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Efficacy of topical anesthesia for foldable phakic intraocular lens implantation for the correction of myopia

van Philips, Lucien A.M. MD

Journal of Cataract & Refractive Surgery: March 2010 - Volume 36 - Issue 3 - p 521-522
doi: 10.1016/j.jcrs.2009.10.043
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Topical anesthesia is not widely used for foldable Artiflex phakic intraocular lens (pIOL) (Ophtec BV) implantation. Retrobulbar, peribulbar, and even general anesthesia are the more common techniques.1 As a less invasive technique, topical anesthesia reduces the risk for systemic complications and eliminates the complications from injection anesthesia such as globe perforation, retrobulbar hemorrhage, retinal vascular occlusion, ptosis, and optic nerve damage.2 The advantages of topical anesthesia are faster visual recovery, higher patient satisfaction, easy application, minimal discomfort on administration, rapid onset of anesthesia, and lower costs. To my knowledge, this is the first report of the efficacy of topical anesthesia for implantation of an Artiflex pIOL for the correction of myopia. The study used the visual analog pain scale described by Stevens.3


Prior to cataract surgery, 26 patients received preservative-free pilocarpine nitrate 2%, preservative-free oxybuprocaine hydrochloride 0.4 %, and preservative-free tetracaine hydrochloride 1% eyedrops. Four doses (approximately 40 μL per dose) of each eyedrop were instilled on the ocular surface 10 minutes apart starting 30 minutes before surgery. All surgery was performed by the same surgeon (L.A.M. van P.). One or 2 weeks before surgery, a laser peripheral iridotomy was created with a neodymium:YAG laser. Fluorometholone drops were used 4 times a day for 1 week. First, 2 vertical paracenteses were made at the 2 and 10 o'clock positions and directed toward the enclavation site. Intracameral acetylcholine and an ophthalmic viscosurgical device (sodium hyaluronate 1.4%, Healon GV) were introduced. After a corneoscleral incision of 3.2 mm was made at the 12 o'clock incision, the Artiflex pIOL was inserted with the use of a specially designed spatula that allows the surgeon to fold and insert the IOL. A special curved forceps was used for the enclavation by holding the poly(methyl methacrylate) haptics at the base. Suturing was not necessary since the incisions were checked and watertight. There were no intraoperative complications, and no patient required additional anesthesia to complete surgery safely, and there were no intraoperative complications.

Before, during, and after surgery, the patients were shown a visual analog pain scale (VAS) with ratings from 0 (no pain) to 10 (severe pain) and their responses recorded. Table 1 and Figure 1 show the pain score for all 3 periods. A VAS score of 0 (no pain) was reported by 53%, 28%, and 50% of patients, respectively, and of 0-1 (no pain, slight discomfort) by 81%, 37%, and 53%, respectively. There was a significant increase in the mean VAS pain score from preoperatively to intraoperatively; however, 91% of patients preferred topical anesthesia to peribulbar or general anesthesia.

Table 1
Table 1:
Pain score (VAS) before, during, and after pIOL implantation.
Figure 1
Figure 1:
Perioperative pain score after pIOL implantation with topical anesthesia (VAS = visual analog scale).


Although a higher percentage (56%) of patients with an intraoperative VAS score of 0-1 during cataract surgery has been reported,4 the mean postoperative pain score of 1.84 ± 2.49 (SD) compares favorably with the mean postoperative pain score of 1.88 ± 2.17 (SD) reported after cataract surgery.4 In conclusion, topical anesthesia seems effective and safe for implantation of the Artiflex pIOL.


1. Dick HB, Budo C, Malecaze F, Güell JL, Marinho AAP, Nuijts RMMA, Luyten GPM, Menezo JL, Kohnen T. Foldable Artiflex phakic intraocular lens for the correction of myopia; two-year follow-up results of a prospective European multicenter study. Ophthalmology. 2009;116:671-677.
2. 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;91:470-475.
3. Stevens JD. A new local anaesthesia technique for cataract extraction by one quadrant sub-Tenon's infiltration. Br J Ophthalmol. 76. 1992. 670-674. Available at: Accessed November 21, 2009.
4. Lofoco G, Ciucci F, Bardocci A, Quercioli P, De Gaetano C, Ghirelli G, Perdicaro S, Schiano Lomoriello D, Cacciamani A. Efficacy of topical plus intracameral anesthesia for cataract surgery in high myopia: randomized controlled trial. J Cataract Refract Surg. 2008;34:1664-1668.
© 2010 by Lippincott Williams & Wilkins, Inc.