At my practice, we do nearly all our procedures in our office-based surgery center. One of the most appealing aspects of transitioning to office-based cataract surgery was the shift toward using light oral anesthesia, such as oral Valium, over heavier forms of sedation. This evolution resulted in a major positive change in how we do our lens procedures, and benefits for everyone involved.
The evolution of anesthesia for lens procedures has been interesting to watch. When I was a first-year resident, the majority of our cases were done under a retrobulbar block with IV sedation. Toward the end of my residency, the trend was moving toward topical anesthesia with moderate IV sedation. In the last 15 years, the process has shifted more toward topical pain relief with less and less systemic sedation. We are at the point now where over 80% of our cases are done under light oral sedation. This was a big change for me, and it took some time to adjust to the concept. Some physicians are apprehensive about the new approach. I had the same concerns when I first considered it. Over time, I have found that oral sedation in an office-based center results in the most relaxed patients of any combination of location and anesthesia that I’ve ever used.
Lighter Anesthesia, Better Outcomes
We have found that the office-based surgery setting reduces patient anxiety from the start, leading to less need for sedation. Patients do not feel like they are in a medical facility having a major medical intervention. They can eat and drink before their procedure. They do not change into a gown or start an IV. Most of the usual signals that surgery is about to happen are not there. It is much more of a LASIK-like experience, with less emotional stress. The patients are in the same environment they have been in for their pre-op evaluations, they recognize the same staff and they feel comfortable and safe.
While this was an interesting discovery as we progressed in our office-based surgical journey, in retrospect, it makes perfect sense. For decades, LASIK has been done with just mild oral sedation to counter an otherwise high anxiety-provoking experience for patients: a strange apparatus comes into the eye, there is suction and pressure, there are loud noises and aromas. Alternatively, for lens procedures, topical and intraocular anesthesia is so good that patients literally feel nothing. So it is no surprise that IOLs can be done under this type of sedation.
A Little Help is Helpful
“Class A” anesthesia means no or light oral sedation, does not require a nurse anesthetist and is fine for most patients and procedures. For “Class B” cases, those with a need for closer monitoring or deeper sedation, I have a certified registered nurse anesthetist (CRNA) present. For the majority of such cases, the CRNA is primarily there for enhanced monitoring of the patient. I prefer a CRNA present if the patient has significant co-morbidity such as heart disease, poorly controlled hypertension or diabetes, or any condition where an extra pair of well-trained eyes could be helpful. The anesthetist may use oral, sub-lingual or higher-level IV sedation if needed, but the patient stays conscious. The sedation is still very light.
We do not do general anesthesia with unconscious sedation, which would require a Class C setting. Almost all of our cases are Class A, with only occasional Class B days that require the nurse anesthetist. Over time the percentage of cases we do in a Class B environment has decreased.
Advice for Newbies of Office-Based Surgery
For surgeons considering transitioning to oral anesthesia, some find it valuable to try it first in their current OR setting before moving to an office-based surgical suite. After several cases, comfort increases and the barrier to transition to an in-office setting is much less daunting. Some surgeons also gain confidence by using a CRNA for a while as they adapt to the new office OR. Before long, surgeons are pleasantly surprised to discover they need much less assistance than they thought they would.