Ophthalmic surgery has long been associated with the administration of anesthesia, owing to the potential for significant patient pain and the discomfort associated with eye operations [1]. Recently, however, medical advances have resulted in the development of less intensive procedures in many cases, allowing eye surgeons to move away from general anesthesia and towards local anesthesia [1]. This move prompts two questions: To what extent can anesthesia be administered without an anesthesia provider during eye surgery? And if surgeons do so, what should they keep in mind to ensure successful pain management and operations? 

The most notable example of a transition towards anesthesia without an anesthesia provider is cataract eye surgery. Although ophthalmologists who do not use anesthesia providers remain in the minority in the United States – one study reported that only 6% of surveyed ophthalmologists never employ the services of an anesthesia provider, and 17% opt not to in some cases – they still represent a growing shift away from the status quo [2]. Furthermore, the study found that patients who received cataract surgery without an anesthesia provider present experienced a low rate of systematic complications, such as stroke and myocardial infarction [2]. With just a topical anesthetic, midazolam, and fentanyl, ophthalmologists can safely manage patient sedation and pain without an anesthesia provider in some cases, which has the potential to reduce patient costs [2]. This study, paired with the growing number of physicians performing cataract surgery without sedation or anesthetic monitoring in other countries, suggests the effectiveness of this strategy [3]. 

Pars plana vitrectomy (PPV) is another example of eye surgery in which anesthesia without an anesthesia provider may be a viable option [4]. Traditionally, surgeons performed PPV alongside an anesthesiologist, who would administer either general anesthesia or monitored anesthesia care, in addition to a local ocular block [4]. Research on this topic is still in its infancy. However, some eye surgeons believe that oral anesthesia for PPV retina surgery, without an anesthesia provider, has potential, and research is ongoing [4]. 

The benefits and risks of performing eye surgery without an anesthesia provider and, particularly, an anesthesiologist are significant. By not having an anesthesiologist present, patients could experience significant cost reductions [4]. This would most benefit patients who either lack insurance or have insurance plans with high deductibles [4]. Of course, finances alone are not a sufficient justification for opting for this potentially riskier course, but it can be an important factor to consider [4]. Conversely, eye surgery without anesthesiologists can carry high risks, including block ineffectiveness, increased risk of complications, lack of patient cooperation with instructions, and opioid dependency [4, 5]. Proper training for the physician administering anesthesia is critical. When weighing these advantages and disadvantages, paying attention to the patient’s profile is essential. 

To successfully perform eye surgery without an anesthesia provider, training and collaboration are key [6]. Even if ophthalmologists opt not to be accompanied by anesthesia providers during surgery, they should nevertheless be guided by the techniques and advice of anesthesia providers to ensure that they are using best practices and avoiding undue risks [6]. Ultimately, anesthesia without an anesthesia provider appears to be a feasible and successful strategy for many eye surgeons, so long as it is undertaken with ample preparation and care. 

References 

[1] S. Prineas, “Local and Regional Anesthesia for Ophthalmic Surgery,” NYSORA. [Online]. Available: https://www.nysora.com/topics/regional-anesthesia-for-specific-surgical-procedures/head-and-neck/ophthalmic/local-regional-anesthesia-ophthalmic-surgery/.  

[2] J. Berthold, “Study Casts Doubt on Routine Use of Anesthesiologists in Cataract Surgery,” University of California San Francisco, Updated October 3, 2022. [Online]. Available: https://www.ucsf.edu/news/2022/09/423931/study-casts-doubt-routine-use-anesthesiologists-cataract-surgery.   

[3] D. Perumal et al., “Anesthesia Care for Cataract Surgery in Medicare Beneficiaries,” JAMA Internal Medicine, vol. 182, no. 11, p. 1171-1180, October 2022. [Online]. Available: https://doi.org/10.1001/jamainternmed.2022.4333.  

[4] M. Adam and E. Podesto, “Virectomy Without Intravenous Anesthesia,” Retina Today, Updated October 2020. [Online]. Available: https://retinatoday.com/articles/2020-oct/vitrectomy-without-intravenous-anesthesia.  

[5] R. S. Davidson et al., “Persistent opioid use in cataract surgery pain management and the role of nonopioid alternatives,” Journal of Cataract & Refractive Surgery, vol. 48, no. 6, p. 730-740, June 2022. [Online]. Available: https://doi.org/10.1097/j.jcrs.0000000000000860.  

[6] A. Pawa and K. El-Boghdadly, “Regional anesthesia by nonanesthesiologists,”  Current Opinion in Anaesthesiology, vol. 31, no. 5, p. 586-592, October 2018. [Online]. Available: https://doi.org/10.1097/ACO.0000000000000643.