Anesthesiology in a Changing Cataract Landscape

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Innovations in phacoemulsification, IOLs, and other aspects of cataract surgery have resulted in safer and less invasive procedures that no longer require a hospital setting, in many cases, said Inder Paul Singh, MD, of The Eye Centers of Racine & Kenosha, in Keno­sha, Wisconsin. These advancements have also reduced surgical time and the need for ocular akinesia. As a result, ophthalmologists have been exploring alternative approaches to standard anesthesia and sedation methods.

Shifting Surgical Theaters

The use of anesthesia during cataract surgery made national headlines in 2018 when Anthem BlueCross Blue­Shield (BCBS) proposed new clinical guidelines stating that the administra­tion of monitored anesthesia care by a dedicated anesthesiologist or nurse anesthetist was not medically necessary for routine cataract procedures given the overall safety profile. (Based on pressure from the Academy and other parties, it subsequently rescinded the proposed guidelines.)

Although the proposal drew strong objections from the Academy and the American Society of Anesthesiologists, and even an author of a study cited by BCBS in its proposed guidelines,¹ it raised a question for ophthalmologists: what exactly is the role of the anesthe­siology team in light of innovations in office-based cataract surgery?

Office-based surgery. The evolution of anesthesia for cataract surgery is closely tied to changing surgical settings, Dr. Singh said. Because of refinements to cataract surgery, there has been a interest in office-based surgery, he said. “There’s such an emphasis on cost sav­ings in medicine right now. These in-office suites can really help us further streamline our workflow by forgoing intraoperative anesthesia monitoring if it is unnecessary.”

Class A and Class B facilities. In-office surgery suites are categorized into two classes, Dr. Singh explained. Class A facilities are accredited for oral and topical anesthetics and do not require a dedicated anesthetist, while a Class B designation allows for monitored oral and higher-level intravenous (IV) sedation—but not general anesthesia—under the supervision of a licensed anesthesiology care team.

Dr. Singh operates a class A in-office surgery suite, in addition to providing services at ambulatory surgery centers (ASCs) and hospitals, all of which have different accreditation standards. In the office-based suite, “We have a crash cart and we monitor vitals, but there’s no IV access,” he said.

ASC and hospital. Office-based cataract surgery is most appropriate for healthy patients or those with only mild systemic disease, said Steven Gayer, MD, at the Bascom Palmer Eye Institute in Miami. More complex cases with other comorbidities as well as anxious patients who may not be able to cope with strictly oral sedation may be best suited for care at an ASC or hospital setting, he said.

Dr. Singh agreed, saying that when a case is complex, or if the patient has health issues or comorbidities, he may want more monitoring and the option of using anesthesia. In these instances, he sends patients to his ASC or the hos­pital, which have the infrastructure of the anesthesiologist with IV. “No doubt, ASCs and hospitals are important and offer a higher level of ability to perform certain type of surgeries.”

In-office advantages. Still, Dr. Singh said, the in-office surgery suite “has been great for the more than 90% of my patients who are otherwise healthy.” And a recent adverse event study backs this up.² In part, he said, this is because the office setting—similar to an ASC—reduces patient anxiety from the start, which leads to less need for sedation. His patients also don’t have the stress of undergoing surgery in a hospital or ASC setting: they don’t have to refrain from eating or drinking prior to their surgery, nor do they have to go through the preadmission process, change into a gown, or prepare for an IV.

CATARACT SURGERY. The anesthesia team at the Bascom Palmer Eye Institute as they prepare for a routine cataract surgery.

IV or Oral Sedation?

IV. Many surgeons opt to use IV sedation as insurance in case a medical emergency arises, and a dedicated anesthesiologist can provide a highly tailored experience for the patient, said Dr. Gayer. “We use short-acting agents at just the right moments,” he said. “We provide an antiemetic if it’s indicated or if we need to rescue the patient should they become nauseated. Our sedation is targeted. It’s refined. It’s elegant.”

Oral. However, even in ASCs, a growing number of ophthalmologists are moving toward oral/sublingual sedation for routine cataract cases, said Kendall E. Donaldson, MD, MS, at the Bascom Palmer Eye Institute. And not having to place an IV is just one of the many reasons surgeons are making the switch.

“The question is how much sedation is truly necessary for a large part of what we do as anterior segment surgeons,” said Dr. Donaldson. “Are we overmed­icating a lot of patients unnecessarily? We’re starting to see significant advan­tages with oral sedation in terms of not only complications and cost savings, but also meeting the expectations of a demanding patient demographic.”

Complications. There is indeed a markedly low complication rate for cat­aract surgery in general, said Dr. Don­aldson. However, data suggest that risk of bradycardia, hypertensive episodes, postoperative drowsiness, and other adverse events are more associated with the use of IV versus oral sedation.³

Costs. Some estimates report signifi­cant cost savings when routine cataract surgery is performed with oral sedation and topical anesthesia versus IV seda­tion and block anesthesia.⁴

Patient satisfaction. Some patients are needle averse, said Dr. Donaldson, and may choose not to undergo cata­ract surgery because of an IV phobia or IV-associated challenges in their past. The IV also may give the impression that the surgery is a more complicated procedure or more cumbersome surgi­cal “experience,” she said.

Oral sedation, on the other hand, can offer these individuals the option to mitigate perioperative pain while maintaining a level of comfort similar to that achieved by IV sedation. In fact, recent studies have found similar levels of satisfaction with both IV and oral sedation among patients undergoing cataract surgery—the same was also true for the surgeons involved.^5,6

And this focus on patient experience is key in today’s health care environ­ment, said Dr. Singh. “Much of how we’re judged as eye care providers now depends not just on the final 20/20 outcome but also on the experience of surgery,” he said. “What was the flow like for the patient? How long did they have to wait? What do they remember from the procedure? Were they com­fortable?” Not only can the reduced use of anesthesia allow for more efficient and cost-effective surgeries, said Dr. Singh, but also it can provide a more positive patient experience.

Diazepam. For Dr. Singh, oral diazepam (Valium) is the ideal sedative for most of his routine cataract surgeries. “A majority of my patients don’t require any IV sedation,” he said, “and so whether it’s in the office or in the ASC, 5 to 10 mg of diazepam is enough to help a patient feel comfortable and yet stay cooperative. In my clinical experi­ence, this method of oral sedation has been the sweet spot.”

MKO Melt. Another IV alterna­tive is the MKO Melt (ImprimisRx), a sublingual troche consisting of 3 mg of midazolam, 25 mg of ketamine hydrochloride, and 2 mg of ondansetron. Although he does not often use this drug, Dr. Singh said studies show that its sedative effects are evident after two to three minutes and peak at about 15 minutes. Studies have shown that not only is MKO Melt as effective as IV sedation in providing a comfortable patient experience but also it can result in improved pre- and postoperative vi­tal signs compared with semiconscious sedation.^6,7

However, there are some drawbacks, said Dr. Gayer. “It’s kind of a shotgun approach because you’re giving a fixed dose of three different drugs that are not specifically tailored to the patient’s needs,” he said. “You’re also essentially giving the patient midazolam (Versed) orally, so you really need to make sure you have good, up-to-date monitoring of the patient’s vitals and be on the lookout for any disinhibition that can result in an uncooperative patient.”

Opioids. Oral sedation can be opi­oid-free, said Dr. Donaldson. “Medical care in general is trending away from opioid use due to societal concerns over addiction and abuse,” she said. “And we know that opioid administration during routine cataract surgery doesn’t need to be a common practice any longer.”

For example, intracameral phenyl­ephrine 1% and ketorolac 0.3% solution (Omidria) is now being used by many surgeons to decrease the inflammatory cascade during surgery and reduce post-operative ocular pain, said Dr. Singh. “The opioid epidemic is what made me look at this new agent, and I actually use it with all of my patients,” he said. “The company’s data clearly support less need for opioids during and after cataract surgery.”

This is not to say that opioids should be avoided at all costs, said Dr. Gayer. “There is an abuse issue in this country, but in the right hands, with the right drugs, in the right dosing, with the right timing, IV anesthesia can be a blessing for many of our patients,” he said. And many new ultra-short-acting agents on the market can ameliorate some concerns, said Dr. Gayer. For example, remimazolam (Byfavo), a benzodi­azepine, and remifentanil (Ultiva), a synthetic opioid, have effective utility for just over five minutes. And unlike ketamine, midazolam, or other narcot­ics, they both are metabolized in the bloodstream, independent of the liver and kidney, so they’re good alternatives for many elderly patients, he said.

Open Communication

In order for cataract surgeons in the ASC or a hospital setting to create the best experiences for all patients, whether their surgical cases are routine or complex, ophthalmologists and the anesthesiology team need to be on the same page and stay aware of the latest updates in their respective fields, said Dr. Donaldson.

An opportunity. Both sides may have different perspectives; however, that’s not a bad thing, said Dr. Singh. “We, as surgeons, can get caught up going through the motions of surgery for efficiency’s sake,” he said. “But we need to learn from one another. I might want to use oral sedation, but there could be rules and regulations that I’m unaware of that preclude its use in certain patients. So, it behooves us as practitioners to stop and discuss with our anesthesiologists the latest changes in our fields and the data on which we are basing our recommendations.”

Checklists. To help with any dis­connects, Dr. Gayer has been working with Dr. Donaldson and other cataract surgeons at the Bascom Palmer Eye Institute on a new formalized com­munication tool. Both ophthalmolo­gists and anesthesiologists now share templated checklists in the morning to keep track of important patient details for high-volume surgical days. “It’s been a great way to facilitate conver­sation,” said Dr. Gayer. “For example, what patients might benefit from a block instead of topical or intracam­eral anesthesia? Should it be short- or long-acting? We also get a heads-up on other important patient details, includ­ing the size and shape of the eye, any concerning medical issues, or a history of anxiety or severe nausea.”

In the end, everyone is on the same team with the patient at the center, said Dr. Singh. “Each anesthesiologist might have their own personal way of delivering sedation, just like each sur­geon might have a different technique,” he said. “But this isn’t a turf battle. It’s a matter of setting and establishing expectations together.”

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1 Rosenfeld SI. EyeNet. 2018;22(4):10.

2 Kugler LJ et al. J Cataract Refract Surg. Pub­lished online June 5, 2023.

3 Katz J et al. Ophthalmology. 2001;108(10):1721-1726.

4 Reeves SW et al. Am J Ophthalmol. 2001;132(4):528-536.

5 Peeler CE et al. Ophthalmology. 2019;126(9):1212-1218.

6 Smith JC et al. AANA J. 2020;88(6):429-435.

7 Dickson D et al. J Cataract Refract Surg. 2020;46(7):1037-1040.

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Dr. Donaldson is professor of clinical ophthal­mology and medical director at the Bascom Palmer Eye Institute in Miami. Relevant financial disclosures: Alcon C; Carl Zeiss Meditec: C; John­son and Johnson Vision: C; Omeros: C.

Dr. Gayer is professor of clinical anesthesiology at the Bascom Palmer Eye Institute in Miami. Relevant financial disclosures: None.

Dr. Singh is president of The Eye Centers of Racine & Kenosha in Kenosha, Wis. Relevant financial disclosures: None.

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