Gombos_subbed_Layout 1 01/09/2009 15:52 Page 44
The psychologist observed that during the procedure the surgeon and the anaesthesiologist to maintain the patient in an
psychological state of the patients became almost hypnotic as a adequate surgical state right through to the end of the procedure.
result of the surgical drapes (which blocked environmental stimuli),
the light from the microscope and the monotonous sounds of the Conclusion
instruments. This is confirmed by data in the literature on operations To summarise data from the literature and our experience, today
performed without anaesthesia.
The psychologist used specific RBA has a reduced role in cataract surgery by phacoemulsification.
verbal suggestion techniques with the more susceptible patients; RBA is still appropriate if the surgeon is less experienced or if
this worked well in terms of reducing their fear and improving patient akinaesia is necessary. RBA should also be considered if the patient
satisfaction. She has since developed a protocol for giving positive insists on anaesthesia by needle, although other possibilities to
verbal suggestions that is easy for doctors and staff to learn.
relieve their anxiety include more specific verbal communication
with the help of a psychologist or general anaesthesia.
Who Is More Susceptible to Pain and Discomfort?
Patients can be divided into two groups: It is questionable whether TA can prevent all autonomous and
somatic reflexes in the eye during the procedure. We found that in
those who do not want to know a lot about the procedure and cases where the patient experienced no pain, the objective measured
are content to leave everything to the doctor’s ability; and parameters changed significantly in TA compared with RBA.
those who want to know everything about the procedure – they
tend to have read a lot on the Internet or in medical books, they Finally, we would like to draw attention to the roles of pre-operative
worry more and need comprehensive information before, during psychological selection, positive suggestive verbal communication
and after the procedure. around the surgery and patient motivation. In order to prevent
unexpected surgical situations, it is better to offer patients the
Based on the literature and our studies, younger people are more most appropriate method of anaesthesia rather than using a ‘one
likely to fall into the latter group.
size fits all’ solution. n
Our efforts to find psychological tests that would predict the
Katalin Gombos is an Assistant Professor in the
suitability of patients for TA were not successful. In clinical practice
Department of Ophthalmology at Semmelweis University
we estimated this from pre-operative discussion and from in Budapest, where she has worked since 1988. She is a
co-operation with patients during ophthalmic examination and the
specialist in ophthalmology and anaesthesiology, and
holds a PhD in ophthalmic local anaesthesiology. Dr
biometry of the artificial lens. If patients did not co-operate well
Gombos also works in a one-day-surgery clinic as an
(e.g. by blinking or moving their eyes) and were more worried about anterior segment surgeon. Her professional interests
the procedure, we tried to solve the problem with verbal
include the use of psychology in anaesthesia and the
connections between general health and the effects of
communication. If this was ineffective, we advised specific
ophthalmic surgery. She is a member of European Vision
psychological preparation. We tried to avoid using intravenous and Eye Research (EVER).
sedation and opioids, despite reports that these can reduce pain
János Németh is a Professor and Director of the
during the procedure, because of the related side effects (nausea
Department of Ophthalmology at Semmelweis
The other possibility is RBA, but this can reduce University in Budapest. He is Chairman of the Hungarian
patient fear only in specific cases. If patients refused this, we
Association for Research in Vision and Ophthalmology
and an active organiser of the Hungarian Vision 2020
offered general anaesthesia.
programme. His main interests are cornea, tear film,
anterior eye segment surgery and glaucoma.
Despite careful pre-operative selection and use of a positive verbal
communication suggestion, in some cases it was difficult for the
1. Atkinson WS, The development of ophthalmic 50,000 consecutive injections, J Cataract Refract Surg, technique in topical anaestesia, Acta Ophthalmologica
anaesthesia, Am J Ophthalmol, 1961;51:1–14. 1999;25:1237–44. Scandinavica, 2007;85:s240.
2. Vörösmarthy D, Oculopressor, an instrument for the 9. El-Hindy N, Johnston RL, Jaycock P, et al.; and the UK EPR 16. Trantos PG, Wickremasinghe SS, Sinclair N, et al., Visual
production of intraocular hypotension, Klin Monatsbl user group, The Cataract National Dataset Electronic perception during phaco-emulsification cataract surgery
Augenheilkd, 1967;151(3):376–82. Multi-centre Audit of 55 567 operations: anaesthetic under topical and regional anaesthesia, Acta Ophthalmol
3. Johnson RW, Anatomy for ophthalmic anaesthesia, techniques and complications, Eye, 2009;23(1):50–55. Scand, 2003;81:118–22.
Br J Anaesth, 1995;75:80–87. 10. Eke T, Thompson JR, Serious complications of local 17. Millodot M, A review of research on the sensitivity of the
4. Kershner RM, Topical anaesthesia for small incision self- anaesthesia for cataract surgery: a 1 year national cornea, Ophthalmic Physiol Opt, 1984;4:305–18.
sealing cataract surgery. A prospective evaluation of the survey in the United Kingdom, Br J Ophthalmol, 2007;91: 18. Pandey SK, Werner L, Apple DJ, et al., No-anaesthesia
first 100 patients, J Cataract Refract Surg, 1993;19:290–92. 470–75. clear corneal phacoemulsification versus topical and
5. AHRQ, Evidence report, Anaesthesia Management During 11. Kumar MC, Dodds C, Ophthalmic reginal block, Ann Acad topical plus intracameral anaesthesia. Randomized
Cataract Surgery, Publication Number ÖÖ-E015, Med Singapore, 2006;35:158–68. clinical trial, J Cataract Refract Surg, 2001;27:1643–50.
Technology Assessment: Number 16, 2000. 12. Gombos K, Jakubovits E, Kolos A, et al., Cataract surgery 19. Jakubovits E, The clinical use of hypnosis in anaesthesia.
6. Friedman DS, Bass EB, Lubomski LH, et al., Synthesis anaesthesia: is topical anaesthesia really better than In: Vértes G (ed.), Hypnosis and Hypnotherapy, Hungary:
of the literature on the effectiveness of regional retrobulbar?, Acta Ophthalmol Scand, 2007;85:309–16. Medicina, 2006;123–43.
anaesthesia for cataract surgery, Ophthalmology, 13. Boezaart A, Berry R, Nell M, Topical anaesthesia versus 20. Morsman CD, Holden R, The effects of adrenaline,
2001;108:519–29. retrobulbar block for cataract surgery: the patients’ hyaluronidase and age on peribulbar anaesthesia,
7. Daniel DG, Nambiar A, Allan BD, Supplementary perspective, J Clin Anesth, 2000;12:58–60. Eye, 1992;6:290–92.
intracameral lidocaine for phacoemulsification under 14. Cagini C, De Carolis A, Fiore T, et al., Limbal anaesthesia 21. Katz J, Feldman MA, Bass EB, et al.; Study of Medical
topical anesthesia: a meta-analysis of randomized versus topical anaesthesia for clear corneal Testing for Cataract Surgery Study Team, Adverse
controlled trials, Ophthalmology, 2008;115:455–487. phacoemulsification, Acta Ophthalmol Scand, 2006;84:105–9. intraoperative medical events and their association with
8. Edge R, Navon S, Scleral perforation during retrobulbar 15. Kalman R, Gombos K, Nagy ZZS, Pain in the different anaesthesia management strategies in cataract surgery,
and peribulbar anaesthesia: risk factors and outcome in stages of cataract surgery by phacoemulsification Ophthalmology, 2001;108:1721–6.
44 EUROPEAN OPHTHALMIC REVIEW