Cataract is the leading cause of reversible blindness worldwide, contributing significantly to the global burden of visual impairment¹. Phacoemulsification with intraocular lens implantation is the gold standard for cataract surgery, and achieving adequate anesthesia is vital to ensure surgical precision, patient comfort, and safety². Traditionally, peribulbar anesthesia has been widely used for cataract surgery, providing profound analgesia and akinesia. However, it carries risks of complications such as chemosis, subconjunctival hemorrhage, and, rarely, globe perforation³.

In recent years, topical anesthesia has emerged as a safer alternative, offering faster postoperative recovery and avoiding needle-related complications. Studies have demonstrated that topical anesthesia is well tolerated in routine cataract surgeries, although it may be associated with higher intraoperative discomfort compared to peribulbar anesthesia⁴⁻⁵. Recent evidence also suggests that anesthesia choice is particularly relevant in patients with systemic comorbidities, where minimizing perioperative risk is essential⁶.

While multiple studies have compared the two techniques, there remains variability in reported outcomes with respect to intraoperative pain, postoperative comfort, and anesthesia-related complications. Therefore, this study was designed to compare topical and peribulbar anesthesia in patients undergoing phacoemulsification cataract surgery at a tertiary care teaching hospital.

Objectives

1. To compare intraoperative pain scores between patients undergoing cataract surgery under topical anesthesia and those under peribulbar anesthesia.
2. To evaluate postoperative comfort and satisfaction levels between topical and peribulbar anesthesia groups using standardized scales.
3. To analyze and compare the incidence of anesthesia-related complications in both groups.

This prospective, comparative, hospital-based study was conducted in the Department of Ophthalmology at a tertiary care teaching hospital. A total of 100 patients aged 40 years and above with senile cataract were enrolled and randomized into two equal groups: Group A (Topical Anesthesia, n=50) and Group B (Peribulbar Anesthesia, n=50). Exclusion criteria included complicated cataracts, previous ocular surgeries, communication difficulties, or contraindications to local anesthesia. Intraoperative pain, postoperative comfort at 1 and 24 hours, hemodynamic parameters, and anesthesia-related complications were recorded. Data were analyzed using SPSS version 25 with significance set at p<0.05.

Table 1: Demographic Characteristics

Chart No 1 - Intraoperative Pain Scores (VAS)

Chart No 2 - Postoperative Comfort (Likert Scale)

Chart No. 3 - Anesthesia-Related Complications

A total of 100 patients were included, divided equally into two groups: topical anesthesia (n=50) and peribulbar anesthesia (n=50). The demographic characteristics of both groups were comparable. The mean age was 62.1 ± 7.4 years in the topical group and 63.5 ± 6.8 years in the peribulbar group. Gender distribution was similar, with a male-to-female ratio of 28:22 in the topical group and 26:24 in the peribulbar group. Mean surgical duration was also comparable, 18.4 ± 3.2 minutes for topical and 19.1 ± 3.5 minutes for peribulbar cases, showing no significant difference.

Intraoperative pain assessment revealed a statistically significant difference between the groups. The mean VAS score was higher in the topical group (3.2 ± 1.1) compared to the peribulbar group (1.5 ± 0.8), indicating better analgesia with peribulbar anesthesia. Postoperative comfort, evaluated using the 5-point Likert scale, was slightly higher in the peribulbar group (4.3 ± 0.5) than the topical group (4.1 ± 0.6), though the difference was not statistically significant.

Anesthesia-related complications were more frequent with peribulbar anesthesia. Chemosis occurred in 4 patients (8%) and subconjunctival hemorrhage in 3 patients (6%). In contrast, no such complications were observed in the topical group. However, the need for supplemental anesthesia was greater in the topical group (12%) compared to the peribulbar group (4%).

This study compared topical and peribulbar anesthesia in phacoemulsification cataract surgery and highlighted the balance between efficacy and safety of both techniques. Intraoperative pain scores were significantly higher in the topical group, reaffirming that peribulbar anesthesia provides superior analgesia³⁻⁵. Similar findings have been reported in earlier studies, where peribulbar blocks ensured greater patient comfort by achieving akinesia and deeper anesthesia³⁻⁴.

However, the drawback of peribulbar anesthesia was evident in the complication profile. Needle-based complications such as chemosis and subconjunctival hemorrhage occurred in up to 14% of patients in our series. These findings align with earlier reports cautioning against potential risks of orbital hemorrhage, globe perforation, and vascular injury when using peribulbar anesthesia³. Conversely, topical anesthesia completely avoided injection-related complications, supporting its role as a safer option, especially in routine cases⁴⁻⁵.

Interestingly, postoperative comfort scores in our study were comparable between groups, with only a marginal advantage for peribulbar anesthesia. This suggests that although topical anesthesia patients experienced more intraoperative awareness of surgical manipulation, their overall satisfaction remained high. Recent evidence also highlights that topical anesthesia may be preferable in patients with cardiovascular comorbidities, as it avoids systemic stress and injection-related risks⁶.

Our findings echo global practice trends where cataract surgery is shifting toward minimally invasive anesthesia approaches, consistent with WHO’s emphasis on improving surgical access with safe and patient-friendly techniques¹. The results confirm that while peribulbar anesthesia remains superior in analgesic efficacy, topical anesthesia provides a complication-free and efficient alternative. Thus, the choice should be individualized based on patient profile, surgeon preference, and comorbid conditions².

Topical and peribulbar anesthesia were both safe and effective for cataract surgery. Peribulbar anesthesia provided superior intraoperative analgesia but was associated with more local complications. Topical anesthesia minimized injection-related risks, though with higher intraoperative discomfort and increased requirement for supplemental anesthesia. An individualized approach to anesthesia selection is recommended to optimize surgical outcomes and patient satisfaction.

1. World Health Organization. Blindness and vision impairment [Internet]. Geneva: WHO; 2023 Aug 10 [cited 2025 Sep 20].
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3. Vakharia D, Gokhale SK. A Comparative Study of Topical Versus Peribulbar Anaesthesia in Phacoemulsification Cataract Surgery and Implantation of Intraocular Lens. J Clin Res Ophthalmol. 2015 Sep 21.
4. Singh S, Sethi V, Khan B, Anand V, Hans M. Comparison of topical and peribulbar anaesthesia in the outcome of clear corneal phacoemulsification in a tertiary care institute. Indian J Basic Appl Med Res.
5. Mehta R, Punjabi S, Bedi N, Nagar CK. Comparison of peribulbar anesthesia and topical anesthesia on outcome of phacoemulsification. Int J Res Med Sci. 2017 Apr 27.
6. Behera G, Kothari A, Subramanian A, Jayaraman R, Rene S. Comparing Peribulbar and Topical Anesthesia in Cataract Surgery among Patients with Cardiovascular Disease. Korean J Ophthalmol. 2024 Jan 15;38:71-76.