Cataract Anaesthesia, Alternative Extraction and Combined Procedures

Plan the entire operation

Cataract surgery includes anaesthesia, asepsis, extraction, implantation and postoperative care. Phacoemulsification is common, but an EBOD candidate must also understand extracapsular and intracapsular extraction and recognise when another technique or a combined procedure is reasonable. The plan should account for lens density, pupil, corneal reserve, zonules, retinal status, patient cooperation and available expertise. An unfamiliar technical name is not a reason to assume the procedure is obsolete in every setting.

Anaesthesia and cooperation

Topical anaesthesia avoids a needle block and permits rapid recovery, but does not provide complete akinesia or eliminate discomfort from every intraocular manoeuvre. Intracameral anaesthetic may supplement it with an appropriate formulation. Sub-Tenon anaesthesia can provide additional analgesia and akinesia, while peri- or retrobulbar techniques carry risks including haemorrhage, globe injury and, rarely, central spread. A short highly myopic globe is not the relevant concern: an elongated eye or staphyloma can increase needle-related risk.

Select general anaesthesia when cooperation, age, anxiety, movement or complex surgery makes it necessary. Discuss medical and airway risks with the anaesthetist. Sedation can help but excessive sedation or sudden movement can compromise safety; it is not a substitute for a suitable anaesthetic plan. For local surgery, confirm that the patient can lie reasonably still and communicate discomfort. Hearing difficulty, tremor and cognitive impairment require practical accommodation rather than automatic exclusion.

Review anticoagulants and antiplatelets in relation to the operation, anaesthetic route and the patient’s thrombotic risk. Do not issue a universal instruction to stop them. Continue or alter treatment only under an appropriate evidence-based local plan, coordinated with the prescribing team when needed. Consent must cover the patient’s likely visual benefit, relevant complications and postoperative needs, including alternatives and the consequences of deferral.

Infection prevention

Ocular-surface antisepsis and an appropriate intracameral antibiotic strategy reduce postoperative endophthalmitis risk. ESCRS recommends intracameral antibiotic prophylaxis and gives cefuroxime 1 mg in 0.1 mL as an example. Use a licensed or validated preparation and check allergy, dose and dilution: an incorrect concentration can cause serious toxicity. Povidone-iodine preparation, contact time and application follow the surgical protocol. The ESCRS cataract recommendations distinguish prophylaxis from treatment of an established infection.

Assess active lid or surface infection before elective surgery, and maintain sterile instrument and theatre processes. Intracameral prophylaxis does not justify omitting antisepsis. Multiple cases of postoperative inflammation require investigation of infectious and toxic causes, including instrument processing and solution preparation. A patient with pain or reduced vision after discharge needs access to prompt reassessment.

Extraction alternatives

Extracapsular cataract extraction (ECCE) removes the nucleus and cortex while retaining posterior capsule. Conventional ECCE uses a larger incision for nucleus delivery; manual small-incision techniques use a self-sealing scleral tunnel and different delivery methods. They can be appropriate for selected dense lenses, resource settings or surgeon expertise. Larger incisions may produce more astigmatic change and require a different wound and recovery plan. Retaining capsule does not guarantee that zonules or posterior capsule will remain intact.

Intracapsular extraction (ICCE) removes the lens and capsule together. It has limited modern indications, but understanding it clarifies the consequences of absent capsular support and increased vitreous involvement. A posterior chamber IOL cannot simply be placed “in the bag” if no bag remains. Anterior chamber, iris-fixated or scleral-fixated options require evaluation of anatomy and long-term risks; leaving aphakia with optical correction is another possible plan.

Combined surgery

A cataract can coexist with glaucoma, endothelial disease or retinal pathology. Combining surgery can reduce separate procedures and recovery periods but changes risk and the reliability of refractive prediction. A phaco-trabeculectomy, phaco with selected MIGS, cataract with endothelial keratoplasty or phacovitrectomy has a different objective and postoperative regimen. Do not assume that combining two useful operations produces the best result for every patient.

With glaucoma, consider the pressure target and severity rather than choosing MIGS solely because a cataract is present. With endothelial disease, discuss whether cataract surgery alone is likely to precipitate decompensation and whether staged measurements could improve IOL planning. With retinal disease, explain how macular pathology limits acuity and how gas or oil can affect refraction and subsequent care. The retinal surgeon’s anticipated tamponade influences lens-material considerations.

A consent and technique case

A patient with a very dense cataract, corneal compromise and poor cooperation needs a coherent discussion of technique and anaesthesia before the operation. Explain why the selected approach is expected to deliver benefit, how limited retinal visibility affects prognosis and which intraoperative findings might change the plan. After surgery, verify wound integrity, pressure and inflammatory response and provide instructions for pain or declining vision. A technically successful extraction is incomplete without safe perioperative preparation and accessible follow-up.