Intraoperative, postoperative pain perception significantly higher with topical anesthesia

This meta-analysis compared clinical outcomes and pain levels for phacoemulsification procedures during which topical anesthesia (TA) or regional anesthesia, including retrobulbar anesthesia (RBA) and peribulbar anesthesia (PBA), were used. The authors found that while TA does not provide the same high level of pain relief during cataract surgery as RBA/PBA, surgical outcomes were similar and, despite the pain, patients had a significantly greater preference for TA over RBA/PBA. The results also indicate that use of TA reduces injection-related complications and alleviates patients' fear of injection.

A lot of discussion will be generated by this article, and sound bites won't give the right message. The authors excluded articles on topical with intracameral anesthesia, and they don't think that systemic sedation needs to be taken into account. I think this is wrong.

The authors performed a literature search for randomized controlled trials of phacoemulsification under TA or RBA/PBA. They included 15 studies reporting on 1,084 TA eyes and 1,121 RBA/PBA eyes.

Intraoperative and postoperative pain perception was significantly higher in the TA group (P < 0.05), with these patients showing more frequent inadvertent ocular movement (P < 0.05) and a greater intraoperative need for supplementary anesthesia (P = 0.03).

There was no statistically significant difference between the two groups in surgeon-assessed intraoperative difficulties (P > 0.05). The RBA/PBA group had more frequent anesthesia-related complications, such as chemosis, periorbital hematoma and subconjunctival hemorrhage (P < 0.05), but surgery-related complications were similar (P > 0.05).

The authors conclude that while TA does not provide pain relief as effectively as RBA/PBA during cataract surgery, its anesthetic effect is reasonably well-tolerated. However, they say that TA is not suitable for patients with a higher initial blood pressure or greater pain perception. They advise that there is not one type of anesthesia that is right for all potential cases, with the best choice varying from patient to patient and from surgeon to surgeon on the basis of experience and predilection.