Oman Journal of Ophthalmology

: 2010  |  Volume : 3  |  Issue : 3  |  Page : 140--144

Cataract surgery under topical anesthesia: Gender-based study of pain experience

Sanjiv Kumar Gupta, Ajay Kumar, Swati Agarwal 
 Department of Ophthalmology, Chatrapati Sahuji Maharaaj University, Lucknow, India

Correspondence Address:
Sanjiv Kumar Gupta
Department of Ophthalmology, Chatrapati Sahuji Maharaaj Medical University, Lucknow. U.P


Background : Pain perception, expression, tolerance, and the healthcare providerSQs evaluation and management of pain are affected by the gender of the patient. To the best of our knowledge, there is lack of gender-based evaluation of pain during cataract surgery under topical anesthesia. Aims : This study has been initiated to evaluate and determine pain experience during cataract surgery under topical anesthesia and to study the gender-based differences of the same. Settings and Design : Hospital-based study involving cataract surgery under topical anesthesia using standard cataract surgery. It was an interventional comparative case series. Materials and Methods : One hundred and sixty patients were included in four groups, according to the gender and choice of surgery. Patients underwent either phacoemulsification with foldable intra ocular lens (IOL) or manual small incision cataract surgery with rigid IOL under topical anesthesia. Patients ranked their pain experience on VAS scale after the surgery and the surgeon recorded the ease/difficulty accordingly using a questionnaire. Statistical Analysis Used : MedCalc version ( ) for windows was used to analyze the results. Analysis of variance (ANOVA) test and Kruskal-Walis test were used to analyze the data. Results : The overall visual analog scale (VAS) score was 0.8 (SD 1.3 range 0-8), with no statistical difference among the groups (P=0.5). The average surgeonSQs score was 3.3 (SD 0.71 range 3-7), with no statistical difference between the groups (P=0.37).There were no sight threatening complications during the surgery in any group. Conclusions : The outcome of the study demonstrates that the patients undergoing cataract surgery under topical anesthesia perceive comparable pain and discomfort irrespective of their gender.

How to cite this article:
Gupta SK, Kumar A, Agarwal S. Cataract surgery under topical anesthesia: Gender-based study of pain experience.Oman J Ophthalmol 2010;3:140-144

How to cite this URL:
Gupta SK, Kumar A, Agarwal S. Cataract surgery under topical anesthesia: Gender-based study of pain experience. Oman J Ophthalmol [serial online] 2010 [cited 2020 Jul 7 ];3:140-144
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A common notion and belief is that there is gender-based difference for tolerance and response to pain. However, there are several contradictory reports in the literature. Some reports conclude that the pain tolerance and analgesic use is unaffected by gender, [1],[2] others report that females report and perceive greater degree of pain when compared to male counterparts. [3],[4],[5],[6],[7],[8],[9],[10] Health care provider's evaluation of pain is also biased by the gender of the patient, but the reports in the literature are inconclusive due to contradictory reports. There are studies which report that physicians treat women less aggressively for their pain, [11] while others report that the female patients are perceived by providers to have more pain than male patients and female patients also receive more medications and stronger analgesics. [4]

The predictive model for pain experience is not simple and straightforward as pain sensitivity is thought to be mediated by socio cultural, psychological, and biological factors. Gender is an important variable and should be taken into account in both research and the clinical practice of pain management. [7] Thus evaluation of pain during any medical or surgical procedure has to be evaluated and analyzed specifically with no scope of a generalized formula applicable to all procedures.

Surprisingly, literature search done using 'Scopus' and 'PubMed' did not yield any result for gender- based pain evaluation among the patients undergoing cataract surgery under local or topical anesthesia, indicating the lack of research in this field. With this perspective, we initiated this study of evaluation of patients' pain experience during cataract surgery under topical anesthesia with intracameral lignocaine supplementation using two different techniques (phacoemulsification and manual small incision cataract surgery). Topical anesthesia may be the choice owing to various advantages it offers in addition to safety for the target elderly population. [12] The aim of the study has been to evaluate the patients' pain experience during cataract surgery under topical anesthesia with intracameral lignocaine, using two standard techniques and to do a gender-based analysis of the pain experience.

 Materials and Methods

A sample size of 40 patients per group was decided upon to detect a difference of 1 unit on average visual analog scale (VAS) scores among the groups (minimum sample size was calculated to be 37 patients per group keeping type I error rate 0.01; type II error rate 0.1; power = 0.9; standard deviation for VAS scores during cataract surgery was taken to be 0.97). [13] Approval by the institute ethical committee was taken before recruiting the patients in the study (ethics committee of Chatrapati Sahuji Maharaaj Medical University, Lucknow, U.P., India). The study was done at a single center and by a single surgeon.

Patients undergoing cataract surgery for visually disturbing uncomplicated cataract were included in the study. Patients were randomized for surgical technique (phacoemulsification or manual small incision cataract surgery) and then further segregated into groups according to their gender, thus forming four groups,

Group I: female gender undergoing phacoemulsification.

Group II: male gender undergoing phacoemulsification.

Group III: female gender undergoing manual small incision cataract surgery.

Group IV: male gender undergoing manual small incision cataract surgery.

Patients were consecutively recruited till there were 40 patients in each group who consented for topical anesthesia and the surgical technique offered. Exclusion criteria were lignocaine sensitivity, inability to understand and follow verbal commands, and any ocular disease other than cataract.

No blinding was employed as patients were aware of the surgical technique due to standard informed consent taken for surgery and the operating surgeon could not be blinded due to obvious reasons. Topical anesthesia was provided by using lignocaine jelly (Xylocaine 2% jelly Astra Zeneca, India) and supplemented by intracameral preservative free 0.5% lignocaine solution (prepared by four times dilution of xylocard 2% solution (Astra Zeneca, India) with ringer lactate solution). The safety and utility of the jelly formulation has been studied and demonstrated in several studies. [14] Jelly provides comparable [15],[16] and possibly superior anesthesia, [17],[18] wets the corneal surface, aids in pupillary dilatation without the use of sympathomimetics or parasympatholytic agents. [14] Adding intracameral lignocaine solution aids in increasing patient comfort and is safe and assists in pupillary dilatation. [19],[20],[21],[22]

Manual small incision cataract surgery (MSICS) was done using sclero-corneal tunnel as described by Gupta et al, with 6.5 mm optic PMMA intra ocular lens (IOL). [13] Phacoemulsification was done with clear corneal 2.8 mm incision using direct chop technique with hydrophilic acrylic foldable lens implantation using cartridge and injector system. No sedation was given to the patients preoperatively.

During the surgery, the patients were instructed to communicate verbally regarding any pain during the surgery. This was recorded with the surgical step. At the end of the surgery, the eye was patched and patients were given a pain evaluation form containing modified Wong scale and a VAS for indicating the grade of pain experienced during the surgery [Figure 1]. Those patients, who could not read the form, were explained the questionnaire and verbal response was recorded by the ophthalmic assistant. The eye patch was removed after a period of 20 to 30 min and topical medications were initiated in all the groups.

The surgeon's experience in terms of ease/difficulty was evaluated using a questionnaire presented to the surgeon just after the surgery. The questions were devised so that the patients' cooperation, unwanted ocular movements and anterior chamber stability were evaluated on a three-point scale (one-three) with a lower grading indication more favorable experience by the surgeon. Thus the total score could range from three to nine. [Figure 1].{Figure 1}


The study included 160 eyes of 160 patients, with patients divided into four groups as described earlier.

The average age of all the patients in the study was 60.08 years (SD 12.04, range 14-87 years). Descriptive analysis of the age distribution of subjects in each group is presented in [Table 1]. No statistical difference was demonstrated in the age distribution of subjects among the groups. (one way ANOVA (analysis of variance) test significance level P=0.58){Table 1}

The overall VAS score was 0.8 (SD 1.3 range 0-8). The distribution of VAS score is illustrated in [Figure 2]. The descriptive statistics of the individual groups is depicted in [Table 2]. The average VAS score was lowest in the patient in group II (0.42 (male patients undergoing phacoemulsification)) and highest among the group III (1.0 (female patients undergoing manual small incision cataract surgery).{Table 2}{Figure 2}

Painless surgery (VAS score zero) was reported by 57.5% (23 of 40) patients in the groups I, III, and group IV. However among group II patients 82.5% (33 of 40) reported painless surgery (VAS score zero). Those patients who experienced mild pain (VAS score ͳ 3) [23],[24] in each group was as follows, group I, II, IV 97.5% (39 of 40) patients and 95% (38 of 40) patients in group III. Kruskal-Wallis test (nonparametric test to compare three or more unpaired groups) to test statistical difference between the VAS scores among the groups revealed no statistically significant difference among the groups (P=0.054).

The comparison graph of surgeon's score for various groups is depicted in [Figure 3]. The average surgeon's score was 3.3 on a scale of 3-9 (SD 0.71 Range 3-7). The descriptive analysis of the surgeon's score in various groups is depicted in [Table 3]. The minimum average score (maximum ease during the surgery) was in group III (3.22) and maximum average score (maximum difficulty during the surgery) was in group II (3.45). D'Agostino-Pearson test for Normal distribution showed that the distribution was non-gaussian in all the groups (P<0.0001). Kruskal-Wallis test (non parametric test for comparing more than two groups) to detect the differences between the surgeon's score among the groups showed that there was no statistical difference between the groups (P=0.37).{Table 3}{Figure 3}

The steps in MSICS 0 when patients had discomfort, included intracameral injection of lignocaine solution, rotation and prolapse of nucleus from the capsular bag after hydrodissection, and irrigation aspiration of cortical matter and insertion of IOL. Patients undergoing phacoemulsification also felt discomfort during the same steps except for nucleus prolapse which was not done in the phacoemulsification group.

There was no sight threatening complication during the surgery in any group. Small descemets' membrane detachment in vicinity of the internal opening of the incision was noted in six and five patients in group III and group IV (both MSICS groups) respectively. These were the patients in whom the nucleus was large and the nucleus was delivered in two or more pieces after getting fractured at the exit of the tunnel. Corneal burn of the anterior lip of the corneal incision was seen in seven patients in group I and 11 patients in group II, but self sealing of the incision and anterior chamber depth was maintained in all these patients and no suturing of the wound was needed. These patients had larger and harder nucleus and phacoemulsification time exceeded more than a minute resulting in wound burn. Sub-conjunctival hemorrhage was seen in majority of cases in manual small incision cataract surgery patients, at the conjunctival incision site and only in four patients undergoing phacoemulsification.


Gender-based evaluation of pain during management of medical conditions has been studied with contradictory reports. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] Going by traditional and common understanding, female gender is associated with being fragile, more sensitive to pain and less tolerant to pain when compared to male gender. Being a common belief and understanding, the health care provider may also share the same view and there may be difference in the pain management provided. [4],[11] During cataract surgery, pain management is not only important from patient's point of view but also the surgical outcome may be adversely affected due to an uncooperative patient suffering from pain during the procedure.

The study has been aimed to detect gender-based differences between the pain experienced during cataract surgery done by two popular and standard techniques using topical and intracameral combined anesthesia. The results may aid in deciding the gender-based preference of surgical procedure under topical anesthesia. The secondary outcome has been to evaluate the safety of the techniques described.

The outcome of the study demonstrates that the patients undergoing cataract surgery under topical anesthesia perceive similar pain and discomfort irrespective of their gender. The female patients had more pain during the surgery in both the groups when compared to the male counterparts but this difference was not statistically significant.

Inter group comparison to evaluate the difference between the pain experienced by the patients undergoing phacoemulsification and manual small incision cataract surgery showed that though the average VAS was higher for manual small incision cataract surgery, there was no statistical difference between the groups.

The surgeon's score with regard to the difficulty during the procedures was most favorable in group III (manual small incision cataract surgery, female gender). Interestingly this was the group with maximum VAS score. Thus analyzing further the group of patients with greatest discomfort were most cooperative during the surgery. This may sound contradictory but looking at the VAS scores we can conclude that these patients although had higher VAS scores but they still did not have intolerable pain and hence were relatively more alert and hence more cooperative, making it easier for the surgeon to operate upon. Overall the surgeon's scores were statistically similar in all the groups. The described procedures were safe, with no sight threatening complications.

The study has been done at a single center and by a single surgeon; thus differences due to skill and personal bias cannot be excluded.

In conclusion, the study showed that both phacoemulsification and MSICS surgery can be done under topical anesthesia. The surgery is uncomplicated, safe and the pain during surgery is acceptable in majority of patients irrespective of the gender in both surgical groups. The surgeon's score of difficulty during the surgery is also similar in all the groups with no statistical difference due to gender or the choice of surgical technique.


1Safdar B, Heins A, Homel P, Miner J, Neighbor M, Desandre P, et al. Impact of physician and patient gender on pain management in the emergency department - A multicenter study. Pain Med 2009;10:364-72.
2Kelly AM. Does the clinically significant difference in visual analog scale pain scores vary with gender, age, or cause of pain? Acad Emerg Med 1998;5:1086-90.
3Fillingim RB, Maixner W. Gender differences in the responses to noxious stimuli. Pain Forum 1995;4:209-21.
4Raftery KA, Smith-Coggins R, Chen AH. Gender-associated differences in emergency department pain management. Ann Emerg Med 1995;26:414-21.
5Soetanto AL, Chung JW, Wong TK. Gender differences in pain perception: A signal detection theory approach. Acta Anaesthesiol Taiwan 2004;42:15-22.
6Hallin RG. Pain more painful in women: Gender perspective neglected in research on the biological mechanisms of pain. Lakartidningen 2003;100:3738-41.
7Dao TT, LeResche L. Gender Differences in Pain. J Orofac Pain 2000;14:169-84.
8Vallerand AH, Polomano RC. The relationship of gender to pain. Pain Manag Nurs 2000;1:8-15.
9Unruh AM. Gender variations in clinical pain experience. Pain 1996;65:123-67.
10Riley 3rd JL, Robinson ME, Wise EA, Myers CD, Fillingim RB. Sex differences in the perception of noxious experimental stimuli: A meta-analysis. Pain 1998;74:181-7.
11Weisse CS, Sorum PC, Dominguez RE. The Influence of Gender and Race on Physicians' Pain Management Decisions. J Pain 2003;4:505-10.
12Sharwood PL, Thomas D, Roberts TV. Adverse medical events associated with cataract surgery performed under topical anaesthesia. Clin Experiment Ophthalmol 2008;36:842-6.
13Gupta SK, Kumar A, Kumar D, Agarwal S. Manual small incision cataract surgery under topical anesthesia with intracameral lignocaine: Study on pain evaluation and surgical outcome. Indian J Ophthalmol 2009;57:3-7.
14Claesson M, Johansson M, Behndig A. Mydriasis with different preparations of topically administered lidocaine hydrochloride. J Cataract Refract Surg 2009;35:277-81.
15Barequet IS, Soriano ES, Green WR, O'Brien TP. Provision of anaesthesia with single application of lidocaine 2% gel. J Cataract Refract Surg 1999;25:626-31.
16Assia EI, Pras E, Yehezkel M, Rotenstreich Y, Jager-Roshu S. Topical anesthesia using lidocaine gel for cataract surgery. J Cataract Refract Surg 1999;25:635-9.
17Bardocci A, Lofoco G, Perdicaro S, Ciucci F, Manna L. Lidocaine 2% gel versus lidocaine 4% unpreserved drops for topical anesthesia in cataract surgery: A randomized controlled trial. Ophthalmology 2003;110:144-9.
18Soliman MM, Macky TA, Samir MK. Comparative clinical trial of topical anesthetic agents in cataract surgery: Lidocaine 2% gel, bupivacaine 0.5% drops, and benoxinate 0.4% drops. J Cataract Refract Surg 2004;30:1716-20.
19Lee JJ, Moster MR, Henderer JD, Membreno JH. Pupil dilation with intracameral 1% lidocaine during glaucoma filtering surgery. Am J Ophthalmol. 2003;136:201-3.
20Ezra DG, Allan BD. Topical anaesthesia alone versus topical anaesthesia with intracameral lidocaine for phacoemulsification. Cochrane Database Syst Rev 2007;3:CD005276.
21Tseng SH, Chen FK. A randomized clinical trial of combined topical-intracameral anesthesia in cataract surgery. Ophthalmology 1998;105:2007-11.
22Crandall AS, Zabriskie NA, Patel BC, Burns TA, Mamalis N, Malmquist-Carter LA, et al. A comparison of patient comfort during cataract surgery with topical anesthesia versus topical anesthesia and intracameral lidocaine. Ophthalmology 1999;106:60-6.
23Collins SL, Moore RA, McQuay HJ. The visual analogue pain intensity scale: What is moderate pain in millimetres? Pain 1997;72:95-7.
24Lee J, Stiell I, Hobden E, Wells G. Clinically Meaningful Values of the Visual Analog Scale of Pain Severity. Acad Emerg Med 2007:5-550.