Table 1 Summary of literature review of anesthesia modalities and pain during cataract surgery
Study reference | Study design | Cases (n) | Methods | Anesthesia modalities compared | Key findings | Other conclusions |
|---|---|---|---|---|---|---|
Jacobi PC, et al. (2000) [14] | RCT | 476 | 2 institutions, risk factors for complicated cases inclusion criteria: exfoliation syndrome, uveitis, posterior synechia, phacodonsesis, previous intraocular surgery | RBB (238) vs. topical (238) | - Intraoperative patient report of pain similar between the two - Higher patient preference for topical (p = 0.01) | - Vitreous loss lower in topical group (p < 0.05) - Intraoperative difficulty lower in RBB (measured by surgeons) (p < 0.01) |
Gombos K, et al. (2007) [9] | RCT | 115 | June- Sept 2004. Exclusion criteria: other eye disease, previous surgery on same eye, increased risk of complication, poor pupil dilation | RBB (57) vs. topical (58) | - RBB provides better pain control (p < 0.01) - Systolic BP lower in RBB (p < 0.05) - Pain sensitivity higher in younger patients and patients with higher initial cortisol and noradrenaline serum levels | - RBB and topical both appropriate - Caution with topical with susceptible groups - Patients remembered pain more than actually indicated intraoperatively in both methods - SBP and DBP increased in the topical group and decreased in the RBB group (p < 0.05) |
Patel B, et al. (1996) [18] | RCT | 138 | Assigned to groups by permuted block restricted randomization; no exclusion criteria | RBB (69) vs. topical (69) | - More discomfort during administration of topical anesthesia and postoperatively with topical (p < 0.05) | - No difference in pain - No difference in surgical conditions - Chemosis, subconjunctival hemorrhage, eyelid hemorrhage, retrobulbar hemorrhage only in RBB - Eyeball movement, squeezing of eyelids more common in topical; neither posed a problem to the surgeon |
Patel B, et al. (1998) [10] | RCT | 99 | Prospectively assigned by permutated block restricted randomization; no exclusion criteria | RBB (45) vs. topical (45) | - Intraoperative operative conditions better in RBB (p < 0.05) - Better pain control with RBB (p < 0.05) | - No difference in postoperative discomfort - More pain in all cases after 20 min |
Fazel M, et al. (2008) [16] | RCT | 564 | Consecutive adult patients presenting to Matini Hospital of Kashan University of Medical Sciences from Feb. 2007- March 2008 assigned via computer-generated number table; exclusion criteria: any other ocular pathology, anxiety history, difficulty laying flat, hearing impairment, cough | RBB (235) vs. topical (238) | No difference in pain between the two modalities | - No difference in blood pressures or heart rates - No differences between phaco time, age, sex, and postoperative visual acuity |
Zhao LQ, et al. (2012) [11] | Meta-analysis | 2205 patients from 15 RCTs | Cochrane Library, PubMed, EMBASE databases until 2010; no exclusion criteria | RBB/PBB (1121) vs. topical (1084) | - RBB/PBB provided better pain control (p < 0.05) | - Topical had more frequent inadvertent eye movements and more need for supplemental anesthesia (p < 0.05) - No difference between intraoperative difficulties - Patients significantly preferred topical (p < 0.00001) - RBB/PBB had more anesthesia related complications (chemosis, periorbital hematoma, subconjunctival hemorrhage p < 0.05) - No difference in surgery-related complications |
Kallio H, et al. (2001) [17] | RCT | 317 eyes of 291 patients | Adult patients consecutively scheduled for cataract extraction from Aug 1998- Aug 1999 by 1 surgeon at the Helsinski Eye Hospital; randomized by the envelope method; no exclusion criteria | RBB/PBB (114) vs. topical (96) vs. combined (topical and propofol) (107) | - No difference in intraoperative pain, frequency of complications, or outcome measures - Fewer intraoperative difficulties in RBB/PBB vs. topical and vs. combined (p < 0.05) | - IV propofol added to topical did not improve operative conditions - Additional sedation was required more frequently in topical than RBB/PBB (p < 0.05) - Patients having bilateral surgery preferred combined over RBB (p < 0.050 |
Boezaart A et al. (2000) [8] | Randomized cross-over observational study | 98 ASA I and II patients for bilateral surgery 1 week apart | Private clinic – patients randomized to receive topical one eye and PRBB in the other eye or vice versa | RBB + TA vs. TA + RBB | - RBB provided better pain control (p < 0.05) - Patients preferred RBB over topical - Most patients (98%) were not aware of RBB being injected | - Duration of surgery was similar (p = 0.06) - Intraoperative difficulty higher for topical (p < 0.050 - Surgical and anesthetic complications unremarkable for both |
Nwosu S, et al. (2011) [7] | RCT | 90 | Consecutive adult patients presenting to Guiness Eye Center in Onitsha, Nigeria between March –June 2008, randomized by simple random sampling | RBB (35) vs. subconjunctival (55) | - RBB worse pain control (p > 0.05) - Difference in movement of the eyeball was more in subconjunctival group (p > 0.05) - Post-operative ptosis slightly more in RBB | -Subconjunctival technique needed less anesthetic volume and no need for ocular massage - More chemosis and subconjunctival hemorrhage with subconjunctival - Higher pain in RBB may be due to longer time of onset of action |
Alhassan M, et al. (2008) [19] | Meta-analysis | 1438 participants from 6 trials | Cochrane Library 2010, MEDLINE 1960-2010, and EMBASE search 1980-2010 | RBB vs. PBB | - No difference in pain between the two modalities | - No difference of akinesia or need for further injections of local anesthetic - Chemosis more common after PBB - Lid hematoma more common after RBB - Retrobulbar hemorrhage occurred once after RBB |
Davison M, et al. (2007) [12] | Meta-analysis | 617 patients, 742 eyes from 7 RCTs | Cochrane Library 2006, MEDLINE 1990-2006, and EMBASE search 1990-2006 | Sub-Tenon’s vs. topical | - Sub-Tenon’s provides better pain relief (p < 0.05) | - Results were statically significant but not necessarily clinically significant - pain scores skewed to lower end - Sub-Tenon’s caused more chemosis and sub-conjunctival hemorrhage - Posterior capsule tear and vitreous loss occurred more often in topical than sub-Tenon (not significant) |
Briggs MC, et al. (1997) [13] | Retrospective | 129 | Two 4 week period audits in which every patient undergoing cataract surgery with one of these two methods was included (chosen by surgeon) at Royal Alexandra Hospital in Paisely, UK | Sub-Tenon’s (74) vs. PBB (55) | - Less pain in administration of Sub-Tenon’s - Fewer patients experienced scores of >3/10 in sub-Tenon’s (p < 0.05) | - Sub-Tenon’s provides better pain relief peri-operatively (p > 0.05) than PBB |