We periodically attempted to use topical anesthesia from 1991 to 1994 with only moderate patient and surgeon satisfaction. It was not until we added intracameral lidocaine, a technique developed by James Gills, MD, that we were actually able to achieve a high degree of success. With this addition, we now perform approximately 80% of our cataract surgical cases using the combined approach of topical and intracameral anesthesia. We continue to use anterior periocular injections of lidocaine for selected cases, such as non–Englishspeaking patients, those who tend to tightly squeeze their eyelids when touched, and those who cannot respond well to oral directions. We have not used retrobulbar or seventh nerve blocks since 1982, and posterior peribulbar blocks since 1991.

Discussion of anesthesia technique with the patient before their surgical date is imperative. We stress that there will be touch, temperature, and pressure sensations, but there should be no “discomfort.” We do not use the term “pain.” On the day of surgery, this theme is reiterated several times during surgical preparation. Patients are advised to tell us immediately if they experience any discomfort and are reassured that this can be relieved in a matter of seconds.

Our premedication consists of the following: Two drops each of cyclopentolate 1% and phenylephrine hydrochloride 2.5%, and four drops of suprofen 1%. If the patient is apprehensive, 0.5 mg to 1.0 mg midazolam is administered intravenously. Approximately 10 minutes before entering the operating room, four drops of proparacaine hydrochloride 0.5% and two drops of bupivacaine 0.75% are instilled. The patient is asked to keep their eyes closed after each instillation.

In the operating room, three additional drops of proparacaine are instilled. A 10% providone iodine periocular skin preparation and 5% povidone iodine ocular irrigation is performed. After the lid speculum is inserted, two to three drops of bupivacaine 0.75% is added. If a peritomy is performed, 0.5 mL of bupivacaine can be irrigated just under the edge of the conjunctiva. Following the paracentesis, 0.3 mL of nonpreserved lidocaine 1% is injected slowly into the anterior chamber. It is very important that this be performed slowly, allowing aqueous egress around the canula. If the medication is injected too rapidly, the sudden rise in intraocular pressure and deepening of the chamber will stretch the iris and cause pain.

If the case takes longer than anticipated, additional lidocaine is instilled into the anterior chamber. If the vitreous face is ruptured, care is taken to instill only a small amount (0.2 mL) and gentle irrigation is used to remove it from the chamber so as to prevent potential retinal contact. If the case proceeds as expected, a small amount of lidocaine can be instilled into the chamber just before inserting the intraocular lens. Although usually not necessary, this assures adequate anesthesia to finish the case and allows for early postoperative anesthesia.

If subtenon antibiotic injection is to be performed, we inject 0.2 mL of unpreserved lidocaine in the area where the injections will be given just before their use. At the end of the case, one drop of proparacaine is placed in the cul-de-sac if an antibiotic ointment is to be used. No patch is used.

We have used this technique in cases of miotic pupils requiring significant intraoperative pupillary stretching, unplanned vitrectomies, combined cataract-trabeculectomies, secondary implants, and intraocular lens exchange procedures.