Comparing Retrobulbar and Topical Anaesthesia in Cataract Surgery by Phacoemulsification – How Can Patient Comfort During Surgery by Phacoemulsification Be Improved?

European Ophthalmic Review, 2009,3(1):42-4 DOI:


The first section of this article is a summary of the development of cataract surgery and the anaesthetic methods used in cataract surgery. When comparing the effectiveness of retrobulbar anaesthesia (RBA) and topical anaesthesia (TA), we found that more patients in the TA group indicated pain during the procedure (p<0.001). After analysing pre-operative data, we could predict which patients would report intraoperative pain with 93% certainty. The type of anaesthesia and the skills of the surgeon are robust factors, while higher levels of stress hormones before surgery are also significant, especially in younger patients. The possible origin of pain and the role of positive verbal communication around the procedure are discussed. In order to prevent unexpected surgical situations, it is better to offer patients the most appropriate method of anaesthesia rather than using a ‘one size fits all’ solution.
Received: March 02, 2011 Accepted March 02, 2011
Correspondence: Phacoemulsification, retrobulbar anaesthesia, topical anaesthesia, prediction of pain, positive suggestive verbal communication

Topical anaesthesia (TA) for cataract surgery was first used by Koller around 1884. However, this method fell out of favour because general anaesthesia and, later, retrobulbar anaesthesia (RBA) could provide better conditions for surgery.1 At this time cataract surgery was performed using an incision of 10mm or more. Accordingly, hypotony and akinaesia were necessary. Hypotony was achieved using oculopression; this could activate the oculo-cardiac system,2 which could be blocked by retrobulbar injection of anaesthetics close to the ciliary ganglion.3

Due to technical developments, cataract surgery methods have changed since the 1970s. Operations by phacoemulsification can be performed through a clear corneal incision of 3.2mm or less. During the intervention, manipulations are performed in a closed system, and movement of the iris diaphragm caused by rapid hydrodynamic changes can be avoided. These surgical developments mean that TA is once again seen as an attractive option.4 TA involves anaesthetising the cornea and conjunctiva using surface anaesthetic drops. The manipulation inside the lens does not cause any pain as the lens does not contain any nerves. Under adequate surgical conditions, TA is theoretically sufficient to perform phacoemulsification. As a result, TA is now in widespread use all over the world.

However, despite the theoretically expected results, the literature shows that more patients indicate pain during surgery and report pain retrospectively after surgery when TA is used rather than retro-/peribulbar or sub-Tenon’s anaesthesia.5,6 The combination of TA with intracameral lidocain can reduce the level of reported pain. However, this neither reduces the necessity for supplementary anaesthesia nor improves the patient’s overall satisfaction. So, based on the literature, the advantages of routinely used intracameral anaesthetics are not clear-cut.7

On the other hand, even if current best practice is used, the retroand peribulbar techniques (using a sharp needle in the orbit) can cause serious and life-threatening complications8 in a limited number of cases (0.066%).9 Sub-Tenon’s anaesthesia by cannula can counteract this complication, but it increases the risk of mild complications of anaesthesia.10 Moreover, these techniques can cause post-operative akinaesia,11 which is undesirable in one-day surgery – an important consideration given the high (and increasing) proportion of procedures carried out in one-day surgery.

So, which anaesthetic method provides the best comfort for patients in the peri-operative period? From our published results, we compared the effectiveness for the patient of RBA and TA and tried to identify factors that increase the risk of patient discomfort or pain in the peri-operative period.12 Our results confirmed the data from the literature: more patients in the TA group indicated pain during the procedure (p<0.001). The difference between the two groups increased when the patients were later asked about the pain they had experienced during the anaesthetic procedure (including the injection in the case of RBA) and the operation itself (p<0.001).13

  1. Atkinson WS, The development of ophthalmic anaesthesia, Am J Ophthalmol, 1961;51:1–14.
  2. Vörösmarthy D, Oculopressor, an instrument for the production of intraocular hypotension, Klin Monatsbl Augenheilkd, 1967;151(3):376–82.
  3. Johnson RW, Anatomy for ophthalmic anaesthesia, Br J Anaesth, 1995;75:80–87.
  4. Kershner RM, Topical anaesthesia for small incision selfsealing cataract surgery. A prospective evaluation of the first 100 patients, J Cataract Refract Surg, 1993;19:290–92.
  5. AHRQ, Evidence report, Anaesthesia Management During Cataract Surgery, Publication Number ÖÖ-E015, Technology Assessment: Number 16, 2000.
  6. Friedman DS, Bass EB, Lubomski LH, et al., Synthesis of the literature on the effectiveness of regional anaesthesia for cataract surgery, Ophthalmology, 2001;108:519–29.
  7. Daniel DG, Nambiar A, Allan BD, Supplementary intracameral lidocaine for phacoemulsification under topical anesthesia: a meta-analysis of randomized controlled trials, Ophthalmology, 2008;115:455–487.
  8. Edge R, Navon S, Scleral perforation during retrobulbar and peribulbar anaesthesia: risk factors and outcome in 50,000 consecutive injections, J Cataract Refract Surg, 1999;25:1237–44.
  9. El-Hindy N, Johnston RL, Jaycock P, et al.; and the UK EPR user group, The Cataract National Dataset Electronic Multi-centre Audit of 55 567 operations: anaesthetic techniques and complications, Eye, 2009;23(1):50–55.
  10. Eke T, Thompson JR, Serious complications of local anaesthesia for cataract surgery: a 1 year national survey in the United Kingdom, Br J Ophthalmol, 2007;91: 470–75.
  11. Kumar MC, Dodds C, Ophthalmic reginal block, Ann Acad Med Singapore, 2006;35:158–68.
  12. Gombos K, Jakubovits E, Kolos A, et al., Cataract surgery anaesthesia: is topical anaesthesia really better than retrobulbar?, Acta Ophthalmol Scand, 2007;85:309–16.
  13. Boezaart A, Berry R, Nell M, Topical anaesthesia versus retrobulbar block for cataract surgery: the patients’ perspective, J Clin Anesth, 2000;12:58–60.
  14. Cagini C, De Carolis A, Fiore T, et al., Limbal anaesthesia versus topical anaesthesia for clear corneal phacoemulsification, Acta Ophthalmol Scand, 2006;84:105–9.
  15. Kalman R, Gombos K, Nagy ZZS, Pain in the different stages of cataract surgery by phacoemulsification technique in topical anaestesia, Acta Ophthalmologica Scandinavica, 2007;85:s240.
  16. Trantos PG, Wickremasinghe SS, Sinclair N, et al., Visual perception during phaco-emulsification cataract surgery under topical and regional anaesthesia, Acta Ophthalmol Scand, 2003;81:118–22.
  17. Millodot M, A review of research on the sensitivity of the cornea, Ophthalmic Physiol Opt, 1984;4:305–18.
  18. Pandey SK, Werner L, Apple DJ, et al., No-anaesthesia clear corneal phacoemulsification versus topical and topical plus intracameral anaesthesia. Randomized clinical trial, J Cataract Refract Surg, 2001;27:1643–50.
  19. Jakubovits E, The clinical use of hypnosis in anaesthesia. In: Vértes G (ed.), Hypnosis and Hypnotherapy, Hungary: Medicina, 2006;123–43.
  20. Morsman CD, Holden R, The effects of adrenaline, hyaluronidase and age on peribulbar anaesthesia, Eye, 1992;6:290–92.
  21. Katz J, Feldman MA, Bass EB, et al.; Study of Medical Testing for Cataract Surgery Study Team, Adverse intraoperative medical events and their association with anaesthesia management strategies in cataract surgery, Ophthalmology, 2001;108:1721–6.