Dear Editor,

We read with great interest the article by Ruschen et al. comparing patient satisfaction during cataract surgery with sub-Tenon’s block (STB) versus topical anaesthesia (TOP) [1]. The authors concluded that in the setting of day case cataract surgery, patients reported significantly higher satisfaction scores with STB than TOP.

We would like to raise two issues for discussion. Firstly, the lower satisfaction score in the TOP group may only reflect a suboptimal TOP that was given in the current study and may not be generalisable to other forms of TOP. In our experience, lignocaine gel (lidocaine hydrochloride 2%, AstraZeneca? Sweden) produces significantly better anaesthetic effects than local anaesthetic eyedrops. Lignocaine gel has been previously shown to be an effective [2,3] and possibly a more superior [4,5] anaesthetic agent in cataract surgery, as well as giving better patient cooperation with less intra-operative supplement [5]. To further evaluate the apparent lower satisfaction scores with TOP than STB, we would be grateful if the authors could provide the details on their TOP anaesthetic procedure, for example how long before the actual surgery were proxymetacaine and amethocaine given and whether supplementary anaesthetic eyedrops were allowed during the surgery?

Secondly, even though the median satisfaction score in the TOP group was significantly lower than that of the STB group, there was a much larger variation in the TOP group (Figure 1). This would imply some patients were satisfied whilst some were dissatisfied. We certainly believe not all patients can tolerate TOP and it would be highly desirable for cataract surgeons to identify the latter group pre-operatively. Were there any specific characteristics in this group showing such dissatisfaction? Moreover, we noted that there were more females (12 out of 14 patients) in the TOP group, compared to the STB group (5 out of 14 patients). This difference was statistically significant (p = 0.018, Fisher’s exact test). We recognise that randomisation had been implemented in the present study and any significant differences in patients? Demographics were beyond the control of the authors. However, such difference might have impacted the satisfaction scores, as it is known that women have high rates of physical symptoms reporting [6].

Nonetheless, we do commend the authors? work on this important topic. We agree with the authors that sub-Tenon's anaesthesia may be a better choice in some patients undergoing cataract surgery. However, other forms of topical anaesthesia may produce equally good, if not better, patient satisfaction especially in selected patients.

References

1. Rüschen H, Celaschi D, Bunce C, Carr C. Randomised controlled trial of sub-Tenon’s block versus topical anaesthesia for cataract surgery: a comparison of patient satisfaction. Br J Ophthalmol. 2005; 89: 291-293.

2. Barequet IS, Soriano ES, Green WR, O'Brien TP. Provision of anesthesia with single application of lidocaine 2% gel. J Cataract Refract Surg. 1999 May;25(5):626-31.

3. Assia EI, Pras E, Yehezkel M, Rotenstreich Y, Jager-Roshu S. Topical anesthesia using lidocaine gel for cataract surgery. J Cataract Refract Surg. 1999 May;25(5):635-9.

4. Bardocci A, Lofoco G, Perdicaro S, Ciucci F, Manna L. Lidocaine 2% gel versus lidocaine 4% unpreserved drops for topical anesthesia in cataract surgery: a randomized controlled trial. Ophthalmology. 2003 Jan;110(1):144-9.

5. Soliman MM, Macky TA, Samir MK. Comparative clinical trial of topical anesthetic agents in cataract surgery: lidocaine 2% gel, bupivacaine 0.5% drops, and benoxinate 0.4% drops. J Cataract Refract Surg. 2004 Aug;30(8):1716-20.

6. van Wijk CM, Kolk AM. Sex differences in physical symptoms: the contribution of symptom perception theory. Soc Sci Med. 1997 Jul;45(2):231 -46.