By Brooks Alldredge, OD | PCLI Boise, ID and Albuquerque, NM
Pacific Cataract and laser Institute
How We Decide
Our surgeons and optometric physicians continually evaluate policies and procedures with one goal—to give patients the best possible treatment experience. Our singular focus is to perform cataract surgery that is both safe and effective. A critical component of good outcomes is minimizing or eliminating fear, stress, and discomfort. Anxiety and pain frequently go together, so both require attention.
With cataract surgery we have a variety of anesthetics and anxiolytics that are very effective. But the type of anesthesia that is ideal for each patient may vary.
All of our offices provide topical anesthesia and retrobulbar blocks. Our guiding principle for selection revolves around informed consent. That is, patients should have a choice based on a clear understanding of risks and benefits. Our informed consent process typically involves three steps.
Step 1: Initial Education
Some primary care ODs discuss anesthesia with patients before their referral, and we appreciate that preparation. During our initial evaluation, patients watch an informed consent video that covers the benefits and downsides of each type of anesthesia. Our technicians also spend as much as an hour working up patients and are skilled at alerting the examining physician for criteria that might make one method of anesthesia more preferable than another.
Step 2: After the Exam
During the examination, our optometric physicians often evaluate clues that guide the discussion of anesthesia and help patients in their choice.
Are they unable to communicate effectively, understand, or follow instructions?
Is the cataract advanced, or is surgery anticipated to be more complex than usual?
Are the eyes deep-set or the palpebral fissures small?
Does the patient have significant photophobia during biomicroscopy and ophthalmoscopy?
If the answer is yes to any of these, a block may best serve the patient’s needs.
After the exam, we consider the benefits and disadvantages of topical anesthesia and retrobulbar block in light of the patient’s specific case, additional risk factors, and preference. I also ask patients if the referring eye doctor has discussed anesthesia options. Then, to set the context and reduce anxiety, I describe how long they should expect to be in our facility on the day of surgery and the steps in our surgical preparation. I explain that they will be offered something to help them to relax. There will be no general anesthesia risk, so they can and should eat their meals and take all medicines as usual without concern.
Step 3: Making the Decision
In my experience, many patients are well suited for topical anesthesia. In the PCLI offices where I work (Boise, ID and Albuquerque, NM), most prefer it because eye drops and anesthetic gels create less anxiety than an injection. Other benefits are avoidance of the slight risk of retrobulbar block complication, and eyelid tape or a patch that is usually not needed. However, poor candidates can have significant discomfort during surgery, which may result in surgical complications.
To help make my decision, I like to ask patients three questions:
Do you feel comfortable with and capable of keeping your eye open with a bright operating light?
Can you keep your eye still during surgery when instructed?
Are you willing to tolerate the possibility of minor discomfort during surgery?
If the answer is yes to all three, and they are otherwise good candidates for topical anesthesia, the vast majority do very well.
WHEN TOPICAL IS NOT THE BEST CHOICE
Topical anesthesia is not the best choice with:
Pain is often amplified by anxiety and vice versa. So we do all we can to reduce stress and anxiety. Our staff is known for providing emotional and physical comfort to patients. Great thought and effort have also been given to create a calming environment in our pre and post-operative areas. This includes comfortable seating and lighting. We affectionately refer to this space as TLC because tender loving care is dispensed in large doses.
Every patient is offered oral sedation to reduce anxiety. It does not usually provide the amnesia of IV sedation, but has advantages. With oral sedation, there is no pain that is associated with the placement of an IV catheter, nor significant grogginess after surgery. Most importantly, oral medication reduces systemic risks of IV sedation—some that can be life-threatening. In our experience, oral Versed or MKO Melt (a non-opioid sublingual compounded formulation of Midazolam / Ketamine / Ondansetron) provides an excellent calming and relaxing effect while allowing patients to follow necessary instructions during surgery.
Our anesthetists are among the most skilled and experienced anywhere in both topical and injectable block anesthesia. They calmly explain to patients what they are doing. Our staff and surgeons also help alleviate fear by talking patients through the surgical procedure. When needed, topical anesthesia can be augmented with intracameral lidocaine or Marcaine to further reduce the chance of discomfort.
Selecting the right anesthesia for cataract surgery is a significant decision that can not be rushed or made carelessly. There are pros and cons with each type, and our guiding principle is to provide the necessary information for patients to select what is best for them. We like to accomplish this through a team effort—referring ODs, PCLI technicians, ODs, anesthetists, and surgeons working together to guide patients in their decisions. Most studies and our experience support the conclusion that the vast majority are comfortable throughout the procedure, regardless of anesthesia type.
distributed quarterly to 2700 optometric physicians FALL 2020
ABOUT THE AUTHOR
PCLI Boise, ID and Albuquerque, NM
Outgoing, gracious and energized, Brooks Alldredge has a natural curiosity and likes to get to know people. Born in Fresno, California, Brooks grew up in the San Joaquin Valley where he discovered a love of books, learning and good conversation. He enjoys mountaineering, climbing, skiing, white water kayaking and marathon running. Brooks and his wife Terri, an optometric physician, live in Boulder, Colorado.
Brooks Alldredge, OD
FROM THE EDITOR
With cataract surgery, several types of anesthesia are available. At PCLI, we provide topical anesthesia and retrobulbar blocks, and our goal is to use the technique that makes each patient feel most comfortable. In this issue, my colleague Brooks Alldredge discusses several steps that help guide our decisions and how we like to rely on a team approach.
As always, enjoy!
Ami Halvorson, OD
Note from the editor