An evaluation of the administration of sub-Tenon local anaesthesia by a nurse practitioner

AIM: To evaluate the administration of sub-Tenon local anaesthesia (LA) by a nurse practitioner. METHODS: 106 consecutive patients listed for cataract surgery were given sub-Tenon's anaesthesia by a nurse practitioner. The surgical procedure was performed within 15 minutes of the administration of the LA. Pain, state and adequacy of anaesthesia, appearance of the eye, and patient anxiety were measured. Patients' experiences of this new nursing role were gained through interview. RESULTS: At the beginning of surgery, few patients showed eye movement in any of the four quadrants and the surgeons reported that akinesia was inadequate in only seven (7.1%) cases. Three patients (3.3%) gave a pain score of 3 out of 10 or above during surgery whereas the surgeons assessed the pain relief to be inadequate in eight (8.1%) cases. Five (5.3%) patients required a top up of anaesthesia and 51 (39.8%) patients developed conjunctival chemosis in two or more quadrants. Overall, patients' comments indicate that they were pleased with the new service. CONCLUSION: The results suggest that nurse practitioner delivered sub-Tenon LA is an effective and safe method of LA administration for cataract surgery.     

Sub-Tenon's block with an ultrashort cannula

PURPOSE: To evaluate the effectiveness and safety of an orbital block using an ultrashort, wide-bore blunt metal cannula to inject local anesthetic agents into the anterior sub-Tenon's space. SETTING: Department of Ophthalmology, North Riding Infirmary, Middlesbrough, United Kingdom. METHODS: Fifty-nine consecutive patients having routine phacoemulsification with intraocular lens implantation were studied. Five milliliters of lidocaine 2% with adrenaline 1:200000 and hyaluronidase 150 units was injected into the anterior sub-Tenon's space in the inferonasal quadrant via a 16-gauge, short (0.6 cm), blunt metal cannula. Horizontal and vertical movements were assessed before injection and 2, 4, and 6 minutes after injection (also at 8 and 10 minutes if akinesia was inadequate). The movements were scored from 0 (no movement) to 3 (full movement). Incyclotorsion and lid movements were assessed at the same intervals. In the first 15 patients, B-scan ultrasonography was performed before, during, and 2 minutes after the injection. If the aggregate akinesia score was higher than 4 at 6 minutes, a supplementary injection was given. Pain during the injection and surgery was assessed using a 10-point verbal rating score. The incidence, severity, and quadrant of chemosis and conjunctival hemorrhage were noted. RESULTS: Forty-eight patients (81.35%) had an aggregate akinesia score lower than 4 at 2 minutes and 58 (98.30%) at 4 minutes. One patient had an akinesia score higher than 4 at 6 minutes and required supplementary injection. Incyclotorsion was present in 42 patients (72.88%) at 2 minutes and in 19 (32.20%) at 4 minutes. Lid opening (levator function) was present in 33 patients (55.93%) at 2 minutes and in 19 (32.20%) at 4 minutes. Lid closure (orbicularis function) was present in 34 patients (57.62%) at 2 minutes and in 18 (30.50%) at 4 minutes. One patient required a supplementary injection at 10 minutes. Ultrasonography showed the injection caused rapid opening of sub-Tenon's space, with fluid spreading around the optic nerve. No pain on injection occurred in 67.79% of patients; 17 (28.81%) had a verbal rating score of 1, 1 (1.69%) had a score of 3, and 1 had a score of 5. No patient reported pain during surgery. A minor degree of chemosis and conjunctival hemorrhage occurred in 43 patients and 37 patients, respectively. Moderate chemosis occurred in 15 cases and severe chemosis in 1 case. CONCLUSIONS: Effective and predictable ocular anesthesia can be achieved using a blunt, ultrashort cannula for sub-Tenon's block. The technique greatly reduces the risks for globe perforation, muscle damage, and other serious complications.     

Sub-Tenon's local anaesthesia: the effect of hyaluronidase

AIMS: A prospective, randomised, double blind study was used to investigate the effect of hyaluronidase on the quality of block achieved with sub-Tenon's local anaesthesia. METHODS: 150 patients scheduled for elective cataract surgery were randomly allocated to either sub-Tenon's block with 3 ml lignocaine 2%/adrenaline 1:200 000 alone or with the addition of 30 IU/ml of hyaluronidase. The blocks were assessed for degree of akinesia and reduction of eyelid movement, and also post-injection and postoperative pain scores. RESULTS: Akinesia and reduction of eyelid movement measured 10 minutes after injection were significantly better in the group with hyaluronidase added to the anaesthetic solution. Postoperative pain scores were not significantly different between the two groups but the post-injection pain score was greater (marginally significant) in the group with hyaluronidase added. CONCLUSION: The addition of hyaluronidase significantly improves the quality of the motor blockade achieved with sub-Tenon's local anaesthesia, but has no effect on the sensory blockade.     

Does the addition of hyaluronidase improve the quality of peribulbar anesthesia in cataract surgery? – A randomized double blinded study

Purpose

To determine the necessity of hyaluronidase as an anesthetic adjuvant for peribulbar anesthesia during cataract surgery and to assess differences in anesthetic outcomes in the absence of hyaluronidase.

Comparison of subtenon anaesthesia with peribulbar anaesthesia for manual small incision cataract surgery

PURPOSE: To compare the safety and efficacy of subtenon anaesthesia with peribulbar anaesthesia in manual small incision cataract surgery using a randomised control clinical trial. METHOD: One hundred and sixty-eight patients were randomised to subtenon and peribulbar groups with preset criteria after informed consent. All surgeries were performed by four surgeons. Pain during administration of anaesthesia, during surgery and 4 h after surgery was graded on a visual analogue pain scale and compared for both the techniques. Sub-conjuntival haemorrhage, chemosis, akinesia after administration of anaesthesia and positive pressure during surgery were also compared. Patients were followed up for 6 weeks postoperatively. RESULTS: About 146/168 (86.9%) patients completed the six-week follow-up. Thirty-one out of 88 (35.2%) patients of peribulbar group and 62/80(77.5%) of subtenon group experienced no pain during administration of anaesthesia. There was no significant difference in pain during and 4 h after surgery. Subtenon group had slightly more sub-conjunctival haemorrhage. About 57 (64.8%) patients of the peribulbar group had absolute akinesia during surgery as compared to none (0%) in sub-tenon group. There was no difference in intraoperative and postoperative complications and final visual acuity. CONCLUSION: Sub-tenon anaesthesia is safe and as effective as peribulbar anaesthesia and is more comfortable to the patient at the time of administration.     

Sub-Tenon's anaesthesia: an efficient and safe technique

AIM—To evaluate sub-Tenon' s anaesthesia as an alternative to peribulbar anaesthesia.
METHODS—109 consecutive patients listed for various eye operations (including cataract, trabeculectomy, and vitrectomy) under peribulbar anaesthesia were operated on under sub-Tenon's anaesthesia instead. After topical anaesthesia a buttonhole was fashioned through the conjunctiva and Tenon's capsule 10 mm posterior to the limbus. 1.5 ml of lignocaine 2% was then delivered to the posterior sub-Tenon's space using a blunt cannula. The surgical procedure was performed immediately after the completion of the anaesthetic procedure. Chemosis, conjunctival haemorrhage, degree of akinesia, and pain scoring were analysed.
RESULTS—There were no anaesthesia related complications. The administration of the block was painless for 99.1% of the patients. In all, 97.3% reported no pain during surgery. There was no akinesia when assessed just after the completion of the block and akinesia was limited when assessed after surgery. Chemosis and conjunctival haemorrhage were frequent but caused no intraoperative problems.
CONCLUSION—Sub-Tenon's anaesthesia is an efficient and safe anaesthetic technique. It is a good alternative to peribulbar anaesthesia.

     

Sodium bicarbonate--an alternative to hyaluronidase in ocular anaesthesia for cataract surgery

PURPOSE: To evaluate and compare the safety, efficacy and cost-effectiveness of 7.5% sodium bicarbonate buffered lidocaine (pH 7.2) with hyaluronidase mixed lidocaine (pH 4.6) for local anaesthesia in cataract surgery. METHODS: This prospective study comprised two parts. Part I: We evaluated the ocular and systematic anaesthetic safety and efficacy of 7.5% sodium bicarbonate buffered lidocaine on 112 consecutive patients undergoing cataract extraction with intraocular lens (IOL) implantation. At 12-week postoperative follow up final visual acuity and detailed fundus examination was done. Part II: It was conducted as a double blind, randomized comparative clinical trial involving 120 patients undergoing cataract surgery under retrobulbar anaesthesia. Patients were randomly assigned to one of the two groups: 60 eyes received 2 ml of 2% lidocaine with 1:200,000 epinephrine and 1 ml of 7.5% sodium bicarbonate, (0.299 mmol/ml); the remaining 60 eyes received 2 ml of 2% lidocaine with 1:200,000 epinephrine and 450 units of hyaluronidase (15 U/ml). In the event of incomplete akinesia, retrobulbar blocks were supplemented at 10 minutes. Onset and duration of anaesthesia and akinesia were assessed and compared in both groups. RESULTS: The pH-adjusted lidocaine group did not show any demonstrable variation in blood pressure (BP) or other systemic reaction. No anaesthesia-related adverse ocular effects were observed either during or after surgery. Thirty-one eyes (51.6%) achieved complete anaesthesia and akinesia within 5 minutes compared to 13 eyes (21.6%) in the hyaluronidase group. However, the overall mean onset time of anaesthesia and akinesia, repeat block rate and the duration of the anaesthesia were comparable in both the groups--p: 0.14). Twelve weeks postoperatively 88.39% of patients showed a best corrected visual acuity of 6/18 or better (73.21%-6/12 or better). CONCLUSION: In this study, sodium bicarbonate buffered 2% lidocaine was found to be a safe and effective local anaesthetic, with reduced time of onset, and improved quality of both anaesthesia and akinesia. Sodium bicarbonate (7.5%) may be used as an alternative to hyaluronidase in ocular anaesthesia. It is readily available and is cost effective.     

Effect of volume used in sub-Tenon's anaesthesia on efficacy and intraocular pressure: a randomized clinical trial of 3 mL versus 5 mL

PURPOSE: To compare the effect of volume used in sub-Tenon's anaesthesia on efficacy and intraocular pressure (IOP). METHODS: A prospective, randomised clinical trial was conducted on 52 eyes of 52 consecutive patients undergoing sub-Tenon's anaesthetic for cataract surgery. Eyes were randomly assigned to either 3 mL or 5 mL volume of anaesthetic solution (0.5% bupivacaine/2% lidocaine in a 50:50 mixture). The main outcome measures were akinesia 5 min post-administration of anaesthetic, changes in IOP immediately after and 5 min after anaesthetic administration, and patient pain perception during procedure. RESULTS: The level of kinesia was greater in the 3 mL group (n = 25) compared to the 5 mL group (n = 27) (P = 0.001, Mann-;Whitney U-test). There was no significant difference in pain perception between the two groups (P = 0.464, student t-test). Although there was great variation in IOP changes following sub-Tenon's anaesthetic, there was a trend for a larger rise in mean IOP immediately after anaesthetic administration in the 5 mL group (mean +/- SD +5.6 +/- 4.2 mmHg) compared to the 3 mL group (+4.3 +/- 3.8 mmHg), but this did not reach statistical significance (P = 0.25, student t-test). CONCLUSIONS: A 5 mL volume of anaesthetic provides akinesia superior to a 3 mL volume in sub-Tenon's anaesthesia for cataract surgery.     

Warming lignocaine reduces the pain of injection during peribulbar local anaesthesia for cataract surgery.

AIMS--To test if the simple technique of warming lignocaine reduces the pain of injection during local anaesthetic cataract surgery. METHODS--Sixty patients undergoing peribulbar local anaesthesia for cataract surgery were allocated randomly to receive either warm (37 degrees C) or cold (room temperature) plain 2% lignocaine for the injection. Pain was assessed subjectively by asking the patients to score their pain from 0 (no pain) to 10 (most severe pain imaginable). RESULTS--The mean pain score for the warm group was 2.3 (SD 1.3) in comparison with a mean score of 5.5 (1.0) for the cold group (p < 0.01). CONCLUSIONS--The process of warming lignocaine to 37 degrees C has been found to reduce significantly the pain of injection during peribulbar local anaesthesia. It is recommended that this technique be more widely adopted in order to minimise patient's discomfort.     

Pain relief with intracameral mepivacaine during phacoemulsification

AIM: To assess the efficacy and safety of an intraoperative intracameral injection of mepivacaine, administered when patients experienced pain during the course of cataract surgery under topical anaesthesia. METHODS: This is a prospective placebo controlled double masked randomised clinical trial. 50 eyes were included; 25 receiving the active compound and 25 receiving placebo. Mepivacaine (2%, 0.4 ml) or placebo was administered intraoperatively under the iris of the patients who experienced pain during the course of phacoemulsification in spite of previous topical anaesthesia. Efficacy was evaluated by the patients themselves using a five point subjective pain rating scale, the Keele verbal pain chart. Safety was measured by assessing intraocular inflammation (clinical evaluation and laser flare meter), intraocular pressure, and endothelial cell count. RESULTS: The pain rating score significantly diminished after intracameral injection in the mepivacaine group (mean 3.0 (95% CI 2.6-3.4) v 0.8 (0.3-1.3), p<10(-4))) while remaining unchanged in the placebo group (2.9 (2.6-3.2) v 2.9 (2.5-3. 3)), the mean reduction in pain score being significantly different between the two groups (p<10(-4)). There was no indication of increased postoperative ocular inflammation, intraocular pressure change, or endothelial cell loss. CONCLUSIONS: These results suggest that it may not be necessary to systematically add intracameral anaesthesia with topical anaesthesia for cataract surgery. An intraoperative intracameral injection, performed only in patients who happen to suffer during surgery, is safe and effective.     

Ropivacaine versus lidocaine for deep-topical, nerve-block anaesthesia in cataract surgery: a double-blind randomized clinical trial

PURPOSE: To evaluate the safety and efficacy of ropivacaine versus lidocaine for deep-topical, nerve-block anaesthesia in cataract surgery. METHODS: This prospective controlled randomized double-blind study comprised 64 patients undergoing clear corneal phacoemulsification. Patients were equally divided into two group receiving either deep-topical anaesthesia with 1% ropivacaine-soaked sponge (Group R, n = 32) or 2% lidocaine-soaked sponge (Group L, n = 32). The level of intraoperative and postoperative pain was assessed by patients using a verbal analogue scale from 1 to 10. The duration of surgery, the need for supplemental anaesthesia, surgeon satisfaction, and intraoperative and early postoperative complications were recorded. The patients' heart rate, arterial blood pressure and peripheric oxygen saturation (SpO(2)) were obtained just before the anaesthesia and during the surgery. RESULTS: The demographic data of the patients and duration of surgery were similar in both groups. No significant difference in the mean pain scores of patients were found in the ropivacaine and lidocaine groups. Surgical satisfaction was also statistically insignificant. None of the patients had significant difference in heart rate, blood pressure or SpO(2) during the surgical procedure. CONCLUSION: Deep-topical anaesthesia with ropivacaine and lidocaine in cataract surgery is safe and the two anaesthetic agents do not present differences in the degree of analgesia achieved. Deep-topical anaesthesia with ropivacaine or lidocaine was equally effective in providing anaesthesia with sufficient quality for cataract surgery.     

Topical versus peribulbar anaesthesia for cataract surgery

BACKGROUND: To assess and compare the efficacy and safety of topical versus peribulbar anaesthesia in patients undergoing routine cataract surgery. METHODS: The unicentre, prospective, randomized, clinical interventional trial included 140 consecutive patients undergoing routine cataract surgery performed by one of two surgeons. The patients were randomly distributed to either peribulbar anaesthesia or topical anaesthesia. To assess intraoperative pain, each patient was asked immediately after surgery to quantitate his/her pain using a 10-point pain rating scale. RESULTS: The study groups did not differ significantly in pain score (p=0.54), duration of surgery (p=0.52), anaesthesia-related intraoperative difficulties (p=0.17), postoperative visual acuity (p=0.94), overall intraoperative surgical complication rate, blood pressure rise (p=0.16) or blood oxygen saturation (p=0.74) CONCLUSIONS: Patient comfort and surgery-related complications did not differ between topical anaesthesia and peribulbar anaesthesia. As there are no significant differences between the two techniques in terms of subjective pain experienced by patients, intraoperative complications and postoperative visual outcome, and in view of the minimally invasive character of topical anaesthesia compared to peribulbar anaesthesia, the present study suggests the use of topical anaesthesia for routine cataract surgery.     

Tetracaine drops versus lidocaine gel for topical anaesthesia in cataract surgery

BACKGROUND: in addition to intracameral anaesthesia, drop anaesthesia with tetracaine drops has been established for topical anaesthesia in cataract surgery. Anaesthesia with lidocaine gel is less established. We compared pain sensitivity of patients undergoing surgery with drop anaesthesia to patients who underwent surgery with gel anaesthesia. PATIENTS AND METHODS: In a questionnaire-based survey in which patients assessed their sensitivity to pain during cataract surgery, we compared the sensitivity to pain of 49 patients during surgery with gel anaesthesia to 62 patients who consecutively underwent surgery with drop anaesthesia. Patients assessed pain intensity postoperatively by checking off a 10-graduation pain scale. Lidocaine gel (2 %) was applied once while tetracaine drops (1 %) were applied three times. All interventions were carried out by two surgeons as phako emulsifications with implantation of a posterior chamber lens via posterior-limbal access. In addition to pain sensitivity we also considered the patients' age, duration of surgery and surgical complications. The data for the patients' age, the duration of surgery and the assessment of intensity were not normally distributed so that a Mann-Whitney-rank-sum test was performed. RESULTS: No differences were observed between tho two groups, neither regarding age (P = 0.63) nor the duration of the surgical intervention (p = 0.43). However, in patients treated with tetracaine drops pain sensitivity was reported as being significantly less (mean 1,77) than in patients treated with lidocaine gel (mean 2.22; P < 0.043). 73.5 % of patients with gel anaesthesia and 83.9 % of those with drop anaesthesia reported "negligible" pains. There were no intra-operative complications. CONCLUSION: Both gel anaesthesia and drop anaesthesia are suitable methods for cataract surgery under local anaesthesia. According to patients' assessment, drop anaesthesia with tetracaine is better suited for pain elimination.     

Light sensitivity and pain sensation during cataract surgery. A comparative study of two modes of anaesthesia

The objective of this study was to compare the light sensitivity and pain experienced by patients undergoing cataract surgery under subtenon and topical with intracameral anaesthesia. Fifty-four patients were randomly assigned to receive either two drops of proxymethacaine 0.5% as topical anaesthesia with 0.5 ml preservative-free 1% intracameral lidocaine or 4 ml 2% lignocaine as subtenon anaesthesia. Light sensitivity and overall pain perception were recorded at the end of surgery. The mean pain score in the subtenon group (0.11; range 0–1) was lower than in the topical group (1.07; range: 0–3, P < 0.001). The mean light-sensitivity score was lower in the subtenon group (0.26; range: 0–4) than in the topical group (1.29; range: 0–4, P = 0.001). Subtenon anaesthesia was more effective in suppressing light sensitivity and pain during cataract surgery than topical with intracameral anaesthesia. This suggests that use of subtenon anaesthesia may lead to a more comfortable operative experience.     

Comparative clinical trial of topical anaesthetic agents for cataract surgery with phacoemulsification: lidocaine 2% drops, levobupivacaine 0.75% drops, and ropivacaine 1% drops

PURPOSE: To assess the safety and efficacy of topical lidocaine, levobupivacaine, and ropivacaine in cataract surgery with phacoemulsification.METHODs: One hundred and five patients scheduled for cataract surgery with topical anaesthesia were randomly allocated into 3 groups of 35 patients each to receive eye drops of lidocaine 2%, levobupivacaine 0.75%, or ropivacaine 1% every 5 min starting 30 min before surgery. Patients graded their pain using a 0-10-point verbal pain score (VPS) at different stages of the procedure. The levels of patient and surgeon satisfaction, the duration of surgery, complications, and the need for supplemental anaesthesia were recorded.RESULTS: There was no significant difference in duration of surgery and demographic variables among the groups. At the intraoperative period, end of surgery, and postoperative first hour the mean VPS in the lidocaine group was significantly higher than the others (P<0.01), but no significant difference was found between the levobupivacaine and ropivacaine groups. At incision and 24 h after surgery, it was not significantly different among the groups. Surgeon and patient satisfaction scores were significantly better in the levobupivacaine and ropivacaine groups than in the lidocaine group (P<0.01).CONCLUSIONS: Topical anaesthesia with levobupivacaine and ropivacaine were safe, feasible and more effective than lidocaine in cataract surgery. Levobupivacaine and ropivacaine provided sufficient and long-lasting analgesia without the need of supplemental anaesthesia for each patient.     

Bupivacaine and lignocaine for ophthalmic surgery.

Bupivacaine 0.5% when used as a local anaesthetic for ocular cataract surgery does not give absolute ocular akinesia but provides adequate and prolonged pain relief. In comparison lignocaine provides good ocular akinesia at operation but pain relief is short lived. The mixture of the two local anaesthetics in equal volumes eliminated the disadvantages of their individual use.     

A comparison of three sub-Tenon's cannulae

PURPOSE: To compare the quality of anaesthesia and complication rates between three sub-Tenon cannula of increasing length (anterior Greenbaum, mid Kumar-Dodds, and posterior Steven's sub-Tenon's cannulae). METHODS: A total of 150 patients undergoing cataract extraction were randomised to receive a sub-Tenon injection of 5 ml of 2% lidocaine with hyaluronidase with one of the three cannulae. The development of akinesia was assessed every 2 min over a 6-min period. Complications were also recorded. RESULTS: There was no difference in the onset of akinesia, with 46, 50, and 46 patients achieving adequate akinesia within 6 min for the anterior, mid, and posterior groups respectively (P>0.05). There was an increase in retained lid opening with anterior compared to mid and posterior cannulae (P=0.0001). There was significantly less retained lid closure with the posterior compared to the mid or anterior cannulae (P<00001). The mean (range, SD) scores for pain during injection were 0.4 (0-5, 0.83), 1.2 (0-9, 1.96), and 1.1 (0-6, 1.19) for the anterior, mid, and posterior groups, respectively. These were not significantly different between the anterior and mid groups, or the mid and posterior groups (P>0.05), but there was significantly more pain on injection with the posterior compared to the anterior groups (P<0.01). All patients scored intraoperative pain as zero. There was significantly more chemosis in the anterior group (76%) compared to the mid (20%) and posterior (32%) groups (P<0.0001). There were significantly (P=0.0004) more conjunctival haemorrhages in the anterior group (56%) than the mid (20%) or posterior (20%) groups. CONCLUSIONS: We have shown that all three cannulae provide high-quality anaesthesia with minor differences in retained muscle activity, chemosis, and haemorrhage rates.     

Limbal anaesthesia versus topical anaesthesia for clear corneal phacoemulsification

PURPOSE: To compare the safety and clinical efficacy provided by limbal anaesthesia with topical anaesthesia in cataract surgery. METHODS: A total of 117 consecutive patients undergoing routine cataract surgery were randomly assigned to receive limbal or topical anaesthesia. Limbal anaesthesia was administered with a cellulose ophthalmic sponge soaked in preservative-free lidocaine hydrochloride 4% applied to the temporal perilimbal area for 45 seconds immediately before surgery. For topical anaesthesia lidocaine 4% was instilled in each patient at 10-min intervals four times before surgery. We studied phaco time, perioperative pain, visual outcome and intraoperative complications. The level of intraoperative pain was scored on a scale of 1-10, where 1 = no pain and 10 = severe pain. RESULTS: 55 patients (91.6%) in the topical group and 54 patients (94.7%) in the limbal group tolerated the procedure well, giving pain scores of 1-3, with no statistical difference. No patients in either group required supplemental anaesthesia and no intraoperative complications were recorded. No eyes had epithelial defects at the end of surgery or at postoperative check-ups. CONCLUSION: Limbal anaesthesia in cataract surgery is safe and the two anaesthesia techniques do not present differences in the degree of analgesia achieved.     

Topical anaesthesia with oxybuprocaine versus sub-Tenon's infiltration with 2% lignocaine for small incision cataract surgery

AIMS—To determine whether topical anaesthesia in small incision self-sealing phacoemulsification cataract surgery provides comparable anaesthesia to sub-Tenon's infiltration.
METHODS—Thirty five patients undergoing small incision self-sealing phacoemulsification cataract surgery were allocated randomly to receive topical anaesthesia with 0.4% oxybuprocaine or sub-Tenon's infiltration with 2% lignocaine. Pain experienced during the operation was assessed by asking the patient to score on a visual analogue graphic pain score chart.
RESULTS—The median pain score for the topical group (3) was significantly higher than that of the sub-Tenon's group (0) (p = 0.004).
CONCLUSION—Sub-Tenon's infiltration is superior to topical anaesthesia in ensuring patient comfort during small incision scleral tunnel self-sealing phacoemulsification cataract surgery.