Ever notice how the continuing education rooms at our major conferences are packed for lectures on new technologies and techniques? It makes us wonder how much attention our colleagues have been paying to other aspects of surgical management.

In this series of articles, we’d like to discuss the therapeutic side of surgery — that is, factors that drive your treatment decisions. Technology and technique may be more glamorous than drug therapy. But your pharmacological approach can do just as much as technology and technique for improving patient satisfaction and building your practice.

We’ll start by focusing on how to minimize patient discomfort with intracameral lidocaine. Also, we’ll discuss how to use this approach to pain control to make the transition to the clear cornea procedure.

Most of us used to primarily focus on helping our patients achieve 20/20 vision, free of complications, after cataract surgery. But the changing expectations of today’s patients have broadened our focus. More surgeons are advertising "no stitch, no patch, no shot" procedures, effectively making them standard treatments.

As result, more patients come to the office assuming that you’ll operate on them in the most comfortable and efficient manner possible. If you don’t provide this approach in your practice, chances are that patients will open their insurance booklets, let their fingers do the walking and find a doctor who does provide it. If you do offer this approach, then you’d better be good at it, knowing which medications will ensure your success.

Most of these patients couldn’t care less about your phaco time, or which technique you use — whether it’s stop and chop or chop and flip, or whatever. How the procedure affects them will count more than any other factor.

The trend toward meeting the expectations of these patients is why more of us are performing topical anesthesia with intracameral lidocaine. Among surgeons who perform 51 or more cataract surgeries per month, an estimated 63% were using topical anesthesia in 1998 — a jump from 52% in 1997. And more than three quarters of these surgeons chose to use intracameral lidocaine.* Let’s look at how to get started with this approach.

To begin cataract surgery, we wheel the patient into the operating room (OR) on a Striker bed that gives us access to the foot pedals. (Several Striker beds are advised, so you don’t have to keep switching patients.)

We administer a drop of non-preserved tetracaine, which eliminates the discomfort of intracameral lidocaine without raising the risk of corneal toxicity. After that, we prep the patient with povidone-iodine (Betadine 5%) solution. A 5% solution is still concentrated enough to maintain stability throughout a morning of surgery. And it doesn’t sting nearly as much as a standard 10% solution.

Some surgeons even dilute down to 1% percent, a concentration that’s also practical for refractive surgery. (See "Prepping the LASIK Patient" above.) A 1% solution will be effective, as long as you use it that morning. (Of course, you would still paint the skin with 10% povidone-iodine.)

To make your solution, take bupivacaine (Marcaine), at .75% (one bottle spread over several surgeries if you want to save on costs), and dilute it 50/50 with your povidone-iodine supply. Besides reaching the 5% solution, this approach provides a more lasting anesthetic effect because of bupivacaine’s longer duration of action.

You don’t want to just apply the solution with one hand and then squirt it out with the other hand right away. To ensure contact time, maximizing kill rate, leave it in the cul-de-sac and on the lids while you’re painting the skin.

One study a few years back even showed that using pre-operative povidone-iodine 10% — with adequate contact time — was the number-one precaution you could take to prevent endophthalmitis.

When you’re finished with the prep, go ahead and put the drapes on, insert a wire speculum into the cul-de-sac and make your paracentesis at 2 o’clock. Then inject about .5 cc of 1% non-preserved lidocaine into the anterior chamber, intracamerally, and squirt .3 cc to .5 cc of the non-preserved lidocaine onto the eye and around the cul-de-sac. That’s all it takes.

A recent study in the Journal of Cataract and Refractive Surgery (Coriro et al, JCRS 1998) compared intracameral lidocaine with the use of topical anesthesia alone. The result? Intracameral lidocaine appeared to help with both patient and surgeon comfort.

The alternative to intracameral lidocaine, if you’re inclined to use it, is topical Xylocaine jelly. Using the jelly with a pledget can help in cases when you have to cut through the patient’s conjunctiva or insert the intraocular lens (IOL) through the sclera.

Either way, using lidocaine lets you avoid sedation in more than 99% of cases. You will get better cooperation because the patient is lucid and alert.

You don’t have to be the fastest cataract surgeon to succeed with this approach, which will work as effectively for a 5-minute procedure as it does for a 15 or 16 minute procedure.

Also, as you know, intracameral lidocaine makes some surgeons uneasy because of possible safety issues. But several studies in recent years have demonstrated that it creates no problems with endothelial toxicity.

Another concern is the possibility of retinal toxicity. We’re certainly not advocating this approach when you anticipate a need to do a vitrectomy going into the surgery. But in most cases, it seems to be a safe choice. Anecdotal reports suggest it’s not a problem for unanticipated vitrectomies, such as after a capsule break.

You’ll see delayed visual performance recovery in patients who need further supplementation of lidocaine toward the end of a case, or when you break a capsule and do a vitrectomy. But visual rehabilitation typically appears to be as swift as it would be after you use only a topical agent.

Some surgeons have succeeded using only topical anesthesia. But it’s important to remember that topical alone won’t hold all patients. We’re much more comfortable when using intracameral lidocaine. If you’re just starting to use intracameral lidocaine, try injecting it slowly, until you get a feel for it. Otherwise, you could create some discomfort by bouncing the ciliary body and the iris plane back and forth too much.

You can tell the patient, "I’m going to put a little anesthetic in your eye. This is the only time when it might sting just a slight amount. Then you’ll be fine."

Talking to your patients during the whole procedure is important. The personal contact lets them know how you’re doing and reassures them.

Besides increasing efficiency and patient comfort, intracameral lidocaine works very well if or when you decide to switch your surgical approach to the increasingly popular clear cornea procedure.

The use of this procedure has increased from 1.5% of all cataract procedures in 1992 to 36% in 1998.* A total of 47% of high volume surgeons (more than 25 cases a month) prefer clear cornea. We believe it’s only a matter of time before the percentages climb to the 80s and 90s. Below are some of the advantages that have convinced us to go with clear cornea over scleral tunneling:

• better visualization
• no need to cauterize the sclera
• no problems with the sclera groove, whether it’s bleeding inside of the eye or leakage
• rare iris prolapse
• consistent incision location.

Making the transition to clear cornea requires the commitment of the whole team. It’s an altogether different type of surgery. You’ll be operating at the side of the Striker bed, an important consideration because it lets you get your legs underneath and still operate the foot pedals.

When you’re operating on the right side of the bed, using the phaco pedal with your right foot is fairly easy. But on the left side of the bed, operating the microscope with your left foot may be a challenge at first. One suggestion is to make sure the bed is high enough so that your arms remain parallel to the bed and so that you have enough room for your left leg to operate the microscope.

These challenges of the new procedure can raise your anxiety, so proceed methodically. Also, your patient’s eyes are moving, which can throw you off a bit during the first 20 to 30 cases. You might want to sedate the initial patients a little until you get used to this procedure.

Another good idea, while you’re still getting used to the procedure, is to choose patients who are calm and cooperative. Choose these patients carefully, looking the ones who have the right disposition.

Indirect ophthalmoscopy provides an effective way of identifying good candidates. If a patient holds up well during this preoperative exam, he or she will generally do well with topical clear cornea. But in the beginning, rule out the procedure for the patient who squirms and can’t stare straight ahead, even with the power turned low on the indirect.

Once you adapt, you can do virtually every surgery with topical anesthesia and lidocaine supplementation. We probably only need to put two to three patients asleep each year — only in cases of severe patient anxiety or when there is a behavioral deficit.

When making the transition to clear cornea, you may want to do 20 or 30 clear cases with your traditional block — such as retrobulbar or peribulbar — until you feel comfortable using the new hand position, working around the table and working with technicians from a different location.

As we mentioned earlier, taking these steps to increase efficiency and patient comfort are well worth the temporary difficulty of the transition. As more patients come to expect this kind of treatment, you’ll find more reasons to change with the times.

If I’m performing laser-assisted in situ keratomileusis (LASIK), I’ll actually have povidone-iodine mixed to 1%, diluted by a ratio of 1 to 10 in sterile water. I’ll prep the skin around the face with 10% skin pledgets. Then I’ll roll the lid back, scrub the lid margin, paint the lid margin and squirt the 1% povidone-iodine into the cul-de-sac. Many surgeons believe this decreases the number of bacteria on the lid margins and also on the skin. Research has shown that it helps significantly in sterilizing the cul-de-sac.

-Robert Snyder, M.D.

Besides routine cataract surgery, you can use topical and intracameral lidocaine for lensectomies and intraocular lens (IOL) exchanges (even when a fair amount of iris manipulation is involved). Certainly, you can use it for all the forms of refractive surgery — radial keratotomy, AK, photorefractive keratectomy and laser-assisted in situ keratomileusis (LASIK), as well as for filtering surgery on glaucoma patients.

Recently, I even saw a presentation by doctors doing cornea transplantation with topical plus intracameral lidocaine, including a triple procedure. So it’s fairly effective at controlling pain. The only limitation is time. You need to complete the procedures within 20 minutes, after which the effects of the lidocaine wear out.

-Robert Snyder, M.D.

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