Cover Story

Consider patient perception of pain when planning cataract procedures

Cataract surgery is thought to be painless for most patients, but for the few who report discomfort during surgery, ophthalmologists can take precautions to limit pain.

Most surgeons believe only 10% of patients report pain during cataract surgery; however, studies have shown that the rate is significantly higher, with the majority of patients, if asked, experiencing some level of pain during the procedure, according to a recent 30-patient study performed by OSN Cataract Surgery Section Editor John A. Hovanesian, MD, FACS.

In a 2015 study published in Journal of Ophthalmology, researchers found that 35% of patients in a 106-patient cohort undergoing first-eye cataract surgery reported intraoperative pain. In a 2014 study published in Pain Research and Treatment, Apil and colleagues wrote that the type of cataract can affect a patient’s perception of pain. Even with topical anesthetic eye drops, cataract surgery is not a completely painless procedure. The study reported most patients with dense cataracts are more likely to experience severe or unbearable levels of pain during surgery.

Patients with high anxiety or those who take anxiety-reducing medications need special attention, according to Preeya K. Gupta, MD.

Source: Preeya K. Gupta, MD

“Pain is a perceptive thing and very individual,” Hovanesian said. “We will probably never completely eliminate it, but we should take all steps to minimize it. In a patient’s mind, and I’ll attribute this to Eric Donnenfeld, MD, pain is considered by the patient to be a complication of surgery. We surgeons don’t view it that way; we view it as a sometimes necessary by-product of doing an operation. In a 2015 survey study done by MDbackline, we asked patients what they fear most before surgery, and they reported that they fear pain more than they fear going blind.”

Preoperative precautions

John A. Hovanesian

Patients have an outsized fear when it comes to their eyes, so it is important for surgeons to limit pain as much as possible during all facets of cataract surgery. Surgeons need to be conscious of every step of the procedure and what is being done to the patient, including the first application of dilating drops, Hovanesian said.

Dilating drops may hurt, so the use of proparacaine first can lessen pain and help the drops penetrate better and more quickly, he said.

“In the beginning of a surgery, if you cause pain in a patient who is wide awake, that patient will be on high alert for further pain,” Hovanesian said. “That’s what you want to avoid. I learned that tip from Lisa Arbisser, MD.”

The use of Omidria (phenylephrine 1% and ketorolac 0.3% injection, Omeros) during cataract surgery can also help reduce pain.

“Putting Omidria into the fusion bottle probably lessens the need for intracameral lidocaine or eliminates the need, and it reduces pain not only during surgery but also after surgery. That is proven in the FDA study because it contains ketorolac, which is a nonsteroidal. Omidria is a good one,” he said.

Uday Devgan, MD, Healio.com/OSN Section Editor, said he loads patients with preoperative NSAIDs for several days before surgery and then continues to give NSAIDs on the day of surgery and into the postoperative period.

Uday Devgan

“During surgery, we give a combination of topical tetracaine and intraocular preservative-free lidocaine. The IV sedation is an important part of the process, and the importance of an excellent anesthesiologist cannot be underestimated. The choice of agents as well as their dosing and timing all play into achieving a comfortable experience,” Devgan said.

Patient expectations

Setting expectations for patients with regard to pain is an important part of the surgical process that is often overlooked, Steve H. Chang, MD, of Nevada Eye Consultants, said.

“Nine out of 10 of your patients may say they have no pain whatsoever during a surgery, but the one patient that does experience pain is often neglected,” he said.

Earlier in his career, Chang said that he typically would tell patients that cataract surgery was a painless procedure.

“But as you do more, you realize that some people actually have pain,” he said. Now he tells patients that cataract surgery is “generally painless” and advises them that medication will help prevent pain, setting that expectation at the beginning of the cataract surgery conversation.

Chang’s protocol begins with patients starting with an NSAID, typically BromSite (bromfenac ophthalmic solution 0.075%, Sun Ophthalmics), on the morning of surgery followed by additional preoperative drops when patients arrive at the surgery center.

“During the surgery we utilize topical proparacaine or tetracaine along with intracameral lidocaine. Also, there is an anesthesiologist or a nurse anesthetist who is giving medication through an IV, usually some sedating and pain control medication, nothing to fully put them out but to try to relax them,” Chang said.

Postoperatively, Chang prescribes BromSite for 2 to 4 weeks, depending on whether retinal pathology is present.

Intraoperative tips

In addition to using pain-relieving NSAIDs and anesthetics, Hovanesian said surgeons can use different techniques intraoperatively to reduce patient pain.

A commonly overlooked problem in young patients, those with high myopia or those who have undergone previous vitrectomy is the issue of fluid pressure in the eye, he said. When the phacoemulsification probe is put into the eye for the first time, the fluid in the eye can cause pressure and pain. The anterior chamber overdeepens, resulting in reverse pupillary block. The pupil is pushed back into the lens capsule, and it falls backward quickly and firmly, Hovanesian said.

“That’s a significant pain to experience,” he said. “It’s like stretching the iris and the front structures of the eye.”

To lessen the effects, Hovanesian recommended tenting up the iris in those patients before infusing fluid.

“We can slip an instrument under the iris while there is viscoelastic in the eye, tent up the edge of the iris so that it won’t fall so far backward, and then turn on the infusion fluid. What that does is it allows fluid to go through that opening and it will equilibrate in front of and behind the iris, and then the patient won’t have that pain,” he said.

The drapes used during the procedure can also cause pain when removed. To reduce the pain, Hovanesian suggested placing a thin film of povidone-iodine or K-Y jelly on the cheeks and forehead to lessen the stickiness of the drapes and make them easier to remove.

Finally, when developing a limbal relaxing incision, lubricating the cornea so that the diamond blade does not cause epithelial defects is another way to reduce pain in the postoperative period, he said.

Factor in anxiety

OSN Cornea/External Disease Board Member Preeya K. Gupta, MD, said that patients with high anxiety or those who take anxiety-reducing medications need special attention to help manage pain during cataract surgery.

In general, patients with pre-existing anxiety are often on an oral medication that can change their receptors, Gupta said. These patients may need higher doses of fentanyl or midazolam to treat pain and decrease anxiety.

William F. Wiley

“Those are patients who may need higher doses to achieve the same therapeutic effect as those with no anxiety,” she said.

Oral sedation with MKO Melt (Imprimis Pharmaceuticals) is another way to alleviate anxiety before cataract surgery, either alone or in conjunction with IV sedation, William F. Wiley, MD, of Cleveland Eye Clinic, said. The compounded midazolam, ketamine and ondansetron troche is administered sublingually.

“We use an MKO Melt and/or, depending on the patient, we’ll use IV sedation with Versed (midazolam, Roche) and ketamine,” Wiley said. “In general, our preference is the sublingual because the patients tend to like that.”

For patients who also need IV access, the troche can be “a nice way to start the process” because they are more comfortable when brought to the operating room, have less anxiety and do not experience the pain point of an IV needle stick, he said.

Second eye surgery

Pain management strategies need to change when a patient is undergoing surgery in the second eye. In a 2016 study published in International Ophthalmology, Akkaya and colleagues reported patients undergoing phacoemulsification for cataracts in the second eye experienced more pain and showed worse cooperation during the surgery compared with the first eye procedure.

Steve H. Chang

“It’s a fascinating phenomenon,” Chang said. “I get this a lot when I’m doing a second eye. Patients say, ‘Oh, I don’t remember this part. That was a little more uncomfortable this time.’”

Chang partially attributed the phenomenon to the amnesic effects of the sedatives.

“A lot of it is psychological as well. They don’t know what to expect when it comes to their first surgery,” Chang said. “The second time around, the body is prepared for eye surgery and expects certain things.”

Despite the two procedures being the same, patients report different experiences between them.

“When they don’t happen exactly the same or not as they recall, the patient thinks something is weird or different, even though everything is exactly the same,” Chang said. “My strategy is not perfect, but when I talk to the patients preoperatively, when I’m prepping them, I tell them this may seem different from the first eye. You forget things from the first eye. My anesthesiologist knows the drill. If they need to give a little bit more medication the second time around, they will.”

Devgan also noted the amnesic effects of sedatives and said it is important to carefully measure and calculate the necessary amount for a second cataract procedure.

“Many of the systemic agents such as benzodiazepines will induce amnesia around the time of administration. This can alter patient perception of the surgery, and if a lesser dose is given for the second eye surgery, the patient can perceive more. Looking at the notes from the first surgery helps us deliver a consistent level of anesthesia and a great patient experience for both eyes,” he said.

More pain vs. more awareness

Patients can also become more “tolerant” to some of the common sedatives used in cataract surgery, Hovanesian said, which can result in more pain in the second surgery despite receiving the same amount of sedative.

“In the second surgery ... patients are not naïve to the sedation drug. We hear it so incredibly often. Patients say, ‘I was much more asleep in the first procedure,’ when in fact they had the same dose or even a higher dose of the sedative with the second procedure. Somehow, particularly with Versed (midazolam), one of the most common sedatives, patients develop a ‘tolerance’ to it. They’re more conscious the second time they receive it about a month later or a few weeks later. I believe that drives the perception of more pain largely in the second procedure. There may be other factors as well,” he said.

Patients experiencing or perceiving more pain in the second eye surgery is a “universal phenomenon,” Gupta said. It is debated as to whether patients feel more pain during the second procedure or if they are more aware and anxious about what is going on the second time around.

“I believe if you ask most cataract surgeons, it’s not that patients experience more pain in the second eye; it’s just that they’re more aware despite getting the same dosage of medication. It makes it harder for them to relax, harder to feel like everything is OK because it’s so different from their initial experience. I’ve always told patients that they’re probably not as nervous the second time because they’ve been through it and know what it’s like, but they’re going to be more aware and being more aware might make them more nervous while they’re in there,” she said.

Surgeons should tell patients that their second surgery may be a different experience from their first, she noted.

“It’s very important for a patient to hear from their doctor that it’s OK if they’re more awake the second time and it’s OK if they’re more aware. It acknowledges the fact that we know that will happen and it’s not abnormal. If we know it’s going to happen and that it’s not abnormal, if a patient knows it’s not abnormal, they’ll be more apt to be comfortable and not alarmed,” Gupta said.

Pain needs to be taken seriously by surgeons. Surgeons should be cognizant of when they consistently cause pain during a cataract procedure and discuss strategies with colleagues to reduce the painful experience for their patients, Hovanesian said.

“Pain is real. The world has enough pain by itself, and we as surgeons should be committed, just as we are to our craft, to minimizing pain for our patients,” he said. – by Robert Linnehan

Disclosures: Chang reports he is a speaker for Sun Pharmaceuticals. Devgan and Gupta report no relevant financial disclosures. Hovanesian reports he is a consultant for Omeros and the founder of MDbackline. Wiley reports he is a consultant for Imprimis Pharmaceuticals.

Click here to read the POINTCOUNTER, "What are the differences between pain management protocols for first and second eye cataract surgeries?"

Cataract surgery is thought to be painless for most patients, but for the few who report discomfort during surgery, ophthalmologists can take precautions to limit pain.

Most surgeons believe only 10% of patients report pain during cataract surgery; however, studies have shown that the rate is significantly higher, with the majority of patients, if asked, experiencing some level of pain during the procedure, according to a recent 30-patient study performed by OSN Cataract Surgery Section Editor John A. Hovanesian, MD, FACS.

In a 2015 study published in Journal of Ophthalmology, researchers found that 35% of patients in a 106-patient cohort undergoing first-eye cataract surgery reported intraoperative pain. In a 2014 study published in Pain Research and Treatment, Apil and colleagues wrote that the type of cataract can affect a patient’s perception of pain. Even with topical anesthetic eye drops, cataract surgery is not a completely painless procedure. The study reported most patients with dense cataracts are more likely to experience severe or unbearable levels of pain during surgery.

Patients with high anxiety or those who take anxiety-reducing medications need special attention, according to Preeya K. Gupta, MD.

Source: Preeya K. Gupta, MD

“Pain is a perceptive thing and very individual,” Hovanesian said. “We will probably never completely eliminate it, but we should take all steps to minimize it. In a patient’s mind, and I’ll attribute this to Eric Donnenfeld, MD, pain is considered by the patient to be a complication of surgery. We surgeons don’t view it that way; we view it as a sometimes necessary by-product of doing an operation. In a 2015 survey study done by MDbackline, we asked patients what they fear most before surgery, and they reported that they fear pain more than they fear going blind.”

Preoperative precautions

John A. Hovanesian

Patients have an outsized fear when it comes to their eyes, so it is important for surgeons to limit pain as much as possible during all facets of cataract surgery. Surgeons need to be conscious of every step of the procedure and what is being done to the patient, including the first application of dilating drops, Hovanesian said.

Dilating drops may hurt, so the use of proparacaine first can lessen pain and help the drops penetrate better and more quickly, he said.

“In the beginning of a surgery, if you cause pain in a patient who is wide awake, that patient will be on high alert for further pain,” Hovanesian said. “That’s what you want to avoid. I learned that tip from Lisa Arbisser, MD.”

PAGE BREAK

The use of Omidria (phenylephrine 1% and ketorolac 0.3% injection, Omeros) during cataract surgery can also help reduce pain.

“Putting Omidria into the fusion bottle probably lessens the need for intracameral lidocaine or eliminates the need, and it reduces pain not only during surgery but also after surgery. That is proven in the FDA study because it contains ketorolac, which is a nonsteroidal. Omidria is a good one,” he said.

Uday Devgan, MD, Healio.com/OSN Section Editor, said he loads patients with preoperative NSAIDs for several days before surgery and then continues to give NSAIDs on the day of surgery and into the postoperative period.

Uday Devgan

“During surgery, we give a combination of topical tetracaine and intraocular preservative-free lidocaine. The IV sedation is an important part of the process, and the importance of an excellent anesthesiologist cannot be underestimated. The choice of agents as well as their dosing and timing all play into achieving a comfortable experience,” Devgan said.

Patient expectations

Setting expectations for patients with regard to pain is an important part of the surgical process that is often overlooked, Steve H. Chang, MD, of Nevada Eye Consultants, said.

“Nine out of 10 of your patients may say they have no pain whatsoever during a surgery, but the one patient that does experience pain is often neglected,” he said.

Earlier in his career, Chang said that he typically would tell patients that cataract surgery was a painless procedure.

“But as you do more, you realize that some people actually have pain,” he said. Now he tells patients that cataract surgery is “generally painless” and advises them that medication will help prevent pain, setting that expectation at the beginning of the cataract surgery conversation.

Chang’s protocol begins with patients starting with an NSAID, typically BromSite (bromfenac ophthalmic solution 0.075%, Sun Ophthalmics), on the morning of surgery followed by additional preoperative drops when patients arrive at the surgery center.

“During the surgery we utilize topical proparacaine or tetracaine along with intracameral lidocaine. Also, there is an anesthesiologist or a nurse anesthetist who is giving medication through an IV, usually some sedating and pain control medication, nothing to fully put them out but to try to relax them,” Chang said.

PAGE BREAK

Postoperatively, Chang prescribes BromSite for 2 to 4 weeks, depending on whether retinal pathology is present.

Intraoperative tips

In addition to using pain-relieving NSAIDs and anesthetics, Hovanesian said surgeons can use different techniques intraoperatively to reduce patient pain.

A commonly overlooked problem in young patients, those with high myopia or those who have undergone previous vitrectomy is the issue of fluid pressure in the eye, he said. When the phacoemulsification probe is put into the eye for the first time, the fluid in the eye can cause pressure and pain. The anterior chamber overdeepens, resulting in reverse pupillary block. The pupil is pushed back into the lens capsule, and it falls backward quickly and firmly, Hovanesian said.

“That’s a significant pain to experience,” he said. “It’s like stretching the iris and the front structures of the eye.”

To lessen the effects, Hovanesian recommended tenting up the iris in those patients before infusing fluid.

“We can slip an instrument under the iris while there is viscoelastic in the eye, tent up the edge of the iris so that it won’t fall so far backward, and then turn on the infusion fluid. What that does is it allows fluid to go through that opening and it will equilibrate in front of and behind the iris, and then the patient won’t have that pain,” he said.

The drapes used during the procedure can also cause pain when removed. To reduce the pain, Hovanesian suggested placing a thin film of povidone-iodine or K-Y jelly on the cheeks and forehead to lessen the stickiness of the drapes and make them easier to remove.

Finally, when developing a limbal relaxing incision, lubricating the cornea so that the diamond blade does not cause epithelial defects is another way to reduce pain in the postoperative period, he said.

Factor in anxiety

OSN Cornea/External Disease Board Member Preeya K. Gupta, MD, said that patients with high anxiety or those who take anxiety-reducing medications need special attention to help manage pain during cataract surgery.

PAGE BREAK

In general, patients with pre-existing anxiety are often on an oral medication that can change their receptors, Gupta said. These patients may need higher doses of fentanyl or midazolam to treat pain and decrease anxiety.

William F. Wiley

“Those are patients who may need higher doses to achieve the same therapeutic effect as those with no anxiety,” she said.

Oral sedation with MKO Melt (Imprimis Pharmaceuticals) is another way to alleviate anxiety before cataract surgery, either alone or in conjunction with IV sedation, William F. Wiley, MD, of Cleveland Eye Clinic, said. The compounded midazolam, ketamine and ondansetron troche is administered sublingually.

“We use an MKO Melt and/or, depending on the patient, we’ll use IV sedation with Versed (midazolam, Roche) and ketamine,” Wiley said. “In general, our preference is the sublingual because the patients tend to like that.”

For patients who also need IV access, the troche can be “a nice way to start the process” because they are more comfortable when brought to the operating room, have less anxiety and do not experience the pain point of an IV needle stick, he said.

Second eye surgery

Pain management strategies need to change when a patient is undergoing surgery in the second eye. In a 2016 study published in International Ophthalmology, Akkaya and colleagues reported patients undergoing phacoemulsification for cataracts in the second eye experienced more pain and showed worse cooperation during the surgery compared with the first eye procedure.

Steve H. Chang

“It’s a fascinating phenomenon,” Chang said. “I get this a lot when I’m doing a second eye. Patients say, ‘Oh, I don’t remember this part. That was a little more uncomfortable this time.’”

Chang partially attributed the phenomenon to the amnesic effects of the sedatives.

“A lot of it is psychological as well. They don’t know what to expect when it comes to their first surgery,” Chang said. “The second time around, the body is prepared for eye surgery and expects certain things.”

Despite the two procedures being the same, patients report different experiences between them.

“When they don’t happen exactly the same or not as they recall, the patient thinks something is weird or different, even though everything is exactly the same,” Chang said. “My strategy is not perfect, but when I talk to the patients preoperatively, when I’m prepping them, I tell them this may seem different from the first eye. You forget things from the first eye. My anesthesiologist knows the drill. If they need to give a little bit more medication the second time around, they will.”

PAGE BREAK

Devgan also noted the amnesic effects of sedatives and said it is important to carefully measure and calculate the necessary amount for a second cataract procedure.

“Many of the systemic agents such as benzodiazepines will induce amnesia around the time of administration. This can alter patient perception of the surgery, and if a lesser dose is given for the second eye surgery, the patient can perceive more. Looking at the notes from the first surgery helps us deliver a consistent level of anesthesia and a great patient experience for both eyes,” he said.

More pain vs. more awareness

Patients can also become more “tolerant” to some of the common sedatives used in cataract surgery, Hovanesian said, which can result in more pain in the second surgery despite receiving the same amount of sedative.

“In the second surgery ... patients are not naïve to the sedation drug. We hear it so incredibly often. Patients say, ‘I was much more asleep in the first procedure,’ when in fact they had the same dose or even a higher dose of the sedative with the second procedure. Somehow, particularly with Versed (midazolam), one of the most common sedatives, patients develop a ‘tolerance’ to it. They’re more conscious the second time they receive it about a month later or a few weeks later. I believe that drives the perception of more pain largely in the second procedure. There may be other factors as well,” he said.

Patients experiencing or perceiving more pain in the second eye surgery is a “universal phenomenon,” Gupta said. It is debated as to whether patients feel more pain during the second procedure or if they are more aware and anxious about what is going on the second time around.

“I believe if you ask most cataract surgeons, it’s not that patients experience more pain in the second eye; it’s just that they’re more aware despite getting the same dosage of medication. It makes it harder for them to relax, harder to feel like everything is OK because it’s so different from their initial experience. I’ve always told patients that they’re probably not as nervous the second time because they’ve been through it and know what it’s like, but they’re going to be more aware and being more aware might make them more nervous while they’re in there,” she said.

PAGE BREAK

Surgeons should tell patients that their second surgery may be a different experience from their first, she noted.

“It’s very important for a patient to hear from their doctor that it’s OK if they’re more awake the second time and it’s OK if they’re more aware. It acknowledges the fact that we know that will happen and it’s not abnormal. If we know it’s going to happen and that it’s not abnormal, if a patient knows it’s not abnormal, they’ll be more apt to be comfortable and not alarmed,” Gupta said.

Pain needs to be taken seriously by surgeons. Surgeons should be cognizant of when they consistently cause pain during a cataract procedure and discuss strategies with colleagues to reduce the painful experience for their patients, Hovanesian said.

“Pain is real. The world has enough pain by itself, and we as surgeons should be committed, just as we are to our craft, to minimizing pain for our patients,” he said. – by Robert Linnehan

Disclosures: Chang reports he is a speaker for Sun Pharmaceuticals. Devgan and Gupta report no relevant financial disclosures. Hovanesian reports he is a consultant for Omeros and the founder of MDbackline. Wiley reports he is a consultant for Imprimis Pharmaceuticals.

Click here to read the POINTCOUNTER, "What are the differences between pain management protocols for first and second eye cataract surgeries?"