Topical versus sub-Tenon's anesthesia without sedation in cataract surgery

To compare pain control using topical anesthesia with that using sub-Tenon's anesthesia for clear corneal phacoemulsification cataract surgery and foldable intraocular lens (IOL) implantation.

Departments of Ophthalmology, General Hospital Asklepeion Voulas and General Hospital of Athens, University of Athens, Athens, Greece.

One hundred consecutive patients scheduled for bilateral cataract surgery 1 to 2 months apart were prospectively randomized to receive topical anesthesia (100 eyes) or sub-Tenon's anesthesia (100 eyes). The randomization was stratified so that one half of first-eye surgeries and one half of second-eye surgeries were assigned to each anesthesia group, with each patient receiving each type of anesthesia once. All patients had clear corneal phacoemulsification with foldable IOL implantation. Patients were asked to rate their pain level on a 10-point scale for 4 periods: during the administration of the anesthetic agent, during surgery, immediately after surgery, and 24 hours postoperatively. The surgeon recorded his subjective assessment of ease of surgery and surgical complications using a standardized template.

Eighty-one percent of patients who received topical anesthesia and 8% of patients who received sub-Tenon's anesthesia reported no pain during delivery of the anesthetic agent. The mean pain score was 0.19 +/- 0.39 (SD) in the topical group and 1.35 +/- 0.63 in the sub-Tenon's group. The difference between groups was statistically significant (P <.001). Seventy-two percent of patients in the topical anesthesia group and 86% in the sub-Tenon's anesthesia group reported no pain or slight discomfort during surgery (mean score 1.13 +/- 1.57 and 0.57 +/- 1.28, respectively) (P <.001). Ninety percent of topical anesthesia patients and 100% of sub-Tenon's anesthesia patients reported no pain or slight discomfort 30 minutes postoperatively (mean score 0.80 +/- 0.93 and 0.12 +/- 036, respectively) (P <.001). All patients in the topical anesthesia group and 77% in the sub-Tenon's group reported no pain 24 hours postoperatively (mean pain 0.00 +/- 0.00 and 0.23 +/- 0.40, respectively) (P <.001). Complications including prolonged akinesia of the globe, chemosis, and conjunctival hemorrhage occurred significantly more frequently in the sub-Tenon's than in the topical group (P <.001).

Patients having cataract surgery under topical anesthesia had more intraoperative and postoperative discomfort than patients receiving sub-Tenon's anesthesia. However, patients having topical anesthesia reported less pain during its administration and had fewer complications. Both anesthesia methods provided high levels of pain control without additional sedation.