Cataract surgery, one of the most frequently performed procedures in the world, is generally quick, safe, and effective. However, ensuring patient comfort and cooperation during the operation remains a critical concern. The choice of anesthesia strategy is central to achieving a successful outcome. Various approaches—ranging from topical anesthetics to regional blocks and general anesthesia—are available, and a comparison of the advantages and disadvantages of each should be informed by the patient’s medical profile and the complexity of the cataract surgery. Sedation complements several of these techniques, offering additional comfort and reducing anxiety without the need for full unconsciousness.
Topical anesthesia is the most commonly used method for modern cataract surgery, especially with phacoemulsification, a minimally invasive technique. In this approach, anesthetic eye drops are applied to numb the surface of the eye. This method is popular because it avoids needles, has minimal recovery time, and is associated with fewer complications. However, while topical anesthesia provides good pain control, it does not immobilize the eye (a state known as akinesia), which can be challenging in patients who are anxious or unable to keep their eye still. In a comparison of topical anesthesia for cataract surgery versus other approaches, this factor is a major disadvantage in many cases.
To enhance patient comfort and reduce intraoperative movement under topical anesthesia, mild to moderate sedation is often used. Sedatives such as midazolam or fentanyl may be administered intravenously to help patients relax while remaining responsive. Sedation alongside topical anesthesia allows for a smoother surgical experience without compromising safety. For patients, it can alleviate anxiety and reduce the perception of time during the brief but delicate procedure.
For patients who require greater control over eye movement or for surgeries expected to be more complex, regional blocks offer an alternative. Retrobulbar and peribulbar blocks involve injecting local anesthetics around or behind the eye to achieve both anesthesia and akinesia. These techniques provide excellent conditions for the surgeon by eliminating pain and involuntary eye movement. Retrobulbar blocks, placed within the muscle cone of the eye, tend to provide faster and deeper anesthesia, but they carry a slightly higher risk of complications such as globe perforation or optic nerve injury. Peribulbar blocks, placed outside the muscle cone, are somewhat safer but may require more time to take effect.
Sub-Tenon’s block, a technique involving injection into the space between the sclera and the Tenon’s capsule, has grown in popularity. It offers good anesthesia and moderate akinesia for cataract surgery, with a lower risk of serious complications in comparison to retrobulbar injections. Like other regional methods, it is often combined with light sedation to reduce discomfort from the injection and to improve patient tolerance during the surgery.
Sedation plays a key role across all these techniques. Even when the eye itself is fully anesthetized, patients may feel nervous or unsettled. Sedation provides a middle ground between full consciousness and general anesthesia, offering psychological relief and promoting a calmer surgical environment. The level of sedation is carefully titrated so that patients remain awake but relaxed, maintaining vital reflexes and communication with the surgical team.
General anesthesia is rarely used in routine adult cataract surgeries due to its increased risks and longer recovery times. However, it remains necessary for certain patients, such as young children, individuals with significant movement disorders, or those with cognitive impairments who cannot cooperate with surgeon instructions. In these cases, the benefits of complete unconsciousness and immobility often outweigh the risks. Anesthesia strategies for cataract surgery are tailored to the individual, balancing safety, comfort, and surgical requirements. Topical anesthesia with light sedation suits the majority of patients, while regional blocks and, in select cases, general anesthesia offer options for those needing more comprehensive management. Sedation enhances nearly every approach, serving as a valuable tool for optimizing the patient’s experience during this highly successful and commonly performed surgery.