24 EyeWorld Asia-Pacific | March 2025 bloodstream, which isn’t the same for ophthalmic surgery. “I routinely use lidocaine intracamerally inside the eye at the beginning of a procedure to help with anesthesia,” he said. “I tell the patient that it’s an option to do without it, [and there] may be a little more discomfort.” He noted that there are not a lot of pain receptors in the eye, so it’s not a huge problem not to use it, but it does make the patient more comfortable. “I’ve never had someone say they don’t want it,” he said. When it comes to “caine” allergies, Dr. Epitropoulos said this is not very prevalent. Lidocaine is a local anesthetic, but it’s widely used in various medical procedures. It’s estimated that less than 1% have a true allergy to lidocaine, she said. Most reactions attributed to local anesthetics are not true allergies but rather side effects such as anxiety, vasovagal reactions, or toxicity due to overdose. True allergic responses are typically IgE-mediated and involve symptoms like hives, swelling, or anaphylaxis. Allergic reactions to amide local anesthetics (like lidocaine) are less common than those to ester anesthetics (such as procaine). “If a patient is suspected of having an allergy, testing by an allergist is recommended to confirm the diagnosis,” Dr. Epitropoulos said. Patients may claim to have an acrylic allergy, but Dr. Epitropoulos pointed out that IOLs do not cause allergic reactions. She explained that while inflammation can occur during cataract surgery, this is not typically due to an allergy. It is usually an expected response to surgery or other factors related to the procedure. Dr. Epitropoulos agreed that a patient may indicate that they have allergies to drugs, but this can just be side effects from that drug. The way to treat an allergic reaction is usually with steroids, she said, noting that the prevalence of allergies to steroids are rare but can occur. “They may develop a contact dermatitis or other type of sensitivity reaction in rare cases,” she said. Something that can be encountered is a sensitivity to preservatives used in ophthalmic solutions, such as benzalkonium chloride (BAK). “I think there’s a trend of seeing more preservative-free formulations to minimize the risk of allergic reactions or patients who might be sensitive,” she said. Dyes that are used for diagnostic procedures, like fluorescein, can also cause allergic reactions. If the patient needs to have fluorescein, you can often pretreat them to prevent an allergic reaction. When there are complications during cataract surgery, physicians often rely on IV medications like acetazolamide. Dr. DelMonte will pay particular attention if someone notes that they have a sulfa allergy because there could be a mild cross reactivity if acetazolamide is used, so having an alternative option is key. One other thing to be aware of, Dr. Epitropoulos said, is a latex allergy, which may impact the use of certain equipment and gloves. “I think more and more, ORs are going to latex-free environments, but again, if someone reports a latex allergy, we’ll usually require that they be tested to confirm if there is a true allergy.” Taking a detailed medical history is critical. Sometimes we might need to adjust medications or techniques based on the patient’s allergy profile and monitor closely for any signs of allergic reactions postoperatively to ensure prompt management, Dr. Epitropoulos said. Dr. DelMonte said it’s important to have a plan to deal with patients’ concerns about reported allergies. After describing the reason certain products are used in surgery, Dr. DelMonte will discuss that sometimes it is best to use this medication and deal with the intolerance rather than deal with the serious complication that may lead to vision loss. “This risk/benefit discussion can be helpful for patients to hear as it shows that while I understand their concerns, the alternative could be much more dangerous.” This comes down to patient education, Dr. DelMonte said. A lot of patients come in knowing they have an allergy or reaction, but describing why it’s still safe or appropriate to proceed with the normal plan is important. “Very rarely do I change anything based on a reported allergy.” Dr. DelMonte added that he works a lot with residents, and this is an important topic to discuss with them. He tells them that it’s good to explain the reason we do what we do and how to manage it with patients to make sure they’re fine with proceeding. About the Physicians Derek DelMonte, MD | Carolina Eye Associates, Greensboro, North Carolina | derek.delmonte@gmail.com Alice Epitropoulos, MD | Ophthalmic Surgeons and Consultants of Ohio, Columbus, Ohio | eyesmd33@gmail.com This article originally appeared in the December 2024 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Relevant Disclosures DelMonte: None Epitropoulos: None CATARACT
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