Is second eye phacoemulsification really more painful?

Comparison of pain between bilateral ICL surgeries in patients with myopia

PURPOSE

The purpose of this study was to compare the preoperative anxiety, aqueous humor monocyte chemoattractant protein-1 (MCP-1) concentration, intraoperative pain, and degree of cooperation of the first eye implantable collamer lens (ICL) surgery with the second eye surgery, of the 1-day interval group with the 1-week interval group, and to investigate the possible causes of these differences, as well as to determine the appropriate interval between bilateral eye ICL surgeries.

METHOD

The study was a prospective observational study. A total of 120 patients who underwent bilateral ICL surgery at the Department of Ophthalmology, West China Fourth Hospital, Sichuan University, from July to September 2023, were enrolled. The patients were divided into a 1-day interval group and a 1-week interval group. The ICL surgery was performed on both eyes according to the schedule. Anxiety levels, aqueous humor MCP1, cooperativeness, surgical time, pain and satisfaction, and patients' estimations of the time spent in the operation were recorded for each eye. The patients were instructed to recall the intraoperative pain of the first eye surgery after the operation of the second eye. Statistical analyses (two independent samples t-test,two paired samples t-test, the rank-sum test, the chi-square test, non-parametric test with multiple independent samples) were performed to compare the differences between each score in both eyes and two groups. Furthermore, we examined the relationship between pain levels and the reproductive history of the patients.

RESULTS

In the 1-day interval group, male/female is 22/52, average age is 25.24±5.00. In the 1-week interval group, male/female is 17/29, average age is 25.39±5.57. There was no statistically significant difference between the two groups. In both groups, patients were less nervous, had significantly more pain, had less surgical satisfaction, had a longer estimated operative time, and had elevated preoperative MCP1 during the second eye operation. In the second eye surgery, the patient's cooperation worsened, but it did not lead to an increase in surgical time. A significant proportion of patients, particularly in the 1-week interval group, recalled experiencing reduced pain during the first eye surgery. The 1-week interval group had a higher difference in all indicators between the bilateral surgeries. In the second eye surgery, patients in the 1-week interval group experienced more severe pain, less cooperation, longer estimated operation duration, and a greater MCP1 than those in the 1-day interval group.

CONCLUSION

Patients undergoing second eye ICL surgery had decreased nervousness, increased pain, decreased cooperation, and satisfaction, and increased MCP1 compared to the first eye surgery. It is recommended that an interval of about one week should be avoided between bilateral surgeries when developing a surgical schedule to improve patients' cooperation, satisfaction, and comfort.

Correlation between Hyperalgesia and Upregulation of TNF-α and IL-1β in Aqueous Humor and Blood in Second Eye Phacoemulsification: Clinical and Experimental Investigation

The aim of this study was to explore the correlation between intraoperative hyperalgesia of the second eye and the dynamic changes of tumor necrosis factor (TNF)-α and interleukin (IL)-1β levels in aqueous humor (AH) of the second eye and whole blood after the first eye cataract surgery. A rabbit model of monocular phacoemulsification was established by administration of 0.3% levofloxacin. Whole blood and AH samples from non-surgical eyes in the experimental group (n =25) and second eye in the blank control group (n =15) were obtained and corneal sensitivity was examined after surgery (1, 3, 7, 14, and 21 days postoperatively). TNF-α and IL-1β levels in AH and TNF-α mRNA and IL-1β mRNA levels in whole blood were measured. In a clinical study, 30 patients who underwent bilateral phacoemulsification within 1 month were divided into six groups in accordance with the operation intervals (1, 3, 7, 10, 14, and 21days). TNF-α and IL-1β levels in AH were measured at the beginning of surgery and intraoperative pain was assessed immediately after surgery. Corneal sensitivity (F =244.910, P <0.05), TNF-α and IL-1β levels in AH (F =184.200, 82.900, P <0.05) of non-surgical eyes and in whole blood (F =272.800, 193.530, P <0.05) in the experimental group were significantly higher than the baseline levels after phacoemulsification. In the clinical study, NRS scores of second eye surgery were higher than those of the first eye(P =0.0025) and 19 (63.3%) patients reported more pain during the second eye surgery. TNF-α and IL-1β concentrations in AH of the second eye were significantly higher than those of the first eye (F =123.60, P <0.05; F =59.60, P <0.05). In conclusion, within 1 month after the first eye phacoemulsification, higher pain sensitivity (hyperalgesia) exists in the second eye, which may be related to dynamic changes in TNF-α, IL-1β levels in AH or whole blood.

Outcomes and Adverse Events of Sub-Tenon's Anesthesia with the Use of a Flexible Cannula in 35,850 Refractive Lens Exchange/Cataract Procedures

Purpose

To describe our technique of sub-Tenon’s anesthesia and report adverse events and patient comfort.

Setting

Optical Express, United Kingdom.

Design

Retrospective case series.

Methods

The outcomes of 35,850 intraocular procedures (phacoemulsification and implantation of an intraocular lens) were retrospectively reviewed and the incidence of adverse events related to sub-Tenon’s anesthesia was calculated. On the first postoperative day, patients were asked to complete a questionnaire enquiring about their comfort during and after the procedure. The anesthetic solution consisted of a combination of Lidocaine and Hyaluronidase, which was administered into sub-Tenon’s space with a single-use sterile polyurethane 22G x 1” (0.9 x 25 mm) cannula. Mild conscious sedation (midazolam) was used during anesthetic and surgical procedure.

Results

No significant adverse events that would affect the posterior segment of the eye or result in vision loss were recorded. Subconjunctival haemorrhage related to sub-Tenon’s anesthesia was noted in 4.3% of eyes. Five minutes after the administration of sub-Tenon’s block, 80.6% of eyes had no chemosis, 14.8% had chemosis that affected only 1 quadrant of the eye and 4.5% of eyes had chemosis affecting 2 or more quadrants of the eye. Other adverse events included 14 cases of cyst/granuloma formation in the area of sub-Tenon’s incision and 7 eyes required suturing of the conjunctival cut. Of all patients, 93.2% experienced no or only mild discomfort during or after surgical procedure.

Conclusion

Sub-Tenon’s anesthesia with the use of a flexible cannula is a safe option for ophthalmic anesthesia. No sight-threatening adverse events occurred.

Factors affecting pain in patients undergoing bilateral cataract surgery

PURPOSE

To compare the perceived pain and estimated operative duration among patients undergoing bilateral cataract surgery and to demonstrate correlations with the surgical interval and the demographic and medical characteristics of the patients.

METHODS

A total of 466 patients with cataract who underwent ocular surgery were included. The patients estimated the perceived operative duration and pain they felt during the operation at two times, immediately after surgery and on the first postoperative day; pain was scored using a visual analog scale ranging from 0 (no pain) to 10 (unbearable pain). Patients undergoing bilateral surgeries were divided into four subgroups based on the interval between the two operations (1, 2, 4, or 6 weeks). The perceived pain score and the estimated operative duration were the primary outcomes.

RESULTS

The pain scores were higher for the second surgery than for the first surgery both immediately after surgery (P = 0.043) and on the first postoperative day (P = 0.002). The estimated operative duration was longer for the second surgery (P = 0.001). Only patients who underwent the second surgery at an interval of 2 weeks perceived more pain both immediately and 1 day postoperatively (P = 0.002, P = 0.022) and a longer operative duration (P < 0.001). Gender, age, and education level might also influence the pain score.

CONCLUSIONS

Female patients, patients with a younger age, and patients with higher education level are likely to report more pain. Patients who require bilateral cataract surgery should not undergo the second surgery before an interval of 2 weeks.

Pain Perception of the First Eye versus the Second Eye during Phacoemulsification under Local Anesthesia for Patients Going through Cataract Surgery: A Systematic Review and Meta-Analysis

Background

Phacoemulsification under local anesthesia is regarded as the major surgery for cataract treatment. Recent research has compared the pain perception between the first eye and the second eye during phacoemulsification. However, these studies have also yielded controversial findings. Consequently, we performed a systematic review and a meta-analysis to investigate the difference in the pain perception between the first and second eyes during phacoemulsification.

Method

We searched the PubMed, EMBASE, and Cochrane CENTRAL databases for the studies published up to October 5, 2018. Prospective observational studies were included. The meta-analysis was conducted by means of random-effects model and fixed-effects model according to the heterogeneity. Evaluation of the methodological quality of studies was based on Newcastle-Ottawa Scale (NOS).

Results

Overall, eight studies were included in the meta-analysis. The analysis of pooled data showed that the pain scores of the first eye shortly after surgery under local anesthesia were significantly lower as compared to the second eye (WMD: 0.69; 95% CI: 0.40, 0.98; P < 0.00001). The average pain scores of the first eye shortly after surgery under the topical anesthesia were also lower than those of the second eye (WMD: 1.08; 95% CI: 0.79, 1.36; P < 0.00001). Conversely, anxiety scores in the first eye surgery were significantly higher than those in the second eye surgery (SMD: −0.40; 95% CI: −0.64, −0.16; P=0.001). However, the difference of the pain scores accessed on the first postoperative day between the first and second eye surgeries (WMD: −0.05; 95% CI −0.40, 0.31; P=0.79) as well as cooperation grades of patients between the first and second eye surgeries (WMD: 0.35; 95% CI −0.07, 0.76; P=0.10) was not statistically significant.

Conclusion

Patients experienced more pain in the surgery of the second eye than that of the first eye, which probably related to lower anxiety before the second surgery. It suggests that we should consider preoperative intervention to reduce the perceived pain during second eye cataract surgery.

Hypnosis intervention for the management of pain perception during cataract surgery

Objective

To investigate the effectiveness of hypnosis in pain management during cataract surgery.

Methods

Male or female patients with bilateral age-related cataract who wished to have both eyes subjected to phacoemulsification surgery were preliminarily admitted. Immediately after the first-eye surgery, each patient was evaluated for pain using the visual analog scale (VAS), and patients with a VAS score >1 were enrolled. By using block randomization, the enrolled patients were allocated to either the treatment group, which received a hypnosis intervention before the scheduled second-eye surgery, or the control group, which did not undergo hypnosis. The levels of anxiety, pain, and cooperation were evaluated independently by the patients and the surgeon.

Results

During the intraoperative pain assessment, 5%, 34%, 38%, and 23% of patients in the control group reported experiencing no pain, mild pain, moderate pain, and severe pain, respectively. In contrast, in the hypnosis group, 18%, 56%, 15%, and 11% of patients reported experiencing no pain, mild pain, moderate pain, and severe pain, respectively, which showed significant differences between the groups (P<0.005). The evaluation of anxiety level showed that the mean score in the control group and hypnosis group was 11.77±0.32 and 6.64±0.21, respectively, revealing a highly significant difference between the two groups (P<0.005). The assessment of patient cooperation showed that only 5% and 18% of patients in the control group and 18% and 36% of patients in the hypnosis group showed excellent and good cooperation, respectively, while 47% of patients in the control group and only 24% of patients in the hypnosis group exhibited poor cooperation, revealing significant differences between the groups (P<0.005).

Conclusion

Hypnosis may be considered as an auxiliary measure in cataract surgery, especially for patients who experienced obvious pain during the first-eye surgery.

[Prevalence and causes of pain after cataract surgery: Comparison of 1st and 2nd eyes]

INTRODUCTION

In our practice, patients undergoing bilateral cataract surgery complain of more significant pain after the 2nd eye surgery. The goal of this study was to compare postoperative pain between the 1st and 2nd eyes with cataract surgery under topical anesthesia and to identify the causes of this pain.

PATIENTS AND METHODS

We conducted a prospective observational study between May and September 2015. We included 69 consecutive adults scheduled for bilateral cataract surgery under topical anesthesia within 2 months by the same surgeon. A self-assessment questionnaire of anxiety (the Amsterdam Preoperative Anxiety and Information Scale [APAIS]) was completed before each procedure. Postoperative pain was assessed by the visual analogue scale (VAS) in the recovery room.

RESULTS

Among the 69 included patients (mean age: 70±1.3 years), 13 (19%) experienced more pain after the 2nd eye procedure. The median VAS was 0 (EI: 0-1) after the first eye versus 0 (EI: 0-2) after the second eye (P=0.836). The patients with the most pain after the second eye surgery had a median anxiety score of 5 (EI: 4 to 9.5), which was comparable to those without pain (P=0.589). On bivariate analysis, women had more pain after second eye surgery (27%) than men (4%) (P=0.026). However, this association lost its significance when the analysis was adjusted for the level of anxiety (adjusted OR 7.7, 95% CI [0.91; 64.6]). In fact, women were more anxious [median anxiety score of 6 (EI: 4 to 8.5)] before 2nd eye surgery than men [median score: 4 (EI: 4-6); P=0.013].

DISCUSSION

Pain levels appeared to be very moderate on both sides when measured postoperatively, as opposed to statements often made in the immediate postoperative period. There is a discrepancy with the literature data. However, each study had small sample sizes.

CONCLUSION

We did not find any significant difference in pain between 1st and 2nd eye cataract surgery under topical local anesthesia. While postoperative pain appeared greater among women, we have noted the possible influence of anxiety, which could justify specific preoperative support.

Comparison between Subjective Sensations during First and Second Phacoemulsification Eye Surgeries in Patients with Bilateral Cataract

Purpose. To evaluate and compare the subjective sensations reported by patients during first and second cataract extractions. Methods. Consecutive patients undergoing bilateral sequential cataract extraction using phacoemulsification were recruited. Following cataract surgery, patients completed questionnaires designed to evaluate subjective sensations, including anxiety, eye bulges, pain, and light sensitivity. Changes in painful sensations experienced by patients between the two surgeries were also recorded. Comparisons were also performed for each subjective sensation between different age groups (<50, 50-59, 60-69, 70-79, and >79 years). Results. A total of 127 patients were included in the final evaluation. Statistical comparison of the results showed that there were significant differences in perception of anxiety, eye bulges, and pain scores between the first and second cataract surgeries (P < 0.05). However, there was no statistically significant difference for light sensitivity scores between the two surgeries (P = 0.555). The differences in anxiety, perception of eye bulges, pain, and light sensitivity scores between both the surgeries showed no correlation with age (P > 0.05 for all). Conclusions. Our research confirms the common observation that patients with bilateral cataracts often report more ocular discomfort during the second surgery. There are, therefore, additional factors that should be considered upon treating patients with bilateral cataracts, and the provision of preoperative counseling could play an important role in providing adequate patient care.

Documenting the subjective patient experience of first versus second cataract surgery

PURPOSE

To examine the subjective patient experience after cataract surgery.

SETTING

Single multisurgeon cataract facility.

DESIGN

Prospective intraindividual observational study.

METHODS

Patients completed a questionnaire immediately after cataract extraction performed in their second eye. All patients had second-eye surgery within 6 months of first-eye surgery. Cases longer than 30 minutes were excluded.

RESULTS

Of the 292 patients who completed the questionnaire, 12 were excluded based on surgical time. The response rate varied per question. The surgery was rated as taking longer or being more painful in the second eye by 127 patients (45.4%) and in the first eye by 38 patients (13.5%) (P < .05); 115 patients (41.1%) reported no difference. Patients (47.83%) who rated the second eye as the generally more negative experience thought their vision would be better and 3.48% worse (P < .05); 48.70% thought it would be the same. No difference was noted in length of surgery (P = .3) or sedation used (P = .96).

CONCLUSIONS

Of 125 patients who rated second-eye surgery as the generally more unpleasant procedure, 90 (72.0%) were similarly or more relaxed during the second procedure. Second-eye cataract surgery was perceived as being a longer and/or more painful procedure by a significant number of patients (45.4%), and only 3.48% thought that vision in the second eye would be worse. These results can help surgeons when counseling patients regarding expectations for second surgery.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.