Topical Anesthesia versus Regional Anesthesia for Cataract Surgery: A MetaAnalysis of Randomized Controlled Trials

Li-Quan Zhao, MD, Huang Zhu, MD, Pei-Quan Zhao, MD, Qi-Rong Wu, MD, Yi-Qian Hu, MD
Purpose: To examine possible differences in the clinical outcomes of topical anesthesia (TA) and regional anesthesia including retrobulbar anesthesia (RBA) and peribulbar anesthesia (PBA) in phacoemulsication. Design: Systematic review and meta-analysis. Participants: Patients from previously published randomized controlled trials (RCTs) of phacoemulsication under TA and RBA/PBA reporting clinical outcomes. Methods: A comprehensive literature search was performed according to the Cochrane Collaboration method to identify RCTs that compare TA and RBA/PBA in phacoemulsication. Main Outcome Measures: Primary outcome parameters investigated were pain score during and after surgery, intraoperative difculties and inadvertent ocular movement, intraoperative necessity to administer additional anesthesia, and patient preference. Secondary outcome parameters investigated were postoperative visual acuity, anesthesia-related complications, intraoperative complications, and severe local or systemic complications. Results: Fifteen studies were identied and analyzed to compare TA (1084 eyes) with RBA/PBA (1121 eyes) in phacoemulsication. Data synthesis showed that intraoperative and postoperative pain perception was signicantly higher in the TA group (P 0.05). The TA group showed more frequent inadvertent ocular movement (P 0.05) and a greater intraoperative need for supplementary anesthesia (P 0.03). There was no statistically signicant difference between the 2 groups in intraoperative difculties as assessed by the surgeons (P 0.05). Patients signicantly preferred TA (P 0.00001). The RBA/PBA group had more frequent anesthesia-related complications, such as chemosis, periorbital hematoma, and subconjunctival hemorrhage (P 0.05). There was no statistically signicant difference in surgery-related complications (P 0.05). Conclusions: Compared with RBA/PBA, TA does not provide the same excellent pain relief in cataract surgery; however, it achieves similar surgical outcomes. Topical anesthesia reduces injection-related complications and alleviates patients fear of injection. The choice of TA is not suitable for patients with a higher initial blood pressure or greater pain perception. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Ophthalmology 2012;119:659 667 2012 by the American Academy of Ophthalmology.

In developed countries, phacoemulsication with intraocular lens implantation is the current standard of care procedure for adult cataract surgery.1 In 2005 and 2006, a national survey covering 287 000 cataract extractions was carried out in the United Kingdom, showing that 99.7% of the adult patients were treated with phacoemulsication.2 Cataract removal has developed into a rapid turnover daycase procedure as it has become faster, safer, and less traumatic.3 The anesthetic techniques available for adult cataract surgery evolved simultaneously.4 Retrobulbar anesthesia (RBA), peribulbar anesthesia (PBA), and topical anesthesia (TA) are most commonly applied in cataract surgery today. Since its introduction in 1993, TA has been widely accepted.5 A recent British national survey found that TA is administered by 33% of cataract surgeons6 (up from 4.1% in 19967 and 20.9% in 20038), particularly those undertaking high-volume surgery. Topical anesthesia was reported to be more cost-effective and safer than regional anesthesia (including RBA/PBA) in terms of anesthesiarelated complications.3,9
2012 by the American Academy of Ophthalmology Published by Elsevier Inc.

In the literature comparing TA with RBA/PBA in phacoemulsication, inconsistencies exist on the outcomes and conclusions.10 26 Therefore, an in-depth review and meta-analysis of the available studies can further clarify the benets of TA and RBA/PBA in phacoemulsication. We incorporated RBA and PBA into 1 group because the meta-analysis by Alhassan et al27 showed that these 2 methods have similar anesthetic and clinical effects in cataract surgery. The meta-analysis by Ezra et al28 showed that TA supplemented with intracameral lidocaine reduces more intraoperative pain in cataract surgery under TA compared with TA alone. For this reason, we omitted studies referencing TA supplemented with intracameral lidocaine. We systematically searched for existing randomized controlled trials (RCTs) that compared TA with RBA/PBA in cataract surgery. We then reviewed the selected studies in detail and carried out a meta-analysis to identify any clinical differences between the 2 anesthetic techniques. The primary objective was to assess pre- and postoperative pain, intraoperative difculties, inadvertent ocular motion, need for additional anesthesia during surgery, and patients preferred anesthetic
ISSN 0161-6420/12/$see front matter doi:10.1016/j.ophtha.2011.09.056

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we manually searched the bibliographies of all potentially relevant articles. In addition, the related articles feature of PubMed was applied. Studies were included if they met the inclusion criteria. There was no language restriction on the publications.

method. The secondary objective was to assess adverse effects and complications attributable to the anesthetic techniques.

Materials and Methods

This meta-analysis was performed following a predened protocol, in keeping with generally accepted methodological practices and recommendations.29 31

Study Inclusion and Exclusion Criteria

We selected studies if they met the following inclusion criteria: The study had been conducted as an RCT, the patients included presented with cataract and were older than 18 years of age, the study intervention included TA and RBA/PBA, and the study assessed at least 1 of the dened primary and secondary objectives. The exclusion criteria were TA in combination with other techniques, such as intracameral lidocaine, regional nerve block, and sponge soaked with drugs inserted deeply into the conjunctival fornices.

Literature Search
Two reviewers (L-QZ and HZ) independently searched the PubMed, EMBASE, and Cochrane Controlled Trials Register databases for publications up to July 6, 2010. To maximize the data search and identify all RCTs that compared TA with RBA/PBA in phacoemulsication, we used the following text terms: topical anesthesia or drop anesthesia, retrobulbar anesthesia or block, peribulbar anesthesia or block, regional or local anesthesia or block, periocular or periocular anesthesia, cataract surgery, cataract extraction, and phacoemulsication. We reviewed the abstracts of related titles and retrieved the full articles if their title or abstract appeared to meet this reviews objectives. To identify studies not found by computerized search,

Quality Assessment of Retrieved Articles

Two reviewers independently appraised the quality of the selected studies according to the methods recommended by the Cochrane Handbook for Systematic Reviews of Interventions.32 They examined the following points of methodological quality: allocation concealment, method of allocation of treatment, masking of outcome assessment, and completeness of follow-up. On the basis of their assess-

Table 1. Characteristics of the 15 Randomized Controlled Trials Investigating Topical versus Retrobulbar
No. of Patients (M/F); Mean Age (yrs) SD (Range) 1-: 2-: 1-: 2-: 1-: 2-: 1-: 2-: 1-: 2-: 1-: 2-: 1-: 2-: 27 (11/16); 65.67.9 27 (11/16); 65.57.9 58 (20/38); 7410 57 (20/37); 7210 155 (97/57); 57.48.5 151 (76/74); 57.28.0 49 (22/27); 73.6 (4690) 58 (28/30); 73.8 (5088) 238 (88/150); 73.15.6 238 (84/154); 72.16.8 69 (4585) 69 (4585) 45 (4580) 45 (4580) Eyes (Dropouts) 1-: 2-: 1-: 2-: 1-: 2-: 1-: 2-: 1-: 2-: 1-: 2-: 1-: 2-: 1-: 2-: 1-: 2-: 1-: 2-: 1-: 2-: 1-: 2-: 1-: 2-: 1-: 2-: 1-: 2-: 27 (0) 27 (0) 58 (0) 57 (0) 155 (1) 151 (1) 49 (0) 58 (0) 238 (0) 238 (0) 69 (0) 69 (0) 45 (0) 45 (0) 71 (0) 69 (0) 49 (0) 51 (0) 45 (0) 45 (0) 36 (0) 36 (0) 27 (0) 27 (0) 136 (0) 163 (0) 35 (0) 41 (0) 44 (1) 44 (1) Intervention (Topical Drops) 2% lidocaine 2% oxybuprocaine 0.5% proparacaine 2% lidocaine 2% lidocaine 0.75% bupivacaine 0.75% bupivacaine

Trial (Location) Topical vs. Retrobulbar Ryu et al 2009 (Korea)10 Gombos et al 2007 (Hungary)11 Rengaraj et al 2004 (India) Chan et al 2002 (China)13 Jacobi et al 2000 (Germany)14 Patel et al 1996 (US)15 Patel et al 1998 (US)16 Topical vs. Peribulbar Sauder and Jonas 2003 (Germany)17 Virtanen and Huha 1998 (Finland)18 Roman et al 1996 (France)19 Zehetmayer et al 1996 (Austria)20 Strobel and Hhnermann 1996 (Germany) Uusitalo et al 1999 (Finland)22 Topical vs. Retrobulbar/Peribulbar Chung et al 2004 (China)23 Nielsen and Allerd 1998 (Denmark)24
21 12

1-: 71; 73.21.4 2-: 69; 74.11.9 1-: 49 (15/34); 67.3 (2480) 2-: 51 (16/35); 66.6 (3780) Total: 45 (17/28); 73 Total: 36 (15/21) 1-: 2-: 1-: 2-: 1-: 2-: 1-: 2-: 27 (15/12); 71.3 (5287) 27 (18/9); 68.5 (2686) 136; 72.2 (3389) 163; 71.3 (3093) 35 (11/24); 41 (22/19); 44 (21/23); 44 (15/29); 70.210.8 75.07.8 79 (5393) 77 (5991)

0.4% oxybuprocaine 0.4% oxybuprocaine 1% tetracaine 4% lidocaine 4% cocaine 0.75% bupivacaine

2% lidocaine 4% lidocaine

1- topical group; 2- control group (retrobulbar or peribulbar); IV intravenous; F female; GSA graded subjective assessment; M male;

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ments and the Cochrane Collaboration guidelines, the 2 reviewers independently drew up a list of trials to be included in the metaanalysis. The lists were compared and found to be identical. them to assess homogeneity. Any heterogeneity between the studies would not have justied pooling of the assessed outcome parameters. They recorded each studys author, year of the trial, number of patients, age, sex of subjects, number of withdrawals, and type of anesthesia administered onto a customized data extraction form described in the Cochrane Handbook for Systematic Reviews of Interventions. The 2 reviewers resolved any disagreement about study inclusion, quality assessment, selection of outcome parameters, and data extraction through discussion until a 100% agreement was reached.

Outcome Measures
The primary outcome parameters investigated by this study were (1) measures of pain during and after the surgery, (2) measures of intraoperative difculties and inadvertent eye movement, (3) need for additional anesthesia during surgery, and 4) patient preference for type of anesthesia. The secondary outcome parameters investigated by this study were (1) postoperative visual acuity; (2) anesthesia-related complications, including chemosis, periorbital hematoma, subconjunctival hemorrhage, postoperative nausea and vomiting, and postoperative analgesia; (3) intraoperative complications, including capsule rupture with or without loss of vitreous, zonular tear, and iris prolapse; and (4) severe local or systemic complications, such as endophthalmitis, respiratory depression, and cardiopulmonary arrest.

Statistical Analysis
The quantitative data of the outcome parameters were entered into the Cochrane Review Manager (RevMan) version 4.2 software program and analyzed. Summary estimates and 95% condence intervals (CIs) were calculated. For continuous outcome data (e.g., pain score), the weighted mean difference or standardized mean difference was calculated by mean and standard deviations. For dichotomous outcomes (e.g., proportions of anesthesia-related complications), the Peto odds ratio was calculated. To identify statistical heterogeneities, the Cochran Q-Statistics chi-square test and inconsistency index (I-squared, I2) were applied. When no signicant evidence of statistical heterogeneity

Data Extraction and Analysis

Two reviewers independently extracted the data onto a preformatted sheet. They tabulated the studies and systematically evaluated

or Peribulbar Anesthesia during Cataract Surgery (Phacoemulsication) Included in the Meta-Analysis

Control (Injection Drugs) 2% lidocaine hyaluronidase 2% lidocaine 0.5% bupivacaine 2% lidocaine adrenaline hyaluronidase 2% lignocaine 0.5% bupivacaine hyaluronidase 2% lidocaine 0.5% bupivacaine hyaluronidase 2% lidocaine 0.75% bupivacaine hyaluronidase 2% lidocaine 0.75% bupivacaine hyaluronidase 2% mepivacaine hyaluronidase 2% lidocaine 0.5% bupivacaine hyaluronidase 2% lidocaine 0.5% bupivacaine 2% lidocaine 0.5% bupivacaine hyaluronidase 2% lidocaine 0.5% bupivacaine 2% lidocaine 0.75% bupivacaine hyaluronidase 2% lignocaine 2% lidocaine 0.5% bupivacaine hyaluronidase No

Sedation

Incision Clear cornea Clear cornea Clear cornea Clear cornea/scleral tunnel Clear cornea Clear cornea Clear cornea

Pain Score VAS (0100) GSA (01) NR NR VAS (010) VAS (010) VAS (010)

Jadad Score 4 3 5 3 4 3 4

Oral alprazolam for all No No Oral midazolam for RBA IV methohexital IV fentanyl, if IV methohexital IV fentanyl, if No Sedation was given to 3 patients in TA and 4 in PBA (drug not reported) IV fentanyl or propofol for PBA; IV propofol for TA if necessary Oral meprobamate for all NR IV fentanyl for all; IV midazolam, if needed for RBA; IV midazolam for TA; necessary for RBA; IV midazolam for TA; necessary

Sclerocorneal Scleral pocket Clear cornea Clear cornea Clear cornea Clear cornea

VAS (010) VAS (010) GSA (04) VAS (0100) GSA (04) VAS (010)

3 3 3 5 3 6

No No

Clear cornea Clear cornea

NR VAS (0100)

3 3

SD standard deviation; NR not reported; VAS visual analog score.

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Eight studies reported a postoperative pain score.10,11,15,16,19,21,22,24 Synthesis of the continuous data showed a signicantly higher postoperative pain score for the TA group than for the RBA subgroup (P 0.03), the PBA subgroup (P 0.002), and the joint RBA/PBA group (P 0.005) (Fig 2). The dichotomized data conrmed that patients receiving TA perceived statistically significantly more postoperative pain (P 0.0003) (Table 2). Intraoperative Difculties and Eye Motility. Five studies reported different degrees of inadvertent intraoperative eye movement.15,16,18,21,24 Strobel and Hhnermann21 ranked eye movement on a 5-point scale of no movement to constant movement.21 Nielsen and Allerd24 reported the number of cases exhibiting intraoperative eye motility. Patel et al15,16 and Virtanen and Huha18 documented the ratios of incidences of inadvertent eye movement during surgery. For the purpose of the review, these data were dichotomized into 2 groups scoring 0 (no movement) or 1 (inadvertent movement experienced). Data synthesis demonstrated that intraoperative ocular movement occurred more frequently in the TA group than in the RBA group (P 0.00001) and PBA group (P 0.00001). Total analysis also did not favor TA (P 0.00001) (Table 2). Six studies reported intraoperative difculties, as assessed by the surgeons.14 17,20,22 Jacobi et al14 recorded 3 levels of difculties: none to slightly difcult, moderately difcult, and difcult to extremely difcult. Sauder and Jonas17 graded intraoperative difculties on a 4-point scale from 1 no difculty to 4 extremely difcult. Zehetmayer et al20 ranked intraoperative conditions on a scale from 5 (poor cooperation) to 5 (ideal cooperation). Uusitalo et al22 documented 5 intraoperative conditions: no difculty, slightly difcult, moderately difcult, difcult, and very difcult. Patel et al15,16 rated surgical conditions on an analog scale, with 10 representing excellent cooperation and 0 representing extremely poor cooperation. We redened no difculty or ideal cooperation as 0 and then transformed the data to continuous outcome data. Data synthesis showed no statistically signicant differences in the intraoperative difculties between the TA group and the RBA subgroup (P 0.29), PBA subgroup (P 0.48), and total group (P 0.19) (Fig 3). Because the criteria for the intraoperative difculties were poorly dened and heterogeneous (I2 87.7%), these results should be interpreted with caution.

or clinical diversity could be established, xed-effects models were used. However, results showing signicant heterogeneity (I2 50%) were subjected to a random-effects meta-analysis applying the DerSimonian-Laird method. In addition, outcome measures were assessed on an intent-to-treat basis. A P value of less than 0.05 was considered statistically signicant.

Results
The present meta-analysis encompasses 15 RCTs involving 2205 eyes that had undergone phacoemulsication under TA, RBA, or PBA.10 24 The 15 studies and their quality assessment are summarized in Table 1.

Primary Outcomes
Pain Score. Twelve studies reported pain outcome measurements.10,11,14 22,24 To measure pain experienced, 3 studies used a 0to 100-mm visual analog scale with a numeric rating scale;10,20,24 6 studies used a visual analog scale with numeric and descriptive ratings from 0 (no pain) to 10 (severe pain).14 18,22 All the above outcomes were presented as continuous outcome data (mean and standard deviation). Three studies used subjective assessment on a scale of 0 (no pain) to 3 (much pain) or 4 (intense pain),19,21,24 and 1 study merely recorded the presence or absence of pain.11 We transformed the data of these 4 studies into dichotomous data by dividing them into 2 groups scoring 0 (no pain) or 1 (pain experienced). Twelve studies scored intraoperative pain.10,11,14 22,24 The synthesis of their continuous data showed that patients receiving TA experienced signicantly greater intraoperative pain than patients receiving RBA (P 0.03). In contrast, there was no statistically signicant difference between the TA group and the PBA subgroup (P 0.07); however, there was an obvious trend of more pain perceived by the patients receiving TA. Overall, the data showed that the TA group perceived statistically signicantly greater pain (P 0.003) (Fig 1). In conrmation, the dichotomized data also showed that patients receiving TA had signicantly more pain than those receiving RBA/PBA (P 0.00001) (Table 2). From this, it can be inferred that RBA/PBA can reduce pain in patients under anesthesia.

Figure 1. Forest plot comparing the mean pain score during surgery with TA and RBA/PBA. CI condence interval; PBA peribulbar anesthesia; RBA retrobulbar anesthesia; SD standard deviation; SMD standardized mean difference; TA topical anesthesia.

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Table 2. Meta-Analytic Findings on Intraoperative and Postoperative Outcome Parameters of Randomized Controlled Trials Comparing Topical versus Retrobulbar/Peribulbar Anesthesia
Crude Rate, n/N (%) No. of Studies Intraoperative pain score (dichotomized data) Postoperative pain score (dichotomized data) Inadvertent eye movement Need for additional anesthesia Patient preference Anesthesia-related complications Chemosis Periorbital hematoma Subconjunctival hemorrhage Postoperative nausea and vomiting Postoperative analgesics Intraoperative complications Capsular rupture Zonular tear Iris prolapse 311,19,24 211,19 515,16,18,21,24 81317,19,20,22 415,19,22,24 61417,22,24 81417,1922 61417,22,24 210,13 210,20 131122,24 414,18,21,24 514,15,17,18,24 TA 51/147 38/103 94/234 9/689 69/133 1/603 0/667 1/603 3/76 9/63 18/1022 12/358 5/471 RBA/PBA 15/146 16/102 28/196 2/723 33/133 72/628 51/692 26/628 1/85 4/63 20/1053 7/360 1/471 Rate Difference% (95% CI) 4.55 (2.588.05) 3.41 (1.766.60) 3.91 (2.546.03) 3.88 (1.1812.75) 3.11 (1.905.09) 0.08 (0.00.13) 0.10 (0.050.18) 0.14 (0.070.31) 3.36 (0.4624.68) 2.39 (0.757.61) 0.94 (0.501.79) 1.72 (0.694.30) 3.83 (0.7719.08) P for Overall Effect 0.00001 0.0003 0.00001 0.03 0.00001 0.00001 0.00001 0.00001 0.23 0.14 0.86 0.24 0.10

CI condence interval; PBA peribulbar anesthesia; RBA retrobulbar anesthesia; TA topical anesthesia.

Need for Additional Anesthesia during Surgery. The need for supplemental anesthesia during surgery was reported by 8 studies.1317,19,20,22 The types of additional anesthesia administered varied greatly. They included PBA, TA, subconjunctival injections, sub-Tenons anesthesia, and intravenous sedation. Among the studies, there was no consistency in the type and administration of supplemental anesthesia. In the interest of our study, we therefore selected the cases of regional anesthesia by injection, which covered 1412 randomized eyes in the assessed trials. The meta-analysis showed that signicantly more patients receiving TA were in need of supplementary anesthesia compared with those receiving RBA/PBA (P 0.03) (Table 2). Preference of Anesthesia. Four studies reported bilateral cataract surgery in which the patients had TA in 1 eye and RBA/PBA in the other eye. In addition, they recorded the proportion of patient preference for either of the 2 anesthetic techniques.15,19,22,24 Our analysis showed a statistically significantly greater preference for TA (P 0.00001) (Table 2).

Secondary Outcomes
Postoperative Visual Acuity. Three studies reported postoperative visual acuity.11,21,22 Within the scope of the 3 studies, preoperative visual acuity showed no signicant difference between the 2 groups. Gombos et al11 demonstrated no statistically signicant difference in visual acuity between the groups on the rst day after surgery (Snellen chart).11 Strobel and Hhnermann21 showed that visual acuity was not signicantly different in the patients of either group 5 hours, 1 day, and 2 days postoperatively (no details of data were given).21 Uusitalo et al22 indicated that the 2 groups did not differ in their proportions of patients reaching a 20/40 visual acuity 4 months after surgery. Because the studies applied no uniform standard to assess visual acuity, we abstained from performing a meta-analysis. Anesthesia-Related Complications. Conjunctival chemosis, periorbital hematoma, and subconjunctival hemorrhage were more frequent in the RBA/PBA group than in the TA group

Figure 2. Forest plot comparing the mean postoperative pain score with TA and RBA/PBA. CI condence interval; PBA peribulbar anesthesia; RBA retrobulbar anesthesia; SD standard deviation; SMD standardized mean difference; TA topical anesthesia.

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Figure 3. Forest plot comparing the intraoperative difculties of TA and RBA/PBA as assessed by the surgeons. CI condence interval; PBA peribulbar anesthesia; RBA retrobulbar anesthesia; SD standard deviation; SMD standardized mean difference; TA topical anesthesia.

(P 0.05) (Table 2). Postoperative nausea and vomiting, and the postoperative need for analgesics occurred more often in the TA group. According to the reported data, the incidence of postoperative nausea and vomiting was more than 3-fold greater in the TA group (3/76) than in the RBA/PBA group (1/85).10,13 However, on analysis there was no overall statistically significant difference between the 2 groups with respect to postoperative nausea and vomiting (P 0.23) (Table 2). Likewise, there was no overall statistically signicant difference between the 2 types of anesthesia in the postoperative need for analgesics (P 0.14) (Table 2). Intraoperative Complications. Thirteen studies reported intraoperative complications, such as posterior capsule rupture with or without vitreous loss, zonular tear, and iris prolapse.1122,24 However, synthesis of these data showed no statistically signicant differences between the 2 anesthetic techniques (P 0.05) (Table 2). Severe Local or Systemic Complications. The 2 trials by Patel et al15,16 recorded 2 cases of retrobulbar hemorrhage in patients receiving RBA (1/69 patients and 1/45 patients, respectively). Globe perforation did not occur in any of the selected trials. Uusitalo et al22 reported that 2 cases of endophthalmitis developed in the TA group (2/136). Ryu et al10 recorded adverse hemodynamic effects: One patient (1/27) in the TA group and 1 patient (1/27) in the RBA group developed bradycardia; 0 patients (0/27) in the TA group and 15 patients (15/27) in the RBA group developed tachycardia; 3 patients (3/27) in the TA group and 12 patients (12/27) in the RBA group developed hypertension.10 No major systemic complications, such as respiratory depression, oxygen desaturation, or cardiopulmonary arrest, were reported in any of the trials.

Discussion
The 15 trials included in this meta-analysis compared in detail the clinical outcomes of TA with those of RBA/ PBA.10 24 Twelve of the trials applied different methods to measure patient discomfort; they also reported different

outcomes and drew different conclusions. The synthesis of all the continuous and dichotomous data showed a statistically signicantly greater intraoperative and postoperative pain perception in the TA group, with one exception: There was no statistically signicant difference in the intraoperative pain scores between the TA group and the PBA subgroup. Eight trials recorded the necessity to administer supplementary anesthesia by regional anesthetic injection in the course of phacoemulsication.1317,19,20,22 The results of the meta-analysis showed that the use of TA resulted in a signicant trend of an increased need for supplementary anesthesia. This trend is likely to reect the higher pain scores and more frequent inadvertent eye movement in the TA group. However, given the poor denition and heterogeneity of the criteria applied to the pain score measurement and the need for supplemental regional anesthetic injection during surgery, this result should be interpreted with caution. Nevertheless, this conclusion is convincing in connection with the different ranges of anesthetized area covered by TA and regional anesthesia such as RBA and PBA. In phacoemulsication, regional anesthesia by injection can achieve lid akinesia, globe akinesia, and total ocular anesthesia. In contrast, TA seems to effect a partial ocular anesthesia. Consequently, in the absence of intracameral anesthesia, the iris is not anesthetized by TA. Therefore, surgery might stimulate pain receptors, particularly if surgical instruments touch the iris, resulting in patient discomfort. As a result, supplemental regional anesthesia by injection might be requested by the surgeon or patient. To offset the subjectivity of pain scores, some trials applied objective parameters to compare the differences in pain score.10,11 Pain perception in the TA group caused blood pressure, heart rate, and serum adrenaline levels to increase. In contrast, patients receiving regional anesthesia by injection required a smaller total amount of patient-controlled seda-

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tion and fewer supplementary bolus doses intraoperatively than the TA group.10 The data analysis demonstrated that TA did not achieve the same level of intraoperative pain relief as RBA/PBA. The patients nevertheless tolerated the extra intraoperative pain and despite the pain preferred TA over RBA/PBA. In addition, the increased pain experience did not negatively affect the surgical maneuvers. This is shown by the result of our data analysis in that there was no statistically signicant difference in intraoperative difculties between the 2 groups. The surgical duration also reects intraoperative difculties and the incidence of supplemental anesthesia. Five trials recorded surgical duration.10,11,17,22,24 Only 1 trial mentioned that a signicantly longer operating time was required under TA.22 The remaining 4 trials reported no statistically signicant difference in the surgical duration between the 2 anesthetic techniques.10,11,17,24 The metaanalysis of these 5 trials showed no signicant difference in surgical time (weighted mean difference 0.52; 95% CI, 0.58 to 1.61; P 0.35). This suggests that the intraoperative requirement of supplemental anesthesia did not substantially prolong the operating time and that the surgeons could control the more frequent inadvertent eye movement. Intraoperative complications, such as anterior capsule tear, posterior capsule rupture with or without vitreous loss, zonular tear, and iris prolapse, are intraoperative difculties encountered in surgical maneuvers. However, these intraoperative complications also did not result in a statistically signicant difference between the 2 groups. All the results compounded would indicate that TA can achieve excellent clinical outcomes to the same degree as RBA/PBA. The fact that there was no difference in surgical time between the 2 groups would imply that surgical time did not affect the pain measurement analysis between the groups. Topical anesthesia provided less pain control during surgery compared with regional anesthesia by injection; however, it was not a prolonged surgical time that weakened the pain control effect of TA. The present investigation demonstrated that signicantly more patients preferred TA. According to Nielsen and Allerds questionnaires,24 the main reason given for this preference was the fear of pain caused by a regional injection. Six trials recorded pain score measurements when delivering drops of topical anesthetic and injecting drugs for regional anesthesia.10,15,16,18,19,24 All showed a higher pain score for the administration of injections and little or no sensation in response to TA drops. The score of intraoperative pain expressed by the TA group was below that of the injection of regional anesthesia.10,19,24 Some studies reported that the patients were sedated before receiving RBA/ PBA.15,16,18,19 Although this abolishes the pain factor induced by injection, the remaining reported pain perception caused by the injection was still higher than that caused by TA drops. Ryu et al10 showed that the mean arterial pressure and heart rate in the regional injection group was signicantly higher than in the TA group during and just after regional block (P 0.05). Tachycardia and hypertension occurred more frequently in the regional injection group than in the TA group. Regional anesthesia by injection caused negative psychologic responses and hemodynamic physiologic change, and increased the incidence of local complications, including conjunctival chemosis, periorbital hematoma, and subconjunctival hemorrhage. The potential risk of rare but severe local complications, such as retrobulbar hemorrhage and globe perforation, still exists. Topical anesthesia may avoid these injection-related complications, although it has been suggested that TA may be associated with an increased risk of endophthalmitis after cataract extraction. Many factors (e.g., vitreous loss, immunosuppression, chronic dacryocystitis) are known to increase the risk of endophthalmitis. The potential risk of endophthalmitis caused by different types of anesthesia remains controversial.25,33,34 The retrospective case-control study by Garcia-Arumi et al25 reported 5011 cataract extractions, of which 27 patients developed endophthalmitis. Of these 27 patients, 2 had received RBA and 25 had received TA.25 They inferred that the intraoperative inadvertent eye movement under TA might cause the corneal incisions to reach polluted areas, such as the conjunctival fornix, eyelids, and eyelashes, all of which can harbor microorganisms. Another reason suggested is that the inammation may be caused by postoperative blinking that could open the corneal incisions in the rst few hours after surgery. Consequently, bacteria from the patients periocular ora could enter through the unstable incisions before the wounds have healed.25 Although their conclusions contain important reections to be included in further studies, their research nevertheless supplies insufcient scientic evidence, not in the least because it is a retrospective, case-control study. The present study also showed that intraoperative inadvertent eye movement was more frequent under TA. Two trials included in this review recorded more frequent squeezing of the eyelid during surgery under TA.15,16 Of the included 15 RCTs, only 1 reported 2 cases of endophthalmitis that developed in the TA group (2/136).22 In contrast with the study by Garcia-Arumi et al,25 the synthesis of all RCTs included in our study showed no statistically significant difference in the incidence of endophthalmitis between the 2 groups (Peto odds ratio 7.65; 95% CI, 0.48 122.47; P 0.15). The potential risks posed by intraoperative inadvertent eye movement and postoperative blinking related to TA must be investigated further and veried. Moreover, 2 trials included in this review exclusively evaluated the patients subjective visual experience at different stages of the cataract surgery under TA and regional anesthesia. Both found that more patients receiving TA perceived light and colors than did patients receiving RBA/ PBA.12,23 In respect of visual rehabilitation, 3 RCTs showed no statistically signicant differences between the groups in visual acuity from 5 hours to 4 months postoperatively. However, we did not perform a meta-analysis because the reports lacked a uniform standard of measuring postoperative visual acuity. In contrast, a comparative study not included in the present meta-analysis reported that TA could hasten visual rehabilitation in the short-term follow-up. One hour after surgery, the TA group had signicantly better

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4. Nouvellon E, Cuvillon P, Ripart J, Viel EJ. Anaesthesia for cataract surgery. Drugs Aging 2010;27:2138. 5. Kershner RM. Topical anesthesia for small incision selfsealing cataract surgery: a prospective evaluation of the rst 100 patients. J Cataract Refract Surg 1993;19:290 2. 6. Chandradeva K, Nangalia V, Hugkulstone CE. Role of the anaesthetist during cataract surgery under local anaesthesia in the UK: a national survey. Br J Anaesth 2010;104: 577 81. 7. Eke T, Thompson JR. The National Survey of Local Anaesthesia for Ocular Surgery. II. Safety proles of local anaesthesia techniques. Eye (Lond) 1999;13:196 204. 8. Eke T, Thompson JR. Serious complications of local anaesthesia for cataract surgery: a 1 year national survey in the United Kingdom. Br J Ophthalmol 2007;91:470 5. 9. Garbee DD. Phacoemulsication procedures performed with topical anesthesia. AORN J 1997;66:2537, 260 2, 265. 10. Ryu JH, Kim M, Bahk JH, et al. A comparison of retrobulbar block, sub-Tenon block, and topical anesthesia during cataract surgery. Eur J Ophthalmol 2009;19:240 6. 11. Gombos K, Jakubovits E, Kolos A, et al. Cataract surgery anaesthesia: is topical anaesthesia really better than retrobulbar? Acta Ophthalmol Scand 2007;85:309 16. 12. Rengaraj V, Radhakrishnan M, Au Eong KG, et al. Visual experience during phacoemulsication under topical versus retrobulbar anesthesia: results of a prospective, randomized, controlled trial. Am J Ophthalmol 2004;138:7827. 13. Chan JC, Lai JS, Lam DS. Nausea and vomiting after phacoemulsication using topical or retrobulbar anesthesia. J Cataract Refract Surg 2002;28:1973 6. 14. Jacobi PC, Dietlein TS, Jacobi FK. A comparative study of topical vs retrobulbar anesthesia in complicated cataract surgery. Arch Ophthalmol 2000;118:1037 43. 15. Patel BC, Burns TA, Crandall A, et al. A comparison of topical and retrobulbar anesthesia for cataract surgery. Ophthalmology 1996;103:1196 203. 16. Patel BC, Clinch TE, Burns TA, et al. Prospective evaluation of topical versus retrobulbar anesthesia: a converting surgeons experience. J Cataract Refract Surg 1998;24:853 60. 17. Sauder G, Jonas JB. Topical versus peribulbar anaesthesia for cataract surgery. Acta Ophthalmol Scand 2003;81:596 9. 18. Virtanen P, Huha T. Pain in scleral pocket incision cataract surgery using topical and peribulbar anesthesia. J Cataract Refract Surg 1998;24:1609 13. 19. Roman S, Auclin F, Ullern M. Topical versus peribulbar anesthesia in cataract surgery. J Cataract Refract Surg 1996; 22:1121 4. 20. Zehetmayer M, Radax U, Skorpik C, et al. Topical versus peribulbar anesthesia in clear corneal cataract surgery. J Cataract Refract Surg 1996;22:480 4. 21. Strobel I, Hhnermann M. Eyedrop anesthesia in cataract surgery [in German]. Ophthalmologe 1996;93:68 72. 22. Uusitalo RJ, Maunuksela EL, Paloheimo M, et al. Converting to topical anesthesia in cataract surgery. J Cataract Refract Surg 1999;25:432 40. 23. Chung CF, Lai JS, Lam DS. Visual sensation during phacoemulsication and intraocular lens implantation using topical and regional anesthesia. J Cataract Refract Surg 2004;30:444 8. 24. Nielsen PJ, Allerd CW. Evaluation of local anesthesia techniques for small incision cataract surgery. J Cataract Refract Surg 1998;24:1136 44. 25. Garcia-Arumi J, Fonollosa A, Sararols L, et al. Topical anesthesia: possible risk factor for endophthalmitis after cataract extraction. J Cataract Refract Surg 2007;33:989 92.

visual acuity than the RBA group; 1 day and 1 week after surgery, there was no difference in visual acuity between the groups.26 Randomized controlled trials focusing on short-term visual rehabilitation are needed to support this conclusion. Other trials indicated that both TA and regional anesthesia were associated with a low incidence of postoperative nausea and vomiting in routine phacoemulsication.10,13 However, there was no statistically signicant difference in postoperative nausea and vomiting between the 2 anesthetic techniques. The use of systemic sedation described in some of these studies is important. Kallio et al35 demonstrated that intravenous sedation by propofol added to TA did not improve the operative conditions or surgical outcome. In addition, during and after surgery, sedatives did not improve the pain score of patients receiving TA compared with patients receiving TA without sedation. Of course, clinicians will be aware that any single RCT should be interpreted with caution. The administration of sedation did not follow a standard procedure throughout the studies. In addition, the number of studies was insufcient for a subgroup meta-analysis. Therefore, we did not perform a sensitivity analysis excluding the trials reporting systemic sedation. The heterogeneity between the included trials reporting anesthesia with or without the use of sedation did not need to be taken into consideration for the validity of the present study. We hope more RCTs investigating the exclusive relationship between systemic sedation and regional anesthesia in phacoemulsication will be performed to answer the question of whether sedatives improve the pain score and operative conditions. In conclusion, although TA does not provide pain relief as effectively as RBA/PBA during cataract surgery, its anesthetic effect is nevertheless reasonably well tolerated by patients. Similar surgical outcomes were achieved by TA and RBA/PBA. Topical anesthesia reduced injection-related complications and alleviated patients fear of injections. The choice of TA is not suitable for specic patients. In patients with a higher initial blood pressure and younger patients who are more susceptible to pain, TA alone should be avoided and alternative anesthetic methods are recommended.11 Today, there are numerous anesthetic techniques from which a surgeon can choose. However, there is not one type of anesthesia that is right for all potential cases. The best choice may vary from surgeon to surgeon on the basis of experience and predilection, and from patient to patient.

References
1. Allen D, Vasavada A. Cataract and surgery for cataract. BMJ 2006;333:128 32. 2. Jaycock P, Johnston RL, Taylor H, et al, UK EPR user group. The Cataract National Dataset electronic multi-centre audit of 55,567 operations: updating benchmark standards of care in the United Kingdom and internationally. Eye (Lond) 2009;23: 38 49. 3. Navaleza JS, Pendse SJ, Blecher MH. Choosing anesthesia for cataract surgery. Ophthalmol Clin North Am 2006;19: 2337.

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26. Nielsen PJ. Immediate visual capability after cataract surgery: topical versus retrobulbar anesthesia. J Cataract Refract Surg 1995;21:302 4. 27. Alhassan MB, Kyari F, Ejere HO. Peribulbar versus retrobulbar anaesthesia for cataract surgery. Cochrane Database Syst Rev 2008;(3):CD004083. 28. Ezra DG, Nambiar A, Allan BD. Supplementary intracameral lidocaine for phacoemulsication under topical anesthesia: a meta-analysis of randomized controlled trials. Ophthalmology 2008;115:455 87. 29. Egger M, Smith GD, Phillips AN. Meta-analysis: principles and procedures. BMJ 1997;315:15337. 30. Pogue J, Yusuf S. Overcoming the limitations of current metaanalysis of randomized controlled trials. Lancet 1998;351:4752. 31. Moher D, Cook DJ, Eastwood S, et al, QUOROM Group. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Lancet 1999;354:1896 900. 32. OConnor D, Green S, Higgins JP, eds. Dening the review question and developing criteria for including studies. In: Higgins JP, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0 [updated March 2011]. Part 2: General methods for Cochran reviews. Oxford, UK: Cochrane Collaboration; Available at: http:// www.cochrane-handbook.org/. Accessed June 25, 2011. 33. Ellis MF. Topical anaesthesia: a risk factor for post-cataractextraction endophthalmitis? Clin Experiment Ophthalmol 2003;31:125 8. 34. Monica ML, Long DA. Nine-year safety with self-sealing corneal tunnel incision in clear cornea cataract surgery. Ophthalmology 2005;112:985 6. 35. Kallio H, Uusitalo RJ, Maunuksela EL. Topical anesthesia with or without propofol sedation versus retrobulbar/ peribulbar anesthesia for cataract extraction: prospective randomized trial. J Cataract Refract Surg 2001;27: 13729.

Footnotes and Financial Disclosures

Originally received: September 30, 2010. Final revision: September 29, 2011. Accepted: September 29, 2011. Available online: February 22, 2012. Academic Discipline Project (Project No. S30205) and General Program of the Biomedical Division of the Shanghai Science and Technology Commission (Project No. 10411966200). Manuscript no. 2010-1358. Correspondence: Huang Zhu, MD, Department of Ophthalmology, Xinhua Hospital Afliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China. E-mail: zhuwjp@sh163.net.

Department of Ophthalmology, Xinhua Hospital Afliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Funding: Grants from the Shanghai Leading

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