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Anaesthesia for phacoemulsification surgery: is it as comfortable as we think?


Anaesthesia for cataract surgery has changed throughout the years from general anaesthesia to local anaesthesia (retrobulbar, peribulbar, subtenons and topical anaesthesia). Cataract surgery techniques have also evolved over the years from the large incision extracapsular cataract surgery to the small incision, sutureless cataract surgery (phacoemulsification), which allows for a shorter recovery period. Local anaesthesia makes cataract surgery more amenable to be an ambulatory day case procedure.

Topical anaesthesia is performed with anaesthesia from oxybuprocaine eye drops. Subtenons injection (a combination of lignocaine and bupivacaine) was given beneath the eyeball tenon's tissue, whereas the peribulbar injection (a combination of lignocaine and bupivacaine) was given into the orbit below the eyeball. However, under topical anaesthesia, 98.8% of patients may have mild pain during the cataract surgery (Irle et al 2005). Jacobi et al 2000 demonstrated that retrobulbar anaesthesia was more comfortable than topical anaesthesia. Topical anaesthesia has however made it safer as no needles are used and retrobulbar anaesthesia has gone out of vogue due to high risk of globe perforation, cardiopulmonary and neurological complications (Redmond & Dallas 1990, Srinivasan et al 2004, Ruschen et al 2005). This study aimed to find which type of local anaesthesia (topical vs subtenon vs peribulbar) was the most comfortable for the patient.


The study was initially started as an audit in the eye theatre after receiving departmental approval, thus institutional approval was not sort for the audit. It was conducted between November 2002 and June 2003 at Selly Oak Hospital, UK.

Consecutive patients undergoing phacoemulsification surgery were recruited in the study. The method of collecting data was by a written questionnaire which was asked by a nurse whilst the patient was in the recovery room immediately after the surgery. The patient was asked to indicate their visual analogue pain score. The visual analogue pain scale consisted of a 10cm horizontal line, scored from 0 (the starting point on the left hand side) to 10 (right hand side). 0 represented no pain and 10 represented the worst possible pain. There were no visible increments markings on the line. The patient was asked to indicate the level of pain felt during the surgery, by marking on the scale from 0-10 with a single vertical line which indicated their level of pain. Data was collected on age, gender, laterality of eye, 1st or 2nd eye surgery, type of anaesthesia, surgeon's grade and visual analogue pain score (VAPS) or the phacoemulsification procedure. Anonymity and confidentiality was maintained during this study. Statistical analysis was done by Minitab[R] Inc version 14.0 (statistical software for education).


The inclusion criterion was that patients were undergoing phacoemulsification under local anaesthesia. They were excluded if they were unable to see the visual analogue pain scale with their fellow eye. 1927 consecutive patients underwent phacoemulsification surgery during this period, however only 1835 had fully completed forms. 61.8% (1135) of patients were females, whose ages ranged from 22-97 years (mean 76.0 yrs). There were 700 males whose ages ranged from 37-99 years (mean 73.6 yrs).


Three types of anaesthesia were used. Topical anaesthesia (53.2%) was the most common anaesthetic, followed by subtenons (28.6%) and then peribulbar (18.2%). The pain scores were analyzed according to the type of anaesthesia, grade of surgeon, patient's age and gender.

Pain scores according to the type of anaesthesia

The pain scores ranged from 0-10 in all three groups. Six patients in the topical anaesthesia group had a maximum VAPS of 10, compared with one in each of the other two groups. 88.2% of patients in the subtenons group felt no pain (VAPS=0) compared to 79.8% and 77.3% of patients in the peribulbar and topical anaesthesia group respectively (Figure 1). The lowest mean pain score occurred in the subtenons group, mean VAPS 0.2 (95% CI 0.1-0.3). The mean pain scores for topical and peribulbar anaesthesia were 0.6 (95% CI 0.5-0.7) and 0.59 (95% CI 0.41-0.76) respectively.

Pain scores according to the grade of surgeon

Consultants performed 70% of all operations, of which 73.8% were under topical anaesthesia (Table 1). Specialist registrars (SpR) performed 19.6% of the cases and the associate specialist and senior house officer (SHO) 6% and 4.4% respectively of the total cases. The SHO only performed 2.9% of patients undergoing topical anaesthesia. Consultants and SpRs had the lowest mean pain scores of 0.2 in the subtenons group. Despite the grade of surgeon the lowest mean VAPS overall for the three types of anaesthesia occurred in the subtenons group, with the exception of the SHO grade. This may be due to various factors. The VAPS for the SHO was 0.5 for topical anaesthesia, compared with 0.6 for subtenons injection (Figure 2).


Pain scores according to age and gender

Both males and females had VAPS ranging from 0-10. Females had a higher mean pain score of 0.6 (95% CI 0.5-0.7) with the highest mean VAPS score 4.7 occurring in the 20-40 year age group (Figure 3). There were no males in this age group that underwent phacoemulsification surgery. The mean VAPS score for males was 0.3 (95% CI 0.2-0.4) (Table 2). Both genders were matched for the type of anaesthesia, however, the males consistently had lower mean pain scores for the group, 1st and 2nd eye and for all three types of anaesthesia (Table 3). Males between 6180 years had the least discomfort during the surgery. Lower pain thresholds were more marked in females <60 years old. Females had a lower threshold for pain compared to males (ANOVA test p=0.002) (Table 2).

1st or 2nd eye surgery

1052 cases were first eyes, 87.3% of these were done by consultants. Patients undergoing 2nd eye surgery had consistently higher mean VAPS for all three types of anaesthesia than those undergoing eye surgery for their first eye. In both categories, of the three types of anaesthesia, subtenons anaesthesia had the lowest mean VAPS 0.2 [1st eyes] and 0.25 [2nd eyes] (Table 3). The mean VAPS was statistically significantly higher in patients undergoing surgery for their 2nd eyes, compared with those for their first eyes (p<0.02).


The visual analogue pain score was consistently lowest in the subtenons group regardless of patient gender, grade of surgeon or 1st or 2nd eye surgery. In our study 88.2% of the subtenons group felt no pain, compared with 79.8% and 77.3% of patients in the peribulbar and topical anaesthesia group respectively. Zafirakis et al (2001) showed that 72% vs 86% reported no pain during the surgery with topical versus subtenons. Our pain scores for the subtenons group were less than that of other studies (Srinivasan et al 2004, Rodrigues et al 2008).

Topical anaesthesia is applied using anaesthetic eyedrops, however, a subtenons injection requires that the conjunctiva and tenons tissue is cut and a blunt tipped cannula passed around the eyeball against the sclera and the anaesthetic injected. Srinivasan et al demonstrated that topical anaesthesia delivery was more comfortable than the sub tenons delivery (81% vs 8%) however, gave more discomfort than subtenons during the surgery. Sauder and Jonas (2003) did not find a difference between patient comfort and surgical complications with topical or peribulbar anaesthesia.

Patients undergoing 2nd eye phacoemulsification had a higher mean VAPS compared with 1st eye surgery. However, our study didn't compare the anaesthesia used in the first surgery with that in 2nd surgery, as in some cases one of the surgeries was outside of the time period of the study. Patients operated on by consultants and specialist registrars had the lowest mean VAPS, but despite the grade of surgeon, the mean VAPS scores were significantly lower in the subtenons group than in the other two groups.

Younger female patients had a higher pain score than males, the highest pain score in females being in the 20-40 year age group. This is not the typical age for cataracts, and there were no males in this age group that underwent phacoemulsification surgery. The lowest pain score was in the 81-100 year old group of patients. Older patients and males had a higher pain threshold in all 3 groups. Patients experienced more discomfort with 2nd eye surgery.

The literature shows that patients undergoing surgery with subtenons anaesthesia were likely to have more subconjunctival haemorrhage, prolonged akinesia and chemosis than patients receiving topical anaesthesia. However, these complications are temporary and do not affect the final visual result (Zafirakis et al 2001, Srinivasan et al 2004, Davison et al 2007). Davison et al (2007) demonstrated that intra operative complications such as posterior capsular tear and vitreous loss were more common in topical (4.3%) than subtenons (2.1%) anaesthesia. Sauder (2003) showed that topical and peribulbar anaesthesia were associated with similar surgery related complications. Therefore, subtenons injection is a safe and effective form of anaesthesia for phacoemulsification surgery.

Subtenons anaesthesia allows for the least discomfort during phacoemulsification. Our study concurs with the recent literature that patients are more satisfied and comfortable during the operation with subtenons anaesthesia than with topical anaesthesia alone, although the latter is more comfortable in its administration (Srinivasan et al 2004, Ruschen et al 2005, Davison et al 2007, Rodrigues et al 2008).

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication September 2009.


Davison M, Padroni S, Bunce C, Ruschen H 2007 Subtenons anaesthesia versus topical anaesthesia for cataract surgery Cochrane Database Systematic Review July (3): CD006291

Irle S, Luckefahr MH, Tomalla M. 2005 Topical anaesthesia as routine procedure in cataract surgery--evaluation of pain and complications in 1010 cases Klin Monatsbl Augenheilkd 222 (1) 36-40

Jacobi PC, Dietlein TS, Jacobi FK 2000 A comparative study of topical vs retrobulbar anaesthesia in complicated cataract surgery Archives of Ophthalmology 118 (8) 1037-43

Redmond R, Dallas N 1990 Extracapsular cataract extraction under local anaesthesia without retrobulbar injection British Journal of Ophthalmology 74 (4) 203-204

Rodrigues PA, Vale PJ, Cruz LM, Carvalho RP, RIbeiro IM, Martins JL 2008 Topical anaesthesia versus subtenon block for cataract surgery: surgical conditions and patient satisfaction European Journal of Ophthalmology 18 (3) 356-360

Ruschen H, Celaschi D, Bunce C, Carr C 2005 Randomized controlled trial of subtenons block versus topical anaesthesia for cataract surgery: a comparision of patient satisfaction British Journal of Ophthalmology 89 (3) 291-293

Sauder G, Jonas JB 2003 Topical versus peribulbar anaesthesia Acta Ophthalmologica Scandinavica 81 (6) 596-599

Srinivasan S, Fern AI, Selvaraj S, Hasan S 2004 Randomized double blind clinical trial comparing topical and subtenons anaesthesia in routine cataract surgery British Journal of Anaesthesia 93 (5) 683-686

Zafirakis P, Voudouri A, Rowe S et al 2001 Topical versus subtenons anaesthesia without sedation in cataract surgery Journal of Cataract and Refractive Surgery 27 (6) 873-879

Lizette Mowatt

MBBS(UWI), MMedSci, FRCS(Ed), FRCOphth

Consultant Ophthalmologist and Associate Lecturer, University Hospital of the

West Indies, Jamaica

Evelyn Youseff


Associate Specialist in Ophthalmology, Selly Oak Hospital, Birmingham

Maria J Langford


Clinical Nurse Specialist Ophthalmology, University Hospitals Birmingham NHS

Foundation Trust, Birmingham

No competing interests declared

Correspondence address: Dr Lizette Mowatt, Department of Surgery, Anaesthesia, Radiology and Intensive Care, University Hospital of the West Indies, Mona, Jamaica. Email:
Table 1: Anaesthetic type according to the surgeon's grade

Surgeon's Grade        Topical   Sub tenons   Peribulibar

Consultant              73.8%      65.7%          66%
SpR                     16.1%      20.8%         27.5%
SHO                     2.9%        7.6%         4.4%
Associate specialist    7.2%        5.8%         1.9%

Table 2: Comparision of gender

Anaesthesia                   Female          Male

Topical                       53.0%          53.7%
Subtenons                     28.3%          29.0%
Peribulbar                    18.7%          17.3%

Consultant                    69.9%          70.4%
SpR                           18.6%          21.1%
Associate specialist           6.9%           4.1%
SHO                            4.6%           4.4%

Pain range (mean)
Total group (gender)       0-10 (0.60)    0-10 (0.21)
1st eye                    0-10 (0.44)    0-3.5 (0.22)
2nd eye                    0-9.5 (0.80)   0-10 (0.38)

Mean VAPS vs anaesthesia
Topical                        0.76           0.34
Subtenons                      0.27           0.16
Peribulbar                     0.64           0.38

Table 3: Mean VAPS for anaesthesia according to the 1st or 2nd eye

Mean VAPS for anaesthesia according to the 1st or 2nd eye

          Topical   Subtenons   Peribulbar

1st eye     0.5        0.2         0.4
2nd eye    0.85       0.25         0.9

Figure 1: VAPS according to the type of anaesthesia

Visual Analogue Pains Score (VAPS) according to the type
of anaesthesia

                      Percentage of patients

Pain Score      Topical (%)     Subtenons (%)     Peribulbar (%)

0                77.3             88.2               79.8
>0-2             13.1              8.6               11.5
>2-8              8.7              2.8                7.4
>8-10             0.6              0.4                1.3

Note: Table made from bar graph.

Figure 2: Mean VAPS according to the surgeon's grade

Mean Visual Analogue Pain Score (VAPS) According to
Surgeon's Grade

                              Mean VAPS

Surgeon's       Topical (%)     Subtenons (%)     Peribulbar (%)

Consultants       0.5              0.2                0.5
SpR               0.5              0.2                0.6
SHO               0.5              0.6                1.1
  Specialist      1.7              0.5                1.3

Note: Table made from bar graph.
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Author:Mowatt, Lizette; Youseff, Evelyn; Langford, Maria
Publication:Journal of Perioperative Practice
Article Type:Clinical report
Geographic Code:1USA
Date:Jan 1, 2010
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