Eyeworld

36 | EYEWORLD | DECEMBER 2023 ATARACT C by Liz Hillman Editorial Co-Director About the physicians Rosa Braga-Mele, MD Professor of Ophthalmology University of Toronto Toronto, Canada Shawn Lin, MD Assistant Professor of Cataract and Refractive Surgery Associate Residency Program Director Medical Director UCLA Stein Eye Center Calabasas Los Angles, California A nxiety is common among patients headed into the OR for cataract surgery, but when anxiety turns into agitation, it could mean a higher risk for intraoperative complications or a delay in surgery. "At least 10% [of patients] can become anxious or agitated. This can take many forms, from a patient shaking their leg to something more drastic such as suddenly moving their head," said Shawn Lin, MD. Rosa Braga-Mele, MD, further differentiat- ed. She also said she thinks anxiety occurs in 10–20% of cases, while 5% of patients expe- rience some disinhibition and 1% reach true agitation. "It's a spectrum," Dr. Braga-Mele said. "Agitation itself is very rare. It's a whole spec- trum of anxiety, disinhibition, agitation." The anxiety spectrum Anxiety is normal and experienced to some level by all patients who are fearful of the operation. Dr. Braga-Mele said anxiousness can be con- trolled with more medications or verbal anes- thesia (talking to the patient before and during the surgery about what to expect and what's going on). Disinhibition is when the person is not en- tirely in control of their faculties, she continued, and can occur with too much medication, due to patient personalities or pre-existing condi- tions, or how they react to medication. Working with anesthesia, handholding, and gentle verbal anesthesia is helpful in these situations. Agitation occurs when the patient is out of control to a point where surgery needs to stop temporarily or be postponed entirely for patient safety. When a patient becomes truly agitated, Dr. Lin said it's often too late for anesthesia to make efficient adjustments for the case. "The key is to recognize it early enough to come out of the eye before the real agitation occurs," Dr. Braga-Mele said. "Deal with the agitation, talk to the patient before you go back into the eye. Don't try to deal with agitation while you're in the middle of doing phaco be- cause they may move." Preventative medicine Dr. Lin said he thinks the most important thing to alleviate anxiety and help avoid true agita- tion in the OR is prevention and setting expec- tations. "I talk to patients outside of the room, get them comfortable, get them to laugh, loosen them up a bit. I tell them it's almost like a con- cert: There is a light show, music, and they're going to have a couple of glasses of wine," he said. "I try to set the expectation of what they're going to experience in a positive light." He said that expectation setting is espe- cially important on the second eye. "I find that discomfort is about two to three times higher on the second eye," he said. "They expect that everything is going to feel the same, but they essentially have perioperative amnesia due to the medications they received during the first surgery. I like to tell them that the second eye will feel like a completely different surgery, and they will likely perceive the whole thing as a brand new experience." Dr. Lin said this is an area he is actively re- searching, seeking to figure out what actions by the surgeon, anesthesiologist, and support team might help patients be less anxious or agitated during the second eye surgery. Agitation in the OR Dr. Lin talks to a patient while administering proparacaine before cataract surgery. He likes to speak with patients outside the room to try to make them comfortable. Source: Shawn Lin, MD

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