Elsevier

Survey of Ophthalmology

Volume 63, Issue 1, January–February 2018, Pages 75-85
Survey of Ophthalmology

Major review
Intraoperative and postoperative pain in cataract surgery

https://doi.org/10.1016/j.survophthal.2017.07.002Get rights and content

Abstract

Technologic improvements in cataract surgery have not only improved visual outcomes, but also have minimized intraoperative and postoperative pain. We review the mechanisms, risk factors, and management of intraoperative and postoperative pain. Summaries of less common sources of physiologic pain have been included to reinforce recognition of when pain represents an expected physiologic reaction to surgery as opposed to signaling a more serious complication. We also discuss various current and emerging anesthetic and analgesic modalities.

Introduction

Cataract is the world's leading cause of blindness according to the most recent data collected by the World Health Organization, and cataract surgery is arguably the most common surgical procedure performed globally.81 Worldwide estimates as of 1999 were 10 million cataract cases per year, which underestimate current rates.31, 35 With advances in technology, there are greater expectations for better visual outcomes and minimal intraoperative and postoperative pain.

There are several proposed mechanisms of physiologic pain in cataract surgery, along with many pain control methods. Severe pain can be a sign of a complication, and ruling out uncommon, but serious, adverse causes should be a priority in initial management. We review the current literature regarding the mechanisms, risk factors, and management of intraoperative and postoperative pain in cataract surgery.

Section snippets

Risk factors for experiencing cataract surgery pain

Recent studies have identified at least 3 key variables that may predispose patients to experience more pain. These are eye dominance, prior cataract surgery, and high myopia.

Insight on the possible contribution of eye dominance to pain has been recorded by work from Aslankurt et al.5 In this study, the authors evaluated a cohort of 76 initial cataract patients and identified a significant increase in mean pain scores on the dominant eye of patients undergoing cataract extraction when compared

Neuroanatomy of ocular sensory innervation

Nociceptive sensations of ocular structures are conducted through bundles of primary myelinated (A-delta fibers) and unmyelinated (C fibers) afferent neurons that run within the ophthalmic (V1) branch of the trigeminal nerve to the trigeminal brainstem nuclear complex.10, 77, 85 The cell bodies of these primary pseudounipolar afferent bundles reside within the trigeminal ganglion.11, 85 From synaptic sites in the brainstem, second order afferent neurons then decussate to join contralateral

Categorization of cataract surgery pain

There are two broad categories of pain: nociceptive (physiologic) and neuropathic (pathologic). We will primarily focus on the nociceptive causes of pain, as they are better characterized in the literature for treatments in the operative and postoperative periods of cataract surgery.

Addressing pain in cataract surgery

This section will summarize anesthetic and analgesic options available for cataract surgery, as well as discuss their utility as presented in the literature. In organizing the discussion, we have stratified options into preoperative, intraoperative, and postoperative periods.

Conclusion

There are many mechanisms for physiologic pain in cataract surgery, along with a number of anesthetic and analgesic modalities available to help minimize it. Future studies may further investigate the discomfort of each procedure step of cataract surgery and evaluate the most suitable methods of minimizing pain.

Method of literature search

In this narrative review, the authors used a PubMed and ScienceDirect search for English or English-translated articles on humans, from January 1, 1981 through November 1, 2016. Keywords used in various orders included “localization of pain receptors in the eye,” “intraoperative pain cataract surgery,” “postoperative pain cataract surgery,” “pain in phacoemulsification,” “analgesics in cataract surgery,” “dry eye after cataract surgery,” “TASS and pain in cataract surgery,” “intracameral

Disclosures

The authors declare no proprietary or commercial interests in any product mentioned or any concept discussed in this article.

Acknowledgments

We would like to recognize Dr. Derek Sakata, MD for his invaluable insights and expertise contributed during the development of this article.

This work was supported in part by an Unrestricted Grant from Research to Prevent Blindness, Inc., New York, NY, to the Department of Ophthalmology & Visual Sciences, University of Utah. This source of financial support had no role in the study design; the collection, analysis, or interpretation of data; in the writing of the report; or the decision to

References (114)

  • J.E. Boulton et al.

    A randomized controlled trial of intracameral lidocaine during phacoemulsification under topical anesthesia

    Ophthalmology

    (2000)
  • M. Chen et al.

    Oral diazepam versus intravenous midazolam for conscious sedation during cataract surgery performed using topical anesthesia

    J Cataract Refract Surg

    (2015)
  • P.L. Cornut et al.

    Toxic anterior segment syndrome

    J Fr Ophthalmol

    (2011)
  • A.S. Crandall et al.

    A comparison of patient comfort during cataract surgery with topical anesthesia versus topical anesthesia and intracameral lidocaine

    Ophthalmology

    (1999)
  • C.M. Cutler Peck et al.

    Toxic anterior segment syndrome: common causes

    J Cataract Refract Surg

    (2010)
  • E. Donnenfeld et al.

    Topical ophthalmic cyclosporine: pharmacology and clinical uses

    Surv Ophthalmol

    (2009)
  • A. Eriksson et al.

    Risk of acute suprachoroidal hemorrhage with phacoemulsification

    J Cataract Refract Surg

    (1998)
  • T. Gillow et al.

    Efficacy of supplementary intracameral lidocaine in routine phacoemulsification under topical anesthesia

    Ophthalmology

    (1999)
  • H.E. Gollogly et al.

    Increasing incidence of cataract surgery: population-based study

    J Cataract Refract Surg

    (2013)
  • A. Grzybowski et al.

    Acute aqueous misdirection syndrome: pathophysiology and management

    J Cataract Refract Surg

    (2014)
  • A.L. Ho et al.

    The effect of combined topical-intracameral anaesthesia on neuroleptic requirements during cataract surgery

    Can J Ophthalmol

    (2010)
  • E.J. Jun et al.

    Toxic anterior segment syndrome after cataract surgery

    J Cataract Refract Surg

    (2010)
  • B.J. Kaluzny et al.

    Oral acetaminophen (paracetamol) for additional analgesia in phacoemulsification cataract surgery performed using topical anesthesia randomized double-masked placebo-controlled trial

    J Cataract Refract Surg

    (2010)
  • C.L. Karp et al.

    Intracameral anesthesia: a report by the American Academy of Ophthalmology

    Ophthalmology

    (2001)
  • J. Katz et al.

    Injectable versus topical anesthesia for cataract surgery; patient perceptions of pain and side effects

    Ophthalmology

    (2000)
  • J. Katz et al.

    Adverse intraoperative medical events and their association with anesthesia management strategies in cataract surgery

    Ophthalmology

    (2001)
  • T. Kohnen et al.

    Evaluation of intraocular pressure with Healon and Healon GV in sutureless cataract surgery with foldable lens implantation

    J Cataract Refract Surg

    (1996)
  • M. Krause et al.

    Does warming of anesthetic solutions improve analgesia and akinesia in retrobulbar anesthesia?

    Ophthalmology

    (1997)
  • P.K. Kutty et al.

    Multistate outbreak of toxic anterior segment syndrome

    J Cataract Refract Surg

    (2008)
  • O.C. Lau et al.

    Acute intraoperative rock-hard eye syndrome and its management

    J Cataract Refract Surg

    (2014)
  • G. Lofoco et al.

    Efficacy of topical plus intracameral anesthesia for cataract surgery in high myopia: randomized controlled trial

    J Cataract Refract Surg

    (2008)
  • R.J. Mackool et al.

    Infusion misdirection syndrome

    J Cataract Refract Surg

    (1993)
  • A. Malik et al.

    Local anesthesia for cataract surgery

    J Cataract Refract Surg

    (2010)
  • M.C. Monson et al.

    Toxic anterior segment inflammation following cataract surgery

    J Cataract Refract Surg

    (1992)
  • S. Muttu et al.

    Comparison of dexmedetomidine and midazolam sedation for cataract surgery under topical anesthesia

    J Cataract Refract Surg

    (2005)
  • P. Rosenthal et al.

    The corneal pain system. Part I: the missing piece of the dry eye puzzle

    Ocul Surf

    (2012)
  • S. Srinivasan et al.

    Randomized double-blind clinical trial comparing topical and sub-Tenon’s anaesthesia in routine cataract surgery

    Br J Anaesth

    (2004)
  • N. Ahmad et al.

    Satisfaction level with topical versus peribulbar anesthesia experienced by same patient for phacoemulsification

    Saudi J Anaesth

    (2012)
  • S. Akkaya et al.

    Differences in pain experience and cooperation between consecutive surgeries in patients undergoing phacoemulsification

    Int Ophthalmol

    (2017)
  • A. Apil et al.

    Topical anesthesia for cataract surgery: the patients’ perspective

    Pain Res Treat

    (2014)
  • C. Belmonte et al.

    What causes eye pain?

    Curr Ophthalmol Rep

    (2015)
  • S. Cetinkaya et al.

    Toxic anterior-segment syndrome (TASS)

    Clin Ophthalmol

    (2014)
  • S.M. Channabasappa et al.

    Efficacy and safety of dexmedetomidine as an additive to local anesthetics in peribulbar block for cataract surgery

    Anesth Essays Res

    (2013)
  • K. Dole et al.

    Comparison of clinical outcomes, patient, and surgeon satisfaction following topical versus peribulbar anesthesia for phacoemulsification and intraocular lens implantation: a randomized, controlled trial

    Indian J Ophthalmol

    (2014)
  • A.T. Epitropoulos et al.

    Effect of oral re-esterified omega-3 nutritional supplementation on dry eyes

    Cornea

    (2016)
  • M. Erdurmus et al.

    Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedation

    Eur J Ophthalmol

    (2008)
  • D.G. Ezra et al.

    Supplementary intracameral lidocaine for phacoemulsification under topical anesthesia

    Ophthalmology

    (2008)
  • Y.T. Fang et al.

    Association of hospital and surgeon operation volume with the incidence of postoperative endophthalmitis: Taiwan experience

    Eye (Lond)

    (2006)
  • R. Fellman et al.

    Malignant glaucoma

    J Glaucoma

    (1999)
  • M.B.C. Fernandes et al.

    Assessing patient satisfaction with cataract surgery under topical anesthesia supplemented by intracameral lidocaine combined with sedation

    Arq Bras Oftalmol

    (2013)
  • Cited by (16)

    • Design and microwave-assisted synthesis of dimers of 1,5-benzodiazepine-1,2,3-triazole hybrids bearing alkyl/aryl spacers and their biological assessment

      2019, Journal of Molecular Structure
      Citation Excerpt :

      Therefore, a considerable interest has been focused on the synthesis of new benzodiazepines. The use of this class of compounds with therapeutic purposes is not only limited to treatment of depression [2], epilepsy [3], but also psychomotor agitation [4], seizures and muscle spasms [5]. Furthermore, many examples of benzodiazepines are described as excellent samples of anticancer [6], antiviral [7] and antimicrobial agents [8].

    • Photophobia and neuropathic pain in Sudecḱs syndrome

      2019, Archivos de la Sociedad Espanola de Oftalmologia
    • Anaesthesia for Cataract Surgery

      2023, Cataract and Lens Surgery
    View all citing articles on Scopus
    View full text