Which is Better: One or Two? (1 st & 2 nd Eye Cataract Surgery) Brian Kirk, MS 1 ; Martin de la Presa, MD 1 ; Molly McFadden, MS 3 William Weatherholtz, MS 2 ; Keith Dockstader 2 ; Zoya Sandhu, BS 1 ; Zac Flinders, BS 1 ; Austin Bohner, BS 1 ; Kandice Olson, MD 4 ; Robert Langston CRNA MSN 4 ; Derek Sakata, MD 4 ; Shad Roundy, PhD 2 ; Craig Chaya, MD 1 1 Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, UT 2 Department of Mechanical Engineering, University of Utah, Salt Lake City, UT 3 Department of Internal Medicine, Epidemiology, University of Utah, Salt Lake City, UT 4 Department of Anesthesiology, University of Utah, Salt Lake City, UT Financial Support: Unrestricted Grant, Research to Prevent Blindness, Inc., New York, NY, to the Department of Ophthalmology & Visual Sciences, University of Utah.
Introduction Derek Sakata MD Professor & Vice Chair Executive Director, Ambulatory Anesthesiology Leland O. and Avanelle W. Learned Endowed Professorship University of Utah, Department of Anesthesiology Executive Medical Director, Ambulatory Southern Service Area University of Utah, Health Sciences Director, Anesthesia Services University of Utah, John A. Moran Eye Center Chair, Faculty Innovation Research & Entrepreneurship (FIRE) Scholars University of Utah, Center for Medical Innovation Adjunct Professor, Bio-engineering & Ophthalmology
Disclosures Derek Sakata MD • NuMask – Free Product for Study • MedVis • Becton Dickenson – Honorarium for Speaking • **Axon – Future Study, Intelliport – Consultant & Royalties • Majelco • Salter Labs – Board Position & Stock – Consultant • Baxter – Honorarium for Consulting
Disclosures Derek Sakata MD • Founder & Owner • Single Product • Past Medical Director
Disclosures Derek Sakata MD • Founder & Owner • Two Products • Current Medical Director
Introduction Robert Langston CRNA, MSN University of Utah, John A. Moran Eye Center
Disclosures Robert Langston CRNA, MSN None
Background • With the widespread use of topical anesthesia for cataract surgery , patient comfort and cooperation during surgery is important to the success of the procedure. • Intraoperative patient cooperation is inversely related to the discomfort they feel. 1 • Multiple studies and anecdotal evidence suggest that the patient’s experience with discomfort during cataract surgery can vary between the first and second eye. 2,3,4,5,6
Background • Prior studies: – Primarily subjective measures (surveys/questionnaires) – Rarely, objective measures (intraoperative vitals: blood pressure, mean arterial pressure, and heart rate. 2 • This study – Primarily objective measures(novel, hand-held device with transmission of real-time biometric data. – Secondarily, subjective measures were gathered to compare and give a more complete picture of the patient experience.
Methods • IRB approved prospective observational study • Study subjects: single, large volume academic eye center Inclusion Criteria Exclusion Criteria • • >18 years old Surgery performed by resident • • Able to receive instruction in Complications or surgery >30 the English language min 1 st and 2 nd eye surgeries within • • Pre-existing condition that 6 months of each other could confound pain analysis • • Topical anesthesia Intraocular non-laser surgery within 3 mo. of first surgery • Intraocular laser surgery within 30 days of first surgery
Methods – Objective Data Gathering • Novel hand-held device • Button for any “discomfort” experienced during surgery (recorded wirelessly). • Acceleration in x,y, and z planes • Grip force • Surgical steps timestamped • Skin conductivity intraoperatively (research assistant & correlated to the recorded device data for each subject.
Methods – Subjective Data Gathering • Questionnaires measured subject’s anxiety using State -Trait Anxiety Inventory ( STAI ), and pain with a Visual Analog Scale ( VAS ) • Surveys: pre-operatively & post-operatively / each surgery Final questionnaire: ~1 month following the 2 nd eye surgery • Pre- • Anxiety: STAI • operative • Satisfaction : surgical Predicted pain: VAS Follow-up experience • (1month) Recall: pain (1 st vs. 2 nd surgery) • Post- operative 101 patients enrolled *23 excluded for • Anxiety: STAI resident performed • Recalled pain: VAS surgery, surgical complications etc.
Results • Only button press was found to be clinically useful for analysis – 6.8 % (1 st surgery) – 8.6 % (2 nd surgery) – Proportional difference: not significant (Chi square, 1 d.f. = 2.7, p = 0.10) • Surgical steps most associated with click event – Intracameral lidocaine (1 st surgery: 11.5% , 2 nd surgery: 12.9% ) – Placement of IOL (1 st surgery: 19% , 2 nd surgery: 23.4% ) • Remembered pain and likelihood of button press: – 1 st Surgery: Each 1 pt increase in “Pain Experienced” decreased the probability of of “zero clicks” by 91% (p=0.01) – 2 nd Surgery: Each 1 pt increase in “Pain Experienced” decreased the probability of “zero clicks” by 60% (p=0.02)
Anxiety Results (Avg. STAI score, max 24) 1 st Surgery 2 nd Surgery *Significantly more pre- Pre-surgery 8.56 Pre-surgery 11.37 p=<0.0001* op anxiety prior to surgery 1 compared to p=0.0308 Post-surgery 7.88 Post-surgery 7.47 surgery 2 Pain Results (Avg. VAS score, max 10) 2 nd Surgery 1 st Surgery p=<0.0001* *Significantly more Anticipated pain 0.41 Anticipated pain 1.48 predicted pain prior to p=0.0817 surgery 1 compared to Remembered pain 0.54 Remembered pain 0.37 surgery 2 Avg. difference 0.17 Avg. difference 1.26
Recalled Pain (Comparison Between 1 st & 2 nd Surgeries) Right after the 2 nd Surgery Number Percentage Same 42 53.8% Less pain 2 nd eye 13 16.6% More pain 2 nd eye 20 25.6% Don’t remember 3 3.8% 3o Days after the 2 nd Surgery Number Percentage Same 39 59.1% Less pain 2 st eye 9 13.6% More pain 2 st eye 18 27.3% Don’t remember 0 0%
Conclusions • Button Presses – No objective difference between the 1 st & 2 nd surgery – Certain surgical steps associated with more – Reliable reflection of the patient experience, given the increase in likelihood of its use with increased reported pain. • Between 1 st vs. 2 nd Surgery – Pre-op anxiety & anticipated pain decreased – No difference in immediate post-op scoring of pain • One month following the 2 nd surgery – Majority claimed to experience equal amounts of discomfort during both surgeries . – Remembering the 1 st surgery as more painful increased the than the likelihood to feel the 2 nd surgery was more painful
References 1. Aslan L, Aslankurt M, Çekic O, Aksoy A, Yildiz H. The pain experience and cooperation of patients in consecutive cataract surgery. Eur J Ophthalmol . 2012;23(3):339-343. doi:10.5301/ejo.5000219 2. Jiang L, Zhang K, He W, Zhu X, Zhou P, Lu Y. Perceived Pain during Cataract Surgery with Topical Anesthesia: A Comparison between First-Eye and Second-Eye Surgery. Journal of Ophthalmology. https://www.hindawi.com/journals/joph/2015/383456/. Published 2015. Accessed March 16, 2018. 3. Adatia FA, Munro M, Jivraj I, Ajani A, Braga-Mele R. Documenting the subjective patient experience of first versus second cataract surgery. Journal of Cataract & Refractive Surgery . 2015;41(1):116-121. doi:10.1016/j.jcrs.2014.04.041 4. 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(10):1511. doi:10.1007/s00417-011-1803-9 5. Ursea R, Feng MT, Zhou M, Lien V, Loeb R. Pain perception in sequential cataract surgery: Comparison of first and second procedures. Journal of Cataract & Refractive Surgery . 2011;37(6):1009-1014. doi:10.1016/j.jcrs.2011.01.020 6. Hari-Kovacs A, Lovas P, Facsko A, Crate ID. Is second eye phacoemulsification really more painful? Wien Klin Wochenschr . 2012;124(15-16):516-519. doi:10.1007/s00508-012-0205-2
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