Eyeworld

SPRING 2026 | EYEWORLD | 63 C Relevant disclosures Feldman: None Lobanoff: Alcon, Bausch + Lomb, iOR, Tracey Technologies Mian: None Contact Feldman: bfeldman@phillyeye.com Lobanoff: mlobanoff@gmail.com Mian: smian@med.umich.edu "What did we do? At the half-hour mark, the nurse put another half MKO Melt [midaz- olam, ketamine, and ondansetron, Imprimis] under their tongue, and we continued on as if nothing happened," he said. "You certainly want to assess the patient, make sure they need it, but that's the situation where you say, 'I know the half-life of this drug. I know its time course. I know when we gave the first dose, and I know how the patient responded to that dose. Let's give half the first dose,' and that often covers the issue." Regardless of where you practice, Dr. Mian said patient safety comes first. There needs to be a system to screen patients and determine if they are truly routine and thus eligible for oral anesthesia. He also said that basic life support and airway management training is important. "Whether it's due to the anesthesia or not, it's imperative that you're prepared to take care of them. Any member of the team who's in the room should be familiar with the medications that the patients are getting and how to reverse the effects of those medications," Dr. Mian said. Also of note are global sedation practices, many of which don't include any sedation for cataract surgery. Dr. Feldman said through- out his years working outside the U.S., he's observed and participated in cataract surgery being safely practiced with limited to no anes- thesia and without anesthesiologists or CRNAs. "We've always had a traditional way of doing it in the U.S., which is anesthesiologists or CRNA and IV sedation. That's been the model here for a long time," he said. "But the experi- ence and data from abroad shows that outcomes can be excellent without IV anesthesia." Types of oral sedation Dr. Feldman said much of the oral sedation he's using for cataract surgery is based on what he uses for refractive surgery: alprazolam or diaz- epam. These medications generally take 15–45 minutes to take effect, which Dr. Feldman said is convenient because that matches the timeframe for pupillary dilation. There is also the MKO Melt. The ondanse- tron acts as an anti-nausea, and the ketamine acts as a dissociative, taking away perception of pain and relieving anxiety, Dr. Feldman said. Younger patients, such as those in the re- fractive lens exchange group, Dr. Lobanoff said, usually require a full MKO Melt, while older patients having cataract surgery are generally given about 10 mg of diazepam. If a patient is still anxious after diazepam, Dr. Feldman said they will consider the addition of an MKO Melt. Dr. Feldman said he's done around 2,000 cases using oral sedation and hasn't had to cancel a single case due to inadequate sedation. In addition, Dr. Feldman said he hasn't had any complications due to over sedation with an oral sedative, while he has had complications occur during cases at the ASC due to over sedation with IV anesthesia. When IV sedation is still necessary The surgeons interviewed for this article all said there are cases where IV sedation is still pre- ferred. These include the highly anxious patient, patients with more advanced medical problems, such as morbid obesity or respiratory issues, and patients whose cataract surgery is likely to be more complex. Practicing at an academic medical center, Dr. Mian said a lot of their patients are not routine. "They have a history of trauma, or they have other health risk factors," he said. "There are many different reasons why we need the ability to have more careful monitoring, more careful evaluation prior to surgery, and monitor- ing for their health overall during the surgery. The cases may also be longer." In addition to a more complicated medi- cal history, Dr. Mian said more complex cases may need IV sedation. "But for routine cases, it certainly is reasonable to consider oral sedation, hopefully in the future sublingual sedation, which could have a faster onset and quicker recovery." "Do you need IV sedation for [routine cataract surgery]? You don't. We've just been accustomed to it. Just because it's what was offered before doesn't necessarily mean it's the best way forward," Dr. Lobanoff said. "Overall, oral sedation is a safe way to provide care, not just based on our small study, but based on other published studies and how people are practicing," Dr. Mian said. "Again, I think making sure that we have appropriate training for the medications that are being used and appropriate screening for patients is important."

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