Advancements in microsurgical techniques and anesthesia have allowed cataract surgery to be conducted extremely efficiently, typically using local or topical anesthesia, with or without systemic sedation. The decision to use sedation is individualized and depends on patient factors, surgical complexity, and institutional practice patterns. Understanding the benefits and limitations of each approach is important for both clinicians and patients.
Modern cataract surgery is most often performed using phacoemulsification through a small corneal incision, followed by intraocular lens implantation. Because the procedure is brief and minimally invasive, patients typically do not require general anesthesia. Instead, topical anesthetic drops, sometimes supplemented by intracameral lidocaine, often suffice for analgesia. In some cases, regional techniques such as peribulbar or sub-Tenon’s blocks are used to provide akinesia and additional analgesia. These local methods allow the patient to remain awake while minimizing ocular discomfort.
When sedation is used, it is usually light to moderate and administered intravenously. Agents such as midazolam, fentanyl, or propofol are commonly employed in small, titrated doses. The goal is anxiolysis and patient comfort rather than deep sedation. Many patients benefit from mild sedation, particularly those with procedural anxiety, claustrophobia, difficulty lying flat, or a low threshold for discomfort. Sedation can improve cooperation and reduce sudden movements, which is critical in microsurgery performed under high magnification.
In many patients, cataract surgery can be safely and effectively performed with or without systemic sedation. Avoiding sedation eliminates the risks associated with systemic medications, including respiratory depression, hypotension, oversedation, and postoperative confusion. This is particularly relevant in elderly patients, who constitute the majority of cataract surgery candidates and who may have significant comorbidities such as cardiovascular disease, chronic lung disease, or cognitive impairment. Notably, these patients are at higher risk for delirium.
From a workflow perspective, surgery without sedation may streamline perioperative care. Patients who do not receive intravenous medications typically require less monitoring, experience faster postoperative recovery, and may be discharged sooner. Studies have shown high levels of patient satisfaction in both sedated and non-sedated groups, provided that preoperative counseling is thorough and expectations are clearly addressed.
Patient factors, including clear discussion between the patient and surgeon, are central to the decision of whether to perform the cataract surgery with or without sedation. Individuals with severe anxiety, tremor disorders, chronic cough, or inability to follow instructions may not tolerate surgery without sedation. Similarly, complex cases that are expected to be prolonged may benefit from additional anxiolysis. Conversely, patients who express a preference to avoid sedation and who demonstrate the ability to remain calm and cooperative are often excellent candidates for topical anesthesia on its own or with a block.
In the pre-operative discussion, it is essential for the surgeon to share information such that patients fully understand what to expect. Patients should understand that they will not see sharp instruments approaching the eye but may perceive light, movement, or mild pressure. Reassurance that discomfort is typically minimal can reduce anxiety and lessen the perceived need for sedation. During the procedure, ongoing verbal interaction between the surgeon and patient further enhances safety and comfort.
Cataract surgery with or without sedation can be safe and effective. The choice should reflect a balanced consideration of medical risk, psychological comfort, surgical requirements, and patient preference. By aligning anesthetic strategy with patient-specific factors and maintaining clear communication, clinicians can optimize both clinical outcomes and the patient experience