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Anaesthesia and perioperative care

TL;DR — Cataract surgery is now overwhelmingly a topical-anaesthesia day-case operation: across 1,354,036 EUREQUO surgeries, topical anaesthesia rose from 30% to 76% between 2008 and 2018 while sub-Tenon fell from 27% to 16% and regional from 38% to 6% (Segers 2022, PMID 36449673). That shift has a measurable cost. In the same registry, sub-Tenon (OR 0.80, 95% CI 0.71–0.91), regional (0.74, 0.71–0.78), general (0.53, 0.50–0.56) and intracameral (0.76, 0.64–0.90) anaesthesia all carried lower posterior capsule rupture risk than topical, and endophthalmitis risk was lower with regional anaesthesia (OR 0.60, 0.44–0.82) (PMID 36449673). Randomised evidence, however, shows the pain differences are small: topical anaesthesia increases intraoperative pain by about 1.1 points on a 0–10 scale and decreases 24-hour pain by 0.2, differences the Cochrane authors judged probably too small to be clinically relevant (Guay 2015, PMID 26308931). Routine preoperative medical testing does not help (OR 1.00 for medical adverse events, 95% CI 0.86–1.16) (Keay 2019, PMID 30616299), and antithrombotic drugs need not be stopped (Katz 2003, PMID 13129878).

Anaesthetic options

Technique Description Evidence position
Topical (± intracameral lidocaine) Drops or gel, no akinesia Now dominant; adequate for uncomplicated phaco (Navaleza 2006, PMID 16701160)
Sub-Tenon block Cannula through a conjunctival/Tenon incision into the sub-Tenon space Better intraoperative analgesia than topical; lower registry PCR risk (PMID 26308931; PMID 36449673)
Peribulbar Needle block outside the muscle cone Largely replaced retrobulbar; needle-related risks remain (Nouvellon 2010, PMID 20030430)
Retrobulbar Needle block within the muscle cone Progressively phased out (PMID 20030430)
General Full anaesthesia Reserved for inability to cooperate, and for children

The main patient risk factor for inadvertent globe perforation with needle blocks is a myopic staphyloma, and the requirement for deep akinesia fell sharply once phacoemulsification replaced large-incision surgery, allowing topical or low-volume sub-Tenon techniques; the corresponding trade-off is that non-akinetic techniques may impair surgical conditions and thereby cause complications (PMID 20030430). That trade-off is exactly what the registry data now quantify.

Topical versus sub-Tenon: the randomised and registry evidence disagree in emphasis

Outcome Result Evidence Source
Intraoperative pain Topical worse by ≈1.1 points on a 0–10 scale (high-certainty evidence) 7 studies, 742 eyes, 617 participants Guay 2015, PMID 26308931
Pain at 24 h Topical better by ≈0.2 points (moderate certainty) same PMID 26308931
Patient satisfaction Lower with topical (moderate certainty) same PMID 26308931
Surgeon satisfaction Lower with topical (low certainty) same PMID 26308931
Intraoperative complications Insufficient evidence to distinguish same PMID 26308931
Intraoperative analgesia (updated meta-analysis) Sub-Tenon better: SMD −0.53 (95% CI −0.70 to −0.36; p < 0.001); on 6 studies with uniform pain scales MD −0.84 (−1.22 to −0.47; p < 0.001). Severe intraoperative discomfort requiring rescue regional anaesthesia occurred with topical 12 studies, 1,370 patients Valizadeh 2025, PMID 40330003
Posterior capsule rupture vs topical Sub-Tenon OR 0.80 (0.71–0.91); regional 0.74 (0.71–0.78); general 0.53 (0.50–0.56); intracameral 0.76 (0.64–0.90) 1,354,036 EUREQUO surgeries, 2008–2018 Segers 2022, PMID 36449673
Endophthalmitis vs topical Regional anaesthesia OR 0.60 (0.44–0.82, P = .001) same PMID 36449673

The randomised trials measure pain; the registry measures complications. Both are informative and neither settles the question, because registry anaesthetic choice is confounded by case complexity — the difficult eye is more likely to receive a block. This is stated plainly as a limitation of the observational design (PMID 36449673). What is not in dispute: both techniques are accepted and safe, an acceptable degree of intraoperative discomfort must be expected with either, and the Cochrane authors call for randomised trials of strategies to prevent intraoperative pain (PMID 26308931).

Newer topical agents are being tested against the standard. Chloroprocaine 3% gel versus tetracaine 0.5% drops in 338 patients showed equivalence with a marginally higher success rate for the gel (152/166, 92.0% vs 153/172, 90.5%) in achieving ocular surface anaesthesia without supplementation before IOL implantation (Figus 2024, PMID 38489057). Intracameral lidocaine as an adjunct to topical anaesthesia in MSICS has been examined in a registered trial (NCT01023334). At the other extreme, "no-anaesthesia" cataract surgery has been described but is not an evidence-supported standard (Kumar 2015, PMID 26287905), and the older editorial literature captures a long-running argument about whether the discipline moved away from blocks too readily (Rubin 1990, PMID 2240529; Steele 1990, PMID 2337540; Smerdon 2001, PMID 11767015; Guise 2005, PMID 16181266; Eke 2003, PMID 12640397).

Systemic risk and monitoring

Routine preoperative medical testing does not make cataract surgery safer. Across three randomised trials totalling 21,531 operations, medical adverse events were 353 in the tested and 354 in the untested group (OR 1.00, 95% CI 0.86–1.16, high certainty), with no reduction in intraoperative (OR 0.99, 0.71–1.38) or postoperative ocular events (1.11, 0.74–1.67), no difference in cancellations (0.97, 0.78–1.21) and 2.55× higher costs (PMID 30616299). The largest single trial randomised 19,557 operations in 18,189 patients and found identical overall complication rates of 31.3 per 1,000 operations in both arms, mostly cardiovascular and intraoperative (Schein 2000, PMID 10639542). Anaesthesia review literature has translated this into a case for individualised rather than routine assessment (Macias 2024, PMID 38278587; Rusk 2016, PMID 27542420), and a retrospective cohort of ophthalmologist-led topical-anaesthesia surgery without dedicated anaesthesia presence — supported only by a medical emergency team, with monitoring limited to blood pressure and plethysmography, no fasting, and continued medications — found the pathway safe (Koolwijk 2015, PMID 25444350). Whether anaesthesia care is overused for routine cataract surgery has been argued vigorously in the correspondence literature (Perumal 2023, PMID 36939671; Dalia 2023, PMID 36939678; Nemet 2023, PMID 36939677).

Two patient groups need specific attention. Hypertension under loco-regional anaesthesia and perioperative glycaemic control in diabetes are both flagged as under-addressed in editorials by the same anaesthetic group (Kumar 2017, PMID 29028916; Kumar 2016, PMID 27956666). Parkinson's disease has no specific guideline for ophthalmic anaesthesia, and the practical considerations — tremor, rigidity, medication timing, cognitive status — are summarised narratively (Chiew 2023, PMID 38021330). Artificial-intelligence support for preoperative anaesthetic assessment has been described but not prospectively evaluated (Guerrier 2025, PMID 40973582).

Antithrombotic management

The default is continuation. In 19,283 cataract operations, 24.2% of patients routinely used aspirin and 4.0% warfarin; among routine users 22.5% of aspirin users and 28.3% of warfarin users stopped before surgery. Rates of stroke, TIA or DVT were 1.5/1,000 in non-users and 3.8/1,000 in continuing users; there were no such events among warfarin users who discontinued, and myocardial infarction or ischaemia rates were 5.1/1,000 (aspirin) and 7.6/1,000 (warfarin) in continuers, no different from discontinuers (Katz 2003, PMID 13129878). Bleeding events attributable to continuation were minor. In 48,862 UK Cataract National Dataset operations with recorded drug history (28.1% aspirin, 5.1% warfarin, 1.9% clopidogrel, 1.0% dipyridamole), any local-anaesthetic block complication was more frequent with clopidogrel (8.0%, P < 0.0001) or warfarin (6.2%, P = 0.0026) than in non-users (4.3%), and subconjunctival haemorrhage was commoner (4.4% and 3.7% vs 1.7%, both P < 0.0001), but choroidal/suprachoroidal haemorrhage and hyphaema were not significantly increased; posterior capsule rupture was higher with clopidogrel (3.23%, P = 0.0057) (Benzimra 2009, PMID 18259210). Practical perioperative management of older and newer agents across ophthalmic subspecialties is reviewed in (Kong 2015, PMID 25425711). Contemporary clinical review states plainly that anticoagulants need not be discontinued for cataract surgery (Chen 2025, PMID 40227658).

Perioperative pharmacology

Intervention Evidence Source
Intracameral phenylephrine 1.0% / ketorolac 0.3% in irrigation Two phase 3 trials, 808 patients: superior maintenance of mydriasis (AUC change in pupil diameter +0.08 mm vs −0.50 mm, P < .0001) and lower early ocular pain (AUC VAS 4.16 vs 9.06 mm) Hovanesian 2015, PMID 26703280
Intracameral antibiotic prophylaxis Reduces endophthalmitis; only the intracameral route significantly reduced risk in a 6.8-million-eye network meta-analysis (OR 0.19, 99.4% CI 0.12–0.30) Kato 2022, PMID 36258003
Postoperative topical antibiotic in addition to intracameral Endophthalmitis 0.016% vs 0.017% with and without topical antibiotic in 42,466 eyes Rathi 2020, PMID 33120637
Duration of topical prophylaxis and steroid 1-week topical antibiotic prophylaxis as effective as the customary 2 weeks; 1 week of dexamethasone resolved inflammatory signs and symptoms in >85% Aragona 2021, PMID 33081522
Drop-free approaches Surgeon-delivered intracameral antibiotic plus periocular or intracameral steroid, with intraoperative pharmacologic dilation, avoids adherence and instillation failures Shorstein 2020, PMID 31688226
NSAIDs Reduce pain, prevent intraoperative miosis, modulate inflammation and reduce cystoid macular oedema Hoffman 2016, PMID 27697257

Early postoperative intraocular pressure elevation is frequent — described as up to 88% of early postoperative complications — with risk factors including residual viscoelastic, resident-performed surgery, glaucoma, pseudoexfoliation, axial length >25 mm, tamsulosin and steroid responsiveness; peak IOP occurs 3–4 hours postoperatively, which is an argument against relying on a day-1 review to detect it, and no agent completely prevents spikes (Grzybowski 2019, PMID 30489361; Katz 2024, PMID 39503401).

Immediate sequential bilateral cataract surgery

Operating both eyes in one session under strict aseptic separation is the main perioperative-organisation question in the field.

Outcome Result Source
Second eye within ±1.0 D of target refraction 97% (404/417) ISBCS vs 98% (407/417) DSBCS; difference −1% (90% CI −3 to 1; p = 0.526) — non-inferiority established Spekreijse 2023, PMID 37201546
Endophthalmitis Not observed or reported in either group of 865 randomised patients PMID 37201546
Adverse events Comparable, except significantly more disturbing anisometropia with DSBCS (p = 0.0001) PMID 37201546
Societal cost €403 (US$507) lower per participant with ISBCS; 100% cost-effectiveness probability across the willingness-to-pay range PMID 37201546
Systematic review (9 studies, 3 RCTs, sample sizes 298 to >496,000 eyes) Comparable BCVA and refractive accuracy; no significant differences in endophthalmitis, cystoid macular oedema or PCR; trend toward higher satisfaction and faster rehabilitation with ISBCS Al-Swailem 2026, PMID 41847523
Registry and narrative synthesis Endophthalmitis rates consistently <1/1,000 for both approaches; up to 50% lower CO₂ footprint per patient with ISBCS Staktopoulou 2026, PMID 41959995
Earlier Danish meta-analysis Three RCTs; no difference in complications or visual outcome; evidence graded low to very low; none reported postoperative anisometropia prevalence Kessel 2015, PMID 26351576

The residual uncertainty is specifically about bilateral rare harm. Even a trial of 865 patients with zero endophthalmitis events cannot bound bilateral endophthalmitis risk, and the update literature explicitly calls for randomised registry studies powered for it (Spekreijse 2023, PMID 36206058; Singh 2017, PMID 27684294; Nowrouzi 2024, PMID 38390776). The carbon and equity arguments have been contested in correspondence (Ting 2024, PMID 38280774; Lin 2024, PMID 38280775; Spekreijse 2024, PMID 38280777).

Wrong-lens and process safety

Perioperative safety in cataract surgery is dominated by process errors rather than physiology — wrong lens, wrong eye, wrong axis for toric alignment — and by drug and device handling failures that cause toxic anterior segment syndrome (Rabinowitz 2018, PMID 30059403; Mamalis 2006, PMID 16565012). TASS begins 12–48 hours after surgery, is limited to the anterior segment, is always Gram-stain and culture negative, and usually improves with steroid; its differential diagnosis is infectious endophthalmitis, and an outbreak is an environmental and toxic-control investigation covering all intraocular solutions, viscoelastics, detergents, sterilisation protocols and IOL residues (PMID 16565012). Multistate outbreak investigation illustrates the required response (Kutty 2008, PMID 18361979). See red flags and safety concerns.

Open questions

  • Does anaesthetic technique cause the complication difference, or does case-mix? The EUREQUO associations are large and consistent (PCR OR 0.53–0.80; endophthalmitis 0.60) (PMID 36449673) but observational; no randomised trial has been powered for PCR or endophthalmitis by anaesthetic technique, and the randomised literature measures only pain (PMID 26308931; PMID 40330003).
  • Can intraoperative pain be prevented without a block? The Cochrane authors specifically call for randomised trials of pain-prevention strategies during cataract surgery (PMID 26308931); the searches behind this page identified new topical agents (PMID 38489057) but no trial of a systematic pain-prevention protocol.
  • What is the true bilateral endophthalmitis risk with ISBCS? Zero events in 865 randomised patients (PMID 37201546) and <1/1,000 registry rates (PMID 41959995) leave the bilateral-event probability unbounded; a federated registry study is the design the field asks for (PMID 36206058).
  • How short can perioperative topical prophylaxis be? One week of antibiotic and steroid appears sufficient in one international study (PMID 33081522), and adding topical antibiotic to intracameral prophylaxis changed endophthalmitis rates from 0.017% to 0.016% (PMID 33120637); no randomised non-inferiority trial of a drop-free regimen with endophthalmitis and inflammation endpoints was identified in this session's searches.
  • Should day-1 review be abandoned? Peak IOP occurs 3–4 hours postoperatively, which undermines the rationale for day-1 detection of spikes (PMID 30489361). A 291-patient randomised trial after uneventful phacoemulsification found similar complication rates with next-day review and no next-day review (5.5% vs 6.2%, p = 0.791), with no difference in unscheduled consultation, inflammation or day-28 acuity (Chatziralli 2012, PMID 22738668); it was far too small to exclude a difference in rare sight-threatening harm.

References

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