This column is one in an invited series by Dr. Osher. The series highlights techniques that may be helpful in particular to young practitioners.

It would be fair to say that I have had a rather turbulent relationship with my anesthesia colleagues for over 4 decades. In 1981, I finished my Heed Fellowship at Bascom Palmer and headed back to Cincinnati to join my father, Morris Osher, a wonderful ophthalmologist. Within the first year, 2 of my patients had died as a result of anesthesia complications. The patients were given so much medication that they were practically rendered unconscious. I tried to explain that Dr. Kelman's phacoemulsification technique was a safer procedure requiring less sedation than the prevailing intracapsular and extracapsular techniques, but my youthful opinion fell upon deaf ears. I was left with no choice but to fight the hospital establishment to build an ambulatory surgical center, which was almost unheard of 40 years ago. The local hospitals banded together erecting insurmountable hurdles, but our brilliant lawyer found a loophole in the Certificate of Need regulations. If we avoided a dedicated recovery room, we could bypass the regulatory obstacles. Being able to deliver the anesthesia care that we preferred seemed worth the time, effort, and financial investment.

Our first ambulatory surgical center had 3 operating rooms and a series of private preoperative and postoperative rooms allowing the family to stay with the patient, observe the surgery by closed-circuit video, and then welcome their loved one back after the surgery had been performed. I recall hiring and firing anesthesiologists who resisted our philosophy of combining minimal anesthesia with maximal patient communication and reassurance. We believed the best anesthesia was not general or local, it was vocal. What sounds pretty routine today was a disruptive approach back in 1983. The American Intra-Ocular Implant Society (the predecessor to ASCRS) and the fledgling Outpatient Surgery Society promoted and validated these changes, which were accelerated by the introduction of the foldable lens, topical anesthesia, and the trend to smaller incisions, which were eventually reduced from 10 to 2.2 mm.1 Less invasive anesthesia options led to unprecedented patient safety and comfort. However, the story for me did not end there.

We eventually built a second surgery center with 7 operating rooms and 23 private rooms. I became aware that many of my patients were experiencing nausea and even vomiting the evening of surgery. Several patients would have an emesis basin in their hand when I examined the post ops on the day following surgery. A meeting took place with the anesthesia team where concerns were expressed. I suspected that the villain was fentanyl, but our highly competent anesthesiologists and certified registered nurse anesthetists insisted that this drug could not be culpable. I continued complaining to the point that the head of anesthesia threatened to withdraw all support for my patients. We reached a compromise, and patients who were receiving a block were given other options. Complaints of postoperative nausea and vomiting nearly vanished.

Several years ago, one of our residents at the University of Cincinnati decided to perform a retrospective study. Dr. Logan DeHoff examined the anesthesia and clinic records from every patient I had operated on in 2012 when fentanyl use was widespread and in 2019 when this drug was seldomly used per my request. Dr. DeHoff discovered that nausea and vomiting were present in 8% of the patients from 2012 compared with 1.8% in 2019. Although his study had weaknesses, such as including unique cocktails used by certified registered nurse anesthetists, the dramatic difference confirmed my suspicions, and since his comparative study was completed, I have discouraged fentanyl use in all of my routine cataract surgeries.

After 4 decades of trying to improve the patient's anesthesia experience, there are some generic recommendations for the young cataract surgeon to consider. First, carefully assess the patient during the initial encounter. Is the patient calm or very anxious? When performing biomicroscopy and indirect ophthalmoscopy, is the patient tolerant of the light or extremely photophobic?

Second, carefully evaluate the preexisting factors that contribute to a higher risk of hemorrhage such as thrombocytopenia or anticoagulation therapy. Try to decide whether the history and examination make the individual patient a better candidate for topical, peribulbar, or retrobulbar anesthesia rather than “paint all with the same brush.”

Third, if a block is indicated, take a moment to explain any risk factors such as long axial length or previous ischemic optic neuropathy to the patient. An explanation is better before rather than after surgery. Patients often ask to be knocked out, so explain why your minimalistic approach is more safe.

Fourth, according to the European Registry of Quality Outcomes for Cataract and Refractive Surgery, there has been a significant increase in the use of topical anesthesia over the past decade.2 However, there was also an increased risk of endophthalmitis noted in this group. The authors postulate that the moving eye could come into contact with contaminated areas. In the early 1980s, I worked with Surgikos to introduce the first split-barrier drape designed to cover the lashes. In my opinion, the lashes and lid margins should always be meticulously isolated, regardless of the type of anesthesia.

Fifth, do not be afraid to talk to the anesthesia team about your preferences.3 It is not an insult to request that the patient is not given fentanyl or that you prefer to keep the patient light, which avoids an unexpected movement and disorientation, and allows better communication.

Sixth, if the patient is going to receive a regional block, let the anesthesia team know your specific preference. For example, I prefer that the volume for a retrobulbar block is limited to 3.5 mL while a peribulbar block can contain 6 mL. If the orbit is cavernous and the globe is deeply set, perhaps more volume to bring the eye forward outweighs the slim risk of creating positive pressure. Conversely, if the patient needs a block but the orbit is tiny and the lids are tight, less volume may be desirable. If a toric intraocular lens is planned with registration using Callisto or Verion, it is better to register before a peribulbar block since the conjunctival anatomy may change.4,5 If a subconjunctival anesthetic balloons the conjunctiva, it can be drained or swept around the limbus to the nasal quadrants to maintain a flat temporal approach (Video 1). If the patient has a severe phenomenon and intense blepharospasm, a rare lid block with an outdated bridle suture may save the day.

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Seventh, ask the patient to tell you if he or she feels any discomfort. If so, stop and supplement with topical and intracameral. Instill additional drops on the sclera rather than the cornea to avoid drug-induced keratitis. If there is intense photophobia, turn the microscope light down and inject an intracameral agent. Only resume operating when the patient is comfortable.

Eighth, if an anesthetic complication occurs, for example, a retrobulbar hemorrhage, know how to differentiate an arterial from venous bleed by retropulsing the globe, assessing proptosis, and evaluating lid mobility.6 Always document both the intraocular pressure, which should be measured, and retinal arterial profusion if an arterial bleed is suspected. Unless a venous bleed is self-limiting, there is no shame in canceling the surgery. With any retrobulbar hemorrhage, be sure to explain what is happening to the patient.3

Ninth, only the eye is anesthetized and the patient's ears are not. The surgeon should constantly remind the team in the operating room that comments which can be interpreted as negative or frightening are forbidden.

Tailoring the anesthesia to each patient's medical and emotional needs is an ideal approach. Your choice of anesthesia should always be supplemented with calm conversation and reassurance. The words you choose are the best drug in the anesthesia formulary.

Acknowledgments

The authors gratefully acknowledge the thoughtful review from Kavitha Sivaraman, MD.

REFERENCES 1. Osher RH. Microcoaxial phacoemulsification: part 2: clinical study. J Cataract Refract Surg 2007;33:408–412 2. Segers M, Rosen P, van den Biggelaar F, Brocato L, Henry Ype P, Nuijts R, Tassignon M, Young D, Stenevi U, Behndig A, Lundström M, Dickman M. Anesthesia techniques and the risk of complications as reflected in the European Registry of Quality Outcomes for Cataract and Refractive Surgery. J Cataract Refract Surg 2022;48:1403–1407 3. Osher RH, Parker JS. What I Say: Conversations That Improve the Physician-Patient Relationship. Thorofare, NJ: SLACK Incorporated; 2019 4. Avakian A, Osher RH. Rescue technique for salvaging toric intraocular lens alignment. J Cataract Refract Surg 2012;38:1716–1718 5. Osher RH. Iris fingerprinting: new method for improving accuracy in toric lens orientation. J Cataract Refract Surg 2010;36:351–352 6. Cionni RJ, Osher RH. Retrobulbar hemorrhage. Ophthalmology 1991;98:1153–1155