Revolutionizing cataract surgery with office-based oral sedation

A new study on office-based cataract surgery is challenging traditional approaches to the procedure, demonstrating that patients can undergo successful surgery with minimal oral sedation instead of with intravenous (IV) sedation at hospitals or ambulatory surgery centers. The study's findings will be presented today at the 129^th annual meeting of the American Academy of Ophthalmology. At a time when greater integration of artificial intelligence and robotics are expected to shape the future of cataract surgery, this study shows the next big transition may occur inside the ophthalmologists' office.

To conduct the study, Brad H. Feldman, MD, and colleagues at Philadelphia Eye Associates and Wills Eye Hospital prospectively analyzed all patients who underwent cataract surgery with oral sedation in an office-based suite.

Dr. Feldman said the findings exceeded their expectations. Only 10 percent of patients required supplemental sedation beyond the standard dose of diazepam, 5 mg for older patients and 10 mg for younger patients. Remarkably, no patient selected for office-based surgery needed to be rescheduled for IV sedation due to anxiety or restlessness.

Before launching our office-based surgical suite, I would have anticipated that more patients would have required higher levels of oral sedation."

Dr. Brad H. Feldman

The study also revealed that more than 99 percent of patients elected to have their second eye performed in the office-based setting, even though an ambulatory surgery center was available less than half a mile away.

The study addresses a gap in existing literature. While large-scale studies have established the safety of office-based cataract surgery - including one from Kaiser Permanente by researchers Tsontcho Ianchulev, David Litoff, and colleagues, and another involving 36 private practices led by Lance J. Kugler and colleagues-specific data on oral sedation protocols in private practice settings has been limited.

"We know that well over 100 private practices in the US have begun performing office-based cataract surgery and that the vast majority of these cases are being performed under oral sedation," Dr. Feldman said. "We wanted to share our center's specific approach as we believe it will be helpful to other ophthalmologists."

The office-based surgical spaces are not simply converted exam rooms. Dr. Feldman's facility was accredited by the Joint Commission and built to high standards comparable to ambulatory surgery centers, with specialized operating rooms, sterile storage, sterile processing areas, specific air filtration systems, and dedicated electrical specifications.

One key advantage of the oral sedation approach is timing, Dr. Feldman said. Since diazepam's onset coincides with pupillary dilation from eye drops, surgeons can simultaneously evaluate both the pupil and the patient's sedation level before entering the operating room. When supplemental sedation is needed, an orally dissolving tablet containing midazolam, ketamine, and ondansetron can be administered quickly and effectively.

"Unlike with IV sedation, patients are not brought into the operating room until they are deemed adequately sedated," Dr. Feldman explained, noting this makes sedation levels during surgery highly predictable.

He also noted how quickly the medical team adapted. "By just my second day in the office-based suite, I felt confident that this setting for cataract surgery was better for most patients in terms of comfort, convenience, and safety," he said.

The research team continues to collect data prospectively on all patients undergoing surgery in their office-based suite and encourages other surgeons performing office-based cataract surgery to share their experiences.

In addition to Dr. Feldman's presentation, two instruction courses on office-based cataract surgery are offered during this week's annual meeting:

• Monday, 9:45 a.m. – 11 a.m. The Shift to Office-Based Cataract Surgery: Insights and Considerations From Surgeons With Varied Practice Profiles Instruction Course
• Sunday, 3:45 p.m. – 5 p.m. Office-Based Cataract Surgeries: Legal and Practical Considerations AAOE Instruction Course