To study patient comfort and surgeon’s perspective in terms of patient cooperation in MSICS under topical anesthesia using only proparacaine 0.5% eye drops without any periocular block or intracameral drug and to popularize topical MSICS similar to topical phacoemulsification.
Manual small-incision cataract surgery (MSICS) is one of the most common surgical procedures in ophthalmology. Most cataract surgeries are performed under local anesthesia. Peribulbar or retrobulbar anesthesia is commonly used to achieve analgesia and akinesia during surgery, but it has various complications. Topical anesthesia using drops or gel provides adequate analgesia but no akinesia and thus requires the cooperation of the patient. Topical anesthesia is in practice using intracameral phenocaine or intracameral lignocaine, which adds up to the cost of surgery.
In this study, we evaluate the patient’s perspective and surgeon’s experience of MSICS using only topical anesthetic eye drops. It will help in doing large-scale surgeries economically and also cut short the time of anesthesia with lesser complications.
It was a prospective analytical study of 33 patients who underwent MSICS surgery from March 2022 to June 2022 using topical proparacaine 0.5% eye drops. Informed written consent for MSICS under topical proparacaine anesthesia was taken after explaining the procedure.
Cases of adult cataract patients of grade 1 to grade 3, who were cooperative during slit-lamp examination, and who could obey commands and with pupil dilatation >7 mm were included.
Cataract patients with grade 4 brown cataract, who are hard of hearing and uncooperative during slit-lamp examination, patients with <7-mm pupil, pediatric patients, and patients with associated complications such as uveitis, lens-induced glaucoma, small pupil, existing ocular pathologies such as corneal opacity, pseudoexfoliation, complicated cataract, subluxated lens, glaucoma, traumatic cataract, and any other complications were excluded.
Topical anesthesia proparacaine 0.5% eye drops were instilled every 5 min for 15 min prior to surgery and once or twice per op if the patient was sensitive to pain. Superior rectus bridal suture was avoided to prevent pain associated with traction on the muscle. A small nick was made on the sclera to hold with Hoskin’s forceps to stabilize the globe and also for adequate exposure to form the sclerocorneal tunnel. A superior scleral straight incision of 6.5 mm was done 2 mm behind the limbus, and the sclerocorneal tunnel was made by entering approximately 2 mm into clear cornea with deep side pockets. Care was taken to prevent premature entry thus avoiding iris prolapse during surgery. The side port was made at 3 o’clock, and staining of the anterior capsule was done using Trypan blue. Continuous curvilinear capsulorhexis was done using a bent 26-G needle mounted on a syringe. Gentle hydrodissection was done, and the nucleus was brought to the anterior chamber without touching or manipulating the iris by using a single dialer. Adequate viscoelastic (HPMC 2%) was used to maintain anterior chamber depth and prevent traction on the iris. Nucleus delivery was done using vectis and dialer by sandwich technique, and cortical wash was done using Simcoe’s cannula avoiding iris touch and manipulation. Rigid PMMA IOL was placed through the sclerocorneal tunnel and dialed into the bag. Viscoelastic was washed adequately, and the anterior chamber was formed using BSS. Subconjunctival antibiotic and steroid injection was avoided, and topical antibiotic steroid drops were used before applying the pad and bandage. If the patient complained of severe pain during surgery, or in the case of a very uncooperative patient, supplementation with 2% lignocaine injection periocular block was done. All the surgeries were performed by a single surgeon. The surgeon’s and patient’s experiences were noted immediately after surgery by using a valid scoring system [Video 1].
Study population included 20 women (60.6%) and 13 men (39.4%). The mean age was 58.7 ± 8.3 years (range: 41–72 years). The majority of the patients had a rural background (54.6%). There were an equal number of people who were illiterate and studied up to secondary school (39.4%) [Table 1].
The average comfort score based on patient feedback after surgery was 3.45 ± 0.96, and the average patient cooperation score based on surgeon assessment was 3.42 ± 1.07. Comfort score was slightly higher in men compared to women. Comfort score was more in the urban population and patients who were educated more than secondary school. Cooperation score was also higher in the male population compared to females and higher in the urban population compared to rural and patients educated more than in secondary school [Tables 2 and 3].
In two patients with a comfort score and cooperation score of 1, intraoperative augmentation of anesthesia, peribulbar using 2% lignocaine 5 mL was done. One of these patients had intraoperative iris prolapse because of premature entry, which was the reason for non-cooperation during surgery and increased discomfort. Periocular block was used, and iris reposition and tunnel suturing were done in this case. The other patient was very anxious about the use of topical anesthesia and was uncooperative during surgery and thus was given periocular block, and the surgery was completed.
MSICS is one of the most common surgical procedures in ophthalmology. Most cataract surgeries are performed under local anesthesia. Advantages of topical anesthesia using drops or gel are that it provides adequate analgesia, early patient recovery, lack of injection-related complications, and lack of complications such as retrobulbar hemorrhage, injury to extraocular muscles, and other complications seen with retrobulbar, peribulbar, and intracameral anesthesia. A study conducted by Rewri et al. at Maharaja Agrasen Medical College, Haryana to determine satisfactory experience from the patient’s as well surgeon’s perspective in cataract surgery by phacoemulsification technique under topical anesthesia concluded that acceptance for topical anesthesia for cataract is high in both patient’s and surgeon’s perspectives.
A prospective comparative study conducted by Gupta et al. comparing the patient’s experience of pain, surgical outcome, and surgeon’s experience in MSICS under topical anesthesia supplemented with intracameral lignocaine concluded that the performance of these surgeries under topical anesthesia has acceptable patient comfort and pain experienced in both techniques is comparable. Topical anesthesia does not compromise surgical results in MSICS. A study conducted by Agarwal at All India Institute of Medical Sciences, Delhi to determine satisfactory experience from the patient’s and surgeon’s perspectives in phacoemulsification cataract surgery under topical anesthesia concluded that the acceptance for topical anesthesia for cataract surgery is high. Patient satisfaction and cooperation depend on several sociodemographic and psychological factors. Gupta et al. demonstrated that both phacoemulsification and MSICS can be done under topical anesthesia supplemented with intracameral lignocaine with acceptable patient comfort, and the pain experienced in both techniques is comparable.
Another study by Dr. Suresh K M concluded that the method of topical anesthesia in performing SICS is acceptable both for the patient and the operating surgeon.
In this prospective analytical study conducted on 33 patients, the average comfort score based on patient feedback after surgery was 3.45 ± 0.96, and the average patient cooperation score based on surgeon assessment was 3.42 ± 1.07. Comfort score was slightly higher in men compared to women. Comfort score was more in the urban population and patients educated more than secondary school. Cooperation score was higher in the male population compared to females. Cooperation score was higher in urban population compared to rural and patients educated more than secondary school. Surgeon’s perspective was also noted. The surgeon was comfortable doing the surgery with topical anesthesia even though it needs some learning curve.
MSICS using only topical proparacaine 0.5% eye drops without the use of any intracameral anesthesia or periocular block can provide sufficient patient comfort and can avoid complications related to injection and peribulbar and retrobulbar anesthesia. The use of topical anesthetic eye drops cuts down the time taken and cost for the administration of local anesthesia and its complications. Hence, it can be used in large-scale cataract surgeries and provides economical utilization of resources and early postoperative recovery without compromising the surgical outcome. This technique, once mastered, can be routinely done and popularized as a daycare procedure for large-scale cataract surgeries, which not only brings down the complication rates but also cuts down the cost of surgery.
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Conflicts of interest
There are no conflicts of interest.
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