March 2014




Help patients relax for better cataract surgery cooperation

by Vanessa Caceres EyeWorld Contributing Writer

Woman in headphones

Education, positive imagery techniques quelled anxiety in recent study

To cataract surgeons, performing surgery can seem like a routine task. However, to patients, it's surgery they have only once or twice in their lifeand that could bring on nervousness and anxiety. Surgical anxiety can affect a patient's pain sensitivity, blood pressure, heart rate, compliance, and even IOP.

A study published recently in the journal Patient Education and Counseling identified a way to help cataract surgery patients reduce their perioperative anxiety.1

Investigators, led by Zoltn Kekecs, Eotvos Lornd University, Faculty of Education and Psychology, Department of Affective Psychology, Budapest, found that listening to an audio CD that included patient education as well as positive therapeutic suggestions to help manage anxiety made patients feel calmer and be more cooperative during their cataract operation.

Study details

In this randomized, controlled, single-blind study, 84 patients slated for cataract surgery were divided into two groupsone group (34 patients) received a 15-minute audio CD and were instructed to listen to the CD four times at home, including once during the night before the operation. They were told that listening to it four times would help get them familiar with the relaxation and imagery techniques. The script on the CD was designed with the help of a hypnotherapist experienced with the use of positive suggestions in the medical field and was read by the cataract surgeon whom the patients were already familiar with. The CD script explained the phases of the operation and the recovery period but also used positive suggestions and imagery techniques, such as focusing attention on breathing and imagining a safe place during the operation.

Some of the script from the text included: "When you arrive in the forefront of the operating room you'll get a number of eye drops. It'll be good to know that with every drop your pupil will be more dilated and dilated and your eye will get more and more anesthetized as long as it's needed. First your eye will be cleaned with a disinfectant solution. Some imagine this like a pleasant cool breeze that washes away not only bacteria but the remaining tension as well."

The 50 patients in the control group did not listen to the audio CD.

As part of standard procedure, all patients received the anti-anxiety medication alprazolam 0.25 mg in the perioperative room after an initial medical exam. Upon return to the clinic the following day, investigators asked the intervention group patients how many times they had listened to the CD at home.

In addition to the usual clinical measures, investigators measured anxiety with the State-Trait Anxiety Inventory. With use of the Pain Affect Faces Scale, patients measured their happiness or discomfort during various times before and after surgery. Patients also provided information on their sleep quality during the night before surgery. A study assistant assessed calmness based on the patients' behavior before and after surgery and during the first postoperative follow-up, while the surgeon (who was blind to the group allocation) assessed cooperativeness during the operation. Investigators also assessed blood pressure and heart rate before, during, and after surgery.

Delving into the results

The study found that the intervention group patients were more cooperative and appeared to be calmer than patients in the control group, particularly during the postoperative visit. Investigators found no difference in heart rate, sleep quality, or subjective well-being.

There was one finding surprising to Mr. Kekecs. "Although our intervention decreased intraoperative and postopertive anxiety, it did not decrease preoperative anxiety. In retrospect, this might be because our intervention was focused on the procedure itself and the recovery period," he said. It may be just as important to tell patients what to expect prior to surgery and give them anxiety-reducing techniques they can use while waiting for surgery, he added. The study shows the importance of patient education before cataract surgery, Mr. Kekecs said. However, ophthalmologists and their staff members will want to be careful how they phrase this information, as some patients want to deliberately avoid information about surgery, thinking that if they know what will happen to them, it will increase their anxiety, Mr. Kekecs said. Oliver Findl, MD, Department of Ophthalmology, Hanusch Hospital, Vienna, Austria, found the study interesting, but he does see patients from time to time who do not want to know what he's going to do in the operating room. Dr. Findl has been involved with previous research that included a video to prep cataract patients preoperatively and found that anxiety levels were lowered if patients had a better idea of what to expect, although the difference was marginal. He also was co-author of a 2012 study in the Journal of Cataract& Refractive Surgery that involved a computer-based tutorial prior to surgery in addition to the traditional informed consent process.2 The intervention group was significantly better informed than the control group, which only had conventional informed consent.

However, Dr. Findl said that for people who are very anxious, there may be no intervention to truly change how they are feeling. He also said he liked the idea of the audio CD used in the study but that cataract surgery patients who are older may not always be receptive to positive imagery techniques and suggestions.

Dr. Findl finds it helpful during surgery to verbally reassure patients that they are doing well and to prepare them for what sensations they might feel or when something in the room, such as the lighting, will change. "About 25% of patients will say, 'Thanks for talking with me during that, it was relaxing,'" he said.

Health literacy educator Jann Keenan, EdS, president, The Keenan Group, Ellicott City, Md., said the intervention in Mr. Kekecs' study worked well for several reasons. First"Hearing the physician's voice on the CD and then having the same physician perform the surgery built trust," she said. Second, patients had the relevant educational information read to them, so there was no concern over how well a patient could read. However, Ms. Keenan said that some words used in the script, such as forefront, dilated, anesthetized, and bacteria, could be changed to easier terms for even stronger comprehension for all.

Ms. Keenan said that the use of an audio CD along with a brief, easy-to-read brochure that discusses surgical success rates and outlines everything to expect before, during, and after surgery would make the educational effort even more effective. She also encouraged cataract surgeons to use the teach-back techniqueasking patients open-ended questions that require them to explain in their own words the health information given to them in order to determine whether it was presented in a way they understand.

Mr. Kekecs said he and fellow investigators have six-month data from the patients in this study; although the data are not yet ready for publication, it appears that the intervention group patients experienced some long-term benefits compared with the control group.


1. Kekecs Z, Jakubovits E, Varga K, Gombos K. Effects of patient education and therapeutic suggestions on cataract surgery patients: A randomized controlled clinical trial. Patient Education and Counseling. 2014;94:116-122.

2. Wollinger C, Himschall N, Findl O. Computer-based tutorial to enhance the quality and efficiency of the informed-consent process for cataract surgery. J Cataract Refract Surg. 2012;38;655-659.

Editors' note: The sources have no financial interests related to this article.

Contact information


Related articles:

What caused a complication that cataract surgeons fear most? by Liz Hillman EyeWorld Staff Writer

Managing makeup after surgery by J. E. “Jay” McDonald II, M.D.

Zonular issues can complicate cataract surgery by Michelle Dalton EyeWorld Contributing Writer

Experts discuss controversies in cataract surgery by Chiles Samaniego EyeWorld Asia-Pacific Senior Staff Writer

Myopic eyes and cataract surgery: Weve come a long way by Dagny Zhu, MD, Lloyd Cuzzo, MD, and Vivek Patel, MD

Help patients relax for better surgery Help patients relax for better surgery
Ophthalmology News - EyeWorld Magazine
283 110
216 180
True, 3