Drop, then decide approach to topical anesthesia.

I developed an approach to topical anesthesia--drop, then decide--with the goal of increasing the percentage of patients able to have topical anesthesia for anterior segment surgery. This study comprised 150 consecutive surgeries performed using the technique, including cataract extraction with intraocular lens (IOL) implantation, trabeculectomy, combined procedures, and McCannel suturing. Six patients also had anterior vitrectomy. Patients were not preselected. All cases were initiated with topical anesthesia and supplemented with at least mild intravenous sedation by an anesthesiologist. The decision on whether to use anesthetic blocks was made after evaluating patient response early in the surgery. The approach had an overall success rate (no regional block needed) of 89.3%; 92.0% of the cataract/IOL implantation cases were successful. Most patients reported they were comfortable throughout the procedure. The success rate was high among patients who may be considered poor candidates for topical anesthesia; younger patients had more difficulty. This approach allows more patients to benefit from the advantages of topical anesthesia over other techniques.