We read with interest Zia et al’s article, which highlights a professional artist’s and a poet’s respective renditions of their visual experiences during phacoemulsification and intraocular lens implantation under local anaesthesia.¹ While it is unclear from the report whether the artist’s elaborate drawing resembling a “colourful monkey” was associated with a pleasant or frightening visual experience, it appears from the poem that the poet’s visual experience was most probably pleasant and delightful.

We have previously reported that the visual experience during cataract surgery under local anaesthesia can be frightening in up to 16.2% of patients.^2–8 The anxiety that may result from the intraoperative visual experience is clinically significant because it may cause patients to become uncooperative during the procedure and trigger a sympathetic stress response. This may result in hypertension, tachycardia, ischaemic strain on the heart, hyperventilation, and acute panic attacks. These stress responses are particularly undesirable in cataract patients who are often elderly, with systemic co-morbidities such as hypertension and ischaemic heart disease.^2,9 The frightening experience may also lower patients’ satisfaction with the surgery.^10,11

The poet’s experience reported by Zia et al reminds us that the intraoperative visual experience during cataract surgery can be pleasant for some patients.¹ In fact, our experience has shown that the majority of patients find their visual experiences pleasant and, in some cases, the visual experience actually increases their satisfaction with the surgery. In a recently reported randomised controlled trial conducted in India involving 304 patients who underwent phacoemulsification under either topical anaesthesia (TA) or retrobulbar anaesthesia (RA), the visual experience was reported by 106 out of 154 (68.8%) TA and 102 out of 150 (68%) RA patients to be pleasant and by 47 (30.5%) TA and 46 (30.7%) RA patients to be unpleasant.¹² In a separate unpublished study conducted in Singapore, eight of 98 patients (8.2%) who had phacoemulsification under TA reported that their satisfaction with the surgery increased because of their visual experiences, whereas only two patients (2.0%) experienced a decrease in satisfaction. The remaining 88 patients (89.8%) reported that their visual experience did not affect their satisfaction with the surgery. Some of the patients who found their visual experiences pleasant commented on the “fantastic colours” that they experienced. In another similar study on patients who had cataract surgery under RA, nine of 152 patients (5.9%) experienced an increase in satisfaction, whereas five patients (3.3%) thought that their satisfaction had decreased as a result of the visual experiences and the remaining 138 patients (90.8%) experienced no change in their satisfaction.

An additional observation is from videotaped interviews conducted by one of us (CMK) with several leading ophthalmic anaesthesia providers in the United States who had cataract surgery under local anaesthesia themselves. The video recordings were made during the annual scientific meeting of the Ophthalmic Anaesthesia Society held in Chicago in October 2004. The videos clearly showed they reported seeing pleasant and beautiful images during their surgery.

In summary, patients may experience pleasant or unpleasant visual sensations during cataract surgery under local anaesthesia. Further investigation is warranted to help ascertain how we can reduce the possibility of the experience being unpleasant or frightening.