Cataract surgery has evolved with technological advances that have enhanced its safety and efficiency. As the procedure has become less invasive and more controlled, approaches to surgical pain management and patient comfort have shifted significantly. Historically, retrobulbar and peribulbar injections were the primary methods of local anesthesia for cataract surgery. Recently, topical anesthesia combined with intravenous (IV) sedation has become the preferred method.
THE PREVALENCE OF OPIOID USE IN CATARACT SURGERY
The medication mixtures used in IV sedation vary, but many include opioid analgesics. Studies have highlighted the high use of opioids in cataract surgery patients. In 2019, a retrospective study examined anesthesia recovery duration after more than 20,000 ophthalmologic procedures performed at an ambulatory surgery center and found that nearly 80% of patients received fentanyl.1 In a more recent study, nearly 97% of patients received at least one dose of fentanyl.2 This trend is concerning, given the ongoing opioid crisis in the United States. Providers must remain vigilant and cautious when prescribing opioids, especially in ophthalmology, where these medications are often unnecessary and exceed the requirements for effective pain management.
RISKS ASSOCIATED WITH OPIOID USE
Several studies have highlighted the risk of persistent opioid use following perioperative exposure during cataract surgery, particularly in opioid-naïve patients.3 Additionally, recent work has demonstrated the risks associated with short-term opioid prescriptions after ocular surgery. A retrospective, cross-sectional analysis reported higher rates of mortality, hospitalization, and opioid dependence in patients who filled an opioid prescription.4
Postoperative opioid prescriptions often exceed what patients need, and intraoperative opioids are unnecessary for cataract surgery.
OUR APPROACH
At Vance Thompson Vision, we avoid opioids and forgo IV access in most patients because obtaining an IV is a major source of anxiety for those undergoing cataract surgery. The MKO Melt (ImprimisRx/Harrow Health), a sublingual compound of 3 mg midazolam, 25 mg ketamine, and 2 mg ondansetron, has transformed our anesthesia approach. Developed specifically for ophthalmic surgery, the MKO Melt is an opioid-sparing option that we have found provides effective sedation, mild amnesia, and analgesia. Our practice has successfully used this method for nearly 9 years.
Implementing an Alternative to Opioids
The MKO Melt is currently available as a compounded medication, with each individual component being US FDA-approved, though the combination itself is not. Meanwhile, MELT-300 (Melt Pharmaceuticals/Harrow Health) is undergoing clinical trials for US FDA approval as a commercially manufactured product. Recently completed phase 2 studies demonstrated that MELT-300 outperformed both midazolam alone and ketamine alone, with more than 80% of patients achieving adequate sedation. Moreover, MELT-300 was associated with the lowest rates of pre- and intraoperative rescue (data on file with Melt Pharmaceuticals).
We strive to create a comfortable environment for our patients while maintaining efficiency and optimizing workflow. The MKO Melt aids in this process, but there is a learning curve for first-time users. The effects of the sublingual troche typically begin within 10 minutes and peak at between 15 to 20 minutes. We aim to administer the dose 20 minutes before the procedure for each patient. After administration, the effects last 60 to 90 minutes, and recovery time is comparable to that experienced after IV sedation.
Considerations for Dosage and Administration
Timing and dosing are critical because it is not possible to supplement sedation quickly with an additional MKO Melt. We base the Melt dosage primarily on the patient’s age, but their weight and comorbidities as well as other patient-specific factors are also considered. Generally, the administration of one and a half to two sublingual troches before surgery works well for the vast majority of patients.
When IV Access Is Necessary
We establish IV access for patients undergoing more complex procedures and those with comorbidities that necessitate an IV. We also obtain IV access for patients who report unusually high levels of anxiety or specifically request an IV. Although IVs are initiated in about 5% of our surgery center patients, IV medication is administered in only 1% of cases. I can recall only a few instances, out of thousands of procedures, when our anesthesia team had to obtain IV access intraoperatively to administer additional anxiolytic agents after initially opting not to.
THE ROLE OF OPHTHALMOLOGISTS IN THE OPIOID CRISIS
Ophthalmologists and anesthesia care providers in eye care settings must recognize the potential role they play in the national opioid crisis. The perioperative use of opioids is not necessary for patients undergoing cataract surgery. Excellent nonopioid pain management strategies are available that allow opioids to be avoided without compromising patient care.
1. Russell KM, Warner ME, Erie JC, Kruthiventi SC, Sprung J, Weingarten TN. Anesthesia recovery after ophthalmologic surgery at an ambulatory surgical center. J Cataract Refract Surg. 2019;45(6):823-829.
2. Davidson RS, Donaldson K, Jeffries M, et al. Persistent opioid use in cataract surgery pain management and the role of nonopioid alternatives. J Cataract Refract Surg. 2022;48(6):730-740.
3. Ung C, Yonekawa Y, Waljee JF, Gunaseelan V, Lai Y, Woodward MA. Persistent opioid use after ophthalmic surgery in opioid-naive patients and associated risk factors. Ophthalmology. 2021;128(9):1266-1273.
4. Thao V, Helfinstine DA, Sangaralingham LR, Yonekawa Y, Starr MR. Hospitalization, overdose, and mortality after opioid prescriptions tied to ophthalmic surgery. Ophthalmology. 2024;131(8):943-949.
