- Email: [email protected]
Reply: Second-eye pain in cataract surgery
LETTERS
Second-eye pain in cataract surgery 1
In their recent article, El Rami et al. addressed the issue of pain in fellow-eye ophthalmic surgical procedures. They propose the interesting central process of sensitization as a physiological mechanism that may explain why many patients report more pain after second-eye procedures. Nonetheless, we believe that the psychological explanation, as proposed by Ursea et al.,2 bears the largest responsibility for this phenomenon, especially in nonsimultaneous cases. In an intraindividual study of second-eye cataract procedures,3 we found an interesting inconsistency between the actual visual analog scale score given by patients at the end of each procedure and their final judgment about which procedure was more painful. Although the actual mean visual analog scale score was not significantly different between first- and second-eye procedures and only 40% of patients actually scored the second procedure more painful than the first, when asked “Did you feel more pain after the first or the second procedure?” 57.41% of the patients judged the second procedure more painful and 41.94% of them had attributed a higher visual analog scale score to the first procedure. The percentage of patients who actually attributed a higher visual analog scale score to the second procedure is the same (40%) as that reported by Ursea et al.2 Moreover, Ursea et al.2 also found a significant disagreement between the subjective response and the actual calculated change in the visual analog scale score. It must be emphasized that in our series no benzodiazepines were administered and that despite such a difference in surgical procedure, similar results were obtained. Psychology of pain perception may help us better understand this phenomenon. In any case, anticipating an enhanced patient perception by alerting the patient or by augmenting anesthesia may achieve better cooperation and improve patient comfort. Antonio Bardocci, MD Rome, Italy REFERENCES 1. El Rami H, Fadlallah A, Fahd D, Fahed S. Patient-perceived pain during laser in situ keratomileusis: comparison of fellow eyes. J Cataract Refract Surg 2012; 38:453–457 2. Ursea R, Feng MT, Zhou M, Lien V, Loeb R. Pain perception in sequential cataract surgery: comparison of first and second procedures. J Cataract Refract Surg 2011; 37:1009–1014 3. Bardocci A, Ciucci F, Lofoco G, Perdicaro S, Lischetti A. Pain during second eye cataract surgery under topical anesthesia: an intraindividual study. Graefes Arch Clin Exp Ophthalmol 2011; 249:1511–1514
Reply : Pain perception in ocular surgery is a complex issue that is not fully understood. Ursea et al.1 mentioned 3 possible mechanisms that could explain why many patients feel more pain in second-eye cataract
1705
surgery; namely, the physiological explanation (surgery in the first eye causes sympathetic irritation that sensitizes the second eye to painful stimuli), the pharmacological explanation (previous exposure to analgesic and sedative medications during the first surgical procedure leads to drug tolerance so the response to the same medications is decreased during the second operation), and the psychological explanation (in the second operation, patients are not as well prepared for the degree of wakefulness and magnitude of sensation they will have during that procedure). Although none of these explanations have been proven, both Ursea et al.1 and Bardocci et al.2 favor the psychological explanation. In our study of pain in the second eye of laser in situ keratomileusis (LASIK) patients, we did not assert that a central process of sensitization is the reason patients felt more pain in the second-eye LASIK procedure because we did not have the means to perform biochemical measurements of humoral factors and the neurotransmitters involved in pain perception; thus, we could not prove or reject the above hypothesis, nor did we favor any of the 3-mentioned explanations. Our clinical experience tells us that in any type of ocular surgery, psychological preparation of patients and/or sedation are more effective when given preoperatively than when given after the patient has begun to experience pain. However, pain perception in cataract surgery is different from that felt in ocular surface surgery. What varies are the sedation and anesthesia used, the consecutive simultaneous or nonsimultaneous surgery, the sensory nerve plexuses involved, the amaurosis felt by the suction ring, and the surveying in the immediate postoperative period. Some of these factors could explain why pain in the secondeye surgery was experienced at a much higher rate (w75%) than in cataract surgery as reported by Ursea et al.1 and Bardocci et al.2 (w40% to 57%). The higher rate could also be due to the fact that the 1-point visual analog scale was administered immediately after the consecutive surgeries and with no intravenous sedation. We fully agree with Dr. Bardocci that “anticipating an enhanced patient perception by alerting the patient or by augmenting anesthesia may achieve better cooperation and improve patient comfort.”2dSharbel Fahed, MD, MS, Hala El Rami, MD, Ali Fadlallah, MD, Daøud Fahd, MD REFERENCES 1. Ursea R, Feng MT, Zhou M, Lien V, Loeb R. Pain perception in sequential cataract surgery: comparison of first and second procedures. J Cataract Refract Surg 2011; 37:1009–1014 2. Bardocci A, Ciucci F, Lofoco G, Perdicaro S, Lischetti A. Pain during second eye cataract surgery under topical anesthesia: an intraindividual study. Graefes Arch Clin Exp Ophthalmol 2011; 249:1511–1514
J CATARACT REFRACT SURG - VOL 38, SEPTEMBER 2012
Second-eye pain in cataract surgery 1
In their recent article, El Rami et al. addressed the issue of pain in fellow-eye ophthalmic surgical procedures. They propose the interesting central process of sensitization as a physiological mechanism that may explain why many patients report more pain after second-eye procedures. Nonetheless, we believe that the psychological explanation, as proposed by Ursea et al.,2 bears the largest responsibility for this phenomenon, especially in nonsimultaneous cases. In an intraindividual study of second-eye cataract procedures,3 we found an interesting inconsistency between the actual visual analog scale score given by patients at the end of each procedure and their final judgment about which procedure was more painful. Although the actual mean visual analog scale score was not significantly different between first- and second-eye procedures and only 40% of patients actually scored the second procedure more painful than the first, when asked “Did you feel more pain after the first or the second procedure?” 57.41% of the patients judged the second procedure more painful and 41.94% of them had attributed a higher visual analog scale score to the first procedure. The percentage of patients who actually attributed a higher visual analog scale score to the second procedure is the same (40%) as that reported by Ursea et al.2 Moreover, Ursea et al.2 also found a significant disagreement between the subjective response and the actual calculated change in the visual analog scale score. It must be emphasized that in our series no benzodiazepines were administered and that despite such a difference in surgical procedure, similar results were obtained. Psychology of pain perception may help us better understand this phenomenon. In any case, anticipating an enhanced patient perception by alerting the patient or by augmenting anesthesia may achieve better cooperation and improve patient comfort. Antonio Bardocci, MD Rome, Italy REFERENCES 1. El Rami H, Fadlallah A, Fahd D, Fahed S. Patient-perceived pain during laser in situ keratomileusis: comparison of fellow eyes. J Cataract Refract Surg 2012; 38:453–457 2. Ursea R, Feng MT, Zhou M, Lien V, Loeb R. Pain perception in sequential cataract surgery: comparison of first and second procedures. J Cataract Refract Surg 2011; 37:1009–1014 3. Bardocci A, Ciucci F, Lofoco G, Perdicaro S, Lischetti A. Pain during second eye cataract surgery under topical anesthesia: an intraindividual study. Graefes Arch Clin Exp Ophthalmol 2011; 249:1511–1514
Reply : Pain perception in ocular surgery is a complex issue that is not fully understood. Ursea et al.1 mentioned 3 possible mechanisms that could explain why many patients feel more pain in second-eye cataract
1705
surgery; namely, the physiological explanation (surgery in the first eye causes sympathetic irritation that sensitizes the second eye to painful stimuli), the pharmacological explanation (previous exposure to analgesic and sedative medications during the first surgical procedure leads to drug tolerance so the response to the same medications is decreased during the second operation), and the psychological explanation (in the second operation, patients are not as well prepared for the degree of wakefulness and magnitude of sensation they will have during that procedure). Although none of these explanations have been proven, both Ursea et al.1 and Bardocci et al.2 favor the psychological explanation. In our study of pain in the second eye of laser in situ keratomileusis (LASIK) patients, we did not assert that a central process of sensitization is the reason patients felt more pain in the second-eye LASIK procedure because we did not have the means to perform biochemical measurements of humoral factors and the neurotransmitters involved in pain perception; thus, we could not prove or reject the above hypothesis, nor did we favor any of the 3-mentioned explanations. Our clinical experience tells us that in any type of ocular surgery, psychological preparation of patients and/or sedation are more effective when given preoperatively than when given after the patient has begun to experience pain. However, pain perception in cataract surgery is different from that felt in ocular surface surgery. What varies are the sedation and anesthesia used, the consecutive simultaneous or nonsimultaneous surgery, the sensory nerve plexuses involved, the amaurosis felt by the suction ring, and the surveying in the immediate postoperative period. Some of these factors could explain why pain in the secondeye surgery was experienced at a much higher rate (w75%) than in cataract surgery as reported by Ursea et al.1 and Bardocci et al.2 (w40% to 57%). The higher rate could also be due to the fact that the 1-point visual analog scale was administered immediately after the consecutive surgeries and with no intravenous sedation. We fully agree with Dr. Bardocci that “anticipating an enhanced patient perception by alerting the patient or by augmenting anesthesia may achieve better cooperation and improve patient comfort.”2dSharbel Fahed, MD, MS, Hala El Rami, MD, Ali Fadlallah, MD, Daøud Fahd, MD REFERENCES 1. Ursea R, Feng MT, Zhou M, Lien V, Loeb R. Pain perception in sequential cataract surgery: comparison of first and second procedures. J Cataract Refract Surg 2011; 37:1009–1014 2. Bardocci A, Ciucci F, Lofoco G, Perdicaro S, Lischetti A. Pain during second eye cataract surgery under topical anesthesia: an intraindividual study. Graefes Arch Clin Exp Ophthalmol 2011; 249:1511–1514
J CATARACT REFRACT SURG - VOL 38, SEPTEMBER 2012