62.3% vs 46.9%; OR 2.13) and those who had previous cataract surgery to the fellow eye (55.3% vs 44.7%; OR 1.61).

    Conclusion The use of 0.5 cc of 1% intracameral lidocaine during phacoemulsification under topical anaesthesia significantly reduces pain experienced by patients. Risk factors for pain include females, non-Chinese and previous cataract surgery.