Eyeworld

62 | EYEWORLD | SPRING 2026 ATARACT C References 1. Chen M, et al. Oral diazepam versus intravenous midazolam for conscious sedation during cataract surgery performed us- ing topical anesthesia. J Cataract Refract Surg. 2015;41:415–421. 2. Hanna A, et al. Intravenous vs nonintravenous sedation for cat- aract surgery: systematic review and meta-analysis. J Cataract Refract Surg. 2025;51:723–730. 3. Peeler CE, et al. Patient satisfaction with oral versus intravenous sedation for cataract surgery: a randomized clinical trial. Ophthalmology. 2019;126:1212–1218. 4. Menezes J, Zahalka C. Anes- thesiologist shortage in the Unit- ed States: a call for action. J Med Surg Pub Health. 2024;100048. for surgery unless that's requested. There's no preoperative testing besides what's done in the ophthalmologist's office. The day of surgery, the time that they're there is shorter. It's less inva- sive. The thing that hurts the most for cataract surgery is the IV needle being placed, so that doesn't happen. From an insurance perspective, the insurer is not paying an anesthesiologist, a primary care physician, and a cardiologist for clearance. There's a lot less cost to the system." But the question of whether oral sedation will become more mainstream is not just a mat- ter of efficacy or economics. "In my ASC, we're torn between competing forces," Dr. Feldman said. Most ASCs employ an anesthesiologist and/or CRNAs, and they need to have enough cases to keep them busy, he said. "We have a minimum number of cases per day that we have to schedule in order to have an anesthesiologist. If we don't meet it, they might cancel the day." In addition, for an ASC to switch from an IV-sedation model to a primarily oral sedation model would not be easy, Dr. Feldman said. Everything from the financial structure to the layout of the building, with multiple large stag- ing areas, is geared toward a more costly, less efficient, and staffing heavy IV-sedation model in ASCs, he said. Dr. Mian described a study that he was involved in that compared oral sedation to intravenous sedation in a large academic, hos- pital setting, evaluating efficiency and patient satisfaction for "simple" cataract surgery. The study, which was presented at major medical meetings but is not yet published in peer review, enrolled 188 patients, 54 of whom received the oral sedation. According to Dr. Mian, there was no differ- ence in procedure time or PACU time, though he noted there was a trend toward it being "a little bit shorter" for patients who received oral se- dation. In terms of patient expectations, patient comfort, and nausea, there was no difference between the two groups. Dr. Mian also said there was no difference in patients saying they felt "out of it" in the postop period. "The patients who got oral sedation did feel overall that they were a little more anxious than the ones who got IV sedation because they were more aware of what was happening. So there was a small difference there," he added. Patients were happy with both types of sedation, and Dr. Mian reported patients saying the most uncomfortable part of the entire surgi- cal process was receiving an IV. In the study all patients received an IV, even if they were given oral sedation. "Our results showed that, at least in our system, there was no downside to switching to oral sedation," Dr. Mian said. "Patients felt just as safe, and they felt that they were comfortable during the procedure. In fact, there was the opportunity to get rid of the IV, which was the most uncomfortable part of the procedure. "We also established that, for our system, it was an efficient process. It did not take more time, which was what we're trying to show to our team—that it is a safe, effective, and effi- cient process, that IV sedation is not necessarily required for all patients," Dr. Mian said. Special considerations While oral sedation in many cases does not require a CRNA or an anesthesiologist, Dr. Lobanoff said it's incumbent on the surgeon administering the sedation and performing the procedure to make sure several things are monitored. "In preop we check everyone's pulse, blood pressure, temperature. We make sure they're within safe parameters. During the procedure itself, we're monitoring heart rates. We're watching the patient, making sure they're breathing," he said. "The patient is awake during the procedure, so you can communicate with them, ask how they're doing. This is better for understanding what their medical condition is at that moment." If you're operating in an office-based surgical suite with oral sedation, Dr. Lobanoff said the facility will have advanced cardiac life support (ACLS) available, and staff members will have passed ACLS training. "You should be able to run a crash cart. A lot of docs say, 'I haven't done that in many years.' But you can learn it. The number of times we've used it? Zero. But you need to be ready in the rare case it ever does occur," Dr. Lobanoff said. Even if there is a surprise during surgery, where a routine cataract procedure becomes complicated, Dr. Lobanoff said he's still been able to manage the case with oral sedation. He described a case that ended up with a posterior capsule tear, requiring an anterior vitrectomy and other measures. The case took about an hour. continued from page 60

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