EyeWorld Asia-Pacific September 2013 Issue

58 September 2013 EW PHARMACEUTICALS Views from Asia-Pacific Cesar Ramon G. ESPIRITU, MD Chairman, Department of Ophthalmology, Manila Doctors Hospital United Nations Avenue, Ermita, Manila, Philippines Tel. no. +63-2-525-2260 Fax no. +63-2-524-3011 loc. 4080 espiritueyemd@me.com T here are several reasons why patients find it easier to submit themselves to modern-day cataract surgery. First and foremost is the prospect of being able to see better with at least some degree of spectacle independence. Sec- ond is the extremely short recovery period that allows them to resume their lives almost immediately. And third is the increased ease, speed, comfort and safety of the actual procedure. It all boils down to the patient’s confidence in getting the desired results and their being comfortable with the process by which this will be achieved. One of the developments in cataract surgery that continues to make a major im- pact, other than small, sutureless incisions and intraocular lenses, is the ability to perform the procedure under topical anesthesia. I estimate that about 97% of my adult cataract cases are done this way with intracameral lidocaine added. The “wow factor” with the patient able to see better immediately after a short, pain- free surgery was never appreciated until the advent of topical anesthesia. Only the anticipation of the inability of the patient to keep still and follow instructions, high anxiety levels, and complicated cases are performed either under peribulbar anesthesia with sedation or general anesthesia. Going further on the topic of “Putting cataract patients into the comfort zone”, I believe that the best way to put the patient at ease is to have them well informed of each and every step of the procedure. Your pre-op chair time should include a walkthrough of the surgery with confident reassurances that they would do just fine. Saying that the whole process is even less stressful than one that they’re familiar with, say an office dental procedure, always puts cataract surgery in the category of a minor procedure in the patient’s perception. This time will also be the best opportunity for you to gauge the patient’s anxiety levels which will guide you in your choice of anesthesia. During surgery, conversing with them in a calm, soothing voice while giving instructions, guiding them through the procedure, and forewarning them of possible mild discomfort during certain steps also does won- ders for anxiety and pain management. I have trained my staff to speak softly and calmly, avoid unnecessary conversations as well as comments that may alarm patients, and to move things around quietly. Having relaxing music playing at just the right volume helps. My anesthesiologist is also very good at extending a gentle, reassuring touch which all patients appreciate. As surgeons whom patients put their trust on, our primary concern, other than visual rehabilitation, should be to make the whole experience a pleasant one. A patient who enjoyed his journey with us starting from the preoperative work-up, sitting down for a partnered decision-making, preparing himself for surgery, going through the procedure, and finally getting his vision back will be our most grateful fan and convincing recruiter. Editors’ note: Dr. Espiritu has no financial interests related to his comments. Choun-Ki JOO, MD, PhD Professor, Department of Ophthalmology & Visual Science, College of Medicine, The Catholic University of Korea; Director, Seoul St. Mary’s Hospital Eye Institute (SSEI) #505 Banpo-dong, Seochu-Ku, Seoul, 137-040, Korea Tel. no. +82-2-2258-1173 Fax no. +82-2-533-3801 ckjoo@catholic.ac.kr W ith advances in surgical techniques and devices in cataract surgery (like small incision phacoemulsification), the need for regional peribulbar or retrobulbar injection was decreased. However, regional block anesthesia is still the first choice of anesthesia for many cataract surgeons. In our clinic, more than 95% of cataract surgery is performed under topical anesthesia because topical anesthesia is more cost-effective and safer than regional anesthesia (including retrobulbar/peribulbar injection) in terms of anesthesia-related complications (optic nerve injury, globe penetration, extraocular muscle malfunction, etc.). Potential disadvantages of topical anesthesia are less serious and include eye movement during the surgery. Also, some patients were not comfortable with the use of topical anesthesia alone, so sometimes we used intravenous sedative agents to give further comfort. Our topical regimen, initially we used alcaine eye drop 0.5% (proparacaine hydrochloride, Alcon) before the prep and betadine instillation. After the eye speculum is inserted, we use 4% lidocaine hydrochloride eye drop and wash out (about 30 seconds later) before the corneal incision, to prevent lidocaine solution from entering the anterior chamber. Most patients were completely comfortable with these eye drops. Communicating with patients and relieving patient anxiety are the most important factors to prevent sudden eye movement during the surgery under topical anesthesia. Especially during the continuous curvilinear capsulorhexis, staving off eye movement is important. When we perform transscleral fixation of an intraocular lens, we give a single retrobulbar injection, about 1.5 cc of a mixture of 2% lidocaine hydrochloride and 0.75% bupivacaine hydrochloride and hyaluronidase. If the patient has bleeding tendency (on anticoagulants like warfarin), we use intracameral lidocaine injection or sub-Tenon’s injections; however, we rarely use intracameral lidocaine injection due to the potential for endothelial toxicity. The most important thing in anesthesia during the cataract surgery is each patient has a different condition that needs to be considered. Editors’ note: Prof. Joo has no financial interests related to his comments. Putting - from page 57