For many ophthalmologists, cataract surgery is routine. It can be easy to forget that, from a patient’s viewpoint, undergoing this procedure is a novel experience. Some patients have never had any surgery before, and many more have never had eye surgery. The concept of an invasive ocular procedure can unnerve some patients, and those stressors can be associated with poorer outcomes, research shows.1 With this in mind, it is incumbent upon both the physician and the surgical support staff to provide an atmosphere of compassion and confidence. “[Patient] anxiety is fueled by fear, and it’s fueled by fear of the unknown,” explains Steve H. Chang, MD, a cataract surgeon at Nevada Eye Consultants in Reno, Nevada. “I try to verbalize as much as I can that everything is going great, ‘you’re doing great.’”
Open, calm, and direct communication is crucial to providing comfort and keeping patients relaxed for their procedure and recovery. Some surgical centers are incorporating unorthodox techniques such as music therapy, guided imagery, meditation, strategic office design, and other preoperative protocols to deliver top quality results.
Researchers and teams such as those at Nevada Eye Consultants and the Eye Surgery Center of Northern Nevada (ESCNN) are finding numerous innovative approaches to remove the dread from cataract surgery. Upon entering ESCNN, individuals are welcomed by name — their arrival is expected. The staff may be seen enthusiastically conversing with patients.
A Comfortable Setting
To care for your nervous cataract patient, start by creating a warm and inviting atmosphere. Think of the soothing decor of a corner coffee shop.
Dr Chang says he performs approximately 1800 cataract surgeries each year in his practice at Nevada Eye Consultants, in Reno, Nevada. In his experience, psychological factors are an extremely important element of recovery. These factors can be influenced by the office itself.
A study on dental offices shows that waiting areas with cooler temperatures, dim lighting, and pleasing fragrances can all put patients at ease.2 Additionally, nature imagery and soft music has been found to have a psychological benefit for patients undergoing any elective procedure.2,3 At the Eye Surgery Center of Northern Nevada, the waiting area features low ceilings, earth-tones, and only a handful of chairs. Patients are not overwhelmed by clutter. It’s designed to feel homey.
“I think how patients perceive the surgery and experience plays a bigger role in how they feel in their healing,” he explains. “If somebody feels like they had too much discomfort or they were too nervous, that sometimes translates into their postoperative period, and ‘I know something was wrong because I felt this (sensation).’”
While the physical setting can influence a patient’s comfort level, the environment patients perceive is not merely lighting and wallpaper. The way clinicians and staff interact is also a part of that.
Dr Chang believes if surgery teams evolve their approaches to stress management, they can prompt a smoother recovery. “If the patient feels like the experience of surgery was great, and all their needs and wants were addressed, and their anxiety was handled, they’re usually extremely happy and very relieved.”
To maximize individualization on surgery day, Dr Chang begins a conversation with a preoperative bedside visit that continues during their time in the operating room (OR). He tells patients that if they ever feel uncomfortable, to tell himself or anyone on the team. This back and forth communication may help them feel safe enough to be an active participant in their care.
“I’ve learned never to underestimate or take for granted how each patient feels, or should feel, or behave before or after surgery,” he says. Part of that customization is simply listening. Patients will sometimes ask questions that take a few minutes to explain. Although it may take extra time, he knows even a 10-minute procedure is a big deal to them; “it’s their eye.”
The Soothing Power of Music
Dr Chang is among a growing number of surgeons who see the value of intraoperative applications of music therapy. He uses a streaming music playlist and incorporates “the softer side” of various genres. He believes a silent OR is an emotionally sterile OR.
“I’ve found over the years that music is good for patients, but it’s also good for me and it’s good for my staff,” he says. The patients are relaxed by the melodies and sometimes ask him who chose the selections.
“Sometimes, they have a certain type of music they want to play and I’m like ‘Yeah, let’s do it’ and we’ll throw on their preference in music. Just want to make the patient know that we’re focused on them. I always try to say ‘this is all about you,” he explains. If the patient would like silence and quiet, he respects those wishes, “always, always, always.”
This isn’t just Dr Chang’s experience. The concept is borne out in research as well. “Musical interventions affect not only the physiologic domains of the patient, such as blood pressure and heart rate, but also emotional domains, such as perioperative anxiety levels” according to a 2016 American Academy of Ophthalmology presentation, later published in Eye (London). “Exposure to auditory stimuli in the operation room such as the sound of the phaco machine and the professional conversations of surgeons may also cause emotional stress to the patient.” In particular, that research looked at binaural beats — defined as “special sounds perceived when 2 auditory stimuli of different frequency are presented to each ear.” Researchers believe these can influence the brain through the entrainment of brainwaves and can reduce anxiety as well as increase pain thresholds.4
But even standard music has a clinically-backed stress-relieving effect. In a randomized clinical trial published in JAMA Ophthalmology, preoperative listening to an app-based music sequence on a tablet with headphones reduced patient anxiety and intraoperative hypertensive incidences. Additionally, the mean number of sedative medications needed during the procedure was notably lower in patients who listened to music (0.04), than in the control set (0.57), and while more than half of the control group (82 individuals, 52.9%) experienced hypertensive events, only 13.6% (21 individuals) of those who listened to music had the same complication (both P <.001).5
Nancy Paul, RN, MSN, clinical director of ESCNN, estimates that 400 cataract surgeries are performed at the center each month, 100 to 125 per week. She advocates for a nurturing approach throughout the process. Typically, the clinic invites family members to the waiting area to support each patient. However, at this time, check-in has been adapted for COVID-19 distancing and safety, and family members do not accompany patients. She explains that staff members now work harder to fill the anxiety-relieving function that families customarily offer for each other. “The things that we do to decrease their anxiety; we don’t make them wait too long in the lobby,” she says. “We certainly communicate and keep things moving. We cover them with warm blankets.”
There are typically at least 3 nurses taking care of each patient in the preoperative period. “We introduce ourselves, and that’s actually an anxiety-calming thing too, that we, everyone introduces ourselves,” Ms Paul notes. “And even though we’re wearing masks, we’re all smiling at them, and I think they feel that.” Four or more nurses circulate in the pre- and post-op room, watching monitors and looking for eye contact. They are sure to continue to ask about their status in a friendly way. “You know, ‘How are you doing? Are you OK? Do you need anything,’” she adds.
Patients arrive an hour and a half before their procedure so there is enough time to receive drops and dilate, but they are typically in a bed for approximately 1 hour.
In Ms Paul’s experience, “pain is pretty uncommon, again, but maybe those (few) patients would have some pain and you might have to hold them a little longer,” she says. In these instances, Ms Paul’s strategies include regrouping, considering over-the-counter pain relievers, and personally phoning the patient before the second eye. If pre-procedure medication changes may be indicated, she obtains the surgeon’s advice.
Robust Patient Education
Research published in the AORN Journal explores many of the evidence-based techniques to decrease patient anxiety, such as the therapeutic patient/caregiver relationship, music, relaxation techniques, essential oils, education, and family-centered surgery preparation.6 But, “the most effective interventions from the current literature are perioperative patient education and music therapy,” according to the review.
Ms Paul describes patient education as starting with the preoperative consultation, which resumes the day of surgery. At admission, consent forms are used as educational materials. Education continues through every step.
A patient is hardly ever alone and is busy learning, according to the ESCNN team. The nurses communicate the current pre-op activities and start to go over post-op instructions. Ms Paul says that slow, even pacing, reinforcing concepts, and frequently asking patients if they have questions lessens anxiety. The 3-word mantra for staff each time they check in with a patient is ‘listening, validation, and reassurance.’
If a patient still expresses worry, a nurse explains that the doctor can prescribe a small dose of anxiety medication. They find most do not need it. “Just knowing what’s going to happen, most do fine,” she says.
In the OR, nurses involve patients in the process, reviewing which eye is being operated on, encouraging feelings of safety. After surgery, in the 20-minute recovery period, 1 to 2 nurses also go over instructions with any waiting family member. Printed instructions are provided, including a color eye drop chart.
Research suggests that some mindfulness techniques before a procedure may reduce pain afterwards. A randomized, single-blind study of 44 patients undergoing same-day head and neck surgery was conducted by US Air Force staff.7 Guided imagery before surgery lessened anxiety compared with control individuals (P = .002), and 2 hours after the procedure, they had significantly less pain (P = .041), as well as an average 9-minute shorter post-op stay (P = .055).7
With specific regard to cataract surgery, a research team in India was able to show that a particular meditative technique resulted in reduced patient-reported anxiety levels, lower blood pressures, and better cooperation during surgery.8 A Chinese research team saw similar results after introducing meditation training the day before cataract surgery, with an additional training 30 minutes before the operation.9
While bringing on a full-time mindfulness meditation instructor may not be in every surgical center’s budget, clinicians can review the many free streaming online videos that offer preoperative meditation techniques and find one they’re comfortable recommending to their patients.
Whether practices opt to incorporate a new look, soothing sounds, or take tips from Eastern wisdom, Ms Paul believes the most important factor in relieving patient stress is the teamwork, engagement, and energy shown by the surgical staff. She recommends investing in a team that will take ownership of the surgical center, and to limit any reliance on per diem nurses.
“It’s not 1 nurse caring for 1 patient, it’s all the nurses caring for 1 patient,” Ms Paul explains. In post-surgery evaluations, she says, patients have written that her nurses seemed like a family.
“Patients pick up on if you’re not working well together or if you are working well together, and that’s what (we do). We are working well together.”
1. Obuchowska I, Konopinska J. Fear and anxiety associated with cataract surgery under local anesthesia in adults: a systematic review. Psychol Res Behav Manag. 2021;14:781-793. doi:10.2147/PRBM.S314214
2. Appukuttan D. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clin Cosmet Investig Dent. 2016;8:35–50. doi:10.2147/CCIDE.S63626
3. Nielsen E, Wåhlin I, Frisman G. Evaluating pictures of nature and soft music on anxiety and well-being during elective surgery. Open Nurs J. 2018;12:58–66. doi:10.2174/1874434601812010058
4. Wiwatwongwana D, Vichitvejpaisal P, Thaikruea L, Klaphajone J, Tantong A, Wiwatwongwana A. The effect of music with and without binaural beat audio on operative anxiety in patients undergoing cataract surgery: a randomized controlled trial. Eye (Lond). 2016;30(11):1407-1414. doi:10.1038/eye.2016.160.
5. Guerrier G, Abdoul H, Jilet L, et al. Efficacy of a web app–based music intervention during cataract surgery: a randomized clinical trial. JAMA Ophthalmol. Published online July 29, 2021. doi:10.1001/jamaophthalmol.2021.2767
6. Bailey L. Strategies for decreasing patient anxiety in the perioperative setting. AORN J. 2010;92(4):445-457. doi:10.1016/j.aorn.2010.04.017
7. Gonzales EA, Ledesma RJA, McAllister DJ, et al. Effects of guided imagery on postoperative outcomes in patients undergoing same-day surgical procedures: a randomized, single-blind study. AANA Journal. 2010;78(3):181-188.
8. Gupta S, Gupta A, Tiwari C, Verma N, Pradhan S. Effect of psychoneurobics (meditation technique) on status of anxiety in patients undergoing cataract surgery: a randomized controlled trial. 2018;4(3):36-42. doi:10.24321/2454.325X.2018229.
9. Wang Yu-juan, Cheng Fang, MA Jing et al. The effects of meditation on patients receiving cataract surgery. Chinese Journal of Nursing. 2016-03.