Second-eye pain in cataract surgery

In their recent article, El Rami et al.1 addressed the issue of pain in fellow-eye ophthalmic surgical procedures. They propose the interesting central process of sensitization as a physiological mechanism that may explain why many patients report more pain after second-eye procedures. Nonetheless, we believe that the psychological explanation, as proposed by Ursea et al.,2 bears the largest responsibility for this phenomenon, especially in nonsimultaneous cases. In an intraindividual study of second-eye cataract procedures,3 we found an interesting inconsistency between the actual visual analog scale score given by patients at the end of each procedure and their final judgment about which procedure was more painful. Although the actual mean visual analog scale score was not significantly different between first- and second-eye procedures and only 40% of patients actually scored the second procedure more painful than the first, when asked “Did you feel more pain after the first or the second procedure?” 57.41% of the patients judged the second procedure more painful and 41.94% of them had attributed a higher visual analog scale score to the first procedure. The percentage of patients who actually attributed a higher visual analog scale score to the second procedure is the same (40%) as that reported by Ursea et al.2 Moreover, Ursea et al.2 also found a significant disagreement between the subjective response and the actual calculated change in the visual analog scale score. It must be emphasized that in our series no benzodiazepines were administered and that despite such a difference in surgical procedure, similar results were obtained. Psychology of pain perception may help us better understand this phenomenon. In any case, anticipating an enhanced patient perception by alerting the patient or by augmenting anesthesia may achieve better cooperation and improve patient comfort.