An anesthesiologist should be mandatory.

THANH HOANG-XUAN, MD

Cataract surgery is the most frequently performed surgical procedure in the world. It is usually performed under local anesthesia consisting of topical anesthesia and/or locoregional (peribulbar or retrobulbar) injections. General anesthesia is reserved for children or patients who are unable to cooperate.

Topical anesthesia for cataract surgery follows one of two protocols: (1) pure topical anesthesia, for which only anesthetic eyedrops are used, or (2) topical anesthesia combined with intravenous sedation (ie, assisted topical anesthesia). The latter requires the presence of an anesthesiologist.

Phacoemulsification cataract surgery under topical anesthesia is considered a safe procedure. Pure topical anesthesia incurs the least cost, especially if no anesthesiologist is used. The current economic situation should favor this procedure; however, only surgeons who encounter few intraoperative complications and who are able to manage them safely should perform phacoemulsification cataract surgery under pure topical anesthesia.

PREVENTING SURGICAL COMPLICATIONS

Some surgeons argue that an anesthesiologist is not required for cataract surgery under pure topical anesthesia. In fact, health care authorities in some countries promote the use of ambulatory surgery centers where patients can undergo cataract surgery under pure topical anesthesia, without the presence of an anesthesiologist, as an outpatient procedure.

To the best of my knowledge, no study has assessed the role of the anesthesiologist on cataract surgery outcomes. Therefore, I conducted an observational, prospective study on the incidence of intraoperative and immediate postoperative ocular and systemic complications in phacoemulsification cataract surgery under local anesthesia (pure topical anesthesia or assisted topical anesthesia). Tetracaine drops were used in all cases. For assisted topical anesthesia, different sedatives were used intravenously, including benzodiazepines, morphinics, and hypnotics.

I operated on 163 consecutive eyes. In 48 cases (29.4%), systolic blood pressure was higher than 160 mm Hg, and in five it was higher than 200 mm Hg. Six of 21 patients (29%) who received pure topical anesthesia experienced elevated blood pressure during surgery. In these cases, the anesthesiologist had to inject medications intravenously to decrease the pressure.

I added another 400 eyes, operated on by 10 experienced high-volume cataract surgeons, to my series for analysis. In total, 26.7% of patients experienced high blood pressure that required intravenous drug injection by the anesthesiologist, and half of the pure topical anesthesia cases experienced high blood pressure. The following complications required the intervention of the anesthesiologist: pain, anxiety, and agitation (n=18); respiratory problems (n=4); vasovagal syncope (n=2); extrasystole (n=2); and cardiac arrest (n=1).¹

DISCUSSION

In ambulatory surgery centers where no blood pressure and cardiac monitoring are performed because there is no anesthesiologist, untreated high blood pressure in old and fragile patients can induce severe cardiovascular complications including myocardial infarction or stroke. In some patients, such as those with high myopia or arteriosclerotic cardiovascular disease, intraoperative peaks of high blood pressure can induce expulsive hemorrhage and blindness. Pain and anxiety can also induce agitation and, consequently, posterior capsular rupture and vitreous loss.

Retrospectively, one can suppose that all the abovementioned intraoperative complications could have induced dramatic consequences if an anesthesiologist was not in the operating room. His or her absence can be considered a lost chance for patients in cases with severe ocular or systemic outcomes. Last year, the French Health Authority (Haute Autorité de Santé) strongly recommended that an anesthesiologist be present during cataract surgery.² The results of our study corroborate that the presence of an anesthesiologist is mandatory during cataract surgery.

Thanh Hoang-Xuan, MD, is Head of Ophthalmology at the American Hospital of Paris. Dr. Hoang-Xuan states that he has no financial interest in the products or companies mentioned. He may be reached at email: thx0106@gmail.com.

1. Hoang-Xuan T.Do cataract surgeons need an anesthesiologist? Paper presented at:The XXVIII Congress of the ESCRS;September 6,2010;Paris.
2. Haute Autorité de Santé website.http://www.has-sante.fr.Accessed September 27,2011.

No anesthesia = no anesthesiologist.

ALEXANDRE D. LEBUISSON, MD

There are many reasons we decided to implement the routine use of pure topical anesthesia in our practice. The first and main motivation was the absence of an available anesthesiologist in our hospital, which is due to the shortage of specialists on our staff. Coinciding with this reason is that, in France, a nurse can neither administer local anesthesia nor take care of an operated patient without a medical anesthesiologist present in the operating theater. But the main medical interrogation is a single question: Why is an anesthesiologist required to apply a few analgesic eye drops?

Our experience is in a public nonprofit hospital. Over the past 12 years, we (seven other surgeons and I) have performed true pure topical analgesic cataract surgery in a total of more than 14,000 primary cases. In pure topical anesthesia, only analgesia is used; however, in the literature, most papers about cataract surgery under topical anesthesia refer to patients who have also received systemic drugs, such as sedatives. This is a strong indication that the patient did not actually receive pure topical anesthesia but rather assisted topical anesthesia, which requires intraoperative monitoring by an anesthetist specialist. We avoid the need for an anesthesiologist by performing cataract surgery under true pure topical anesthesia.

DISCUSSION

In my opinion, the patient’s general status must the same before and after surgery; and by after I mean 1 minute following the conclusion of the procedure. However, this does not require that an anesthesiologist be present in patients with systemic diseases. Patients with hypertension, diabetes, and emphysema can be operated on without specific precautions if they are already under medical care for these conditions. The surgeon can avoid instability, anxiety, and pain by implementing proper preoperative counseling and attentive care during surgery. When pure topical anesthesia is used, systemic medication and sedation are administered during surgery. In our estimation, no drug use means that there will be no undesirable drug side effects. Additionally, no fasting and no smoking interdiction are required before surgery.

Patient stress, indicating the possible need for assisted topical anesthesia, can be detected before surgery by using an oral questionnaire, thus eliminating 95% of risky cases. Frank patient selection is easy and can be done by the surgical assistant; however, the surgeon should give the final green light to perform the procedure under pure topical anesthesia.

CONSIDERATIONS AND PROTOCOL

Topical anesthesia is safe, effective, and potentially underutilized. We do not consider intracameral anesthesia a form of topical anesthesia because it increases the systemic effect and is delivered inside the eye. Lidocaine gel, however, is a pure topical anesthetic; it requires about 10 minutes to achieve a full reaction and has a longer duration than topical eye drops. We use topical eye drops (tetracaine or proparacaine), applying four drops 2 minutes before surgery.

Some ophthalmologists hate to perform surgery on their own. One reason these surgeons still use an anesthesiologist for cataract surgery with pure topical anesthesia is fear; they want the help of a specialist to monitor the patient. This is teamwork, but at what cost? The surgical expense increases without any notable reduction of risk.

Cataract surgery is typically performed in elderly people with multiple comorbidities, and the potential for adverse systemic events must be considered when choosing pure topical anesthesia over assisted topical anesthesia. However, in our unit, the percentage of adverse events is low (0.4%); bradycardia is the most frequent event. As long as the patient is monitored with common devices such as oxymeters and ecocardiograms, it is easy to detect intraoperative changes. The most frequent events include minor and transient changes in IOP, oximetry, and heart rate. In our practice, the incidence of these adverse events is not associated with age, American Society of Anesthesiologists (ASA) classification, procedure time, number of medications used, or number of comorbidities. On the other hand, a French study found that, with peribulbar anesthesia, 34% of adverse systemic events required treatment.

Medical events depend on the quality of care and on the patient’s attitude. Breakthrough pain is observed in 2% to 3% of cases. This adverse event is frequent in patients with poor iris dilation and anxious patients; in such cases, the surgeon may prefer to perform cataract surgery using intracameral preservative-free lidocaine 1%.

Contact lenses were initially resisted before they became accepted. The use of pure topical anesthesia during cataract surgery is undergoing similar initial backlash. I believe that this method is here to stay, despite criticism from certain quarters. Some argue that assisted topical anesthesia is better for the general care of the patient, but in France and many other countries there is an economic benefit to pure topical anesthesia.

As with any new surgical approach, there is a learning curve with pure topical anesthesia. Surgeons must possess specific skills to master intraoperative difficulties. Surgical training for pure topical anesthesia may be easier for a young ophthalmologist than a senior surgeon with a lifetime of habits. There is no obligation to use this approach in all cases; there is still a place in cataract surgery for the anesthesiologist. Many patients feel secure and relaxed knowing an anesthesiologist is attending to them during surgery— but patients also do not know much about the safety of surgery with pure topical anesthesia. It is our job as surgeons to educate patients so that they understand this is a safe procedure. The power of suggestion is strong, and a determined surgeon can reassure a hesitant patient. Additionally, patients would prefer that there is no pain and, in most cases, do not care what method of anesthesia is used.

Various anesthesia management strategies have been shown to be safe and effective. The decision regarding which to use must be the surgeon’s own, and the procedure must be certified at the clinic. My advice is to create a position statement for your practice. Listen to your patients’ expectations and give them not only a safer surgical technique but also a simplified general protocol in an outpatient facility.

Alexandre D. Lebuisson, MD, is Chief of the Surgical Eye Unit of Hospital Foch and Medical Director at Clinique de la Vision Paris, and practices in the Ocular Anterior Eye Surgery Unit at Foch Hospital Suresnes, Paris. Dr. Lebuisson states that he has no financial interest in the products or companies mentioned. He may be reached at email: dalebuisson@ orange.fr.

TAKE-HOME MESSAGE

• On one hand, intraoperative complications can induce dramatic consequences if an anesthesiologist is not in the operating room.
• On the other hand, topical anesthesia is safe, effective, and potentially underutilized.