I present an atraumatic technique for small pupil phacoemulsification using topical anesthesia. Fifty consecutive small pupil phacoemulsification cases were performed with topical anesthesia and mild intravenous sedation. Viscoelastic combined with a modified two instrument stretch was used for pupillary enlargement adequate for phacoemulsification. After preoperative cycloplegia, two or more multidirectional stretches were used for 3.0 to 5.0 mm pupils; three or more multidirectional stretches were used for pupils less than 3.0 mm. Pain and proprioceptive responses were avoided by reducing the stretch length, leaving the angle structures and ciliary body untouched. Sodium hyaluronate (Healon GV) created additional expansive power. Of 50 successfully implanted cases, 45 (90%) had acceptable pupillary form and function postoperatively. The 5 (10%) with enlarged, atonic pupils had past injury or inflammatory disease. This technique minimizes anterior segment trauma, instrumentation, and operating time.

I developed an approach to topical anesthesia--drop, then decide--with the goal of increasing the percentage of patients able to have topical anesthesia for anterior segment surgery. This study comprised 150 consecutive surgeries performed using the technique, including cataract extraction with intraocular lens (IOL) implantation, trabeculectomy, combined procedures, and McCannel suturing. Six patients also had anterior vitrectomy. Patients were not preselected. All cases were initiated with topical anesthesia and supplemented with at least mild intravenous sedation by an anesthesiologist. The decision on whether to use anesthetic blocks was made after evaluating patient response early in the surgery. The approach had an overall success rate (no regional block needed) of 89.3%; 92.0% of the cataract/IOL implantation cases were successful. Most patients reported they were comfortable throughout the procedure. The success rate was high among patients who may be considered poor candidates for topical anesthesia; younger patients had more difficulty. This approach allows more patients to benefit from the advantages of topical anesthesia over other techniques.

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* BACKGROUND AND OBJECTIVES: Phacoemulsification with topical anesthesia has been accepted by some ophthalmologists as a minimally invasive alternative technique for cataract surgery. This study approaches a 1 00% success rate using topical anesthesia with mild intravenous (IV) sedation in phacoemulsification procedures. * PATIENTS AND METHODS: Two hundred consecutive patients underwent clear-comeal phacoemulsification. Patients were not preselected. Lidocaine hydrochloride topical anesthesia was supplemented with small-dose IV midazolam hydrochloride and/or fentanyl citrate. Patients underwent meticulous preoperative counseling. Those with dementia, deafness, movement disorders, or hyperanxiety, or those who spoke a foreign language or who were young required special management. Additional techniques were employed for ophthalmologic problems such as small pupil, mature cataract, and strong blink/Bell's phenomenon. Patient comfort was noted intraoperatively and postoperatively. * RESULTS: Ninety-seven percent of the patients did well, with only 3% requiring regional block or general anesthesia. * CONCLUSION: Using nucleofractis phacoemulsification with special techniques in more difficult situations, most patients were successful with topical anesthesia plus IV sedative anesthesia. [Ophthalmic Surg Lasers 1996;27:935-938.]

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