Cataract Surgery Anaesthesia: What Are Your Options and What Should You Expect?

Cataract surgery is one of the most commonly performed surgical procedures in the world, and the vast majority of patients have it performed under local anaesthesia, meaning they are awake during the procedure but their eye is completely numb. For most patients this is safe, comfortable, and allows for a rapid recovery with no fasting required and no risk of general anaesthetic complications. Understanding the anaesthesia options available, what each involves, and which is most appropriate for a given patient, is an important part of the pre-operative discussion. This post covers the three main anaesthesia approaches used for cataract surgery: topical plus intracameral anaesthesia with sedation (the standard approach), local anaesthetic block, and general anaesthesia. If you are still in the process of deciding whether to proceed, see the guide on how to know if you need cataract surgery.

Why anaesthesia choice matters in cataract surgery

Cataract surgery requires the eye to be completely still and pain-free during a 15 to 25 minute microsurgical procedure. The anaesthesia approach must achieve reliable pain control and adequate patient cooperation while minimising systemic risk, particularly in elderly patients with cardiovascular, respiratory, or neurological comorbidities. The trend over the past two decades has been a significant shift toward topical and intracameral techniques and away from injection-based regional blocks.

Unlike most other surgical procedures, the eye has no natural tolerance for pain and any unexpected movement during the critical stages of lens removal and implantation carries risk. The anaesthesia approach must achieve reliable pain control and, in most cases, adequate patient cooperation, while minimising systemic risk particularly in elderly patients with cardiovascular, respiratory, or neurological comorbidities.

Data from the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) covering hundreds of thousands of procedures showed that sub-Tenon and regional (peribulbar and retrobulbar) anaesthesia decreased from 27 percent and 38 percent respectively to 16 percent and 6 percent of cases over the registry period, reflecting the widespread adoption of topical anaesthesia as the standard [1].

Topical plus intracameral anaesthesia with sedation: the standard approach

The most commonly used anaesthesia technique for cataract surgery in contemporary practice is topical anaesthesia combined with intracameral anaesthesia and intravenous sedation. This three-part combination provides reliable pain control without any injection around the eye, carries the lowest systemic risk profile of any anaesthesia option, and allows rapid recovery with most patients going home within one to two hours of the procedure.

Topical anaesthesia involves the instillation of anaesthetic eye drops onto the surface of the eye before and during the procedure. The most commonly used agent is lignocaine (lidocaine) 2 to 4 percent, which numbs the corneal surface and conjunctiva. Topical anaesthesia alone is effective for the skin incision and corneal entry but may provide less reliable coverage during intraocular manipulation, particularly during the stage of cortex removal and irrigation.

Intracameral anaesthesia involves the injection of a small volume of preservative-free lignocaine directly into the anterior chamber of the eye at the beginning of the procedure. This supplements the topical anaesthesia by numbing the iris and ciliary body, which are the structures most sensitive to intraocular manipulation. A Cochrane systematic review updated in 2020 analysing data from randomised controlled trials found moderate-quality evidence that topical anaesthesia supplemented with intracameral lidocaine reduced intraoperative pain compared with topical anaesthesia alone [2]. A prospective study of 100 patients published in the European Journal of Ophthalmology in 2024 found that patients receiving topical plus intracameral anaesthesia reported significantly less pain during surgery and over the first 24 hours postoperatively compared with topical anaesthesia alone [3].

Intravenous sedation, sometimes called twilight anaesthesia or monitored anaesthesia care, is administered by an anaesthetist alongside the topical and intracameral anaesthesia. The sedation does not put the patient fully to sleep. Instead it produces a state of deep relaxation and mild drowsiness while the patient continues to breathe independently. The patient is not intubated (no breathing tube is placed), and they remain responsive to verbal instructions during the procedure, which is important as the surgeon may need to ask the patient to look in a particular direction or to keep still. The anaesthetist monitors the patient's vital signs throughout the procedure and can adjust the level of sedation as needed.

Patients breathe independently throughout, there is no intubation and no risk of the complications associated with general anaesthesia. Fasting is generally not required for topical anaesthesia procedures in most Australian centres, though individual anaesthetist and hospital protocols vary and patients should follow the instructions given at their pre-operative assessment. Recovery is rapid and most patients go home within one to two hours of the procedure.

What does the procedure feel like under topical and intracameral anaesthesia?

Most patients are surprised by how comfortable the procedure is. The most common sensations reported are pressure and vibration rather than pain. Patients typically see light and movement but not the surgical instruments themselves. The experience is usually much less uncomfortable than patients anticipate. For a detailed explanation of what happens surgically during the procedure, see the guide to the phacoemulsification technique.

Patients typically see light and movement but not the surgical instruments themselves. The bright operating microscope light is visible and can be intense, and some patients see shifting colours or light patterns during the procedure.

The most common sources of discomfort are the speculum that holds the eyelids open, which some patients find uncomfortable but not painful, and occasionally a sensation of pressure during the phacoemulsification stage. The intracameral lignocaine minimises the discomfort during intraocular manipulation. Most patients rate the experience as much less uncomfortable than they anticipated.

Patients who are very anxious, who have a strong aversion to the idea of being awake during eye surgery, or who have difficulty lying still for 15 to 25 minutes may find the experience more challenging. These factors are discussed during the pre-operative assessment and influence the anaesthesia recommendation.

Local anaesthetic block: peribulbar and sub-Tenon approaches

In a minority of patients, injection-based local anaesthetic blocks are used instead of or in addition to topical anaesthesia. These approaches produce both anaesthesia (pain relief) and akinesia (absence of eye movement), making them more suitable for longer or more complex procedures. The most common approaches in current practice are peribulbar block and sub-Tenon block, with retrobulbar block largely replaced by safer alternatives.

A peribulbar block involves injecting local anaesthetic into the space surrounding the eye but outside the muscle cone. The anaesthetic diffuses through the orbital tissues to block the optic nerve and the nerves supplying the extraocular muscles. The injection is given through the skin of the lower eyelid or through the conjunctiva, and patients experience the injection as a pressure sensation and brief discomfort.

A sub-Tenon block involves passing a blunt cannula beneath Tenon's capsule, the fibrous layer that surrounds the globe, and injecting local anaesthetic into this space. It avoids the use of a sharp needle within the orbit, making it safer than retrobulbar block while achieving reliable anaesthesia and akinesia. It is particularly useful in complex cases where the eye must remain completely still, such as combined cataract and corneal transplant procedures.

A retrobulbar block involves injection directly into the intraconal space behind the eye. It produces the most rapid and dense akinesia of any regional block but carries a higher risk of serious complications. A review published in the Journal of the Foundations of Ophthalmology (2025) described the risks of retrobulbar anaesthesia as including retrobulbar haemorrhage, globe perforation, optic nerve injury, and brainstem anaesthesia, leading to a significant decline in its use in contemporary practice [4]. Evidence comparing peribulbar with retrobulbar anaesthesia has consistently demonstrated a superior safety profile for peribulbar block [5].

The advantages of injection-based blocks over topical anaesthesia are more complete akinesia and more reliable analgesia in patients where topical coverage may be less predictable. The disadvantages are the discomfort of the injection itself, the risks associated with orbital injection (haemorrhage, perforation, intravascular injection), and a longer time before the block takes full effect. Patients are typically unable to see out of the blocked eye for several hours after surgery, which can be alarming if not anticipated.

Injection-based blocks are more likely to be recommended for patients with complex cataracts requiring longer surgical times, patients who are anxious or unable to cooperate with topical anaesthesia, patients undergoing combined procedures such as combined cataract and vitreoretinal surgery, and patients with certain ocular anatomical factors that make topical anaesthesia less reliable.

General anaesthesia for cataract surgery: when it is used and what it means

General anaesthesia is used for cataract surgery in a small minority of patients. It involves the patient being fully asleep with airway management and a longer recovery period than local anaesthesia. It is indicated for patients who cannot cooperate with local anaesthesia due to cognitive impairment, movement disorders, severe anxiety, or the need for a complex combined procedure anticipated to take substantially longer than a routine operation.

General anaesthesia is indicated for cataract surgery in the following circumstances: patients with severe cognitive impairment or dementia who cannot cooperate with local anaesthesia, patients with movement disorders such as Parkinson's disease or severe tremor who cannot remain still for the procedure, patients with severe anxiety disorders or needle phobia who cannot tolerate local anaesthesia despite maximal sedation, children or young adults requiring cataract surgery who cannot cooperate with awake techniques, patients with very complex combined procedures anticipated to take significantly longer than a standard cataract operation, and patients with known contraindications to local anaesthetic agents.

The risks of general anaesthesia in the cataract surgery population are relevant because these patients are typically elderly and frequently have significant comorbidities. General anaesthesia in elderly patients carries risks of postoperative cognitive dysfunction and delirium, which are uncommon but more likely in patients with pre-existing cognitive impairment, cardiovascular disease, or prolonged operative times. Regional and local anaesthesia techniques avoid these central nervous system effects because the patient remains awake and does not receive the systemic anaesthetic agents responsible for postoperative cognitive effects.

For most patients for whom general anaesthesia is being considered, a careful discussion with both the surgeon and the anaesthetist about the specific indications, the risks relevant to their individual health status, and whether any modifications to local anaesthesia technique might allow the procedure to be performed more safely under local anaesthesia is an important part of pre-operative planning.

How comorbidities affect anaesthesia choice

The anaesthesia choice for cataract surgery takes into account the patient's medical history, systemic comorbidities, medications, and the complexity of the planned surgical procedure. For most patients with cardiovascular or respiratory conditions, local anaesthesia with sedation is the safest approach. Specific conditions that affect planning are outlined below.

Cardiovascular disease: Patients with ischaemic heart disease, heart failure, or significant arrhythmias are best managed under local anaesthesia wherever possible. The haemodynamic stability of topical anaesthesia with sedation is superior to general anaesthesia for these patients. Significant anxiety or pain during the procedure can cause a sympathetic response that increases heart rate and blood pressure, which is why adequate sedation alongside the local anaesthesia is important.

Respiratory disease: Patients with severe chronic obstructive pulmonary disease (COPD), obstructive sleep apnoea, or other significant respiratory conditions are particularly well served by topical anaesthesia with sedation, as they breathe independently throughout and are not intubated. General anaesthesia with intubation in patients with severe respiratory disease carries meaningful risks of respiratory complications including bronchoconstriction, difficult extubation, and postoperative pneumonia.

Anticoagulation: Patients on anticoagulants such as warfarin, rivaroxaban, apixaban, or aspirin require specific consideration if an injection-based local anaesthetic block is planned, as orbital injection in anticoagulated patients carries a risk of retrobulbar haemorrhage. Topical anaesthesia is the preferred approach in anticoagulated patients as it avoids any injection and does not require modification of anticoagulation therapy. If a block is required for specific reasons, the anaesthetist and surgeon will discuss the risks and whether anticoagulation should be modified before the procedure.

Alpha-blockers: Alpha-blockers such as tamsulosin (Flomax), used for benign prostatic hypertrophy, cause intraoperative floppy iris syndrome (IFIS), which affects the surgical technique rather than the anaesthesia choice directly. All patients taking alpha-blockers should inform their surgeon before surgery, as IFIS affects the anaesthesia and surgical plan even if the patient has ceased the medication.

Cognitive impairment and dementia: Patients with mild cognitive impairment can usually undergo cataract surgery under topical anaesthesia with sedation, with careful pre-operative preparation and an experienced team. Patients with moderate to severe dementia who cannot follow instructions, remain still, or understand what is happening are more likely to require a deeper sedation or general anaesthesia, and this decision is made in conjunction with the anaesthetist after a pre-operative assessment.

Tremor and movement disorders: Patients with Parkinson's disease or essential tremor require individual assessment. Many patients with mild to moderate tremor can undergo cataract surgery under topical anaesthesia with sedation, with the sedation reducing movement. Patients with severe tremor or significant dyskinesia may require general anaesthesia for the procedure to be performed safely.

Recovery from cataract anaesthesia

Recovery differs between the three anaesthesia approaches. Topical anaesthesia with sedation allows the fastest recovery, with most patients alert and ready to go home within one to two hours and able to resume normal activities the following day. Local block extends recovery by the time needed for the block to wear off. General anaesthesia requires the longest recovery. For a full guide covering the first days and weeks after surgery, see the guide to cataract surgery recovery.

Topical plus intracameral anaesthesia with sedation: The sedation wears off within 30 to 60 minutes of the procedure ending, and most patients are alert and ready to go home within one to two hours. Vision may be temporarily reduced immediately after surgery due to the dilating drops and the intracameral medication, but this typically improves within a few hours. Patients must not drive on the day of the procedure due to the sedation, but most can resume normal activities the following day.

Local block: Recovery is slightly longer than topical anaesthesia because the block takes several hours to wear off fully. During this time the eye is numb and the eyelid may be droopy (ptosis), and patients cannot see normally from the operated eye. Vision returns as the block wears off over two to six hours. Patients who have had a sub-Tenon or peribulbar block typically have a bruised appearance around the eye for a few days, which is cosmetically noticeable but not harmful.

General anaesthesia: Recovery takes longer and patients typically remain in the recovery room for one to two hours after the procedure. Nausea, grogginess, and fatigue are common in the hours after general anaesthesia. Most patients can go home the same day for routine cataract surgery under general anaesthesia but should have a responsible adult with them for 24 hours. Cognitive effects may persist for longer in elderly patients, particularly those with pre-existing cognitive vulnerability.

What to discuss with your surgeon and anaesthetist before cataract surgery

At your pre-operative assessment, raise any significant medical conditions, all medications including blood thinners, any previous experiences with anaesthesia, any anxiety about being awake during eye surgery, any difficulty lying flat or remaining still, and any history of relevant eye conditions or previous eye surgery. Your surgeon and anaesthetist will use this information to plan the most appropriate anaesthesia approach for your individual situation. For a detailed overview of what the pre-operative consultation covers, see what to expect at your consultation.

For the large majority of patients, topical anaesthesia with intracameral supplementation and intravenous sedation provides an excellent and safe experience. The decision to use an alternative approach is made based on specific clinical factors and is always a collaborative decision.

References

1. 1.Segers MHM, et al. Anesthesia techniques and the risk of complications as reflected in the European Registry of Quality Outcomes for Cataract and Refractive Surgery. J Cataract Refract Surg. 2022;48(12):1403-1407.
2. 2.Minakaran N, et al. Topical anaesthesia plus intracameral lidocaine versus topical anaesthesia alone for phacoemulsification cataract surgery in adults. Cochrane Database Syst Rev. 2020.
3. 3.Ripa M, Ricci F, Rizzo S. Pain experience in patients undergoing topical anesthesia alone versus topical plus intracameral anesthesia during cataract surgery. Eur J Ophthalmol. 2024;34(2):425-431.
4. 4.Anaesthesia for Cataract Surgery: Changes, Considerations and Current Practice. Journal of the Foundations of Ophthalmology. 2025.
5. 5.Peribulbar versus retrobulbar anaesthesia for cataract surgery. Cochrane Database Syst Rev. PMC7175781.