This important study by Rosenfeld and colleagues is the first to assess the need for MAC during cataract surgery [2]. The authors prospectively studied the incidence and the nature of interventions required by anesthesia personnel in 1,006 consecutive cataract operations (both phacoemulsification and extracapsular techniques were included) performed under peribulbar block. They also analyzed the risk factors for intervention including patient demographic data, medical history, and preoperative laboratory tests for reliability in predicting those patients at greatest risk for intervention. They found that 37% of patients required some type of intervention and that, in general, the majority of those interventions could not have been predicted before surgery. The modifications ranged from minor ones, such as verbal reassurance and hand holding, to administering such intravenous medications as supplemental sedation or antihypertensive, pressor, or antiarrhythmic agents, or to providing respiratory assistance. Although hypertension, lung disease, renal disease, and a diagnosis of cancer were related to interventions, these four conditions combined accounted for only a small portion of the needed interventions. Moreover, although many of the interventions were relatively minor, several were more serious and 30% of the interventions were considered (by the involved anesthesia personnel) to be critical to the success of the operation. The investigators concluded that MAC by qualified anesthesia personnel is reasonable and justified and contributes to the quality of patient care when cataract surgery is performed with local anesthesia. Although there were few, if any, injection-related problems, one wonders if this conclusion would be different if the patients had received topical analgesia instead of peribulbar block [2].

Changes to effect cost reductions are worth considering, provided such modifications do not compromise the quality of patient care. Well-designed prospective studies enable us to address these issues rationally instead of emotionally. A national cooperative study, funded by the Agency for Health Care Policy and Research, has been undertaken recently to examine the benefits and costs of routine preoperative laboratory testing for cataract surgery. Stay tuned.

References:

1. N�rregaard JC, Schein OD, Bellan L, et al. International variation in anesthesia care during cataract surgery: results from the International Cataract Surgery Outcomes Study. Arch Ophthalmol. 1997;115:1304-8.
2. Rosenfeld SI; Litinsky SM; Snyder DA; Plosker H; Astrove AW; Schiffman J. Effectiveness of monitored anesthesia care in cataract surgery. Ophthalmology. 1999 Jul;106(7):1256-60.