Anaesthesia for cataract surgery: are you asleep?

1st choice

local anaesthesia with drops, recommended by the French National Authority for Health for cataract surgery

0 injections

with topical anaesthesia, used in almost every case

Same day

return home, whatever the type of anaesthesia for cataract surgery

The three levels of anaesthesia for cataract surgery

Cataract surgery takes about ten minutes, through a 2 mm incision, on an organ that can be numbed with simple drops. That is why anaesthesia for cataract surgery has changed profoundly in thirty years: general anaesthesia, once the rule, has become the exception.

Topical anaesthesia: drops and gel

Anaesthetic drops or gel are instilled a few minutes before the operation. The eye becomes numb without any injection. The surgeon may add an intracameral injection: a drop of anaesthetic placed inside the eye through the incision, entirely painless. According to the French National Authority for Health, this is the reference technique as first choice.

Regional anaesthesia: around the eye

An anaesthetic is injected beside the eye (peribulbar) or beneath its conjunctiva (sub-Tenon’s). The eye becomes numb and still, and the eyelid closes for a few hours. It is chosen when stillness of the eye is essential or when the patient cannot cooperate under drops. The deeper retrobulbar injection is no longer recommended.

General anaesthesia: the exception

You sleep throughout the operation. It is reserved for children, young adults and situations in which the other techniques are contraindicated: neurological disease with uncontrollable movements, profound deafness, inability to lie flat, allergy to local anaesthetics, major anxiety resistant to sedation.

In Dr Gozlan’s practice, anaesthesia for cataract surgery is topical in almost every case: no injection, no eye pad, and visual recovery that begins as soon as you leave the theatre.

Dedicated page—cataracte.fr Cataract surgery: the procedure step by step

What you feel during the operation

Under topical anaesthesia you are awake, lying on your back, your face covered by a sterile drape that leaves the eye exposed. Knowing in advance what you will perceive removes most of the apprehension.

What you see

The light of the microscope, bright and sometimes coloured; blurred shapes and movements, never the instruments themselves. Many patients describe a rather pleasant “kaleidoscope”. You are simply asked to look at the light.

What you feel

Cool fluid running over the eye, slight pressure at times, the contact of the drape. No pain: should any discomfort appear, additional anaesthetic is given immediately.

What you hear

The surgeon’s voice, warning you of each step, and the steady sound of the phacoemulsification machine. You may speak if necessary, but you are asked to stay still and not to move your head.

The whole thing takes about ten minutes. With regional anaesthesia, visual perception is more limited; under general anaesthesia there is none.

Sedation: calming without putting you to sleep

Between drops alone and general anaesthesia lies an intermediate level that many patients are unaware of: sedation. It complements anaesthesia for cataract surgery in the anxious patient without turning it into a general anaesthetic.

A mild anxiolytic

A tablet taken before the operation is often enough to relax you. It does not make you sleep and does not prevent you from cooperating.

Intravenous sedation

Given by the anaesthetist present in theatre, it produces deep relaxation while leaving you rousable and able to look at the light. It requires an anaesthesia consultation and someone to take you home.

What sedation does not do

It does not remove the sensitivity of the eye — that is the role of the drops — and it does not make it safe to move about. A patient who absolutely cannot stay still needs general anaesthesia, not heavier sedation.

The anaesthesia consultation, fasting and your medication

Even for simple drops, the French National Authority for Health recommends an anaesthesia consultation before the operation and monitoring by an anaesthetist present on site during it. This is no formality: it is where the type of anaesthesia for cataract surgery is decided, and where three practical questions are settled.

Fasting

The clinic applies the same rule to everyone, whatever the type of anaesthesia: no food in the 6 hours before the operation; clear drinks — water, coffee, tea — remain allowed until a few hours before. The instruction, with the exact times, is given to you in writing at the anaesthesia consultation; never decide on your own whether to eat or take a medicine on the morning of the operation.

Anticoagulants and antiplatelet drugs

They are continued. Topical anaesthesia and the 2 mm incision do not bleed; a large American study found no increase in bleeding complications in patients operated on under these treatments, whereas stopping them exposes you to a risk of thrombosis. Only a peribulbar injection may lead the anaesthetist to adjust the strategy.

Other medication

Treatments for blood pressure, the heart, the thyroid or asthma are taken as usual. Diabetes calls for a specific instruction depending on fasting. Finally, mention any prostate medication of the alpha-blocker family: it does not alter the anaesthesia, but it prepares the surgeon for floppy iris syndrome.

Dedicated page—cataracte.fr The cataract preoperative assessment, step by step Dedicated page—cataracte.fr Floppy iris syndrome and alpha-blockers

How the type of anaesthesia is chosen

The choice is made by three people: you, the surgeon and the anaesthetist. The starting point is always topical anaesthesia; we depart from it for precise reasons, never out of habit.

What argues for drops

An ordinary cataract, a patient able to fix on the light and stay still for ten minutes, anticoagulant treatment, the wish to recover quickly and go home without an eye pad.

What favours an injection

Surgery expected to be long or delicate — fragile zonules, a very hard cataract, combined retinal surgery —, an eye that cannot stay still, deafness or a language barrier that prevents instructions being followed.

What requires general anaesthesia

Children, young adults, the involuntary movements of a neurological disease, inability to lie on the back, true allergy to local anaesthetics, anxiety or claustrophobia that sedation cannot control.

Age on its own is never an argument: anaesthesia for cataract surgery with drops is perfectly suited to a 90-year-old, and it is precisely in the frailest patients that it shows its full value.

The risks of each anaesthetic technique

Each type of anaesthesia for cataract surgery has its own risk profile, and it is precisely that profile which explains the recommended hierarchy.

Topical anaesthesia

No general risk. The drops sting for a few seconds. The only drawback is numbness slightly less complete than with an injection: a meta-analysis of randomised trials found discomfort slightly more frequent under drops, with no difference in surgical complications or visual outcome.

Regional anaesthesia

The injection carries a risk of bruising of the eyelid or orbit, harmless but spectacular, and much more rarely of perforation of the globe or spread of the anaesthetic. The peribulbar and sub-Tenon’s routes were adopted because they greatly reduce these risks compared with the old retrobulbar injection.

General anaesthesia

The classic risks of any general anaesthetic, especially in an older patient or one with heart or lung disease: nausea, transient confusion, cardiovascular complications. That is why it is now chosen only when no other technique is possible.

Further reading—docteurgozlan.fr Cataract in a single functional eye: what precautions?

After the anaesthesia: the following hours

Under drops, the sensitivity of the eye returns within about half an hour. What you feel afterwards is normal, and what is not should make you call.

Normal

A gritty or prickling sensation for 24 to 48 hours, watering, discomfort in bright light, vision still blurred on the first day. After a peribulbar injection, the eyelid stays droopy for a few hours.

To report without delay

Frank pain, especially if it increases, a drop in vision after an initial improvement, an eye that is getting redder. None of these signs is linked to the anaesthesia itself: they must be examined the same day.

Going home

You do not drive on the day of the operation, whatever the type of anaesthesia. A companion is advisable under drops and compulsory after sedation or general anaesthesia.

Dedicated page—cataracte.fr Recovery after cataract surgery and the warning signs

Frequently asked questions about anaesthesia for cataract surgery

No, in almost every case. Anaesthesia for cataract surgery is local: anaesthetic drops, sometimes completed by a painless injection inside the eye. You remain awake, lying down, and you hear the surgeon. General anaesthesia is reserved for specific situations, such as being unable to stay still or to lie flat.

No. The drops sting for a few seconds when instilled, then the eye becomes numb. During the operation you feel at most some pressure, cool fluid and a bright light, never pain. If an injection around the eye is chosen, the needle prick itself is brief and given after an anaesthetic drop.

Yes. The clinic asks for 6 hours without food before the operation, whatever the type of anaesthesia; clear drinks (water, coffee, tea) are allowed until a few hours before. The precise instruction, with the times, is given to you in writing at the anaesthesia consultation.

It can be discussed, but it is not the first-choice option: the French National Authority for Health reserves it for children, young adults and contraindications to the other techniques. Significant anxiety is treated first with light sedation, which calms without putting you to sleep and without the risks of a general anaesthetic.

No, as a general rule. Under topical anaesthesia the operation does not bleed, and anticoagulant or antiplatelet treatments are continued: stopping them would expose you to a risk of thrombosis far greater than the benefit. Simply mention every treatment at the anaesthesia consultation.

Anaesthesia for cataract surgery: are you asleep? Does it hurt?